MAINTEKKES : The Journal of Management Information and Health Technology
Maintekkes: Published since 2023 by Politeknik Kesehatan Kartini Bali. Maintekkes is published twice a year, in June and December. It contains articles that focus on the results of research in the field of health information management and technology. The editorial board invites academics, lecturers, and practitioners to submit their articles, which consist of the results of field research or literature reviews in accordance with the discipline and the provisions of our journal. The scope of disciplines includes Health Information Management, Electronic Health Record, Medical Record, Health Data Analytics, Health Financing System, Clinical Coding including Classification and Terminology, Healthcare Quality, Health Information and Communication Technology, and Health Information Systems.
ANALISIS FAKTOR YANG MEMPENGARUHI KETIDAKLENGKAPAN PERSETUJUAN TINDAKAN KEDOKTERAN (INFORMED CONSENT) MENGGUNAKAN METODE 5M DI RSUD KABUPATEN KLUNGKUNG TAHUN 2025
Informed consent (persetujuan tindakan kedokteran) merupakan dokumen penting yang berfungsi sebagai perlindungan hukum bagi pasien maupun tenaga kesehatan. Namun, dalam praktiknya, pengisian informed consent seringkali tidak dilakukan secara lengkap. Penelitian ini bertujuan untuk menganalisis faktor-faktor yang memengaruhi ketidaklengkapan pengisian informed consent di RSUD Kabupaten Klungkung dengan menggunakan pendekatan 5M, yaitu: Man, Money, Method, Market, dan Machine Penelitian ini merupakan studi kualitatif dengan pendekatan fenomenologi. Data diperoleh melalui wawancara mendalam terhadap 9 orang dokter yang aktif melakukan pelayanan medis dan pengisian informed consent. Data dianalisis dengan metode coding tematik berdasarkan lima kategori utama sesuai pendekatan 5M. Hasil penelitian menunjukkan bahwa faktor Man (beban kerja tinggi, keterbatasan waktu, dan tantangan komunikasi dengan pasien) dan Machine (hambatan teknis sistem rekam medis elektronik, keterbatasan perangkat) merupakan faktor yang paling dominan menyebabkan ketidaklengkapan pengisian IC. Faktor Method berhubungan dengan ketidakkonsistenan penerapan SOP, sedangkan Market berkaitan dengan latar belakang sosial budaya dan tingkat pendidikan pasien yang memengaruhi pemahaman terhadap IC. Sementara itu, faktor Money meliputi kurangnya insentif terhadap kegiatan edukasi pasien dan keterbatasan sarana. Kesimpulan dari penelitian ini adalah bahwa ketidaklengkapan pengisian informed consent disebabkan oleh faktor internal tenaga medis dan eksternal seperti sistem dan pasien. Diperlukan perbaikan dari sisi kebijakan manajerial, pelatihan komunikasi, serta penguatan sistem teknologi untuk meningkatkan mutu dokumentasi informed consent
Copyright (c) 2026 MAINTEKKES : The Journal of Management Information and Health Technology
ANALISIS PENYEBAB PENDING KLAIM BPJS RAWAT INAP MENGGUNAKAN DIAGRAM FISHBONE DI RUMAH SAKIT BHAYANGKARA JAYAPURA PADA TAHUN 2025
Kelancaran arus kas operasional rumah sakit sering kali terhambat oleh penundaan pencairan klaim JKN akibat masalah ketidaklengkapan dokumen atau kesalahan administratif dalam proses verifikasi BPJS Kesehatan. Penelitian ini bertujuan untuk mengidentifikasi dan menganalisis akar penyebab terjadinya pending klaim BPJS rawat inap di RS Bhayangkara Jayapura menggunakan metode Diagram Fishbone. Jenis penelitian ini adalah deskriptif kualitatif dengan pendekatan studi kasus. Pengumpulan data dilakukan melalui observasi langsung, dokumentasi arsip, dan wawancara mendalam terhadap 9 informan yang dipilih melalui teknik purposive sampling dari Unit Rekam Medis, Keuangan, Administrasi Rawat Inap, dan IT/SIMRS. Analisis data menggunakan metode reduksi data, penyajian data, dan penarikan kesimpulan yang dipetakan ke dalam Diagram Fishbone berdasarkan aspek Man, Method, Machine, Material, Measurement, dan Environment. Hasil penelitian menunjukkan adanya penurunan efektivitas klaim pasca-Januari 2025, yang memicu berkas pending berkisar 200–240 per bulan. Faktor utama penyebab pending klaim meliputi: aspek Man (kurangnya pelatihan berkelanjutan bagi petugas pengkodean dan administrasi); Method (perubahan regulasi dan SOP yang tidak disosialisasikan secara merata); Machine (sistem SIMRS yang sering error dan belum terintegrasi langsung dengan aplikasi BPJS); Material (resume medis tidak lengkap atau format tidak sesuai); Measurement (belum adanya pelaporan berkala dan dashboard monitoring klaim real-time) ; serta Environment (koordinasi antarunit yang bersifat reaktif dan arus informasi eksternal yang lambat). Kesimpulan: Masalah pending klaim di RS Bhayangkara Jayapura bersifat sistemik dan saling berkaitan. Oleh karena itu, diperlukan standarisasi dan digitalisasi kontrol melalui intergrasi sistem SIMRS-BPJS, pemberlakuan checklist dokumen, serta evaluasi rutin bulanan guna meminimalkan hambatan finansial rumah sakit.
