Records management risks affecting healthcare service in the Greater Accra region of Ghana

Records in business aid in preserving corporate memory, policy formulation, decision-making, risk reduction, documentation, achievement meeting and compliance with statutory and regulatory requirements (ISO 15489–1, 2016). However, public health institutions face challenges in managing e-records due to ineffective systems, a lack of skilled staff and a lack of documented policies (Marutha and Ngulube, 2012, p. 39; Modiba et al., 2019, pp. 2–3). This hinders the accessibility of patient information and negatively impacts records’ function as memory and basis for continuous care (Marutha and Ngulube, 2012, p. 39).

Healthcare services are becoming increasingly information based, requiring accurate information for evidence-based decision-making (Otto et al., 2015, p. 1; Oweghoro, 2015, p. 69). This requires systematically collected and analysed data to guide improvement at all levels of care and hold providers and institutions accountable (Otto et al., 2015, p. 1). Medical records are crucial for better healthcare, as without complete information, medical practitioners and patients may face pressure and risks for incorrect diagnosis and treatment (Marutha, 2016, p. 1). Therefore, health records creation and management risks should be of the utmost concern to all stakeholders.

The studies of Adjei and Mensah (2016, p. 142), Attafuah et al. (2022, p. 4–8), Botchwey et al. (2021, pp. 26–29) and Adjei (2004, pp. 42–44) revealed challenges faced by the medical records units at Korle-Bu Teaching Hospital, Ridge hospital, Amasaman Municipal hospital and LEKMA hospital to include low record-keeping standards, insufficient storage space and computerised resources, haphazard procedures and poor quality of recorded information. Additionally, Gmagna (2013, pp. 55–56 and 58) revealed that the paper-based records management system at Tema General Hospital experienced retrieval difficulties, leading to medical errors and dissatisfaction with services. These issues are partly due to the recruitment of unqualified and inadequate training of personnel (Adjei and Mensah, 2016, p. 149; Mensah and Adjei, 2015, p. 455; Botchwey et al., 2021, pp. 26–29; Attafuah et al., 2022, pp. 4–8).

However, to access comprehensive and accurate medical information to support healthcare delivery, there is a need for well-equipped infrastructure, staff and a well-organised medical records system (Adjei and Mensah, 2016, pp. 141–142; Amoako-Coleman et al., 2015, p. 8). The study revealed that despite being designated as support staff, the majority of medical records/health information staff at Korle-Bu Teaching Hospital lacked formal training in medical records management. This lack of knowledge and training hinders effective retrieval of patient information at Korle-Bu and Amasaman Municipal hospitals for healthcare delivery (Adjei and Mensah, 2016, p. 149; Mensah and Adjei, 2015, p. 455).

Healthcare professionals require access to the full medical history of patients for purposes of reference in providing quality healthcare services (Weiskopf Hripcsak et al., 2013, p. 831; Marutha, 2019, pp. 21–24; Sungur et al., 2019, pp. 329–330). However, in the case of distorted, non-authentic, fragmented and incomplete medical information, patients are subjected to risks of inappropriate medical care (Teviu et al., 2012, pp. 137 and 140; Marutha, 2019, pp. 21–24; Sungur et al., 2019, pp. 329–330). That is, patients continue to be exposed to and suffer healthcare risks as a result of actions and decisions taken due to these medical records management challenges (Marutha, 2019, pp. 21–24; Sungur et al., 2019, pp. 329–330). Contributing to this, according to Adjei and Mensah (2016, pp. 142, 149) and Mensah and Adjei (2015, p. 455), are the low standards of record-keeping practices in healthcare institutions. As a result, the healthcare institutions in the Greater Accra region face significant challenges of weak and uncoordinated medical records systems and other issues, including misfiling, missing files and multiple patient file creation. These issues highlight the need for proper records management practices that promise safe and quality healthcare service.

The purpose of the study was to investigate risks arising from poor records management practices associated with uncoordinated and weak healthcare records management systems affecting healthcare services in the Greater Accra Region of Ghana. This study was necessary due to growing concerns regarding healthcare records management challenges including missing and incomplete patient’s records, inefficient systems and limited access to reliable information. These pose risks to patient safety, quality and effective healthcare service. As a result, the study proposes a framework to address the identified challenges.

