Procedia of Engineering and Life Science

Mortality Reporting Modeling in Healthcare Facilities in Indonesia

Achmad Jaelani Rusdi — 2024-11-21

Healthcare facilities in Indonesia, such as hospitals and public health centers, play a crucial role in recording and reporting mortality data necessary for health policy development and quality assessment. Although various reporting methods are available, ranging from manual to electronic systems, the primary focus has often been on morbidity rather than mortality. External reporting processes typically involve basic coding for morbidity and mortality, and the application of the International Classification of Diseases (ICD) for cause-of-death determination in electronic medical records is still underdeveloped. This study employs a qualitative descriptive approach with a system modeling framework to design a comprehensive mortality reporting model that incorporates data mining techniques. By analyzing secondary data from integrated mortality reporting systems in Indonesian healthcare facilities, the study proposes a model that enhances data processing and presentation, offering a structured approach for utilizing mortality data for policy development and future forecasting. The results demonstrate that this model significantly improves data management processes and provides a valuable framework for advancing health policy. Future research should explore the implementation of this model and assess its impact on health policy outcomes in Indonesia.

Review Of Pmik Readiness In The Implementation Of Electronic Medical Records (Rme) At The Islamic Hospital "Siti Hajar" Mataram: A Qualitative Study

Wulandari Dewi Susilawati — 2024-11-21

Medical recorder and health information (MRHI) in the implementation of electronic medical records (EMR) at the Islamic Hospital (IH) “Siti Hajar” of Mataram is still not ready to implement EMR because there is no budget for its implementation, facilities and infrastructure as well as inadequate human resources and supporting devices in the implementation of EMR which are still inadequate. The study aims to identify the 5M elements (man, money, material, machine and methods) related to MRHI readiness in implementing EMR. The type of research used a qualitative design with interviews, observation and documentation. The research informants were the head of the medical record unit, coordinator of the medical record unit, medical record officers and information technology officers. The results of research from the man element, namely officers have not received special training related to EMR. The element of money is that officers do not know the budget related to the implementation of electronic medical records. The element of machine is that the facilities, infrastructure and supporting devices (hardware and software) are still inadequate. The material element is that there has been no creation of special documents related to the implementation of electronic medical records. The methods element, namely standard operating procedures (SOPs) related to the implementation of EMR does not yet exist. It is necessary to invest in technology upgrades, improve staff training programs, strengthen data security measures, and develop a comprehensive change management plan.

Analysis of Differences Between Hospital Rates and INA-CBG's Claim of Sectio Caesarea

Afriliya Hayati — 2024-11-21

Hospitals as advanced referral facilities have an important role in implementing the National Health Insurance (JKN) programme. For payment of advanced health services for JKN participants at the hospital, BPJS makes payments based on the Indonesian case-based groups (INA-CBG's) package. However, the problem that is often found in hospitals is the difference between hospital rates and INA-CBG's claim. This study aims to determine and analyse the difference between hospital rates and INA-CBG's claim for sectio caesarea cases at Bhayangkara Polda DIY Hospital. This study was a descriptive quantitative study with a retrospective approach. The object of the study was the BPJS patient's inpatient claim file for sectio caesarea cases at Bhayangkara Polda DIY Hospital in the fourth quarter of 2023. The number of samples was 39 patients using the total sampling technique. The results showed a significant difference (p< 0,05) between hospital rates and INA-CBG’s claim for sectio caesarea cases at Bhayangkara Polda DIY Hospital. The difference between hospital rates and INA-CBG’s claim caused a negative difference of Rp.10,865,028,00. There is a negative difference between the hospital rates and the INA-CBG's claim for sectio caesarea cases at Bhayangkara Polda DIY Hospital, so the hospital suffers a loss.

Analysis of the Diagnosis’s Inaccuracy Codes for Infection Cases in Dahlia Ward’s Inpatients at Majenang Regional Hospital