ANALISIS KESIAPAN RUMAH SAKIT DALAM IMPLEMENTASI TELEMEDISIN DI POLIKLINIK GERIATRI RSUD TABANAN
Telemedicine merupakan salah satu inovasi layanan kesehatan digital yang menjadi prioritas dalam transformasi sistem kesehatan nasional. Penelitian ini bertujuan untuk mengukur tingkat kesiapan penerapan Telemedicine di Poli Geriatri RSUD Tabanan berdasarkan kerangka Technology-Organization-Environment (TOE). Penelitian menggunakan desain deskriptif kuantitatif dengan melibatkan 21 responden yang terdiri atas tenaga kesehatan, staf manajemen, dan staf teknologi informasi. Instrumen berupa kuesioner yang terdiri dari 3 dimensi (teknologi, organisasi, lingkungan) diuji reliabilitasnya dengan Cronbach’s Alpha. Analisis data dilakukan menggunakan statistik deskriptif dan korelasi Pearson. Hasil penelitian menunjukkan bahwa secara umum RSUD Tabanan memiliki tingkat kesiapan yang cukup baik. Pada dimensi teknologi, ketersediaan prasarana seperti listrik dan jaringan internet memperoleh nilai rata-rata tertinggi (mean = 4,19), sedangkan pada dimensi organisasi, dukungan manajemen dan kompetensi tenaga IT memiliki korelasi signifikan dengan total skor (r = 0,799 dan r = 0,665; p < 0,01). Dimensi lingkungan menunjukkan kontribusi besar terhadap kesiapan implementasi, di mana keselarasan kebijakan internal dengan kebijakan nasional (r = 0,920; p < 0,001) serta pemanfaatan media digital (r = 0,871; p < 0,001) menjadi faktor dominan. Nilai Cronbach’s Alpha sebesar 0,828–0,831 pada seluruh instrumen menunjukkan konsistensi internal yang baik. Kesimpulan bahwa penerapan Telemedicine di RSUD Tabanan memiliki fondasi infrastruktur dan dukungan organisasi yang memadai, namun masih memerlukan penguatan pada integrasi sistem informasi, pengembangan aplikasi mandiri, serta standarisasi sarana pelayanan. Temuan ini sejalan dengan penelitian sebelumnya di beberapa rumah sakit di Indonesia yang menekankan pentingnya sinergi antara teknologi, organisasi, dan dukungan lingkungan eksternal dalam mengoptimalkan adopsi layanan Telemedicine.
ANALYSIS OF FACTORS CAUSING INACCURACY OF DIAGNOSIS CODING OF INPATIENTS AT RSI AISYIYAH MALANG
A preliminary survey conducted on 50 inpatient medical records at Aisyiyah Islamic Hospital Malang showed that the accuracy rate of diagnostic coding was 68%, while the inaccuracy rate was 32%. This study aims to identify the factors contributing to the inaccuracy of inpatient diagnostic coding at Aisyiyah Islamic Hospital Malang based on the elements of Man and Materials. This research employed a qualitative method with a cross-sectional approach, using interviews and observations as instruments. The participants consisted of the head of the medical records unit and two medical record officers responsible for coding at Aisyiyah Islamic Hospital Malang. The findings revealed that there were no dedicated officers assigned specifically for coding inpatient medical records. Coding was conducted alternately, and training was not provided regularly. The completeness of important reports in medical record documents reached only 66%. Furthermore, 40% of diagnoses were unreadable, based on the researcher’s observation of 70 inpatient medical records. Additionally, 40% of the medical records lacked the attending physician’s signature, and 47% did not include the attending physician’s name. The factors contributing to inaccuracies in inpatient diagnostic coding based on the Man element include experience, educational background, years of service, training, and knowledge. Meanwhile, the contributing factors based on the Materials element are reflected in the completeness of important reports in inpatient medical record documents, the readability of diagnoses, and the use of abbreviations or medical terminology by physicians.
IMPLEMENTASI SNI ISO/IEC 27001:2022 TERHADAP PERLINDUNGAN DATA REKAM MEDIS ELEKTRONIK (RME) PADA FASILITAS PELAYANAN KESEHATAN DI INDONESIA
Penerapan Rekam Medis Elektronik (RME) pada fasilitas pelayanan kesehatan (fasyankes) di Indonesia dapat menjadi kerangka kewajiban normatif yang ditetapkan melalui regulasi sektor kesehatan, dan diperkuat oleh Undang-Undang Nomor 27 Tahun 2022 tentang Perlindungan Data Pribadi (UU PDP). Data kesehatan dikategorikan sebagai data pribadi spesifik dengan tingkat perlindungan tinggi. SNI ISO/IEC 27001:2022 sebagai standar nasional keamanan informasi dipandang cukup relevan untuk mendukung perlindungan data RME melalui penerapan Sistem Manajemen Keamanan Informasi (SMKI) karena berbasis manajemen risiko. Penelitian ini bertujuan mengkaji secara kritis implementasi SNI ISO/IEC 27001:2022 terhadap perlindungan data RME pada fasyankes di Indonesia dari perspektif hukum normatif. Metode yang digunakan adalah systematic literature review berbasis protokol PRISMA dengan kerangka kerja (framework) Theory-Context-Characteristics-Methodology (TCCM). Hasil kajian menunjukkan bahwa mayoritas literatur masih memposisikan SNI ISO/IEC 27001:2022 sebagai instrumen teknis dan administratif, tanpa mengaitkannya secara eksplisit dengan pemenuhan kewajiban hukum berdasarkan UU PDP. Implementasi SMKI memiliki kecenderungan berorientasi pada kepatuhan prosedural dan sertifikasi, sementara perlindungan substantif terhadap hak privasi pasien belum menjadi fokus utama. Temuan ini menegaskan bahwa kepatuhan terhadap SNI ISO/IEC 27001:2022 belum memiliki sifat legal safe harbour, tetapi hanya dapat berfungsi sebagai bukti due diligence yang harus diintegrasikan dengan tata kelola kepatuhan hukum untuk menjamin perlindungan data RME secara komprehensif.