The objectives of the study were:

• to identify healthcare information management risk in the Greater Accra Region of Ghana;

• to determine misfiling, missing files and multiple folder creation risks in the Greater Accra Region of Ghana;

• to establish health records retention and disposal risks in the Greater Accra Region of Ghana;

• to explore access and security of health records in the Greater Accra Region of Ghana;

• to explore health information management system risks in the Greater Accra Region of Ghana; and

• to identify risks from operations on the health information systems in the Greater Accra Region of Ghana.

This study explored the risks of poor healthcare services due to improper record creation and maintenance. It highlights the importance of a comprehensive standard records management system with technological infrastructure to address risks in healthcare service arising from misfiling, multiple folder creation, retrieval, storage, access, retention and disposal (Teviu et al., 2012:137). Healthcare records are created for authorised users, legal authorities and internal and external reviewers for various purposes.

Storage devices and space must be provided to search, identify, locate and retrieve patient-specific information across multiple systems, including electronic HIS and manual systems. Adhering to standards for classifying, indexing, labelling and filing patient records ensures accessibility and retrievability for healthcare businesses (Spiteri, 2012, p. 13; ITI Planning Committee, 2015, p. 22). Health records storage must prevent inappropriate acquisition, access, disclosure, loss, tampering and corruption (ITI Planning Committee, 2015, p. 23; Marutha, 2021, pp. 9–10). Retrieval of patients’ information is crucial for quality healthcare service. Proper records management systems support various forms of records-keeping activities, including creation, acquisition, storage, use, retrieval and distribution, minimising missing patient files and ensuring the organisation’s corporate memory (Marutha and Ngoepe, 2017, p. 4).

National archival institutions play a crucial role in managing healthcare records, with professionals playing a vital role in accessing and using these records (Khumalo et al., 2017, pp. 46–49; Marutha, 2021, p. 13). They advise and assist public sector institutions, including healthcare, on long-term preservation and general management of health records (Khumalo et al., 2017, pp. 46–49; Marutha, 2021, p. 13). Professional records managers and archivists are essential for a successful implementation of records management policies, principles and procedures.

Poor healthcare records management can lead to significant challenges in the provision of quality services, as it often involves unqualified personnel who lack both professional ethical standards, and the necessary knowledge in proper record-keeping practices (Khumalo et al., 2017, pp. 46–49; Adjei and Mensah, 2016, pp. 149–165). This results in inappropriate procedures, processes, principles and controls, increasing risks associated with healthcare provision. Inadequate patient information, misfiling, missing files and multiple folder creation can lead to inaccurate decisions and increased costs.

Inappropriate engagement in healthcare records management can compromise authenticity, integrity and long-term preservation (Khumalo et al., 2017, pp. 47–50). It is crucial to involve national archives in the initial stages of regional or national e-health programmes, as IT specialists may not prioritise archival principles for long-term preservation (Khumalo et al., 2017, pp. 47–50; Marutha, 2021, pp. 9–13). Records management professionals need to improve their IT skills to understand and address e-records concerns, as they are crucial for healthcare provision (Khumalo et al., 2017, pp. 47–50 and 57–59). They should be engaged in policy formulation alongside information and communication technology (ICT) initiatives to ensure the proper preservation of various record formats.

Patient records are vital in healthcare, providing evidence of patient encounters and their medical history [World Health Organization (WHO), 2012, p. 24; Sungur et al., 2019, pp. 329–330]. However, missing files and misfiling of health data can hinder effective, accurate and continuous healthcare provision (Sungur et al., 2019, p. 330; Marutha, 2018, pp. 1–7). This can lead to risks such as poor record-keeping or inadequate and inconsistent patient information (Ngoepe, 2014, p. 2). Healthcare providers often create multiple folders due to missing files or misfiling, thereby increasing healthcare risk and costs for both institutions and patients (Sungur et al., 2019, p. 330; Marutha, 2018, pp. 1–7). In such situations, healthcare professionals are denied complete and well-informed data, limiting their ability to make accurate decisions about diagnosis, care and treatment (WHO, 2012, p. 24; Marutha, 2018, pp. 1–7).

Factors contributing to missing files or misfiling include negligence, inexperience, lack of concentration, inadequate staff, lack of staff training and inadequate health information system resources and policy directions (Tweve, 2016, pp. 30–31; Adjei and Mensah, 2016, pp. 141–142 and 149–164; Sungur et al., 2019, pp. 330–335; Gaunt, 2020, pp. 12–15; Marutha, 2018, pp. 1–7). Effective records management is crucial for strategic decision-making, cost reduction and reducing litigation risks from healthcare defects (Sungur et al., 2019, pp. 330–335; Marutha, 2018, pp. 1–7). Misfiling of patient health records in traditional paper records management systems can lead to time-consuming searches and hinder institutional functioning (Ondieki, 2017, p. 2; Asinor and Leung, 2016, pp. 10145–10147; Marutha, 2018, pp. 1–7).

