Fitur-Fitur RME - Handout

Fitur-Fitur
Rekam Medis Elektronik
dr. Rano I Sudra, M.Kes

Health Information Management Consultant
Contoso
Pharmaceuticals
page 1
S3 – Candidate Doctor Ilmu Hukum (Hukum Kesehatan)

S2 – Magister Kesehatan (SIMKes) – UNDIP – 2003
S1 – FK UNDIP – 1992
Konsultan Rekam Medis & Manajemen Informasi Kesehatan
Pengurus DPP MHKI (Masyarakat Hukum Kesehatan Indonesia)
Pengurus DPW MHKI Jateng
Konsultan Akademik beberapa Perguruan Tinggi
Dosen bidang RMIK (D3, D4, S1)
Dosen S2 SIMKES & S2 Hukum Kesehatan
dr. Rano I Sudra, M.Kes Reviewer dan Editor Jurnal Hukum Kesehatan Indonesia (JHKI)
Reviewer Jurnal Manajemen Informasi & Administrasi Kesehatan (JMIAK)
rano.indradi@gmail.com
08112702894 Narasumber berbagai seminar & pelatihan bidang RMIK
Penulis buku Rekam Medis & Manajemen Informasi Kesehatan
Pemilik & Pengelola RanoCenter
2
dr. Rano I Sudra, M.Kes
• Sudra, Rano I. 2020. Harmonization of Regulations Related to the Medical Record

Retention Period. 2nd International Conference on Law, Economic, and Health (ICLEH).
• Sudra, Rano I. 2020. Legal Certainty Regarding Electronic Medical Record
Retention Period. 2nd International Scientific Meeting on Health Information
Management (ISMoHIM).
• Kumala, Ratih; Sudra, Rano I. 2020. Analysis of “Do Not Resuscitate” Form Design.
2nd International Scientific Meeting on Health Information Management (ISMoHIM).
• Sudra, Rano I, 2020. The Urgency of Regulatory Needs Regarding Standardization
of Documentation in Electronic Medical Records. International Conference of Law,
Publikasi Government, and Social Sciences (ICoLGAS).
• Sudra, Rano I, 2020. Patient Access Rights in the Electronic Medical Record System
(Case Study on Electronic Medical Record Trainee Hospital). International
Conference of Public Health for Tropical and Coastal Development (ICoPH-TCD).
• Sudra, Rano I, 2020. Certainty of Information in News Related to COVID-19 (case
study on reporting of active COVID-19 case in Semarang). International Conference :
Democracy in Digital Era.
• Sudra, Rano I, 2020. Standardisasi Resume Medis Sebagai Langkah Pelaksanaan
Permenkes Nomor 21 Tahun 2020 Terkait Pertukaran Data Dalam Rekam Medis
Elektronik.
3
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5
An electronic health record

is not a simple replacement
of the paper record.
6
What are Electronic Medical Records?
The IOM 2003 Patient Safety Report describes an EMR as
encompassing:
• “a longitudinal collection of electronic health information for

and about persons
• Immediate electronic access to person- and population-level

information by authorized users;
• Provision of knowledge and decision-support systems that

enhance the quality, safety, and efficiency of patient care and
• Support for efficient processes for health care delivery.”
7
Health
ITC Management
Law
8
Kemana arah
pengembangan RME
di Indonesia ???
Contoso
Pharmaceuticals
page 9
10
Privacy & Security Standardization
KPIs CDI
Anonymization/ Information
De-Identification Governance
Cloud Storage Retention
Audit Trail RoI/ HIE

Contoso
Kebutuhan Regulasi Pharmaceuticals
Standardisasi Healthcare
CDI Data Analitycs
Regulasi Pemberdayaan Human

Pasien (Stake Aspects
holder)
Tantangan & Peluang Contoso

Dalam Digitalisasi Rekam Medis Pharmaceuticals
Berbagai Aspek Terkait
Digitalisasi Rekam Medis
13
Rekam Medis Elektronik

tidak sekedar
memindahkan
dari kertas ke layar. Rekam Medis Elektronik
(RME)
Contoso
Pharmaceuticals
page 14
15
Karakteristik RME
Akses simultan dari berbagai tempat
Dapat dilihat dari berbagai pendekatan
Data entry lebih terstruktur
Sistem pendukung keputusan
Mempermudah analisis data
Mendukung data sharing
Dapat bersifat multimedia
16
Fitur Dasar RME
Availability
Confidentiality
Disaster recovery
Quality (AC2IR4A)
17
Fitur Dasar RME

Availability
Confidentiality
Disaster recovery
Quality (AC2IR4A)
18
19
Lengkap saja tidak cukup !