EFFECTIVENESS OF THE IMPLEMENTATION OF WEB-BASED ELECTRONIC MEDICAL RECORDS IN THE OUTPATIENT SPECIALIST POLYCLINIC OF BALIMED GENERAL HOSPITAL DENPASAR USING THE PIECES METHOD IN 2025
BaliMed General Hospital implemented a desktop-based EMR on February 4, 2019, and switched vendors on February 5, 2024, to implement a web-based EMR. All specialist polyclinics simultaneously used the web-based EMR. However, an interview with the Head of the Medical Records Unit revealed that no evaluation of its effectiveness had been conducted during the implementation of the web-based EMR. The potential impacts of this lack of evaluation include data inaccuracy, slow service processes, and medical errors. This study used the PIECES method to assess the effectiveness of the EMR implementation. This method encompasses the dimensions of performance, information, economics, control, efficiency, and service. The study used quantitative research. The results of this study were based on the performance dimension, namely achieving highly effective results; the information dimension, namely achieving highly effective results; the economic dimension, namely achieving effective results; the control dimension, namely achieving effective results; the efficiency dimension, namely achieving effective results; and the service dimension, namely achieving highly effective results. This demonstrates that the system is capable of meeting user needs well.
Copyright (c) 2025 MAINTEKKES : The Journal of Management Information and Health Technology
EVALUATION OF THE IMPLEMENTATION OF ELECTRONIC MEDICAL RECORDS USING THE HOT-FIT METHOD IN THE INPATIENT UNIT OF BHAYANGKARA HOSPITAL, DENPASAR
The development of an electronic medical record (EMR) system is a strategic step in improving the quality of health services, including service acceleration, data accuracy, and ease of integration. The effectiveness of the system is crucial in the development of health information. A preliminary study revealed obstacles to the implementation of EMR at Bhayangkara Hospital, Denpasar, such as unstable network connections and the system's inability to accommodate user needs, especially in the inpatient unit. This study aims to evaluate the implementation of EMR in the Inpatient Unit of Bhayangkara Hospital, Denpasar, using the HOT-Fit method to comprehensively measure the system's success. The method used was quantitative analytic with a sample of 47 people. Data collection techniques used a checklist questionnaire and direct observation in the field. The evaluation results showed that the human (92.02%), organizational (92.55%), and technological (90.07%) aspects of EMR implementation were in the very good category and had a positive relationship with net benefits. However, identification of discrepancies revealed discomfort and lack of understanding of the system guidelines from users, lack of management support and communication between units, and system unreliability (errors). Therefore, these areas require substantial improvement to optimize the implementation of EMR at Bhayangkara Hospital, Denpasar.
EVALUATION OF THE IMPLEMENTATION OF ELECTRONIC MEDICAL RECORDS USING THE HOT FIT METHOD AT TANGGUWISIA REGIONAL GENERAL HOSPITAL, BULELENG REGENCY
Tangguwisia General Hospital has implemented a Hospital Management Information System (SIMRS), especially electronic medical records, since October 2021 with a transition period until December 2021 and January 2022 for comprehensive implementation in all units. There are risks that arise from the implementation of electronic medical records, such as system down time, human error and database backup problems. It is necessary to measure and evaluate the implementation of the electronic medical record system using the Human Organization Technology Fit (HOT FIT) method. The research method uses a quantitative approach with a cross sectional design, statistical tests using the Spearman Rank test (multilevel correlation) to see the relationship between the Human Organization Technology variable and Net Benefits. The sample in this research amounted to 124 users of electronic medical records. There is a significant relationship between the Human variable and Net Benefits with results (p-value 0.000) < 0.05. The Spearman correlation coefficient value (r/rho=0.532) shows a strong level of relationship. There is a significant relationship between the Organization variable and Net Benefits with results (p-value 0.000) < 0.05. The Spearman correlation coefficient value (r/rho=0.597) shows a strong level of relationship. There is a significant relationship between the Technology variable and Net Benefits with results (p-value 0.000) < 0.05. The Spearman correlation coefficient (r/rho=0.693) shows a strong level of relationship. The Human Organization Technology aspect of Net Benefits is proven to have a strong relationship and the direction of the relationship is unidirectional so that if Human, Organization, Technology increases, Net Benefits will also increase and have a significant impact
ANALYSIS OF SECURITY ASPECT OF MEDICAL RECORD DATA IN THE IMPLEMENTATION OF ELECTRONIC MEDICAL RECORDS IN KLUNGKUNG GENERAL HOSPITAL
The development of technology in the world of health has grown rapidly. One of these technologies is the implementation of an electronic medical record system. Klungkung Regency Hospital is one of the hospitals that has implemented an electronic medical record system (EMR) since 2021. In its implementation, there are several obstacles that threaten the security and privacy of medical records such as employee discipline and the absence of SOPs that regulate the security mechanism of usernames and passwords. The potential for data leakage or loss is a serious threat in the implementation of EMR. The aim of this study was to analyze the security aspects of patient medical record data in the implementation of electronic medical records at the Klungkung Regency General Hospital. The research method uses qualitative descriptive with a purposive sampling technique. The sample in this study amounted to 9 people. Data collection techniques by interview. The results of the EMR Implementation study at Klungkung Regency Hospital show varying information security. Privacy is threatened by user negligence, but data integrity and authentication have been guaranteed through automatic notifications, usernames, passwords, and electronic signatures. Data availability is important for service quality, supported by good access control and non-repudiation through electronic signatures. System optimization and increasing user capacity needed. Overall, the management of the security aspects of the RME system at Klungkung District Hospital is quite good.