Syifa Khurotun Azizah — 2024-11-21

The large number of infection cases in Indonesia has caused the number of BPJS claims related to these cases to continue to increase. The claim process carried out by the hospital must go through various stages in order to be claimed, including the coding process. The medical recorder's role as a coder is responsible for the correctness and accuracy of the code for a diagnosis that has been determined by medical personnel (doctors). Inaccuracies in diagnosis codes will impact the effectiveness of health service data and information management as well as pending claims. Pending claims that occur due to inaccuracies can impact hospital cost profit which will result in the hospital experiencing losses. Based on a preliminary study conducted in the Dahlia Ward, Majenang Regional Hospital, 3 medical records with incorrect codes were found (3.54%) out of 58 medical records. This study aims to calculate the inaccuracy of diagnosis codes for cases of infection for inpatients in the Dahlia Ward, Majenang Regional Hospital and identify the factors that cause inaccurate diagnosis codes for cases of infection for inpatients in the Dahlia Ward, Majenang Hospital.The research method used is a qualitative method with a narrative descriptive design. Data collection techniques were carried out using two methods, namely observation and interviews. Interviews were conducted to obtain reasons for inaccurate diagnosis codes, while observations were used to verify interview results. There were 3 resource persons in this study, namely the head of medical records and 2 inpatient coders. The research results showed that inaccuracies occurred due to incomplete diagnosis writing by the DPJP, such as doctors tending to write abbreviations, and coders tending to use rote memorization in determining diagnosis codes.

A Review of The Effectiveness of Independent Outpatient Registration Through The Mobile JKN at Sukosari Health Center and Manguharjo Health Center in Madiun City

Al Wafi Rahmaputri Ardianingrum — 2024-11-21

Law Number 40 of 2004 stipulated that the National Social Security System mandates social security for all Indonesian citizens, namely the National Health Insurance (JKN). The Mobile JKN application provides an essential service to the public online, eliminating the need for long queues at health institutions. Research conducted from July 2022 to April 2023 showed that of the 196,917 residents of Madiun City, only 46 participants used the Mobile JKN application. The low enthusiasm for registering independently for outpatient services through Mobile JKN is attributed to either the inability to use the application or the inadequate quality of the service. This study employed a descriptive quantitative design based on observations. The results showed that the application process for Mobile JKN at health centers in Madiun City aligned with technology acceptance. Overall effectiveness was deemed "successful," with a percentage score of 79.02%, attributed to the application's quick access time, reliable information, and prompt handling of consumer complaints. Madiun City health centers encourage the public to use the Mobile JKN application by promoting it through leaflets and social media.

Evaluation of RME Implementation Based on Digital Maturity Index (DMI) in the Digital Transformation Stages of Healthcare at Muhammadiyah University Malang Hospital

Ali Hanafiah — 2024-11-21

This study aims to evaluate the implementation of Electronic Medical Records (EMR) at the General Hospital of Muhammadiyah University Malang (RSU UMM) based on the Digital Maturity Index (DMI) in the context of healthcare digitalization transformation. This research employs the Hospital Information System Maturity Model (HISMM) to measure the digital maturity level of RSU UMM. The research method utilized includes surveys and observations involving medical, administrative, and managerial staff directly engaged in the use of EMR. The results indicate that the digital maturity level at RSU UMM is at 65.3%, suggesting that while the EMR implementation is progressing well, improvements are still needed in several indicators such as Data Analysis, Strategy, Information Security, and Human Resource Management. Factors influencing the successful implementation of EMR include technological readiness, managerial support, user training, and data security policies. This evaluation is expected to assist RSU UMM in enhancing the efficiency and effectiveness of healthcare services by optimizing the EMR system and accelerating the digital transformation process in the healthcare sector Keywords— Personal Health Record, Acceptance, medical record

Assessment of Data Quality in Hospital Reporting on Sumatra Island in 2023 through the RS Online Application

Maura Elfrida — 2024-11-21

One of the uses of technology in the healthcare sector is the implementation of health information systems (HIS). An example of HIS implementation in Indonesia is RS Online. RS Online is part of the hospital information system used for routine hospital reporting by adjusting data and information needs at the Ministry of Health. Data from health facilities, such as hospital data in RS Online, are the main data source for evaluating the performance of the health sector. Data urgency arises due to the importance of data quality and its resulting impacts. The aim of this research is to determine the level of hospital reporting data quality on Sumatra Island in 2023 on the RS Online application. This research was quantitative with a cross-sectional design. The sample consisted of 753 hospitals on Sumatra Island, which was determined by total sampling. The results of routine data quality assessment reached 100% in the uniqueness dimension, 94.59% in the completeness dimension, 98.71% in the accuracy dimension, and 99.52% in the validity dimension. The results show that the routine hospital reporting data quality on the RS Online application in 2023 on Sumatra Island is categorized as good.

