Procedia of Engineering and Life Science

Mortality Reporting Modeling in Healthcare Facilities in Indonesia

Achmad Jaelani Rusdi, Untung Slamet Suhariyono — Thu, 21 Nov 2024 03:17:05 +0000

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

Thu, 21 Nov 2024 03:27:03 +0000

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, Savitri Citra Budi, Ika Aria Dani — Thu, 21 Nov 2024 03:32:20 +0000

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, Agya Osadawedya Hakim, Gunawan Gunawan — Thu, 21 Nov 2024 03:37:31 +0000

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, Dika Apriani, Eltigeka Devi Apriliani — Thu, 21 Nov 2024 03:47:01 +0000

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, Ervita Nindy Oktoriani, Dyah Rangga Puspita — Thu, 21 Nov 2024 00:00:00 +0000

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, Panggih Dewi Kusumaningrum, Angga Eko Pramono — Thu, 21 Nov 2024 04:03:18 +0000

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, Fitra Wulandari, Halima Arinnisa — Thu, 21 Nov 2024 04:10:26 +0000

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, Desi Purwati, Budi Marini — Thu, 21 Nov 2024 04:15:48 +0000

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

Thu, 21 Nov 2024 04:21:31 +0000

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, Alfian Listya Nugrahaini — Thu, 21 Nov 2024 04:29:14 +0000

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, Aldi Pratama, Arif Zaenal Abidin — Thu, 21 Nov 2024 04:35:40 +0000

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, Dhea Keyle Fortunandha — Thu, 21 Nov 2024 04:40:47 +0000

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

Thu, 21 Nov 2024 04:50:57 +0000

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, Dian Budi Santoso — Thu, 21 Nov 2024 04:57:19 +0000

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, Dion Romodon — Thu, 21 Nov 2024 05:03:15 +0000

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, Anis Ansyori — Thu, 21 Nov 2024 06:11:31 +0000

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.

Development of a Machine Learning-Based Web Application for Quality Justification in Dialysis Healthcare

Fri, 22 Nov 2024 04:11:29 +0000

The quality of healthcare services, especially for chronic conditions like kidney failure requiring dialysis, is critical. This study aims to develop a machine learning-based web application to evaluate and justify dialysis healthcare quality. Conducted at Siti Khodijah Hospital from January to June 2024, the research employed a developmental and experimental design involving 123 medical professionals. The methodology included needs assessment, system design, algorithm selection, data collection, model training, system integration, and validation. The web application, named Renal Data Processor, features user-friendly navigation, robust data visualization, and machine learning algorithms. It provides real-time analysis and predictive insights, allowing healthcare providers to make data-driven decisions. Results showed significant improvements, including a 20% reduction in data entry time and a 15% enhancement in nurse certification tracking efficiency. User feedback indicated high satisfaction with the application's functionality and its impact on workflow efficiency. In conclusion, the Renal Data Processor has enhanced dialysis healthcare quality by streamlining data management and providing actionable insights. This study demonstrates the potential of machine learning to transform healthcare delivery and outcomes, suggesting further research to expand its capabilities and applicability in other healthcare settings.

Relationship between Education Level and Performance of Medical Record Officers at the Mataram City Hospital

Fri, 22 Nov 2024 03:56:28 +0000

Efforts to improve the performance of health workers in hospitals are very important because of the various aspects related to efforts to improve health services. One of the vital units in the hospital is the medical record which with its duties is expected to support the quality of service by improving performance well. This study aims to determine the relationship between education level and the performance of medical record officers at the Mataram City Regional General Hospital. The research design used was quantitative analytic The research sample was 70 medical record officers with total sampling. The analysis in this study used univariate and bivariate analysis with a confidence level of 95% or a value of α < 0.05. This study shows that there is a relationship between educational background and performance with a p value = 0.000 < α value = 0.05. The level of education affects the performance of medical record officers at the Mataram City Hospital.

Unveiling the Challenges and Opportunities Behind Social Determinants of Health (SDOH): Data Security, Clinical Coding, and EMR Standards in Indonesia's Digital Health Era

Wahyu Wijaya Widiyanto, Rizka Licia, Wahyu Ratri Sukmaningsih — Fri, 22 Nov 2024 03:58:15 +0000

The increasing adoption of Electronic Medical Records (EMR) in Indonesia has brought about significant challenges related to data security, consistency in clinical coding, and the influence of Social Determinants of Health (SDOH). These issues are critical as they impact the effectiveness and reliability of healthcare information systems, potentially compromising patient data and the quality of healthcare services. This study employed a systematic review of 25 relevant articles published between 2018 and 2023. The articles were analyzed using the PRISMA approach to identify gaps in the literature concerning the implementation of EMR, data security, and clinical coding standards in Indonesia. The review also explored the role of SDOH in influencing these factors. The objective of this study was to explore the challenges and opportunities in integrating SDOH with data security and clinical coding within the framework of EMR implementation, with a specific focus on Indonesia’s healthcare sector. The findings indicate that data security remains a critical issue, with many healthcare institutions in Indonesia not fully implementing adequate security measures. The study also revealed inconsistencies in clinical coding standards across institutions, with only 60% adopting internationally recognized coding systems. Additionally, SDOH such as digital literacy and access to technology significantly affect EMR adoption, with regions having better technological access showing more effective implementation.

Compensation Audit Case at Casemix Hospital X

Yastori Yastori, Riza Suci Ernaman Putri, Nurul Fitri Khumaira, Dewi Oktavia — Fri, 22 Nov 2024 03:59:13 +0000

Audit Compensation Audits result in operational activities and hospital financial systems becoming disrupted and unstable. Based on a preliminary survey at Hospital This research aims to analyze Compensation Audit cases carried out by health insurance providers in 2023. The type of research used is using the Mixed Method, a research approach that combines or associates qualitative and quantitative forms. This research was conducted in March - June 2024. The research population was 11 compensation audit cases in 2023. Total sampling technique. An in-depth analysis was carried out on 11 compensation audit cases based on analysis of medical resumes, related regulations and based on ICD-10 and ICD-9-CM coding rules. The results of research that carried out an in-depth analysis of compensation audit cases showed that most compensation audit cases were caused by the enforcement of treatment classes with a total of 3 cases, specific management 2 cases, combination code 1, availability of death reports 1, regulations for enforcing the main diagnosis 1, specific management for main diagnosis 1, unavailability of anatomical pathology attachments 1, errors in establishing the main diagnosis and non-compliance with medical procedures and supporting documents 1. Compensation Audit Case Solution, namely the coder must understand medical records, claim submission documents, ICD-10, ICD-9-coding rules CM, health insurance provider and hospital PPK claim regulations, doctors need to provide clear, specific management and be able to determine the patient's condition. treatment class from the start of entry and the health insurance verifier must have the same perception as the previous verifier and be careful in reading and analyzing the claim submission documents.