ANALYSIS OF ELECTRONIC MEDICAL RECORDS (EMR) READINESS IN THE INPATIENT FACILITY OF BALI MANDARA REGIONAL HOSPITAL USING THE DOQ-IT APPROACH
Increasing the effectiveness of recording accurate and fast medical record data can utilize current technological advances, namely with Electronic Medical Records. Every health service facility is required to organize electronic medical records in accordance with the Regulation of the Minister of Health. Based on the results of the preliminary study, negative impacts were still found due to the lack of implementation of electronic medical records in the inpatient installation of Bali Mandara Regional Hospital. Based on these problems, the "Analysis of Electronic Medical Record Readiness in the Inpatient Installation of Bali Mandara Regional Hospital with the DOQ-IT (Doctor's Office Quality-Information Technology) Approach" will provide a more detailed and easier picture in preparing for the implementation of Electronic Medical Records in the Inpatient Installation of Bali Mandara Regional Hospital. The research method used is a qualitative descriptive study DOQ-IT method with a sample of 10 people. The type of data collected is primary and secondary data taken from interviews and observation checklists. The results found that the readiness of electronic medical records in the inpatient installation of Bali Mandara Regional Hospital has received support from the management of Bali Mandara Regional Hospital, support in the form of planning that has been made a top priority, budgeting costs, infrastructure procurement and the formation of a special team. Further planning is still needed to ensure adequate infrastructure, including primary facilities and supporting facilities, hardware, and software, to ensure the smooth operation of electronic medical records in inpatient settings. Furthermore, human resource development is also needed, both in terms of knowledge, understanding, and the number of available personnel.
ANALISIS FAKTOR-FAKTOR YANG MEMENGARUHI KETIDAKAKURATAN KODE DIAGNOSIS PENYAKIT RAWAT JALAN DI PUSKESMAS DINOYO TAHUN 2023
At Dinoyo Community Health Center, inaccurate diagnosis codes contained in medical record documents will affect monthly reports and data validation. Based on the results of a preliminary study, data obtained that the accuracy of diagnosis codes in outpatient medical record documents at the Dinoyo Community Health Center was 82% (41 DRM) and 19% inaccurate (9 DRM). This study aims to determine the flow of outpatient disease coding at Dinoyo Health Center in 2023, the percentage of accuracy and inaccuracy of outpatient disease diagnosis codes at Dinoyo Health Center in 2023, and the factors that influence their inaccuracy. The method used in this research is mixed methods with a retrospective approach where researchers use quantitative and qualitative methods simultaneously. This research was conducted in the medical records unit of the Dinoyo Community Health Center using a DRM population of 10,229. The sample in this study was 100 DRM outpatients with a sampling technique, namely simple random sampling and 1 medical records officer and 1 poly doctor as informants. Method of collection is by observing and interviewing. Data analysis was carried out using descriptive analysis and univariate analysis. The research results showed that the percentage of accuracy of diagnosis codes was 51% (51 documents) and the percentage of inaccuracy was 49% (49 documents). Factors that influence the inaccuracy of diagnostic codes are coders who have never received coding training, working period of less than 5 years, coding work that also coincides with other work, coding carried out by doctors, coding SOPs that have not been implemented properly, the ICD-10 book which is still the old version, there is no supporting dictionary book, namely the Dorland dictionary, the completeness and readability of the doctor's writing in anamnesis and patient assessment and there is no budget to involve coding officers in taking part in training and procuring Dorland medical dictionary books. To prevent inaccuracies in diagnosis codes, the health center needs to hold special coding training for medical record officers, officers who carry out coding according to their competence, namely a Medical Recorder to improve accuracy in determining diagnosis codes as well as procuring the latest ICD-10 books and Dorland medical dictionaries.
ANALYSIS OF FACTORS CAUSING PENDING CLAIMS DUE TO CODING OF INPATIENT BPJS PATIENT FILES AT EYE HOSPITAL BALI MANDARA 2024
Hospitals as advanced health facilities send monthly claims to BPJS Health to receive compensation for services to JKN participants, no later than the 10th of the following month. This claim is verified by BPJS Health to ensure the validity of service administration. This study aims to determine the factors causing pending claims for inpatient BPJS files at the Bali Mandara Eye Hospital in 2024. The specific objectives include the completeness of inpatient medical resumes, coders' perceptions in the data input process, and an overview of infrastructure in the coding process. The research was conducted qualitatively using a phenomenological approach in the Coding Room of the Medical Records Unit at the Bali Mandara Eye Hospital from January to April 2024. The research population was PMIK officers, with a sample of 4 PMIK officers and 2 teams of verifiers from the finance department. Data was collected through observation and in-depth interviews with informants selected purposively from January to March 2024. The results of the analysis show several factors causing pending claims including incomplete files, such as claim forms or medical records. Inaccurate coding of diagnoses or procedures. Lack of appropriate supporting examinations. required. Unavailability of adequate documentary evidence. There is no clear Standard Operating Procedure (SPO). To overcome this problem, it is necessary to create a special job description for coding officers.
THE EFFECT OF COMPLETENESS OF INFORMED CONSENT IN INPATIENT ROOMS ON THE QUALITY OF MEDICAL RECORDS AT RSAD TK. II UDAYANA
The completeness of filling in the informed consent sheet in the medical record file is very important because it will affect the legal aspects of the medical record and the quality of the medical record so that filling in the complete data in the informed consent sheet needs to be done with maximum implementation. This study aims to determine the effect of completing the Informed Consent form in the inpatient room on the quality of medical records at RSAD Tk. II Udayana, Bali. The research method used is quantitative research with a cross sectional approach. The data collection technique used is by taking questionnaires, observation, checklists and case studies. The sampling technique was random sampling technique with a sample of 33 informed consents and 33 respondents. Based on the research results, the influence of completeness of informed consent in the inpatient room on the quality of medical records at RSAD Tk. II Udayana by 75%. The problems that occur are: (1) There are still incomplete informed consent forms, (2) There are unclear written actions, (3) Delays in returning incomplete medical records to the KLPCM department. The suggestions given are: (1) Conduct socialization on fixed procedures regarding filling out informed consent, (2) Medical records officers and other health workers must continue to remind each other about filling in complete informed consent, (3) Conduct training regarding the implementation of filling out informed consent forms.