Usability Evaluation of Hospital Information System Applications Based on The System Usability Scale

Arif Kurniadi — 2024-11-21

The key to successful technology adoption is to pay attention to several aspects including top management support, system quality, information quality, and user perception through usability. The Khanza Hospital Management Information System (SIMRS) application in the UDINUS Medical Records laboratory is prepared as a learning medium for students of the Medical Records and Health Information Study Program. This study aims to evaluate the use of Khanza SIMRS application based on user experience, namely students through usability testing to measure learnability, efficiency, memorability, error, and satisfaction.Quantitative research was designed through a survey to 3rd year students of D3 Medical Records and Health Information Study Program by purposive random sampling. Quantitative data was collected from 40 respondents by answering 10 questions of the System Usability Scale (SUS) questionnaire using a Linkert scale of answers Strongly Disagree, Disagree, Neutral, Agree, and Strongly Agree.The results showed SIMRS application with SUS Score 62 (0-100 scale), Acceptability Marginal Low, Grade D, and Adjective Rating category "OK". Recommendations for the SIMRS application in the learnability aspect need to add vertical navigation on the left screen for ease of eye-tracking, while in the memorability aspect, it is necessary to add tooltips, tour wizards, screen transitions, and prominent visual effects.

The Influence of Medical Record Officers' Perceptions of the Quality of Medical Records On The Completeness of Filling Out Electronic Medical Resumes at RSUD Ajibarang

Arum Astika Sari — 2024-11-21

Medical record officers play an important role in improving the quality of medical records, officers must have good knowledge and understanding in the medical record unit. Completeness of medical resume filling is an aspect that can have an impact on the quality of medical records. Health professionals, including doctors, nurses, and other medical staff, use medical resume sheets to record patient information. Incomplete medical resumes can cause major problems for medical records, which must fill out medical resumes thoroughly in their capacity as health service providers. This study aims to determine how the influence of medical record officers' perceptions of the quality of medical records on the completeness of filling out electronic medical resumes at RSUD Ajibarang. This research method is descriptive quantitative with a cross sectional approach and the test conducted with the Chi Square test. The population and sample were medical record officers totaling 32 respondents and inpatient medical resume forms totaling 32 medical resumes. The results showed that 32 respondents had a good perception of 31 people and an unfavorable perception of one person. The results of the analysis showed that the perception of medical record officers about the quality of medical records on the completeness of filling out electronic medical records showed that the p-value of 0.000 <0.05, so that H0 was rejected and H1 was accepted. It can be concluded that there is an influence between the perception of medical record officers about the quality of medical records on the completeness of filling out electronic medical resumes at RSUD Ajibarang.

Analysis of the Accuracy of Diagnosis Codes Based on ICD-10 with the Application of the 4th Character at the Puskesmas of Semarang City

Munandziroh Munandziroh — 2024-11-21

The accuracy of the diagnosis code on the medical record document is used as a basis for making reports. If the diagnosis code is not properly coded then the resulting information will have low validation. The results of the initial survey at Puskesmas Genuk in the Top 10 of Disease in 2022, there are still many diagnosis codes that have not been coded until the 4th character. Objective is determine the accuracy analysis of disease diagnosis codes based on ICD-10 with the application of the 4th character of the fourth quarter at Puskesmas Genuk in 2022.This type of research is descriptive quantitative with a retrospective study approach. The primary data sources used are observation and interviews while the secondary data is from medical record data obtained from SIMPUS. The total population was 4,861 medical record data while the samples used were 98 with systematic random sampling techniques.Based on the results of research on 98 medical record data, the exact code is 21 (27.23%) while the incorrect code is 77 (72.77%). The inaccuracy of the diagnosis code is because the coding officer is not PMIK, the code is given only up to the 3rd character, there is no SOP for giving Disease Diagnosis Codes, not using ICD-10 but a list of SIMPUS codes. Conclusion are accuracy of the diagnosis code of 27.23% is much lower than the inaccuracy, coding officers from PMIK should be conducted, Training on Giving Disease / Action Coding, Diagnosis Codes at SIMPUS are given keys so that coders can choose a specific code, SIMPUS plus facilities for PMIK officers to validate coding after service

Evaluate The Use Of The Independent Registration Tools Outpatient Patients Using The Hot-Fit Method At Roemani Muhammadiyah Hospital Semarang