Records retention is crucial in the healthcare system, and healthcare institutions must allocate resources for managing health records (Adjei and Mensah, 2016, p. 147; Marutha, 2021, p. 11). The continuum model suggests that records with sound evidential characteristics should be retained as long as they are valuable to the organisation, its successor or society (Spiteri, 2012, p. 33; Marutha, 2018, pp. 1–7 and 13–17). All healthcare records, whether paper-based or electronic, must be retained as long as they are evidential for patient care or research purposes (Adjei and Mensah, 2016, p. 147; Marutha, 2021, p. 11). Without records retention schedules, professionals may dispose of dormant patient records, posing risks to patients and future research (Ngoepe, 2014, p. 7; Adjei and Mensah, 2016, p. 147).

Effective record management is essential for identifying and preserving records of continuous activity and archival value (Spiteri, 2012, p. 16; Ngoepe, 2014, p. 7; Adjei and Mensah, 2016, p. 147; Marutha, 2018, pp. 1–7 and pp. 13–17). Allocating the right procedures for large quantities of semi-active and inactive records helps allocate resources effectively, preventing clogging up office space and HIM servers (Spiteri, 2012, p. 16; Ngoepe, 2014, p. 7; Adjei and Mensah, 2016, p. 147; Marutha, 2018, pp. 1–7 and 13–17). Disposal of health records requires assessing their value, transferring historical or research records for permanent storage and destroying those deemed to have no further value (Spiteri, 2012, p. 14; Marutha, 2021, p. 11).

Accessing electronic health information is crucial for healthcare provision, but it can be compromised when unauthorised individuals access it (Koppel and Kuziemsky, 2019, pp. 220–221). This could be due to staff shortages, negligence, insufficient funding and low-quality personnel. Physical security systems and a lack of physical security can also negatively impact patient privacy. Modern systems and devices exacerbate these risks. IT professionals must perform statutory roles to protect the integrity and survival of patients’ information, requiring document audit trails to track and trace the use and access of patients’ information (Sittig, Belmont and Singh, 2018, pp. 7–11; Kruse et al., 2017, pp. 1–8). Implementing a patient information access control policy supports privacy and security requirements for providers (Kong, 2010, p. 17). Records and archives professionals must establish guidelines on access to records regarding privacy and confidentiality to maintain strict adherence (Kruse et al., 2017, pp. 1–8).

ICTs and mobile technologies in health systems improve healthcare access and information flow, reducing medical errors and facilitating effective communication among clinicians (Azeez and Van der Vyver, 2019, pp. 97–107; Alhan and Ahmad, 2014, pp. 1287–1290). However, access to these systems is limited to authorised users, and inter-facility access must be considered. The adoption of electronic health information systems presents risks to patients, including a lack of interoperability, errors in medical information and a lack of financial resources required for EHR systems (Kruse et al., 2018, pp. 2 and 12; Tsai et al., 2020, p. 2). Additionally, the quality and safety of healthcare services are hindered by a lack of well-trained ICT professionals and inadequate awareness and experience, especially in developing countries (Alhan and Ahmad, 2014, pp. 1287–1288 and 1295).

The success of HIS and related e-health relies on the knowledge, experience and technological expertise of records/information management, ICT staff and healthcare processes (Odekunle et al., 2018, pp. 11–13). The absence of these results in risks including privacy and security of medical information being compromised, financial risk from billing errors, software system obsolescence, computer crashes and electronic system failures (Thakkar and Davis, 2006, pp. 3 and 5–6; Scantlebury et al., 2021, pp. 1–2).

The interoperability of health information systems is crucial for patients’ safety and prevents deficiencies in medical record-keeping. Fragmented healthcare journeys and paper-based systems hinder informed decisions, ineffective care and costly medical tests (Warren et al., 2019, pp. 1–2; WHO, 2012, p. 18). Electronic health records (EHR) are suggested as a key solution due to their ease of sharing with healthcare stakeholders (Warren et al., 2019, pp. 1–2; Thomas, 2019, pp. 1–5; WHO, 2012, p. 18). EHRs can be connected automatically and accessed by external systems, institutions or clinicians, enabling better, safer and quality healthcare at a reduced cost (Thomas, 2019, pp. 1 and 16; Alhan and Ahmad, 2014, pp. 1287–1289 and 1295).