RELATIONSHIP BETWEEN COMPLETENESS OF MEDICAL INFORMATION AND DIAGNOSIS ACCURACY CODES APPENDIX
Health information has an important role in patient medical records, where medical information can facilitate patient care and as information needed by management in managing health service facilities, especially hospitals. Completeness of health information has an important role in assigning diagnosis codes to patient medical records, where complete medical information has a very important role in the accuracy of assigning patient diagnosis codes. Especially in the diagnosis of appendicitis in inpatients at RSU. Puri Raharja. This research was carried out by observing the forms in the patient's medical record, regarding the completeness of the patient's medical information and the accuracy of providing diagnosis codes in the patient's medical record. The results obtained are that there is a relationship between the completeness of medical information and the accuracy of the diagnosis code in the patient's medical record.
ANALYSIS OF TELEMEDICINE IMPLEMENTATION CHALLENGES AT BALI MANDARA EYE HOSPITAL 2024
Regulation of Health Minister No. 20 of 2019 on the Implementation of Telemedicine Services between Healthcare Facilities. Rumah Sakit Mata Bali Mandara (RSMBM) has plans to develop a comprehensive teleophthalmology network with referral hospitals and primary care facilities. The purpose of this study is to analyze the challenges in implementing telemedicine using the 5 M (Man, Money, Materials, Machines, Methods) approach. This study is a qualitative descriptive analysis using purposive sampling with a total of 7 respondents. The results of the study found that Rumah Sakit Mata Bali Mandara still requires specialized personnel such as ophthalmologists, support staff, and IT personnel to develop telemedicine services. The procurement of telemedicine services must go through a planning, submission, and realization process. Procurement of the required equipment must be proposed and recorded in the RKBMD and must meet TKDN requirements. There is also no determination of telemedicine service fees yet. RSMBM must have a consulting healthcare facility, facilities that can support communication aspects, and a telemedicine service cooperation agreement. The consulting healthcare facility must have at least basic and advanced eye examination equipment, communication technology equipment, and challenges related to the relatively high price of examination equipment and applications or software, network systems, and internet connections. There are no regulations regarding the legality of services and no regulations for determining telemedicine service fees.
EVALUASI IMPLEMENTASI ePUSKESMAS DENGAN MENGGUNAKAN METODE HOT-FIT DI UPTD PUSKESMAS KEDIRI I
Digital transformation has become the main focus in efforts to improve the health system in Indonesia, as stated in various regulations and policies. However, there are challenges in implementing information technology in the field, such as a lack of human resources skilled in IT, a lack of written policies, as well as technical obstacles such as the quality of the internet network. The formulation of the research problem is how to evaluate the implementation of ePuskesmas using the HOT Fit method at UPTD Puskesmas Kediri I. The research objective includes a description of the implementation of ePuskesmas based on human, organizational, technological aspects and perceived benefits. The method used is descriptive qualitative using the Human, Organization, Technology and Net-Benefit (Hot-fit) methods. Evaluation of the implementation of ePuskesmas using the HOT-Fit method at UPTD Puskesmas Kediri I highlighted the potential of the system to increase the efficiency and effectiveness of health services, but also identified several significant obstacles. From the human aspect, the main challenges include imbalances in training and variations in user understanding of the system. In the organizational aspect, the focus on regulatory compliance more than on organizational needs leads to a lack of system flexibility and adaptability. From a technological perspective, the main obstacles include poor network reliability and suboptimal management of technological resources.
Copyright (c) 2024 MAINTEKKES : The Journal of Management Information and Health Technology
ANALISIS KEPUASAN PENERAPAN REKAM MEDIS ELEKTRONIK RAWAT JALAN MENGUNAKAN METODE END-USER COMPUTING STATISFACTION (EUCS) DI RUMAH SAKIT ‘AISYIYAH BOJONEGORO
Improved the efficiency and quality of health services Aisyiyah Bojonegoro Hospital has adopted EMR to support faster and more accurate patient data management. To assess the success of EMR implementation, it is necessary to analyze the level of user satisfaction covering various important dimensions. Analyzing user satisfaction with the implementation of EMR at Aisyiyah Bojonegoro Hospital using the EUCS method. Research Method: This study uses a quantitative descriptive method with data collection through questionnaires. The sampling technique used is purposive sampling. The results showed that the majority of respondents were very satisfied with the various dimensions measured. As many as 81.67% of respondents were satisfied with the content dimension, related to the information generated by the system. In the format dimension, 83.47% of respondents were very satisfied with the appearance and aesthetics of the EMR interface. In addition, 81.27% of respondents were satisfied with the accuracy of the data. However, in the timeliness dimension, satisfaction was lower, with 79.67% of respondents satisfied, indicating the need to improve timeliness in presenting information. Meanwhile, 83.20% of respondents were very satisfied with the ease of use of the system, including the process of inputting and searching for information. Overall, the implementation of Electronic Medical Records at Aisyiyah Hospital Bojonegoro has succeeded in increasing user satisfaction, especially in terms of information content, interface display, data accuracy, and ease of use. However, this study shows the need for improvements in the timeliness of information provision to achieve more optimal efficiency in the operation of effective and efficient medical records.
KETEPATAN RESLEKSI DIAGNOSA DAN KODE UTAMA PASIEN PROLIFERATIVE DIABETIC RETINOPATHY BERDASARKAN ATURAN MORBIDITAS PEMBIAYAAN JAMINAN KESEHATAN INA-CBG DI RUMAH SAKIT MATA BALI MANDARA
In the national health insurance payment system, the INA-CBG (Indonesian Case Base Groups) method is used to determine health service costs based on diagnoses and disease codes. Accuracy in diagnosis and coding is very important because it has a direct impact on the funding the hospital receives from BPJS Health. This study aims to assess the accuracy of diagnosis and coding of Proliferative Diabetic Retinopathy (PDR) patients at the Bali Mandara Eye Hospital to ensure that the funding received is in accordance with the services provided. This research uses quantitative analytical methods. The population and sample of this research is the inpatient medical record documents for January-March 2024 with a sample size of 48 medical record documents. The instrument used in the observation guide is a checklist. The test used is chi square. There is a significant relationship between the accuracy of diagnosis reselection and PDR diagnosis codes with INA-CBG health insurance financing (p-Value 0.000<0.005).
