Kori Puspita Ningsih, Tika Sari Dewi, Sugeng Santoso, Stevanus Slamet Riyadi

ELECTRONIC MEDICAL RECORD ADOPTION MODEL (EMRAM) IN DR.SOEDJONO MAGELANG HOSPITAL

Introduction

Electronic medical record adoption model (emram) in dr.soedjono magelang hospital. Tingkat adopsi RME (EMRAM) di RS Dr. Soedjono Magelang telah mencapai level 4. Pelajari implementasi rekam medis elektronik terintegrasi & tantangan DMI.

Abstract

Adopsi RME telah merambah di negara berkembang, salah satunya Indonesia. Hal ini sejalan dengan urgency implementasi RME di Indonesia seperti yang tertuang pada Permenkes 24 tahun 2022. Salah satu metode menilai kematangan RME di tingkat fasyankes berdasarkan dimensi tingkat adopsi RME (Electronic Medical Record Adoption Model/ EMRAM) dengan menggunakan  skor 0 sampai 7. Penelitian ini menggunakan jenis penelitian observational analitik. yang dilaksanakan di RS TK II Dr.Soedjono di Kabupaten Magelang, Jawa Tengah pada tahun 2023. Implementasi RME di RST dr. Soedjono Magelang menggunakan mode adopsi RME sesuai EMRAM sudah berada pada level 4. Hal ini ditunjukkan dengan pencatatan dokumentasi rekam medis oleh dokter dan PPA sudag terintegrasi, dokter mendokumentasikan dalam catatan dalam template terstruktur yang menghasilkan beberapa data diskrit untuk interaksi dengan pendukung keputusan klinis. Tersedia hasil lab disimpan dalam bentuk terstruktur diskrit yang memungkinkan interaksi pendukung keputusan klinis, namun hasil laboratorium belum diimpor secara elektronik RME mampu menghasilkan output laporan untuk kepentingan internal dan eksternal, meskipun masih perlu perbaikan kembali pada kualitas informasi laporan tersebut. RST dr. Soedjono Magelang juga dapat menggunakan penilaian Digital Maturity Index (DMI) untuk menilai tingkat kematangan digital, karena metode EMRAM memiliki kekurangan potensi kegagalan menangkap aspek jalur perawatan di seluruh sektor perawatan kesehatan.

Review

This paper presents a timely and relevant assessment of Electronic Medical Record (EMR) adoption at Dr. Soedjono Magelang Hospital, leveraging the well-established Electronic Medical Record Adoption Model (EMRAM). Given the accelerating push for EMR implementation in developing nations, including Indonesia as mandated by Permenkes 24 tahun 2022, understanding the maturity level of such systems is crucial for guiding further development and ensuring effective healthcare delivery. The study provides a valuable snapshot of a specific hospital's journey, contributing to the broader discourse on digital transformation within the Indonesian healthcare landscape. Through an observational analytic study conducted in 2023, the research identifies that Dr. Soedjono Magelang Hospital's EMR system has reached EMRAM Level 4. This achievement is characterized by several key functionalities, including integrated medical record documentation by doctors and other healthcare professionals (PPAs), the use of structured templates for physician notes that generate discrete data, and the availability of structured, discrete laboratory results that facilitate interaction with clinical decision support systems. However, the abstract also critically points out areas for improvement within this level, specifically noting that laboratory results are not yet electronically imported, and while the EMR can generate internal and external reports, the quality of information within these reports still requires refinement. The findings offer a concrete basis for Dr. Soedjono Magelang Hospital to strategize its next steps towards higher EMRAM levels. The paper commendably suggests that the hospital consider the Digital Maturity Index (DMI) in addition to EMRAM, acknowledging EMRAM's potential limitations in capturing holistic care pathway aspects across the broader healthcare sector. This recommendation highlights a critical consideration for future assessments, encouraging a multi-dimensional approach to evaluating digital maturity. Future research could further elaborate on the specific challenges encountered in achieving higher EMRAM levels, particularly concerning the electronic integration of external data and enhancing report quality, thereby offering more comprehensive guidance for other institutions on a similar digital transformation journey.

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