Medical Records Study: The Relationship between Pregnancy Complications with the Incidence of Low Birth Weight Baby at Ajibarang General Hospital

Yektiningtyastuti Yektiningtyastuti, Pety Valeri Amalia — Fri, 22 Nov 2024 04:00:02 +0000

Low Birth Weight (LBW) is a baby born with a weight of less than 2500 grams. Based on data from the Indonesian Health Profile (2020), LBW is the largest contributor (32%) to the cause of neonatal deaths. BPS Central Java Province data shows that in 2021 there were 22,240 babies born with LBW, while in Banyumas Regency the number of babies born with LBW was 1,629. Many factors are associated with the incidence of LBW, including complications during pregnancy. This medical record research aims to determine the relationship between pregnancy difficulties/complications and the incidence of LBW at Ajibarang General Hospital in 2022. The research design used a case-control study. The research was carried out from July to August 2023, with a sample of 146 newborn babies at Ajibarang General Hospital consisting of a case sample of 73 LBW babies (PO7.1), and a control sample of 73 babies born with normal weight (Z.38.0). The results of the study showed that of the 146 samples of newborns, 31.5% were born to mothers who experienced the pregnancy complication of preeclampsia (O14.9), gemelli (O30.0) 8.9%, premature rupture of membranes/PROM (O42.9) 30.1%, oligohydramnios (O41.0) 25.3%, and anemia (O99.0) 2.1%. The results of statistical tests show that there was a significant relationship between pregnancy complications and the birth of LBW babies, preeclampsia (p-value = 0.002, OR = 3.289), gemelli (p-value = 0.004, OR = 14.164), PROM (p-value =0.002, OR = 3.407), and oligohydramnios (p-value = 0.008, OR = 0.321). There is no significant relationship between anemia pregnancy complications and the incidence of LBW (p-value = 1.000).

Accuracy of diagnostic codes for Dengue Hemorrhagic Fever patients based on anamnesis and supporting examinations in 10 Central Java Hospitals

Fri, 22 Nov 2024 04:01:00 +0000

Dengue Hemorrhagic Fever (DHF) often occurs every year and attacks all age groups and is related to community habits and environmental factors. However, there are incomplete forms and some codes that are not yet appropriate. This study aims to determine the accuracy of the Dengue Hemorrhagic Fever disease code in 9 hospitals in Central Java. This study is descriptive with a case study approach. The data collection method uses an observation sheet to observe 1653 Medical Record Documents. The results showed that Dengue Fever patients The main complaint in DHF patients was fever 1653 (100%) and other complaints such as: vomiting, shock, heartburn, nosebleeds and petechia. Most patients experienced a decrease in platelets <150.00 1448 (87.6%), a decrease in leukocytes <5000 there were 254 (15.4%). Most with the main diagnosis were DHF 1526 (92.3%). most of the primary diagnosis codes are A91 there are 1526 (92.3) medical record documents. Accurate codes are 1529 (92.5%), while inaccurate data are 124 (7.5%).. Suggestions in this study, Hospitals should complete all patient information and physical examination results or supporting, especially the number of platelets that affect the decision on diagnosis and primary codes.

Computerized Website-Based Health Recording of Pregnant Women

Yunita Wisda Tumarta Arif, Kiki Astutik, Sri Widodo, Siti Farida — Fri, 22 Nov 2024 04:05:50 +0000

Posyandu is a forum for community empowerment to obtain basic health services, one of which is controlling the health of pregnant women by recording health in a register book. These records are used as a guide for pregnant women and as a reference for midwives to control the health of pregnant women during pregnancy until delivery. Currently, it is still found that recording is carried out manually, namely written in the register book of pregnant women. This results in the data not being able to be read properly, as well as data processing being difficult and the resulting reports being inaccurate. This research aims to design and build a website-based computerized system for recording and processing pregnant women's health data which is expected to speed up and make it easier for cadres and midwives in the process of recording, data processing and reporting. This type of research is descriptive research using observation and interview data collection methods and using a cross sectional approach. The subjects in this research were cadres and midwives, while the object of this research was recording and processing data on pregnant women. Using the System Development Life Cycle (SDLC) system development method, namely the system design and creation process as well as the methodology used to develop the system.Computerized websitebased health records for pregnant women were built using the PHP programming language and a MySQL database with input data for pregnant women, staff data (cadres and midwives), and examination data. The resulting output is a pregnant woman's report, an officer's data report, a monthly examination data report and a chart of the development of pregnant women. This system can be accessed by cadres, midwives and pregnant women. Cadres can enter and edit data on pregnant women, officer data, examination data and reports. Midwives can edit and add examination data and view all reports. Meanwhile, pregnant women can see their own history of examination data

User Readiness and Acceptance of Electronic Medical Record: A Partial Least Square Approach

Reni Chairunnisah, Nurul Khatimah Ismatullah, Helmina Andriani — Fri, 22 Nov 2024 04:08:07 +0000

Electronic medical records (EMR) are increasingly popular in global healthcare to enhance service quality. However, transitioning to EMR poses challenges, particularly in adapting to the technology. Researchers are therefore interested in exploring the readiness and acceptance of EMR adoption using the Technology Readiness and Acceptance Model (TRAM). This study employs quantitative analytical methods and involves a sample size of 30 healthcare professionals responsible for medical record keeping. Total sampling was utilized to select participants. The variables examined in this research include Optimism (OPT), Innovativeness (INN), Discomfort (DIS), Insecurity (INS), Perceived Usefulness (PU), Perceived Ease of Use (PEOU), and Use Intention (USI). The study's findings, analyzed through Partial Least Squares (PLS), reveal that Innovativeness (INN) exerts the strongest influence on Perceived Ease of Use (PEOU) with a β-value of 0.434. Additionally, PEOU shows the most significant impact on Intention to Use (USI) with a β-value of 1.106. Approximately 71.8% of the variability in the USI variable is accounted for by Optimism (OPT), Innovativeness (INN), Discomfort (DIS), Insecurity (INS), Perceived Ease of Use (PEOU), and Perceived Usefulness (PU). At the same time, other factors outside the scope of this study explain the remaining variation.

Keywords— Electronic Health Record, EMR, Readiness Index, Technology Readiness, Acceptance Model, TRAM

Electronic Medical Record: Challenges in Terms of Management Elements Related to The Implementation of Inpatient Electronic Medical Records

Tria Harsiwi Nurul Insani, Nurvita Wikansari, Ehci Febrian — Fri, 22 Nov 2024 04:09:02 +0000

Patient medical records began to switch to an electronic basis with the issuance of Minister of Health Regulation Number 24 of 2022 concerning Medical Records. This policy regulates health service facilities to run an electronic patient medical history recording system. The transition process will be carried out no later than 31 December 2023. Hospitals are one of the health service facilities that are required to maintain electronic medical records. It is important to assess readiness before implementing electronic medical records, to optimize its implementation. This research aims to analyze the challenges of implementing inpatient EMR at the PKU Muhammadiyah Bantul Hospital which will be reviewed from management elements, namely Man, Method, Machine, Material, and Information. This research carried out in the early 2023. The type of research used is descriptive research with a qualitative approach, to explore or obtain comprehensive, broad, and in-depth information regarding the challenges of implementing inpatient electronic medical records in terms of management elements. The result of this study; the challenge of implementing EMR from the Man element; there are found officers who do not have an educational background in medical records or are not qualified as medical recorders. Money; The hospital's operational cost budget is obtained from the hospital itself and funds for implementing inpatient electronic medical records are already available, so there are no obstacles to the budget for implementing the EMR. Method; Hospital does not have yet an SOP or proedure, especially for implementing inpatient EMR. Machine; facilities such as computers or PCs in each ward still need to be added. Material; Inpatient EMR materials are still in the development stage and are built by the hospital itself without any collaborating (third-party) vendors or teams. Information; Hospital has not conducted external training and outreach to medical staff who will use EMR in the inpatient unit. Conclusion, The hospital still has several obstacles such as in terms of man, method, machine, material, and information but there are no difficulties with money so it is necessary to increase the time allocation for implementing inpatient EMR.