EVALUASI PENERAPAN DAN PENGGUNAAN SISTEM DENPASAR INFO RESPON CEPAT KESEHATAN DENGAN END USER COMPUTING SATISFACTION MODEL DALAM UPAYA PENINGKATAN SISTEM INFORMASI KESEHATAN DI DINAS KESEHATAN KOTA DENPASAR
To determine the level of satisfaction and better acceptance of the use of the Denpasar fast response health information (DIRECK) system, So it is necessary to carry out an evaluation of the DIRECK system. This is because the DIRECK system is a health information system that is used for decision making. This type of research uses the end user computing satisfaction (EUCS) method for the DIRECK system evaluation process, which includes the dimensions of content, format, accuracy, timelines, ease of use. Where this research was carried out using a descriptive qualitative approach, as well as a sampling technique using purposive sampling and also data saturation, there were five informants in this research. From the results of interviews with the evaluation of the EUCS model, it was found that the user felt that the DIRECk system was in accordance with the user's wishes based on the content dimension, but the content dimension still required additions such as indicators for recording P4K reports and indicators such as recovery rates or adding follow-up LOS numbers. Then from the dimensions of the format, users also find it suitable because there is a dashboard that helps the user's work. Furthermore, from the accuracy dimension, users feel that the system is accurate in storing and managing information. And from the timeliness dimension, users feel the system is timely in displaying and managing data. And finally, based on the ease of use dimension, users feel that the DIRECK system is easy to understand and use. Based on the evaluation of the DIRECK system with the EUCS model, it was found that users felt that the DIRECK system was in accordance with the user's wishes.
EVALUASI PENERAPAN REKAM MEDIS ELEKTRONIK RAWAT JALAN DI RSAD TK II UDAYANA DENGAN METODE TECHNOLOGY ACCEPTANCE MODEL (TAM) TAHUN 2024
RSAD TK II Udayana has implemented RME since 2022 and has never carried out an evaluation of the implementation of RME since then. The impacts that occur if you have not evaluated the implementation of RME are a decrease in service quality, potential violations of regulations related to privacy and security of patient data, an increase in long-term operational costs. Based on preliminary studies, the implementation of RME at RSAD TK II Udayana is still in the adjustment stage. Because there are still several obstacles in implementing RME. These obstacles include the application not being optimal in meeting user needs, network limitations causing limited RME access. This study aims to evaluate the application of Electronic Medical Records using the Technology Acceptance Model (TAM) method. The aim of the TAM method is to find out how RME users perceive the usefulness aspect (Perceived Usefulness), the convenience aspect (Perceived to Use) and the behavioral interest aspect (Behavioral Intention to Use). This type of research uses descriptive qualitative, namely by narrating the research results based on the data obtained. The results of this research are based on the aspect of usefulness (Perceived Usefulness), namely that the use of outpatient electronic medical records at RSAD TK II Udayana is very useful for officers, making the officer's work complete more quickly, making work easier and increasing performance and productivity, based on the aspect of convenience (Perceived to Use). ) in receiving outpatient electronic medical records at RSAD TK II Udayana, it is considered easy to understand, quite flexible with the officer's work and easy to use to help the officer's work. Based on the interest aspect (behavioral intention to use) obtained, namely the officer shows interest in the RME system and plans to use it. system in the future. Officers also hope that in the future they can fully use electronics
STUDI KUALITATIF PENYEBAB KETIDAKLENGKAPAN REKAM MEDIS PASIEN DI KLINIK TA DENPASAR
Rekam medis adalah dokumen penting bagi fasilitas pelayanan kesehatan, karena segala bentuk informasi terkait tindakan dan pengobatan tercantum dalam rekam medis. Berbagai permasalahan yang terjadi, jika dalam pengisian rekam medis tidak dilakukan secara konsisten dan benar. Klinik TA merupakan salah satu klinik milik swasta yang berada di Denpasar. Hasil studi pendahuluan dengan kordinator klinik, menunjukan bahwa rekam medis di klinik tersebut masih sangat minim sekali pengaturannya, sehingga saat akreditasi tim klinik agak sedikit kesulitan menyiapkannya. Manfaat penelitian ini yaitu sebagai bahan masukan dan evaluasi bagi dokter, perawat dan pimpinan klinik terjadap pentingnya kelengkapan berkas rekam medis pasien di klinik TA. Metode penelitian yang digunakan adalah kualitatif dengan case study. Berdasarkan hasil observasi dokumen rekam medis, ditemukan bahwa belum mempunyai formulir Unit Gawat Darurat (UGD). Pada rekam medis rawat inap terdapat kekurangan formulir yaitu pelayanan lain yang dilakukan oleh tenaga kesehatan tertentu dan formulir kematian. Selian itu, klinik TA belum memiliki SOP pengadaan dan pemusnahan rekam medis. Petugas tidak memiliki buku ekspedisi sebagai alat untuk menegndalikan berkas keluar atau dipinjam. Rekam medis di klinik TA belum elektronik. Adapun simpulan hasil penelitian yaitu ketidaklengakapan rekam medis pasien disebabkan oleh 5M yaitu man, money, methode, machine, dan material. Terdapat faktor penyebab lain yaitu dukungan pimpinan yang kurang terhadap proses rekam medis pasien di Klinik TA.