Government regulators play a role in coordinating, implementing and maintaining standards for interoperable EHR systems. Incentivisation and legislation, such as the 21st Century Cures Act of 2016, aim to improve the interoperability, usability and security of EHR systems (Sittig et al., 2018, pp. 9–10; Odekunle et al., 2018, pp. 8–13; Azeez and Van der Vyver, 2019, pp. 100–107). To ensure interoperability, EHR functions and features must be the primary concern of institutions, developers and other stakeholders (Sittig et al., 2018, p. 9; WHO, 2012, p. 19; Odekunle et al., 2018, pp. 8–13).

Using a mixed-methods research approach based on the convergent design (Mavodza, 2020, pp. 6–8; Creswell and Plano Clark, 2018) and underpinned by the pragmatist paradigm, the study integrated the qualitative and quantitative approaches. Using an interactive approach, the study therefore gave concurrent timing and equally prioritised both the qualitative and quantitative components during analysis (Creswell and Plano Clark, 2018; Creswell and Creswell, 2018).

The study’s population included information technology staff and records management staff, as well as healthcare professionals of public hospitals in the Greater Accra Region of Ghana. Sampling of the population involved using the stratified random sampling method for questionnaire data collection, whereas the purposive sampling method was used for interview data (Sarantakos, 2013, p. 177; Creswell and Creswell, 2018). The study used stratification due to the diverse nature of professionals as hospital staff, which included healthcare and information professionals. Out of a total population of 9,869, a sample size of 370 was selected using the Raosoft sample size calculator with a 95% confidence level and a 5% margin of error.

The study was conducted across 15 hospitals comprising Korle-Bu Teaching Hospital, Greater Accra Regional Hospital (Ridge), Weija-Gbawe Municipal Hospital, Tema General Hospital, Maamobi General Hospital, Achimota Hospital, La General Hospital, Shai Osudoku District Hospital, Ga West Municipal Hospital, Ga East Hospital, Ga North Municipal Hospital, Lekma Hospital, Ada East District Hospital, Ussher Hospital, Mamprobi Hospital and Princess Marie Louise Hospital. However, La General hospital was excluded due to infrastructural renovation that had halted healthcare activities.

Four data collection tools, namely, questionnaires, interviews, observation and document analysis were used by the study to gather primary data for analysis and presentation. These methods were adopted to address gaps or limitations associated with each technique and thus complemented one another. The heads of medical records, IT and healthcare units were interviewed, whereas nurses, midwives, physician assistants, technical officers, pharmacists, dieticians, biomedical scientists, biostatisticians/records management and IT professionals completed questionnaires. Additionally, both the paper-based and EHR systems, the medical records staff, shelves, cupboards, computers and temperature control resources for managing medical records were also observed. Again, the document analysis exercise reviewed the medical records policy, the legal framework for health information, the district information utilisation manual, Ghana’s e-health strategy, the Health Information Management System standard operating procedures, the ICT for Accelerated Development Policy and the Health sector ICT policy and strategy.

The study obtained ethical approval from Ghana Health Service Ethics Review Committee for hospitals under its jurisdiction, and separately from Korle Bu Teaching Hospital, an autonomous institution with its own ethical review processes. Additionally, as part of PhD study requirement, ethical clearance was granted by University of South Africa. Informed consent form and anonymity of participants, and security and confidentiality of data were ensured throughout the study.

Separate analyses were performed for quantitative and qualitative data using two different software packages. The SPSS was used to analyse quantitative data, and this was thematically performed in alignment with the study objectives (Creswell and Plano Clark, 2018; Ngulube, 2023). Regarding the qualitative data analysis, data from interviews, document analysis and open-ended questionnaire responses were thematically conducted using ATLAS.ti® version 24 software (Creswell and Plano Clark, 2018; Ngulube, 2023). Before this, the interview data were transcribed, verified for accuracy before setting up transcripts in the ATLAS.ti software. Interview participants were given anonymous names to ensure confidentiality, security and anonymity.

Integration was accomplished during the combined analysis phase by using an interactive strategy that merged both quantitative and qualitative results. The process aimed to identify areas of convergence and divergence. Since no divergent findings were detected, a side-by-side comparison method was used to clearly present the merged results in the findings, discussion and conclusions sections.