Evaluation of Diagnostic Specifications and Appropriateness of ICD Codes for Diabetes Mellitus Based on Age and Gender of Inpatients in Magelang City Hospital in 2023

Ratnaningsih Mulyati, Jaka Prasetya, Faik Agiwahyuanto — Fri, 22 Nov 2024 04:10:04 +0000

Diabetes militus is classified into two types, namely type 1 and type 2, the disease ranks top as a non-communicable disease with a high number of sufferers. The determination of diagnoses and diagnosis codes must be precise so that the codes given by PMIK can be declared specific and appropriate, therefore it is necessary to review the provision of diagnosis codes on patients to determine the factors that cause non-specific and inappropriate codes based on age and gender and present the distribution of diabetes militus in Magelang City. The method used was descriptive qualitative by observing 144 medical record documents of patients with the main diagnosis of diabetes mellitus. The results showed that the specification of the main diagnosis of diabetes mellitus in Magelang City Hospital was 100%. The suitability of the main diagnosis code of diabetes mellitus based on the category can be concluded that the specific and appropriate code was found as much as 61%. While specific and inappropriate codes were found at 39%. The age of patients with diabetes is 23-90 years old, with the average age of patients being 59 years old. Patients with 56 years of age occupied the highest number of sufferers. Patients with female gender are more dominant in experiencing diabetes militus, when presented it reaches 63% while male patients are only 37%. The highest distribution of patients with diabetes mellitus in Magelang Hospital came from outside the city, namely Magelang District or 68%. Patients in Magelang city only reached 32%. Suggestions for further research would be better to consider taking the file period to avoid recording medical records during the media transfer period

Documentation of Tuberculosis Statistic Data Reporting at Primary Healthcare Facilities in Malang City

Retno Dewi Prisusanti, Lilik Afifah — Fri, 22 Nov 2024 04:13:52 +0000

Background: Tuberculosis is one of the top ten causes of death in the world, and is a serious public health problem in Indonesia. Malang City is one of the regions in Indonesia with a high incidence of TB. Based on data from the Malang City Health Office in 2023, there are 2,500 new TB cases with a death rate of 200 people. This shows that TB is still a public health problem that needs serious attention in Malang City. Objective: what is to be achieved in this study in order to find out the implementation and process of documenting the reporting of tuberculosis statistical data at the first level health service facility in the city of Malang. Research method: the research method uses qualitative descriptive with one respondent in each Health Service Facility that has been interviewed directly. Results: The results of this study refer to the implementation and process of documenting the reporting of tuberculosis statistical data at the first level of service facilities in Malang City. Conclusion: Documentation of TB statistical data reporting at FKTP Malang City is still not optimal. Efforts need to be made to improve the documentation of TB statistical data reporting at the Malang City FKTP.

Evaluation of the Implementation of Outpatient Electronic Medical Records

Riska Rosita, Azzahra Mifta Risqika, Novita Yuliani, Ni Luh Putu Devhy — Fri, 22 Nov 2024 04:14:39 +0000

The implementation of Electronic Medical Records (EMR) in X hospital has been running since 2022 but its use is still not optimal, especially in outpatient installations. This study aims to evaluate the implementation of outpatient EMR at X Hospital based on the HOT-FIT (Human, Organisation, Technology, and Net Benefit) framework. The research method with descriptive qualitative, uses a cross sectional approach. The research subjects were the head of medical records, head of outpatient polyclinic, head of outpatient registration, head of pharmacy, head of laboratory, doctor, head of cashier and head of IT team. The object of research was the implementation of outpatient EMR. Data collection through interviews and observations. The results showed that in the human aspect, there were still doctors who could not use EMR due to age. In the organization aspect, the standard operating procedures (SOPs) regarding EMR are still in draft form, have not been approved by the hospital director and have not been socialized. In the technology aspect, EMR system features that are not in accordance with user needs cause the output of health data information to be incomplete. The net-benefit aspect of RME, the use of EMR is more time efficient in health services and paperless. Conclusion, that the development of EMR at Hospital X is still ongoing, starting from improving the competence of medical personnel, organizational commitment, and improving the EMR system coding.

Optimizing the Success of Hospital Management Information Systems in the Digitalization Era

Rizkiyatul Amalia, Sri Lestari — Fri, 22 Nov 2024 04:15:23 +0000

Digitalization has changed aspects, one of which is in the Healthcare sector. Digitalization will help organizations overcome the problem of limited resources. Hospital management information systems (HMIS) are becoming increasingly important in operational, clinical, and administrative management. Although many hospitals have adopted HMIS, not all systems have successfully achieved their goals. Some common problems include data integration difficulties, user resistance, and lack of management support. Accurate and complete data is key to the success of HMIS. However, hospitals still face challenges in managing data quality. HMIS can provide valuable data to support strategic and operational decision-making. However, existing data has not been optimally utilized. The study aims to analyze how system quality affects HMIS Implementation. This study used an analytic observational method conducted at Dr. Gondo Suwarno Hospital. The sample consisted of 65 HMIS users. Data analysis in this study used SEM (Structural Equation Modeling) analysis techniques. The application used is Smart Partial Least Square (SmartPLS). The results showed that the quality of the system on the implementation of HMIS through System Use and Organizational Structure provides a negative value. The path coefficient values obtained are -0.005 and -0.048 and the P-value is 0.722 and 0.256. The implication of this result is that system quality should be able to increase system usage, in the context of this study, the quality of the existing system is not enough to encourage users to be more active in using HMIS. This may be due to other factors such as lack of adequate training or technical support for users. system quality did not contribute significantly to the organizational structure that supports the implementation of HMIS. Although the existing system has certain qualities, the existing organizational structure may not be supportive enough to facilitate effective implementation.

An Online-based Application of Health Education Media for Prolanis Participants

Setya Wijayanta, Indah Naryanti — Fri, 22 Nov 2024 04:16:24 +0000

Prolanis is a government program to reduce the prevalence of chronic diseases and prevent patients with chronic diseases from entering the complication stage. In Prolanis activities conducted by health facilities or Fasyankes, Prolanis participants sometimes come late to the health education activities, so participants do not receive information or benefit from health education activities. The purpose of this study is to investigate the use of online-based health education media for Prolanis participants. This research method is descriptive, with primary data sources from the interviews, documentation studies and literature. The application is developed using the prototype method. The Prototypes is created, evaluated, and continued to the implementation stage. The result of this research shows the developing of an online-based application for presenting health education materials to Prolanis participants. This application was tested on Prolanis participants from Padangsari Puskesamas in Semarang City and received positive responses from them. However, some participants still complained about the limited access to smartphones and the assistance need for elderly participants.