Astri Sri Wariyanti — 2024-11-21

In Indonesia, the implementation of electronic medical records will begin to be implemented in health service facilities in December 2023 [1]. The HOT Fit method is a complete model in the aspect of the assessment carried out and is most suitable to existing problems compared to other models, where this model places three important parts, namely Human, Organization and Technology [2]. The aim of this research is to find out how to evaluate the use of the Outpatient Self-Registration Platform using the HOT – Fit Method.The method used is qualitative research with data for January until May 2024. The research instrument uses observation guidelines and interviewand data collection method is by observation and interview. How to collect data by observation Data processing techniques include data reduction, data display and verification. The research results show that from the human aspect of system users, the self-registration platform was socialized at the beginning of the implementation of the new system for users in outpatient registration but there was no training, and users were not satisfied with the features in the self-registration platform. Organizational aspects, support and policies from management provide support in its implementation, but system monitoring and written policies regarding the implementation of independent registration platforms have not been carried out. In terms of system quality, the independent registration platform at Roemani Muhammadiyah Hospital Semarang ensures data security because each officer has a username and password. In terms of benefits, the self-registration platform at Roemani Muhammadiyah Hospital Semarang is useful for its use, namely helping and facilitating patient care, especially reducing patient backlogs.

Overview of the Causes of BPJS Health Pending Claims Due to Inaccuracy of Diagnosis Codes in Sebelas Maret University (UNS) Hospital

Cindy Rozza Bella — 2024-11-21

In submitting a BPJS Health claim, not all submitted documents can be claimed. Claim status is declared ineligible or pending. A pending claim occurs if the claim file submitted by the hospital is incomplete or does not comply with the requirements set by BPJS Health. Delayed claims can disrupt hospital cash flow and cause losses for the hospital and BPJS Health participants. This research aims to describe the causes of pending claims at UNS Hospital. This research is a quantitative descriptive study with a population of 182 inpatients pending claim documents at UNS Hospital for the period August-October 2023. The sample for this research is 78 pending claim documents based on diagnosis code verification. The sampling technique is total sampling. Based on the data obtained, the number of documents with coding confirmation is 78 pending claim documents s or 11.3% of the total pending claims in the period August – October 2023. This data shows that the majority of pending claim documents are due to inaccurate diagnosis. The factor causing pending claims from BPJS Health inpatients at UNS Hospital occurs due to differences in perception between hospital staff and BPJS Health and is not purely due to coder error, but due to a lack of supporting data as a diagnosis enforcer which affects the accuracy of the code.

Optimizing Integrated Patient Progress Notes through the Application of Electronic Medical Record to Improve the Quality of Health Services: a Narrative Review

Danu Tirta Nadi — 2024-11-21

Background: The completeness and accuracy of Integrated Patient Progress Notes (CPPT) are crucial for effective communication among healthcare professionals and safeguarding patient safety. However, Indonesian hospitals face significant challenges in achieving complete and accurate CPPTs, leading to risks such as medication errors. Objective: This study aims to identify the practices and challenges of CPPT in Indonesia through a narrative literature review and explore best practices from hospitals in various countries, focusing on the implementation of integrated patient progress note systems and the application of the Plan-Do-Study-Act (PDSA) quality improvement model. Method: The methodology used in this study is a narrative review concerning the usage, effectiveness, and issues faced by hospitals in implementing CPPT. Result: The narrative review reveals several barriers to CPPT completeness in Indonesia, including insufficient management commitment, limited healthcare personnel capacity, and inadequate infrastructure. An Ishikawa diagram was used to categorize these barriers. To address these issues, the study conducted benchmarking with international best practices, highlighting innovations such as the digitalization of CPPTs through Electronic Medical Records (EMR). Using the PDSA model, the study proposes a structured approach to digitalizing the CPPT process. The "Plan" phase identified key areas for improvement, the "Do" phase involved pilot implementation of digital CPPTs, the "Study" phase assessed the outcomes, and the "Act" phase provided recommendations for broader implementation. Conclusion: This study concludes that the digitalization of CPPTs is essential for improving patient safety and healthcare quality in Indonesia, aligning with national health regulations and international best practices.

Recruitment System for Human Resources in the Medical Records Units a Private Hospital’s Medan City in 2024

Desi Nur Pradita — 2024-11-21

Hospital’s must provide adequate human resources to ensure optimal and high-quality health services. Establishing a medical records unit is one of the supporting efforts for health in hospitals. Managing a medical records unit that produces quality health information requires adequate resources, including human resources, facilities, and equipment. One crucial step in managing human resources effectively is recruitment. This study aims to understand the Human Resources Recruitment System for the Medical Records Unit at Private Hospitals in Medan City in 2024. This research is a qualitative study with a naturalistic approach to obtain in-depth information. The sampling technique used is purposive sampling. Data collection is done through in-depth interviews. In this study, the researcher acts as the primary research instrument, with informants 1, 2, 3, 4, 5, and 6 serving as supporting instruments using interview guides and voice recording tools (mobile phones). The research informants are HRD personnel and Heads of the Medical Records Unit at each hospital (RSU Imelda Pekerja Indonesia, RS Advent, and RSU Eshmun). The results show that there are no Standard Operating Procedures (SOPs) or policies related to the recruitment of human resources for the Medical Records Unit at the hospitals studied. The sources of job vacancy information used at the three hospitals are internal sources, and some employees do not have a background in medical record education. It is recommended that these hospitals establish SOPs or specific policies for the recruitment of human resources in the medical records unit to ensure a structured recruitment process and that recruited employees meet the qualifications in medical record education.