From a sample size of 370, a total of 257 paper-based questionnaires, distributed manually were completed and returned by medical records, information technology and healthcare professionals in 15 hospitals. Additionally, the researchers conducted interviews with 21 heads of departments for medical records (33%), information technology (19%) and specialised healthcare units (48%). The interviews which lasted between 30 and 60 min were respectively conducted and recorded in the offices of participants and voice recorder.

Again, concerning document analysis, the medical records policy, legal framework for health information, district information utilisation manual, Ghana e-health strategy, Health Information Management System standard operating procedures, ICT for Accelerated Development Policy and Health sector ICT policy and strategy were reviewed.

The study findings revealed that non-functional record-keeping systems significantly impacted healthcare delivery and posed risks to patients. Additionally, these resulted in missing files, misfiling and incomplete patient information. Again, as shown in Figure 1, it was revealed that non-functional record-keeping systems impeded effective healthcare services through misdiagnosis and non-existent or incomplete medical histories, which contributed to loss of lives or permanent paralysis. The results as presented in Figure 1, showed that incomplete medical records occurred due to uncoordinated medical records from different departments. Furthermore, according to Figure 2, interview participants added that ineffective record-keeping practices led to treatment delays, incorrect drug prescriptions and medico-legal actions. However, data from document analysis revealed that the Ministry of Health is responsible for the provision of these resources to ensure comprehensive accessibility to medical records.

The study again sought to find out what the challenges and risks associated with managing paper-based patient records, particularly incomplete, missing files or misfiling were. The responses revealed that easy accessibility to healthcare was hindered because patients waited longer for medical files to be retrieved before receiving healthcare. As a result, the study findings revealed that new files were created and fresh data collected whenever paper-based medical records were not found. Due to this, patients were sometimes requested to undergo medical tests they had already done for purposes of updating their medical information. The results showed that patients’ missing files and misfiled health data obstructed effective, accurate, exhaustive and continuous healthcare service. Data from interview participants confirmed that the right medical information was not available, and this hampered continuity in patient management, making healthcare providers stranded, and affecting regular clinical audits. Interview participants again confirmed that incomplete patient records resulted in repetitive medical tests, long patient waiting time, increased cost of healthcare service, aggravated patients’ ailments and possible misdiagnosis.

The study also identified that due to the inadequacy of staff for the medical records unit, individuals with professional qualifications, different from records management, were mostly transferred to the records unit. This resulted in fatigue among medical records staff. It was also found that these categories of staff were partly responsible for missing files and misfiling. All these, in addition to difficulties in locating paper-based medical records, during disruptions in electricity supply or internet connectivity, were risks to patient care.

The study was conducted to determine whether the risk of unavailable patient information and associated misdiagnosis had legal implications and caused disciplinary actions against the healthcare institutions. Most respondents responded affirmatively. Furthermore, some of the respondents indicated that these issues were causing substantial financial losses to their institutions.

The findings of the study, according to interview participants, revealed that there have been instances of medico-legal action against their institutions due to misdiagnosis or inaccurate healthcare arising from incomplete or unavailable patient information. That is, on a few occasions, some patients sued the hospital, while others received compensation for negligence. Similar to these, according to interview participants, are repetitive medical tests and the resultant effect of inaccurate diagnoses, mistreatment, increased costs for patients and the health risks it poses.

Solutions to address the issue of incomplete or unavailable patient information, and associated misdiagnosis, repetitive medical tests, and medical errors were explored by the study. Results on recommendations from questionnaire respondents showed staff training by 5.1%, proper records management practices by 14.8%, digitisation of paper-based medical records by 6.6%, adopting EHR management systems by 19.8% and holding staff accountable by 1.6%, whereas 52.1% did not respond to this question. In addition, interview participants indicated similar suggestions by recommending proper documentation and storage, mandatory fields in electronic systems, merging paper-based and electronic medical records systems, regular staff training, making patient information accessible to healthcare practitioners, adhering to standard operating procedures, and a records supervisor who will ensure the completeness of medical records. Furthermore, interview participants suggested the engagement of qualified staff, periodic monitoring and evaluation of staff and resources and the use of modern resources.

Responding to measures used in protecting medical records from inappropriate acquisition, access, disclosure, loss, tampering and corruption, questionnaire respondents mentioned steps undertaken by the healthcare institutions. That is, 13.6% indicated an introduction of EHR management system, 3.5% stated that access to EHRs is limited to authorised personnel and 13.6% said provision had been made for authenticating credentials, such as unique passwords and usernames for authorised personnel. Again, 5.1% mentioned provision of shelves, burglar-proof doors and locks for paper-based records, and 1.6% stated the existence of standard procedures for entry and retrieval of paper-based records. Backup systems for EHRs were mentioned by 0.4% of the questionnaire respondents, and 3.9% mentioned training workshops, whereas 58.4% did not respond.