Implementation of the Support Vector Machine Method for Early Detection of Stunting Based on Anthropometric Features

Sri Widodo, Anik Sulistiyanti, Anan Yuliana — Fri, 22 Nov 2024 04:17:11 +0000

Stunting describes chronic undernutrition during the growth and development period from the beginning of life. This situation is represented by a z-score for height for age (TB/A) less than -2 standard deviation (SD). The current method used to detect stunting in toddlers is to use KMS. The way to do this is to weigh the under-fives every month, the weighing results are recorded in the KMS, and between the points of weight from last month's weighing results and the results of this month's weighing are connected with a line. The series of child growth lines forms a child growth chart. This procedure is of course less effective. Based on these problems, the research conducted is the Implementation of the Support Vector Machine Method for Early Detection of Stunting Based on Anthropometric Features. The SVM method consists of a training process as system learning and testing to obtain classification results. The parameter tests carried out are lambda, complexity, and maximum iteration tests. The data used in this study were 90 data which were divided into 2 classes, namely stunting toddlers and normal toddlers. The SVM algorithm is a linear classification method, so it uses the kernel to deal with nonlinear data. The final results of this research produce the highest average accuracy of 86% λ = 10, C = 1, itermax = 200 and also use polynomial kernels. Comparison of the results of the classification of child stunting with the help of midwives shows that the system produces good accuracy

Factors Associated with Length of Stay of Inpatients: A Cross-sectional Study at RSD KRMT Wongsonegoro, Semarang, 2024

Tiara Fani, Kriswiharsi Kun Saptorini — Fri, 22 Nov 2024 04:18:00 +0000

Length of hospital stay is an essential indicator of the quality of inpatient hospital services, including in RSD KRMT Wongsonegoro as a Type B hospital in Semarang City. There were various factors related to the length of hospital stay. Therefore, the study objective was to determine the factors associated with the length of stay of inpatients at RSD KRMT Wongsonegoro Semarang. The cross-sectional study distributed a questionnaire to 122 inpatients in RSD KRMT Wongsonegoro from January to February 2024. The variables in this study were patient characteristics, self-rated health status (physical and mental), and hospital stay. The data analysis used descriptive and inferential statistics with comparative tests to determine the study objective. The results showed that the average length of hospital stay among the respondents was five days. The majority of respondents in this study were female patients (55.7%), junior high school (36.9%) and high school graduates (31.1%), and aged >45 years or older (63.9%). The results of the comparison test showed that gender (p-value: 0.987), education (p-value: 0.278), and age (p-value: 0.425) were not associated with the number of patient care days. Based on the comparison test, self-rated physical health (p-value: 0.034) and self-rated mental health (p-value: 0.016) were significantly associated with the number of hospital days. In general, patients who perceived poor physical and psychological health had longer hospital stays than patients who perceived better physical and mental health. Therefore, hospitals need to assess patients' perceived physical and mental health status to improve inpatient services.

Analysis Of The Use Of Electronic Medical Records With The Fishbone Method Approach At Rokan Hulu General Hospital

David Maulana, Wen Via Trisna, Tri Purnama Sari — Fri, 22 Nov 2024 00:00:00 +0000

RSUD Rokan Hulu has started implementing electronic medical records (RME) since September 2023 in outpatient services. RSUD Rokan Hulu provides 20 Polyclinics, of which 6 Polyclinics have implemented RME and 14 Polyclinics have not implemented RME. In its implementation, of course, it has obstacles. This study aims to determine the inhibiting factors for the use of electronic medical records based on the Man, Machine, Material, Method, Money factors. The type of research used is descriptive qualitative. The subjects in this study were the head of the medical record installation, nurses, doctors, IT / IMRS staff and KASI Humas. The object of this research is electronic Medical Records at Rokan Hulu Hospital, the methods used are interviews and observations. Data analysis uses descriptive analysis and the results are presented using a fishbone diagram. The results of inhibiting factors in the use of electronic medical records with the fishbone method approach at Rokan Hulu Hospital in 2024 based on the Man factor, namely the lack of special training in the use of RME to health workers, the limitations of health workers in using computers, and not all doctors want to use RME. The machine factor is the unavailability of electronic pens. Network material factors often experience interference and the RME application used is not easy for doctors to use. The method factor is that there is no SOP related to the use of RME and there are no guidelines for the flow of RME implementation. The money factor has no problems and obstacles.

Review of the Implementation of Electronic Medical Records at RSU Banyumanik 2 Semarang in 2024

Puspa Ayu Nuraeni, Tiara Fani — Fri, 22 Nov 2024 04:19:51 +0000

PMK No. 24 of 2022 requires all health services to implement electronic medical records no later than the end of 2023. RSU Banyumanik 2 Semarang has been using an electronic medical record system since 2022 with SIMRS called SIM KHANZA. The aim of this research is to describe the implementation of electronic medical records at RSU Banyumanik 2 Semarang in 2024. This research is qualitative research with a case study approach. Data were collected by interviewing the head of the medical records installation, and a questionnaire to measure knowledge of 7 medical records officers and 41 nurses. Interview data analysis was carried out using the content analysis method. Characteristic data analysis is presented in the frequency distribution table. The results show that the majority or 87.5% of respondents have good knowledge about the implementation of Electronic Medical Records. The Hospital has provided an operational budget for Electronic Medical Records. SIMRS RSU Banyumanik 2 Semarang is called SIM KHANZA where all medical record sheets are generally integrated, except for Informed Consent because it relates to clarity of authentication for both doctor and patient. Infrastructure is available in all service units that use Electronic Medical Records. Suggestions, hospitals should regularly monitor facilities and infrastructure every week, upgrade computer specifications with larger data storage capacity so that service is fast and uninterrupted.

Electronic Medical Record Implementation for Regional-based Disease Trend Analysis in Semarang City

Hanif Pandu Suhito, Prahita Indriana Raniasmi, Sholikun Sholikun — Thu, 21 Nov 2024 00:00:00 +0000

Electronic medical records (SIMPUS) has been implemented since 2019 in Semarang City, enabling community health centers to store patient medical data efficiently. Decision-making in disease control must be based on data and evidence-based approaches. The objective of this study is to display trends of disease based on visits to health centers in Semarang City. Using data from routine services provided by 37 health centers (Puskesmas) from 2020 to June 2024, a total of 8.669.287 patients were included. A quantitative descriptive analysis approach was used to determine the distribution of disease based on top 10 diagnoses, age groups, districts, and time periods. The results show that Acute upper respiratory infections of multiple and unspecified sites (J06) have increased and become top rank in the last three years. Hypertension (I10) also increased with the number of cases still high as runner up. Most of the cases in the top 10 diseases increase in number of cases from year to year. The sub-district of Tembalang, Semarang Barat, and Pedurungan tend to have the highest number of patient visits. Based on age groups, the most frequent visits to the health center are adults and pre-elderly groups, followed by teenagers and toddlers. This is related to the types of cases that are most often found. This trend analysis can be used to determine changes in patient visit patterns at Semarang community health centers from year to year and can help in comparing morbidity rates so it can help in determining health policy in Semarang.

Effective Strategy to Reduce Infant Mortality Rates through Neonatal Death Rate (NDR)

Harjanti Harjanti, Risma Ayu Novita — Thu, 21 Nov 2024 07:47:39 +0000

Infant Mortality Rate (IMR) is an important indicator of a country's level of social welfare and public health status. The target of the Sustainable Development Goals (SDGS) in 2030 is to end with the aim of reducing neonatal mortality to 12 per 1000 live births. The results of the calculation of neonatal mortality rates at RSUD dr. Soeroto Ngawi exceed the SDGS tolerance limit of 32 per 1000 live births. The purpose of the study was to analyze strategies to reduce the Neonatal Death Rate (NDR) by classifying it based on age characteristics, birth weight and diagnosis of cause of death. The type of research is descriptive quantitative, which will describe the neonatal mortality rate with a retrospective study approach. Total sampling technique with a sample of 47 medical record documents of newborn patients aged 0-28 days. The neonatal mortality rate obtained results of 48 per 1000 live births for 1 year. The proportion of neonatal mortality with the highest in age characteristics is 0-7 days of age, which is 39 (82.97%) cases, normal weight (2,500-4,000 grams) there are 17 (36.17%) cases, and the diagnosis of the cause of death there are 30 (63.84%) cases caused by Low Birth Weight (LBW). It can be concluded based on the characteristics of the main cause of NDR, namely LBW which occurs in premature and dysmastur babies. Strategies that can be carried out are routine antenatal care examinations, screening of newborns, basic emergency obstetric neonatal services, provision of hypno breastfeending therapy and mother kangaroo mother care, provision of exclusive breastfeeding.