Perancangan Tracer Rekam Medis di Rumah Sakit Prima Husada Malang
Penelitian ini menggunakan rancangan studi kasus, merupakan jenis rancangan penelitian yang mencakup pengkajian satu unit penelitian secara intensif. Populasi pada penelitian ini terdapat 6 staff unit kerja rekam medis dan pendaftaran. Sampel pada penelitian ini adalah staf unit kerja rekam medis di Rumah Sakit Prima Husada Malang. Adapun jumlah sampel dalam penelitian ditentukan menggunakan teknik purposive sampling dimana sampel sumber data adalah seluruh staf yang bertugas pada unit rekam medis di rumah sakit Prima Husada Malang. Sedangkan prosedur penelitian menggunakan tiga tahap yaitu tahap persiapan, tahap pengumpulan data dan tahap pengolahan serta penulisan data. Berdasarkan hasil wawancara, staff Rumah Sakit Prima Husada Malang mengetahui kegunaan tracer dan memiliki SOP dengan fungsi berkas rekam medis sehingga perancangan tracer diperlukan yang terdiri dari alternative I, II, dan III. Hasilnya, yang digunakan sebagai perancangan adalah tracer alternative 1 karena ukurannya yang Panjang yaitu 30x15cm, warna yang kontras, dan menggunakan bahan yang tebal
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ANALISIS KEAKURATAN KODE DIAGNOSIS PADA KASUS TUBERKULOSIS BERDASARKAN ICD 10 DI RUMAH SAKIT PRIMA MEDIKA
Pengkodean diagnosis penyakit di RSU Prima Medika dilakukan terpisah antara pelayanan rawat inap dan rawat jalan. Berdasarkan hasil studi pendahuluan dari total sampel 30 rekam medis dengan diagnosis Tuberkulosis terdapat 11 rekam medis dengan kode diagnosis yang tidak tepat dan 19 rekam medis yang tepat. Penelitian ini bertujuan menganalisis ketepatan kode diagnosis pada kasus Tuberkulosis berdasarkan ICD 10 di RSU Prima Medika Tahun 2022 menggunakan metode analisis 5M. Jenis penelitian ini menggunakan analisis kualitatif yaitu dengan menarasikan hasil penelitian berdasarkan data - data yang didapatkan. Informan pada penelitian ini berjumlah 5 orang dan data pendukung 30 rekam medis. Berdasarkan hasil penelitian diketahui berdasarkan unsur Man diketahui koding diagnosa sudah dilakukan oleh koder untuk pelayanan rawat inap, sedangkan untuk rawat jalan masih dilakukan oleh perawat. Berdasarkan unsur metode bagian rekam medis sudah memiliki SPO Koding, namun belum pernah dilakukan sosialisasi SPO. Berdasarkan unsur machine, untuk koding rawat inap sudah menggunakan ICD 10 dan SIMRS tetapi untuk rawat inap hanya menggunakan pedoman kode ICD 10 dan SIMRS. Berdasarkan unsur machine pelayanan rawat inap maupun rawat jalan menggunakan rekam medis elektronik dan rekam medis konvensional. Berdasarkan unsur money diketahui bahwa petugas belum mengikuti pelatihan khusus terkait kodefikasi diagnosis. Disimpulkan berdasarkan hasil analisis 5M terhadap ketepatan kode diagnosis tuberculosis diketahui bahwa yang menjadi penyebab ketidaktepatan kode diagnosis dari berasal dari unsur Man, Metode, Machine, Material dan Money.
Analisis Kuantitatif Dan Kualitatif Kelengkapan Rekam Medis Pasien Rawat Inap Kasus Pneumonia Di Rumah Sakit Daerah Mangusada Kabupaten Badung-Bangli
Pneumonia was the first disease of top ten disease of inpatients aat Mangusada Regional Hospital in Badung Regency in 2019 with a total of 1,369 patients. The purpose of this study was analysed the inpatient medical records(MR) of pneumonia patients in Mangusada Regional Hospital in Badung Regency in 2019 both quantitatively and qualitatively. This type of research is quantitative with approach cross sectional with data collection techniques through observation and documentation. The population in this study was 342 MR of pneumonia patients, with a total sample of 100 MR. Data was analysed descriptively based on aspect of quantitative and qualitative completeness analysis. The results of the quantitative analysis of MR obtained the completeness of patient social data (demographic) was 7%, recording evidence was 40%, validity of the record was 35%, complete of recording procedure was 5%. As for the administrative qualitative analysis obtained the completness, namely the clarity of the problem and condition or diagnosis was 49%, consistent input was 83%, the reasons for service was 100%, the review of records was 6%, approval of medical action (Informed Consent) was 100% and maintenance fee 100%. Based on the results of quantitative and qualitative analysis on each form shows that all medical records are declared incomplete.
Analisis Faktor Penyebab Pengembalian Berkas Klaim BPJS Kesehatan Pasien Rawat Inap Di RSUD Tabanan
Return of claim files is one of the requirements for claim files that are declared incomplete by the BPJS. The results of initial observations in October - December 2022 showed that 2,833 claim files were submitted and 165 files were not accepted so they were returned. This study aims to determine the relationship between membership administration factors, service administration factors and health service administration factors on the return of BPJS Health claims. The research design used in this research is quantitative with a cross sectional research type. Methods of data collection by observation and checklist. The sample in this study was 96 BPJS claim files for inpatients in October 2022 – April 2023. The research results obtained were from 65 claims that were not returned and 31 were returned, showing a relationship between membership administration factors, service administration factors and health service administration factors on the return of BPJS Health claims with a p value = 0.0001. The conclusion from this study is that the membership administration, service and health care factors greatly influence the return of BPJS Health claims for inpatients. The advice given is that it is hoped that officers will pay more attention to the suitability of BPJS health claims so that they can improve the quality of the hospital. Keyword : File Return, BPJS Claims
Pengendalian Persedian Obat (Drug Inventory Control) di Rumah Sakit pada Masa Non Pandemi (Sebuah Tinjauan Literatur)
The supply chain and inventory of drug in hospitals is critical because it concerns aspects of the quality and availability of health services for patients. This research seeks to review 15 publications related to controlling drug supplies in hospitals. The findings showed that in terms of drug inventory control the main orientation is to minimize costs and prevent stock that does not meet needs. In existing cases, drug inventory control is managed independently by the hospital alone or by creating an integrated system with parties outside the hospital. Modeling of drug inventory control can form non-linear programming, mixed integer linear programming or Markov chain models. The process of solving drug inventory control problems can be done analytically, heuristically or by simulation depend on the case and system being handled.