Development of a Mobile-Based Personal Health Record for Mothers and Children Using Glide App: A Usability Study

Deva Indri Saputri Ombong — 2024-11-21

The increasing need for efficient personal health records (PHRs) for mothers and children has driven the development of innovative healthcare solutions. This study presents the development and evaluation of "SIKIA," a PHR application created using the Glide App. SIKIA aims to streamline health data management and enhance accessibility for mothers and children.The research methodology involved developing the SIKIA app, followed by user trials and an evaluation using the System Usability Scale (SUS). A group of mothers with young children, pregnant woman, and midwifes participated in the study, testing the application and providing feedback on its usability and functionality.The results indicate that SIKIA is well-received by users. The SUS scores demonstrate high user satisfaction, with users praising the app's ease of use, accessibility, and comprehensive health data management capabilities. The positive feedback highlights SIKIA's potential as a valuable tool in personal health record management, addressing the specific needs of mothers and children. This study underscores the importance of user-friendly PHRs in improving health outcomes and healthcare service efficiency. By providing a seamless platform for health data management, SIKIA can contribute significantly to the well-being of mothers and children. The findings suggest that further development and broader implementation of SIKIA could enhance healthcare delivery and patient engagement in personal health management.

The Effect of the Completeness of Electronic Inpatient Medical Summaries on the Accuracy of Medical Record Quality at Purwokerto Islamic Hospital

Shafa Mutiara Aulia Senja — 2024-11-21

Background: An electronic medical summary is a concise overview provided by healthcare professionals, particularly doctors, during a patient's treatment period until discharge, whether the patient is alive or deceased. The completeness of electronic medical records is crucial as it impacts the quality of hospital services; incomplete data entry can affect the quality of medical records and the services provided by the hospital.Objective: This study aims to determine the effect of the completeness of electronic medical summaries on the accuracy of medical record quality at Purwokerto Islamic Hospital.Methodology: This research uses a quantitative approach with cross-sectional data collection and a descriptive correlation design. The study sample consists of 89 electronic medical summary forms for inpatient care, selected using simple random sampling. The data was analyzed using the Chi-square test.Results: The study found that the completeness of electronic medical summaries was 89%, while the incompleteness rate was 11%. The accuracy rate was 84%, with an inaccuracy rate of 16%. The primary cause of incomplete electronic medical summaries was missing patient diagnoses. The Chi-square test results showed a p-value of 0.001 (p 0.05). Based on this p-value, the null hypothesis (H0) is rejected and the alternative hypothesis (H1) is accepted, indicating that there is a significant effect of the completeness of electronic medical summaries on the accuracy of medical record quality.

A Systematic Review Of RME Data Privacy And Security

Fita Rusdian Ikawati — 2024-11-21

Education (RME), where sensitive data pertaining to individuals and institutions is frequently collected, analyzed, and stored. The systematic review of RME data privacy and security is not only timely but also crucial for understanding the current landscape, identifying gaps, and proposing frameworks to enhance data protection measures. This research aims to analyze A Systematic Review Of RME Data Privacy And SecurityThis type of research is a literature review.. In this research conducted 15 journal literacy study regarding RME Data Privacy And Security. Data collection techniques using documentation from journals on Google Schoolar. Data analysis technique using Systemic Literature Review (SLR).The results of the study are The systematic review of RME data privacy and security revealed several critical areas requiring attention. Firstly, it was evident that current data handling practices often fall short of ensuring comprehensive privacy and security, posing risks to both researchers and participants. Additionally, there is a noticeable lack of standardized protocols across different institutions, leading to inconsistent protection measures. To address these issues, it is recommended that educational institutions adopt unified, stringent data privacy frameworks that comply with international standards. Furthermore, continuous training for researchers on data security best practices should be mandated to keep pace with evolving threats. By implementing these measures, the integrity of research data can be preserved, thereby fostering a more secure and trustworthy research environment.