Challenges of medical records interoperability in developing countries: A case study of the University Teaching Hospital in Zambia

Abstract

The University Teaching Hospital (UTH) is an integral national referral Hospital made up of eight departments. Standardized systems and semantic interoperability is key for successful flow of patient information from one department to another and from section to section within a department. Lack of a SNOMED CT E.H.R System in surgery departments causes inefficient scheduling of surgical procedures, insufficient and inaccurate pertinent patient historical information, misconceptions and error arising from ambiguities in terminology usage. The result is unhealthy clinician working environment leading to high death rates among patients. Baseline Survey was conducted using questionnaire to establish the major drawbacks of the current manual system in use at the department. Record inspection was done followed by roundtable discussion with stakeholder. Convenient sampling was used, out of 40 respondents 72.5% had computers in their section, 27.5% did not have, 60% were using partial electronic records and paper based, 37.5% were using manual system, 2.5% reported that they were using electronic record system. The result reviewed more than 50% of the medical practitioner ranging from nurses to surgeon reported to be dissatisfied with the current system. In addition, record inspection was conducted by going to each section of the department to understand the business process and the form and format of data storage; this exercise reviewed redundancy in the capture, storage and management of patient records due to the fact that in every section where a patient pass, while undergoing diagnosis procedure, basic details are collected afresh for the same patient. This situation has brought about unnecessary duplication of work. The other drawback is the storage of patient records arising from lack of storage space. Record which are ten years old are destroyed to create space for new ones. This destruction of records robs researchers of the much-needed data for trends analysis and patient disease history. Because of these draw backs, it is very apparent that a standardized E.H.R is implemented.