ANALISIS FAKTOR-FAKTOR YANG MEMENGARUHI KETIDAKAKURATAN KODE DIAGNOSIS PENYAKIT RAWAT JALAN DI PUSKESMAS PANDANWANGI KOTA MALANG
The accuracy of the patient's disease diagnosis code has an important role in the smooth running of health services. An inaccurate code will have an impact on reporting and quality of service to patients because it has a low level of data validation. The inaccuracy of disease diagnosis codes is influenced by several factors according to the conditions of the health care facility. This research uses a type of quantitative research with a descriptive approach. This study aims to analyze the level of accuracy and inaccuracy of disease diagnosis codes and the factors that influence the inaccuracy of disease diagnosis codes at the Puskesmas Pandanwangi which include coding officers, completeness of medical record documents, coding policies and facilities infrastructure. The population in this study were 4702 medical record documents with a total sample of 98 medical record documents. How to collect data by observing and interviewing. The results showed that the percentage of accuracy of the disease diagnosis code was 40,8% (40 files) and the percentage of inaccuracy was 59,2% (58 files). The factors that influence it are that the coding officer in general poly is still carried out by doctors and nurses, all coding officers have never attended coding training, the work experience of coding officers is around 3 years, the completeness of medical record documents is not yet 100% complete, the use of SOP and ICD-10 has not been used optimally, and there has been no decree on the determination of the coding officer and the English dictionary to translate foreign words.
FAKTOR-FAKTOR YANG MEMPENGARUHI SIKAP PERAWAT RAWAT INAP TERHADAP PERALIHAN REKAM MEDIS KONVENSIONAL KE REKAM MEDIS ELEKTRONIK (RME) DI RSUD KABUPATEN KLUNGKUNG
Nurses are the largest potential group of RME users in healthcare facilities, therefore it is very important to understand nurses' interaction with RME and its subsequent impact on nurses' activities and routines. Nurses being the largest part of the health workforce, nurses' attitudes towards computer use are likely to have a major impact on the process of implementing information technology systems in health services. This type of research is observational analytic with a quantitative approach. The study population was inpatient nurses who served at Klungkung Regency Hospital with a total of 189 nurses. The sample in this study amounted to 120 respondents taken by purposive sampling. Data collection was carried out by distributing questionnaires filled in by nurses. Data analysis using univariate analysis and bivariate analysis. The results showed that there were 4 factors that influenced nurses' attitudes in switching conventional medical records to electronic medical records (RME), namely perceived usefulness (p-v=0.000), perceived convenience (p-v=0.000), social influence (p-v=0.000). And facilitating conditions (p-value=0.000). Age, gender, employment status, and nurse education do not moderate the relationship between perceived usefulness, perceived convenience, social influence and facilitating conditions on attitudes towards using RME.
PEMANFAATAN APLIKASI MY HOSPITAL X UNTUK PROSES RETENSI REKAM MEDIS DI RUMAH SAKIT WANGAYA DENPASAR
RSUD Wangaya saat ini masih belum memiliki sistem retensi khususnya belum adanya sistem yang dapat membantu petugas rekam medis dalam pemindahan rekam medis aktif menjadi rekam medis in-aktif serta memungkinkan untuk dilakukan pemilahan formulir. Penelitian ini bertujuan untuk mengetahui pemanfaatan Aplikasi My Hospital X untuk proses retensi rekam medis di RSUD Wangaya. Rancangan penelitian ini adalah pengembangan dengan menggunakan Desain Eksperimental untuk implementasi teknis menggunakan Balsamiq dan Visio. Hasil perancangan menunjukkan bahwa rancangan fungsional dari diagram konteks, Data Flow Diagram (DFD), Entity Relationship Diagram (ERD) serta implementasi antar muka. Simpulan dari penelitian ini Rumah sakit harus melakukan retensi rekam medis untuk mengurangi jumlah arsip rekam medis yang terus bertambah. Dengan adanya sistem retensi memudahkan untuk dapat memilah berkas rekam medis yang akan dilakukukan retensi.
GAMBARAN PROSES IMPLEMENTASI REKAM MEDIS ELEKTRONIK DI UNIT RAWAT JALAN DENGAN METODE HOT-FIT DI RUMAH SAKIT UMUM ARI CANTI
Electronic medical records are very important to overcome various problems that often occur in hospitals such as the loss of medical records, large storage areas, and PERMENKES Republik Indonesia Number 24 of 2022 concerning Medical Records, Article 45 states that all health service facilities hold electronic medical records in accordance with the provisions in this ministerial regulation no later than December 31, 2023. At Ari Canti General Hospital there are no complaints related to services, but Ari Canti General Hospital is still semi-medical records. An electronic medical record is a version of a paper medical record that is made electronic. Barriers to the implementation of electronic medical records in hospitals include 4 aspects including human resources (HR), policies and regulations, infrastructure and costs, This study aims to describe the process of implementing electronic medical records with the Hot-Fit model. This model places important components in information systems, namely Human, Organization and Technology and Net-benefit. The result of this study is that there is a significant relationship between human, organizational, and technological components to net-benefit.