Interview participants added that the institution’s EHRs system (LHIMS) could only be accessed by authorised staff who have been provided with usernames and passwords, but they could not alter any patient data. They again mentioned the implementation of a central data centre for storing and securing patients’ information. Also, physical security measures were put in place to prevent unauthorised access to the hospital’s archival repository. The document analysis revealed that necessary security, backup, purpose-built storage and regular maintenance were prescribed for both the EHRs and paper-based systems.

The study sought to understand the challenges faced by healthcare institutions arising from the current health records management system being operated. As a result, 30.4% of questionnaire respondents agreed that the system was facing challenges due to the lack of qualified records management professionals, though 46.3% were unsure. As a result, 75.1% agreed that engaging professional and experienced records managers and archivists could improve the situation. This was confirmed by the results of the analysis of the medical records policy, which prescribes the engagement of qualified medical records officers, accredited by the Allied Health Council for healthcare facilities. Interviews confirmed that the healthcare institutions system continued to face challenges due to the calibre of staff, inadequate hardware computing devices, unavailable infrastructure, internet downtimes and an absent network operating centre. The interview participants added that the EHR system (LHIMS) was still fraught with challenges.

The study found that a lack of commitment by top management towards the records unit negatively impacted the health records management situation, with 44.4% of respondents agreeing. Additionally, 44.7% of respondents stated that the medical records unit was not adequately resourced to help prevent healthcare risks arising from missing files, misfiling and multiple folder creation. Data from interviews and observation showed that the records unit and the IT unit received limited support from their hospital’s management. Observation revealed insufficiency of paper-based storage space and equipment, storage of files on the floor and overpacked shelves. Additionally, observation revealed alternation to the paper-based system due to electrical and internet connectivity disruptions. Observation again revealed absent digitisation of patients’ paper-based records, leading to their retrieval to the consulting room to enable accessing full medical history. In the analysis of the documents, the medical records policy mentioned the need for the provision of adequate authority, personnel and resources to enable effectiveness. However, these policy requirements did not consistently reflect in practice, thus contributing to the identified risks in healthcare records management

Again, the study revealed that 17.1% of respondents believed there had never been disposal of health records, though they might have fully served their purpose. Additionally, most of the interview participants indicated that there has never been any disposal, except in situations of force majeure. However, the medical records policy requires application of disposal and retention schedules to inactive records, and by so doing seek relevant authorisation. Document analysis as a result enabled comparison between policy provisions and actual practices, thus supported the identification of key risks that informed the study’s recommendations.

The study identified that there were risks to healthcare due to non-functional record-keeping systems in healthcare institutions in the Greater Accra region. Accordingly, the majority (68.9%) of questionnaire respondents were of the view that this was primarily due to improper record creation and maintenance, which mostly led to missing files and misfiling. This further led to incomplete patient information, as confirmed by 74.7% of the questionnaire respondents. It is therefore crucial that healthcare institutions maintain an effective and efficient records-keeping system that supports and provides resources for the storage and retrieval of health records (Marutha, 2018, pp. 1–6; Marutha, 2021, pp. 9–10).

Incomplete patient records hinder effective healthcare services, leading to misdiagnosis and financial loss. This was confirmed by 58.4% (150) questionnaire respondents who indicated that incomplete patient records arose from uncoordinated medical records from the paper-based and EHRs systems by various units of the same institution or other institutions. Additionally, 70% of the questionnaire respondents indicated that these records impede efficient healthcare services. Interview participants also confirmed that ineffective record-keeping practices led to loss of medical information, incorrect drug prescriptions and associated side effects. This puts patients’ lives at risk, which sometimes leads to medico-legal actions against the healthcare institutions. Meanwhile, upon analysis of the medical records policy, it was identified that the Ministry of Health is mandated to provide the needed resources to healthcare institutions. This resource provision is expected to ensure comprehensive dissemination, implementation and monitoring of appropriate medical records management systems that guarantee complete patient information capture and access.