Completeness of Medical Record Files and The Timeliness of BPJS Claims on Inpatients With Bronchitis Cases at Purwokerto Islamic Hospital

Putri Sepna Regina, Harry Fauzi — Thu, 21 Nov 2024 00:00:00 +0000

One of the things that determines the quality of medical services provided by hospitals is the availability of adequate and complete data or information regarding medical records so that it will affect the submission of BPJS claims. This study was conducted to describe the completeness of medical record files and the timeliness of BPJS claims on inpatients with bronchitis cases at Purwokerto Islamic Hospital. This study uses quantitative methods with descriptive research design, data collection design using cross sectional. Completeness of medical record file on inpatients with bronchitis cases with indicators of participant eligibility letter, spporting examination, code accuracy, and resume of inpatient bills or billing costs with a complete category of 75 (100%), medical resumes with a complete category of 34 (45,33%) and an incomplete category of 41 (54,67%), and indicators of hospitalization orders with a complete category of 6 (8%) and an incomplete category of 69 (92%). The timeliness of inpatient BPJS claims with the timely category was 49 (65,33%) and the untimely category was 26 (34,67%).

Development of a WEBGIS-Mapping Information System of Tuberculosis (MISS TB) For Plotting Tuberculosis Cases: A Case Study in Sleman District, Yogyakarta Province, Indonesia

Hendra Rohman, Alwhan Nurrochman — Thu, 21 Nov 2024 00:00:00 +0000

Geographic information system for health information management and public health to analyze the spatial disease distributions in surveillance has increasingly applied in the last few decades. The programming skills needed to utilize the software appropriately in contact tracing and follow up control measures for tuberculosis (TB) patients. This study aimed to develop a more user friendly application by applying XAMPP application to create WEBGIS localhost, PHP My Admin for MySQL database management, MySQL server as a database management system (DBMS), Visual Studio Code application for creating programming. The system development method uses a waterfall model. These data were collected from infectious disease prevention and control officers at the Sleman District Health Service and tuberculosis reporting programmer officers at community health centers. Data on rainfall, humidity, altitude, temperature, area, population and population density were obtained from the Central Statistics Agency of Sleman Regency. Data visualization in mapping for 17 sub-districts in Sleman Regency. The geographic menu contains information on rainfall, humidity, altitude and temperature for each month in tabular form. The demographics menu contains information on the area, population and population density of each sub-district in tabular form. The distribution location input menu is used to add data on tuberculosis cases. The distribution list menu contains a table that contains a database stored from the location input. The account menu on the administrator user contains a list of accounts created or registered in system. The website-based geographic information system (GIS) application is expected to improve case data reporting, case monitoring, support data availability, and visualize the distribution of tuberculosis cases in Sleman Regency through the mapping menu. The application developed should assist health information management and public health experts to utilize medical record data and spatial data for the surveillance purposes comprehensively.

Investigating Acceptance of Electronics Medical Record: Applying TAM Model

Irma Nuur Rochmah, Erna Zakiyah, Widya Kurnianingsih, Bambang Eka Purnomo — Thu, 21 Nov 2024 00:00:00 +0000

Electronic medical records are used to increase interoperability, efficiency and flexibility in medical record services. There are many obstacles in implementing electronic medical records at Clinic ‘X’ Sukoharjo, but this does not prevent health workers from using them. Investigation of users of electronic medical records needs to be carried out to determine the perceptions of health workers. TAM is a model that we use to determine user acceptance of technology. The TAM variables used are Perceived ease of use (PEU), Perceived Usefulness (PU), Attitude towards Using (IU), and Actual Usage (AU). The sample we used was 30 health workers. Our data was collected and calculated using PLS-SEM with the SmartPLS 4 application. The results of this research show that health workers feel helped by the existence of electronic medical records. The ease of using technology helps health workers in their work. So electronic medical records are considered useful for health workers. This usefulness encourages health workers' behavioral interest in using electronic medical records to improve their performance.

Analysis of Patient Satisfaction With The Use of The Jkn Mobile Application At Godong Community Health Center

Isnaini Qoriatul Fadhilah, Siti Masrochah, Sri Lestari, Eko Teguh Kusdianto — Thu, 21 Nov 2024 00:00:00 +0000

BPJS Health implements a digital transformation in the form of the JKN mobile application. The JKN mobile application is expected to provide easy access and more optimal service for participants. The JKN Mobile Application is expected to simplify the registration process and improve the quality of health services [1]. A preliminary survey at the Godong 1 Health Center registration regarding the use of the Mobile JKN application was carried out in February 2023 on 10 BPJS Health patients, 5 patients said they were satisfied and 5 other patients said they were dissatisfied, 5 patients said they were dissatisfied due to user complaints, including: The application sometimes cannot be used if it is not updated immediately. This study aims to determine patient satisfaction with the quality of online registration for the JKN mobile application based on the dimensions of content, accuracy, format, ease of use, timelines at Godong Community Health Center. The type of research used is quantitative descriptive research. The data collection method uses a questionnaire. The instrument used was a questionnaire. The population and sample in this study were all BPJS Health participants who used the JKN mobile application, namely 226 participants and a sample of 70 respondents. The research results showed that the majority of respondents were satisfied with the quality of registration via the Mobile JKN application. Aspects of ease of use and speed of the registration process receive high ratings from patients [2]. Research shows that from the dimensions of content, 77.1% were satisfied and 18.6% were very satisfied, accuracy was 81.4% satisfied and 14.3% very satisfied, format was 84.3% satisfied and 11.4% very satisfied, ease of use expressed satisfaction 81.4 and very satisfied 14.3%, timelines expressed satisfaction 80% and very satisfied 15.7%.

Klakson: Innovation in the Development of a Barber Johnson Charting Calculator Based on an Early Warning System (EWS)

Fri, 22 Nov 2024 00:00:00 +0000

Data on bed management in Indonesia is currently managed in an integrated manner by the Ministry of Health through the Integrated Referral System (SISRUTE) on the Satu Sehat website. Hospital bed management data can be presented in the Barber-Johnson Graph. The Barber Johnsons graph is a good tool. It makes it easier for managers to monitor the efficiency of bed use, because TOI (Turn Over Interval), LOS (Length Of Stay), BTO (Bed Turn Over), and BOR (Bed Occupation Rate) are presented in one graph. The problem currently faced by society is that the management of beds in healthcare facilities is not yet efficient and is still done manually. In some hospitals, they still describe the Barber-Johnson Chart in Microsoft Excel. Therefore, innovation is needed to develop the Barber-Johnson Graph Calculator application Johnson is based on an Early Warning System (EWS) called Klakson. The existence of efficient bed management will demonstrate quality service. This is certainly expected to impact improving public health in Indonesia. This research uses action research, with a qualitative data collection approach. Data analysis uses content analysis. The results of need identification show that hospitals, health centers, and clinics that provide inpatient care need a Klakson application based on the Early Warning System (EWS) in the form of notifications and sound to support early decisions. The results of the feasibility study show that users are accustomed to using computers, software, and hardware available to support the development of web-based information systems. Information system development using prototype methodology. The prototype test results using the Blackbock method show that the function/reaction is according to the actor, the system works well and can meet user needs. The development of the web-based Klakson application using prototype methodology stages has been tested in DIY clinics and shows that the system can meet user needs.