Missing files and misfiling of patients’ health data hinder effective healthcare provision (Sungur et al., 2019, p. 330; Marutha, 2018, pp. 1–7). In the Greater Accra region, healthcare institutions encountered incomplete patient records due to missing files and misfiling in paper-based records. As a result, affected patients have to wait longer for their medical files to be retrieved before receiving healthcare. In some cases, especially with the introduction of and focus on mainly the LHIMS, healthcare institutions struggled to locate and retrieve these paper-based medical records, especially when there are disruptions to electrical power supply or internet connectivity. This happens because the manual records system becomes the only alternative. These issues negatively impact patients and the management of paper-based patient records.

Multiple folder creation arising from missing files or misfiling leads to inconsistent, uncoordinated patient information (Sungur et al., 2019, p. 330; Marutha, 2018, pp. 1–7). A majority of questionnaire respondents stated that new files are created and fresh data on patients are collected whenever paper-based medical records are not found. This creates a lack of adequate health data on patients, further increasing healthcare risk and cost for both the institution and the patient. Patients often had no option but to repeat medical tests whenever misfiling or missing files occurred, as confirmed by 68.1% questionnaire respondents.

ICT in healthcare has improved service delivery (Marutha, 2019, p. 24), for which 63% of questionnaire respondents have recommended full implementation of an exhaustive EHR system to provide timely, accurate and efficient healthcare information and its retrieval. Implementing an EHR system can help address the issues of misfiling, missing files, multiple folder creation, repetitive medical tests, misdiagnosis and other risks to patient care, and also to improve healthcare service delivery. In the Greater Accra region in particular, missing files or instances of misfiling were attributed to activities within the medical records units, primarily due to the involvement of non-records management professionals and insufficient staffing levels. This is because standards and guidelines for records management education are neglected, leading to the engagement of unqualified personnel in the medical records unit to manage institutional records.

The risk of unavailable patient information leading to repetitive medical tests and misdiagnosis caused significant financial losses to healthcare institutions in the Greater Accra region. Factors that contributed to these issues included wrong data capturing, missing medical records, negligence, incorrect diagnosis and wrong medical treatment. Further risks to patients included emotional stress, delayed diagnosis, wrong medication, death and additional costs for repeated medical tests.

The study revealed that there are risks to patients due to incomplete or unavailable patient information and a resultant impact on healthcare provision. To overcome the record-keeping challenges and avoid the risks it poses to patients, questionnaire respondents suggested training of staff to adhere to record-keeping principles to ensure that standard practices and job performance are demonstrated. Again, 14.8% of questionnaire respondents suggested that the healthcare institutions in the Greater Accra region should adopt proper records management practices. Accessing electronic health information is crucial for remote healthcare provision, and relating to this, 6.6% of the questionnaire respondents suggested digitising paper-based medical records for digital and remote access. A total of 19.8% suggested adoption of an EHR management system for patient information creation, use and other management functionalities. Providing the right resources for medical records management can lead to quality healthcare services. Interview participants also recommended the implementation of a proper medical records management system and adequate storage resources for healthcare activities. Interview participants again recommended the implementation of an EHRs system capable of managing both electronically generated and digitised paper-based patients’ information.

Health information is crucial for identifying health complications and suggesting alternative treatments. Healthcare institutions in the Greater Accra region, according to questionnaire respondents, have implemented measures to protect patient records from inappropriate acquisition, access, disclosure, loss, tampering and corruption. Again, 13.6% of questionnaire respondents and interview participants confirmed the implementation of an EHR management system, specifically LHIMS, which has improved healthcare service provision. The EHR system in healthcare institutions in the Greater Accra region is limited to authorised personnel, with login details set by the IT department and authorisation notes from department heads. Again, 13.6% of questionnaire respondents stated that authenticating credentials were provided for these personnel, and login credentials are used to track user activities on the system. A backup system is in place, with patient information being backed up to a national server for a global search and backup for all healthcare institutions in the region.

Though inadequate, healthcare institutions in the Greater Accra region have implemented measures to protect paper-based patient records, including shelves, burglar-proof doors and locks. Access to these records is restricted to records staff, but all other staff require authorisation before accessing the storage area. Again, the study participants revealed that the healthcare institutions have ensured that the indexing system is not easily comprehensible to unauthorised individuals.

Healthcare institutions have standard procedures for patient record entry and retrieval, with guidelines for EHR system use requiring authorised staff access. This also applies to manual health records systems.

Poor healthcare records management can lead to challenges in quality service provision due to the appointment of unqualified personnel (Khumalo et al., 2017, pp. 46–49; Adjei and Mensah, 2016, pp. 149–165). These individuals lack professional ethical consideration and focus on storage, accessibility, security, confidentiality, retention and long-term preservation of healthcare records (Marutha, 2021). In this case, 30.4% of questionnaire respondents reported that the current health records management system faces challenges due to the engagement of non-records management professionals. They contribute to misfiling, missing files and related issues affecting the activities of the medical records unit. The medical records policy requires healthcare institutions to employ qualified personnel to work in the medical records unit. This means that managing records without professional archivists and records managers to assist in this task, risks to healthcare provision are likely to continue. As a result, 75.1% of questionnaire respondents confirmed that the appointment of professional and experienced records managers and archivists could improve the current records management situation.

The current health records management system of healthcare institutions faces challenges due to a lack of a common platform for clinicians to access accurate patient information. This is because of top management’s non-commitment, which has a negative impact on the system, as highlighted by 44.4% of questionnaire respondents. Insufficient resources allocated to the records management department also contribute to these challenges, causing risks such as missing files, misfiling and multiple folder creation. While the medical records department receives support, it is not fully provided, and for that matter, there is a need for better allocation of resources to ensure effective health record management.

Hospital management’s commitment to providing adequate resources for medical records management can improve patient information management. Adherence to the medical records policy ensures the department performs all required functions. Retention and disposal schedules guide the proper disposal of important healthcare records. However, 17.1% of questionnaire respondents and interview participants in the Greater Accra region reported that their hospitals have never carried out disposal actions on health records that might have served their purpose. Heads of medical facilities should consult PRAAD for advice, support and approval to carry out appraisals and disposal actions as indicated in the medical records policy, and in adherence to the PRAAD Act 1997 (no. 525). This is crucial for implementing an Electronic Document and Records Management System (ERDMS), where records that have outlived their usefulness are disposed of before embarking on any form of digitisation.

This section presents a framework for healthcare institutions in the Greater Accra region concerning healthcare records management risks affecting healthcare services. The framework synthesises study findings, participants recommendations, gaps between current practices and the medical records policy requirements into a structured approach to addressing identified risks. As represented by Figure 3, adequate and sufficient resources capable of ensuring comprehensive dissemination, implementation and monitoring of appropriate medical records management systems should be acquired to help ensure that complete patient information is provided. Based on this, healthcare institutions should ensure that functional medical record-keeping systems are in use. There should be coordination of medical information systems that are operated at different times, and also by different departments, due to system challenges and/or lack of resources. Additionally, the medical records units of the healthcare institutions of the Greater Accra region should adhere to proper records management practices devoid of missing files, misfiling and multiple folder creation.

The medical records unit must be supported by top management with the right and adequate human, infrastructural and technological resources for its effective functioning to enable it to abide by the right record-keeping practices. Additionally, staff must be provided with adequate training and sponsorships to attend external records management workshops and appropriate relevant orientation before they are transferred to the medical records unit during staff reshuffling. Again, since the healthcare institutions have not undertaken any form of disposal of patients’ paper-based records, the framework recommends that the medical records unit design a disposal plan and implement it after receiving approval from their management and PRAAD. The medical records unit must ensure that all manual records on patients generated during electrical power outages and/or internet connectivity disruptions are digitised and uploaded onto the ERDMS until all such challenges are resolved.

In collaboration with the Ministry of Health and Ghana Health Service, the hospitals should organise at least a week-long and regular practical records management training for all existing medical records staff. This training will introduce the staff to records management principles, legalities in records management, file/folder classification, disaster prevention and recovery, as well as basic IT skills, to help manage basic electronic information. This will inculcate records management discipline in the medical records staff to uphold the tenets of records management and related record-keeping practices. This will help reorganise the paper-based medical records to make way for digitisation and migration to ERDMS.

In addressing the study objectives, the findings show that non-functional record-keeping systems, characterised by misfiling, missing files, repeated medical tests and engagement of unqualified staff, undermine healthcare delivery and increases risks to patients. Coupled with this, were the absence of records management training for records staff, and inadequate resources for managing the health information systems.

The study again identified gaps between existing practices and established records management principles and policy requirement. As a result, the study recommends that healthcare institutions of the Greater Accra region strengthen records management training, ensure adherence to records management standards, improve the functionality of the EHRs systems and engage qualified records management professionals. These serve as basis for addressing the identified risks and improving healthcare provision in the Greater Accra region of Ghana. These findings are of practical and societal implications emphasising the necessity for improved records management systems and practices, staff capacity and policy adherence to promote patient well-being.