A Death Rate in Patients Ngudi Waluyo Blitar District Hospital

Fri, 22 Nov 2024 00:00:00 +0000

Record by integration (RME) management efficiency has improved the health care database at the hospital, including mortality data. Mortalitas data an indicator of health service that evaluates the quality of critical care in a hospital, that is essential for decision making strategic and policy evaluation. The research aimed to identify the mortality in patients at Ngudi Waluyo Blitar District Hospital in 2023. This research used the descriptive to describe method mortality in patients at hospital Ngudi Waluyo Blitar District in 2023. The result showed that the total number of patients alive and died in 2023 was 14.485, with the number of 13410 live patients and the patient dies of 1.075. The analysis shows ICCU death as a room with the highest death, especially in time; it is < 25 ‰ or < 2.5 ‰ per year. Factors such as age, associated territories, and some septicemia as a medical condition, chronic kidney disease, stage 5, intracerebral hemorrhage, intraventricular, keys respiratory failure, and pneumonia, unspecified as the cause of death. For that reason, we need to repair constants on information systems and electronic medical records to support better decision making in the management of health services. Evaluation deep to events of death, especially in the ICCU, and focus on management of elderly patients and patients with chronic diseases such as septicemia and chronic kidney disease, be a key to increasing the quality of services.

Dengue Hemorrhagic Fever in Jepara Indonesia: Reporting Data From The Discrict Disease Surveillance

Fri, 22 Nov 2024 00:00:00 +0000

Indonesia is a tropical country vulnerable to infectious diseases, including dengue fever caused by mosquito bites. Dengue fever cases are a burden on the world because they can cause death. WHO reported that in May 2024, there were a total of 465 cases in districts/cities in 34 provinces, the national death rate until May 2024 was 777 deaths. Recording a complete medical record can support good disease reporting. This study aims to determine the distribution of dengue fever cases in Jepara district, Central Java in 2023-2024. The method of this study is descriptive. The population is disease reports in 2023 and 2024, and the sample used is the dengue fever disease report for the period January - May 2024 with random sampling techniques. Data imported from Microsoft Access is processed with a stata application and narrated descriptivelyThe number of dengue fever sufferers spread across 16 sub-districts is 3,549 with 1,728 male and 1,821 female sufferers. Of the 16 sub-districts, the highest number is in Pecangaan District 543 cases, and the lowest cases are in Karimunjawa District. The category of patients based on the highest age group in category 1 (0-4 years old) was 2,136 (60.17%), with the highest mortality rate in category 2 (5-14 years old) as many as 12 people and the highest CFR at Kartini Hospital with a total of 19%, namely 12.9% in male patients and 7.24% in female patients. (dengue fever, cases, reporting).

Dengue fever, Jepara District, Case Fatality Rate, Age group, Epidemiology

An Overview of the Accuracy of Injury Coding, External Causes of Traffic Accident Patients, and “SI CALAKAN” Reporting at Advent Hospital Bandung

Lanang Eko Sampurno, Noveliana Berlian Sinaga, FX. Kusna Arintaka — Fri, 22 Nov 2024 00:00:00 +0000

Traffic accidents are the leading cause of death for children and young adults. The accuracy of injury and external causes coding in hospitals plays an important role in building databases needed for epidemiologic analysis, risk management, and improving the quality of health services. The purpose of this study was to determine the accuracy of injury coding, external causes of traffic accident patients, and "SI CALAKAN" reporting at Advent Hospital Bandung. This research used a quantitative study approach and was studied from the point of view of the research reference period with a retrospective research design. The results showed that there were 62 (59%) incorrect medical records, 44 (41%) correct medical records of injury and external cause codefication.

Literature Riview: Analysis of Readiness for Implementing Electronic Medical Record Policy in Hospital Health Service Facilities

Lienda Wati, Sigit Budiharto, Prilian Ayu Minarni — Fri, 22 Nov 2024 00:00:00 +0000

IT advancements in healthcare services, particularly the use of Electronic Medical Records (EMR) are expected to increase the efficiency and quality of health services. However, there are still many obstacles during the implementation of EMR in Indonesia in accordance with government directives based on the Minister of Health Regulation Number 24 of 2022, which requires all health facilities to implement this technology. A literature review approach on electronic medical records was used by examining various studies on the readiness for EMR implementation in hospitals. Based on research findings, the readiness for EMR implementation is influenced by various important factors such as technological infrastructure, human resource (HR) policies, management support, and organizational culture. Analysis using the diffusion of innovation theory shows that the benefits of EMR in improving service efficiency and excellence are widely recognized. Nevertheless, challenges remain regarding compatibility with the complexity of current work practice systems for certain users and the need for additional testing. This study concludes that although there is considerable readiness to adopt EMR, further efforts are needed in modifying HR training infrastructure and user engagement to improve the implementation of EMR in health facilities in Indonesia.

Adoption of Electronic Medical Records: A TOE Framework Analysis

Lina Khasanah, Adnin Sania, Maula Ismail Mohammad — Fri, 22 Nov 2024 00:00:00 +0000

The implementation of digital technology in the global health sector has received strong support, with the adoption of Electronic Medical Records (EMR) becoming a primary focus in modernizing health systems to improve service quality. However, in Indonesia, 48.9% or 4,807 community health centers (Puskesmas) have not yet adopted EMR technology. Therefore, pre-implementation analysis is crucial to identify barriers and opportunities for success. The TOE (Technology-Organization-Environment) framework serves as an analytical model for technology adoption at the organizational level, capable of explaining the factors influencing the decision to adopt technological innovations.This study aims to develop a TOE instrument in Indonesian, adapted from previous research, and adjusted to the research context. The instrument is structured in the form of a questionnaire, tested for validity and reliability. The validity test results indicate that all questionnaire items are valid (r calculated > r table), while the reliability test shows a Cronbach’s Alpha value of 0.916, indicating that the instrument is reliable. This questionnaire can be used to analyze the factors influencing technology adoption in the implementation of EMR in health facilities and can serve as a basis for future research development

Analysis of Human Resource Needs in Inpatient Medical Record Officers Using WISN and ABK-Kes Methods in “X” Hospital

Fri, 22 Nov 2024 00:00:00 +0000

Every hospital must have qualified human resources both in the field of medical and health personnel. Hospitals have a responsibility to fulfill health service criteria. One of the minimum services that must exist in hospitals is medical records. Several hospitals in Indonesia, there are problems related to the needs of Human Resources (HR) in the medical records, including problems regarding the completeness of filling out medical records and high workloads. Therefore, it is necessary to calculate the staffing needs of the medical records and health information unit using the Workload Indicator Staffing Needs (WISN) method and Health Workload Analysis (ABK-Kes) in the inpatient unit at Hospital "X". This research uses a qualitative descriptive method. Data collection using observation methods and interviews with medical record officers in the inpatient unit to determine their main tasks and jobs. The results of the analysis of human resource needs in the inpatient unit at Hospital "X" using the WISN and ABK-Kes methods both obtained the results of 6 officers. Hospital "X" currently has 3 officers, so it is necessary to change 3 officers.

Implementation of The Waterfall Model in Designing a Prescription Abuse Prevention System with Patient Identification in Sleman Regency Pharmacies

Netti Kautsar Dinasti, Nuryati Nuryati — Fri, 22 Nov 2024 00:00:00 +0000

Psychotropic drugs are used to treat psychiatric disorders, but they carry a risk of dependence. Prescription abuse includes using these medications without a prescription and attempting to obtain them illegally. Problems also arise from the improper use of patient cards and doctor's prescriptions. Currently, patient identification is managed separately by each pharmacy, allowing multiple drug purchases at different locations. Based on the preliminary study conducted, there is a need for an integrated recording system between pharmacies to prevent drug misuse, especially psychotropic substances. This requirement aligns with the competencies that must be possessed by medical recorders according to the Decree of the Minister of Health Number 312 of 2020. A medical recorder must be capable of designing health data standards that include data elements, data sets, databases, and the structure and content of health data, ensuring that the data can be used to support healthcare services. This research aims to conduct a needs analysis, design, and assessment for creating a psychotropic patient identification system. The methodology employed in this research follows a waterfall model approach in developing information systems. The stages of the waterfall model include needs analysis, design, implementation, testing, and evaluation. The System Usability Scale (SUS) questionnaire was applied in the testing and evaluation process to assess the level of system usability. The research findings indicate the necessity of an integrated patient identification system among pharmacies to prevent prescription misuse. It is hoped that this system design will serve as a planning model for the next phase. The system usability scale results show that the designed system is effective and acceptable.

Review Of Workforce Needs In The Filing Section Based On The ABK – Kes Method At RSJD Dr. Arif Zainudin Surakarta In 2024

Fri, 22 Nov 2024 00:00:00 +0000

The ABK - Kes method is one way of calculating health human resource needs based on the workload carried out by each type of SDMK in accordance with their main duties and functions. Dr Arif Zainudin Surakarta Regional Mental Hospital has 2 filing officers. There are several problems including filing officers having to sort documents manually, the transition of manual medical records to electronic medical records, and limited medical record document folders in medicolegal services. This study aims to determine the number of labour requirements in the medical record unit of the filing section using the ABK - Kes method. This research is a descriptive research, with a cross sectional approach. The subjects in this research are 2 filing officers while the object in this research is the workload of filing officers. Data collection methods were carried out by observation and interview. The results of this research are a health facility of the type of regional psychiatric hospital owned by the Central Java provincial government with the type of SDMK medical records unit in the filing section, available work time of 75.600 minutes/year, workload components totalling 13 main tasks and 3 additional tasks, workload standards of 285.773 minutes/year, FTP value of 2.75% and STP value of 1.03 and the need for SDMK in the filing section after being calculated using the ABK - Kes method is 4 officers. The number of officers of the medical record unit in the filing section at Dr Arif Zainudin Surakarta Hospital currently amounts to 2 officers, from the results of calculations using the ABK-KES method resulting in 4 officers. The suggestion that researchers can give is that they should add 2 medical record officers in the filing section, so that the workload of filing officers is not high which will result in the quality of officer performance.

Application of the Hot-Fit Method in Evaluation of the Use of ePuskesmas at Community Health Care I South Denpasar

Fri, 22 Nov 2024 00:00:00 +0000

ePuskesmas is a multi-user web-based application that allows simultaneous access by multiple users. It facilitates electronic patient recording and data management. The implementation of ePuskesmas services at UPTD Denpasar Selatan 1 has not been conducted previously, but the application aids the Health Department in monitoring public health data. Therefore, it is crucial to evaluate the readiness of personnel in adopting ePuskesmas using the HOT-FIT method. The aim of this study is to assess the Usage Evaluation of ePuskesmas at UPTD Puskesmas I Denpasar Selatan using the HOT-FIT Method. The research adopts a Cross-Sectional Study approach, with a sample comprising all 32 ePuskesmas users at Puskesmas I Denpasar Selatan selected through purposive sampling. Data analysis includes multivariate analysis using multiple linear regression. The findings reveal significant correlations between human, organizational, and technological factors and the net benefit of ePuskesmas usage. Specifically, multivariate analysis identifies organizational factors as the most significant predictor influencing ePuskesmas net benefit (p<0.001). This underscores the pivotal role of organizational readiness in ePuskesmas utilization. Hence, enhancing organizational structure in ePuskesmas management is essential, alongside fostering communication and organizational experience in utilizing ePuskesmas for patient recording and reporting purposes

Analysis of The Causes of Pending in JKN Claims For Outpatients at Orthopedic Hospital Prof. Dr. R. Soeharso Surakarta

Umi Nurherawati, Nunik Maya Hastuti, Mutik Mahmudah, Coelestina Astri Bhoko — Fri, 22 Nov 2024 00:00:00 +0000

Based on a preliminary survey at RS Ortopedi Prof. Dr. R. Soeharso Surakarta in the third quarter of 2023, outpatient JKN claims were pending with a percentage of 5.02% or 938 of the total submission of 18,703 medical records. The aim of the research was to determine the factors causing pending JKN claims for outpatients in the fourth quarter at RS Ortopedi Prof. Dr. R. Soeharso Surakarta. This type of research uses descriptive research with a cross sectional approach. This research was carried out to the JKN outpatient claims section at RS Ortopedi Prof. Dr. R. Soeharso Surakarta from February to April 2024. The subjects in this research were coding officers, INA-CBG's data entry officers, and internal verification officers at RS Ortopedi Prof. Dr. R. Soeharso Surakarta with the research object being the JKN outpatient claim file in the fourth quarter of 2023. Observation guide and an interview guide were used as the research instrument. The data were analyzed using processing techniques used are collecting, editing, tabulation and data presentation. Descriptive data analysis techniques. The research results show the percentage of pending JKN claims for outpatients in the fourth quarter of 2023 at RS Ortopedi Prof. Dr. R. Soeharso Surakarta amounted to 2.04% with a total of 396 pending claims for medical records with a total of 19,399 medical records submitted. The highest cause of pending is in the administrative aspect. Result of the research shows the percentage of pending JKN claims for outpatients in the fourth quarter of 2023 at RS Ortopedi Prof. Dr. R. Soeharso Surakarta is 2.04% with the number of 396 pending files from 19,399 medical records submitted. Therefore, officers are more careful in inputting patient information and completeness of files before submission and maximizing.

Human Resource Placement System for Medical Record Work Unit at Private Hospitals in Medan City in 2024

Fri, 22 Nov 2024 00:00:00 +0000

The processing of a quality Medical Record unit requires a very important resource, namely human resources. The first step in producing skilled and reliable human resources requires planning in placing employees/employees who are suitable for their jobs. The process of placing human resources for medical record work units at Imelda Workers' General Hospital Indonesia, Adventist Hospital Medan and Eshmun General Hospital still found that some medical record employees were not in accordance with their qualifications because the employees had a diploma in computers, high school and a bachelor's degree in mechanical engineering. This can certainly lead to a lack of security in maintaining the confidentiality of medical record files, allowing duplication of medical record numbers, lack of quality of data produced and lack of quality of hospital services. The type of research used is descriptive research with a qualitative approach. The subjects of this study are 6 people, namely 1 HRD and 1 head of medical records at each of the Imelda Workers' General Hospital of Indonesia, Adventist Hospital Medan and Eshmun General Hospital. This sampling technique is by purposive sampling method. The results of the research that have been obtained are still medical record work unit officers who are not in accordance with their educational qualifications in the three hospitals, such as the registration section is not included in the medical record unit so that the officers who work are not medical recorder graduates. Work experience and physical health are factors that need to be considered in the placement of human resources and the average placement age of each officer is 25 to 40 years old, this age factor is considered with the intention of avoiding low productivity produced by the employee concerned. To the three hospitals, it is recommended that the placement of human resources in the medical record work unit is adjusted to their educational qualifications, experience, physical health and age.

Quality of Electronic Medical Record Information and Satisfaction of Electronic Medical Record Users at Pandan Arang Boyolali Regional Hospital

Sri Sugiarsi, Sri Mulyono, Trismianto Asmo Sutrisno — Fri, 22 Nov 2024 00:00:00 +0000

Information Quality can be defined as how well the function concerning the value of the output of information produced or managed by the application/ system for users can meet everyone’s expectations and will help complete their work. Information Quality measurement indicators (Riskinanto, 2016) are information quality based on accuracy value, information quality based on timeliness of delivery, and information quality based on relevance. This study aims to explaining the quality of information and user satisfaction of electronic medical records at the Pandan Arang Regional General Hospital. This study is descriptive with the aim of describing the quality of information and satisfaction of electronic medical record users. The sample was 77 people consisting of doctors, nurses and medical record officers. Primary data were collected using questionnaires. Data analysis using descriptive analysis. Results: of the information quality variable have a mean of 17.5. With a mean of 17.5, it can be concluded that the quality of information is included in the very high-quality category with an interval of 16.8-20. information satisfaction variable have a mean of 8.4. With a mean of 8.4, it can be concluded that information satisfaction falls into the satisfied category with an interval of 8.4-10. Although information satisfaction has an average value that falls into the satisfied criteria, there are still respondents who choose to be quite satisfied regarding the information satisfaction received by system users. Conclution: Electronic medical record (EMR) information quality and user satisfaction are closely related, impacting the effectiveness and adoption of EMR systems in healthcare settings. Research shows that while EMRs can improve perceived medical record quality

Security of Electronic Medical Information and Patient Privacy

Katherine P. Andriole, Sings Sings — Fri, 22 Nov 2024 00:00:00 +0000

Tujuan penelitian ini adalah untuk mengeksplorasi implementasi keamanan sistem Rekam Medis The responsibility that physicians have to protect their patients from harm extends to protecting the privacy and confidentiality of patient health information including that contained within radiological images. The intent of HIPAA and subsequent HIPAA Privacy and Security Rules is to keep patients’ private information confidential while allowing providers access to and maintaining the integrity ofrelevant information needed to provide care. Failure to comply with electronic protected health information (ePHI) regulations could result in financial or criminal penalties or both. Protected health information refers to anything that can reasonably be used to identify a patient (eg, name, age, date of birth, social security number, radiology examination accession number). The basic tools and techniques used to maintain medical information security and patient privacy described in this article include physical safeguards such as computer device isolation and data backup, technical safeguards such as firewalls and secure transmission modes, and administrative safeguards including documentation of security policies, training of staff, and audit tracking through system logs. Other important concepts related to privacy and security are explained, including user authentication, authorization, availability, confidentiality, data integrity, and nonrepudiation. Patient privacy and security of medical information are critical elements in today’s electronic health care environment. Radiology has led the way in adopting digital systems to make possible the availability of medical information anywhere anytime, and in identifying and working to eliminate any risks to patients.

Implementing Artificial Intelligence in the United Arab Emirates Healthcare Sector

Shaikha FS Alhashmi, Said A. Salloum, Chaker Mhamdi — Fri, 22 Nov 2024 07:22:14 +0000

The United Arab Emirates (UAE) has recently focused on implementing Artificial Intelligence (AI) projects in the government healthcare sector to help manage chronic diseases and early detection. However, successful AI implementation depends on adoption and acceptance by decision-makers, physicians, nurses, and patients. This paper develops and tests a modified Technology Acceptance Model (TAM) to explore critical success factors (CSFs) for the adoption of AI in the healthcare sector. The most widely used CSF variables for TAM are Perceived Usefulness (PU), Perceived Ease of Use (PEU), Attitudes toward Use (ATU) and Behavioral Intention to Use (BIU). However, a review of 23 qualitative and quantitative studies of TAM literature from 2015 to 2018 suggested that five key external factors should be included in CSF studies using TAM. An extended model was developed (ETAM) and tested using a qualitative study comprising 53 employees working in the Dubai IT and healthcare sectors. The study showed that managerial, organizational, operational and IT infrastructure factors have a positive effect on PU and PEU and, hence, should be included as CSFs in determining the implementation of AI in the healthcare sector.

Why Should Developing Nations Implement ICD-11 for Morbidity Coding?

Islam Ibrahim — Fri, 22 Nov 2024 00:00:00 +0000

The International Classification of Diseases (ICD), maintained by the World Health Organization (WHO), is the global standard for morbidity and mortality coding. The 2022 release of ICD-11 brought improvements such as enhanced clinical detail, user-friendly technology, and multilingual support, offering a significant upgrade from ICD-10. Developing countries often face challenges with ICD-10, including limited morbidity data capture and the high costs of adopting other country-specific modifications. ICD-11 addresses these issues with features like postcoordination, extension codes, and electronic coding tools, which enhance coding accuracy, reduce training costs, and improve interoperability. Pilot studies in Kuwait, China, and Malaysia have demonstrated ICD-11’s successful implementation, showing improved coding accuracy, better clinical documentation, and high user satisfaction. Key enablers of success include tailored training, multidisciplinary collaboration, and IT infrastructure readiness, though challenges remain with DRG integration and infrastructure gaps. ICD-11’s support for both morbidity and mortality coding, its freely available mapping tools, and its multilingual capabilities improve the international comparability of health data. These findings highlight ICD-11’s potential to transform health information systems in developing countries, enhancing data quality and supporting evidence-based policymaking. Strategic investments in technology, effective change management, and stakeholder engagement are essential for successful implementation.

Study of Some Immune Changes That Related to Leishmania (CL) Infection

Maha Mahmoud Shaker — Fri, 06 Dec 2024 00:00:00 +0000

Cutaneous leishmaniasis is an infection of the skin. The symptoms graduated causes bumps that after that turn into ulcers (large) in the future. Healing may take a long time. Symptoms begin within weeks or may be months after bite of sand fly.This study was conducted in the city of Hilla. This study included 90 patients who were selected from visitors to private clinics. These study participants were then divided into two groups of similar ages. The first group included 60 people with cutaneous leishmaniasis who were diagnosed by a doctor, in addition to a second group that included 30 people who were not infected with any disease as a control group. Cytokine concentrations were also measured using... ELISA technique, then statistical testing was performed. Results: showed high concentration of the cytokines that were under study interleukin 17 and interleukin 33 in the patient group compared to the group of control. Conclusions and recommendations: The increase in the level of cytokines in the patient group may indicate the role that these cytokines play in the regression of the disease

Highlights:

Cutaneous Leishmaniasis: Skin infection causing bumps, ulcers, slow healing.
Study Groups: 60 patients, 30 controls, cytokines measured via ELISA.
Findings: Elevated IL-17, IL-33 indicate cytokines' role in disease regression.

Keywords: Cutaneous leishmaniasis, cytokines, interleukin-17, interleukin-33, ELISA