Butuh
AC2IR4A
20
Fitur Penunjang RME
Lengkap & akurat
(complete & accurate patient data),
Sistem peringatan & pengingat klinis
(clinical reminders & alerts system),
Sistem penunjang pengambilan keputusan

(decision support system),
Keterkaitan dengan sistem penyedia basis
data pengetahuan atau data yang terkait
(related data & knowledge bases links).
21
Kita membutuhkan RME

(Rekam Medis Elektronik)
Bukan MKE
(Mesin Ketik Elektronik)
22
Mutu RMIK
23
Fitur Penting RME
Contoso
Pharmaceuticals
rano.indradi@gmail.com page 24
Fitur Penting RME
• ITC
• Bar code, QR • Alert & Warning system
• Finger print • Double order
• E-sign • Alergy
• scan • Contra indication
• Transcription • Drug interaction
• Abstraction
(Discharge Summary)
25
26
27
28
29
30
Fitur Penting RME
• User reminder • Audit trail
• Completion • Access
• Messages • Changed, completion
• Lab results • Delete
• Retention • Copy, print
• Deletion • Backup
• Not yet • Labeling of printed report
• Never (water marking)
• Secure
31
Fitur Penting RME

• Communication • Encription
• RoI, HIE • Office hour
• Retrieval, viewing & • Idle time
distribution
• Automatic log-out
• Copy
• CD, UFD
• BT, WiFi
• Copy-Paste
• Screen capture
32
Fitur Penting RME
• Anonimity • Coding system
• Correction methode • Automatic coding
• Computer guided
• Completion methode &
deficiency management • Indexing
• E-sign
33
Fitur Penting RME

• Input Validation • Information visualization
• Data processing • Table
• Indicator/ KPIs • Naration
• Charts
• Data mining
• Dashboard
34
Smart Internal-Check
Jenis kelamin Kondisi Pasien
Rwyt Mens
(L/P atau P/W)
Status Gyn Rwyt alergi obat Indikasi

Tindakan
Umur
Dx Jenis & BSO Kontra Indikasi
(hr/bl/ th)
Kodefikasi Interaksi Obat
Pendidikan
Pekerjaan BB
TB/PB Dosis
(g/ kg)
(cm/ m)
35
page 36
Siapkan Kebutuhan Output-nya Dulu
• Kebutuhan informasi setiap
stake holder
• Narasi, single text, table, grafik,
GIS, dashboard, dll Need assessment
• Periode: terjadwal, insidentil
• Media: layar, kertas (fitur printout)
• Abstraction
• Anonimitas FGD
• Kebutuhan pelaporan eksternal stake holder
• Kebutuhan konektivitas &
interoperabilitas
page 37
Standardisasi
Contoso
Pharmaceuticals
page 38
Standards Relevant to Health Data
• Data Standards
• Information Content Standards
• Information Exchange Standards
• Entity/Person Identifiers Standards
• Privacy and Security Standards
• (Functional Standards; Business Requirements)
Source: Public Health Data Standards Consortium; http://www.phdsc.org/; Accessed: June 3, 2012
39
Data Standards • Disease Classification

• Drugs Classification
• Laboratory Data Standards
• Digital Images
• Medicinal Products, Pharmaceutical Doses,
Units, Common Terminology Services
Examples only
(non exhaustive list)
40
Data Standards • Clinical Procedure Terminology
• Pharmacy Terminology
• Nursing/HRH Terminology
• Payer Terminology
• Financial/Business Transactions Terminology
• Units of Measurements
Examples only
41
Information • Healthcare Content

• Public Health Card
Content
• Medical Device Communication
Standards
Examples only
42
Information • Digital Images
• Pharmacy Business Transactions
Exchange
• Country-specific Mandated Transactions
Standards Terminology
• Financial/Business Transactions Terminology
Examples only
43
Entity/Person • Patient Identifier

• Provider Identifier
Identifier • Employer Identification Number
Standards • Country Identifier
• Health (Insurance) Card Issuer Identifier
Examples only
44
Information • Standard Generalized Markup Language
(SGML) ISO 8879:1986
Technology • HyperText Markup Language (HTML)
Standards ISO 8859-1
• Extensible Markup Language (XML)
• Simple Object Access Protocol (SOAP)
ISO/IEC 40210:2011
Examples only
45
Privacy and • Anonymization and

Security Pseudonymization
Standards Standards
• Security Standards
• Confidentiality Standards
• Patient Consent Standards
• Data Audit Trails
Examples only
page 46
Anonimitas
Informasi terkait identitas :
1. Nama
2. Alamat (nama jalan, kota, desa, RT, RW)
3. Tanggal terkait individu (tgl lahir, admisi, keluar RS/ kematian)
4. Usia (diatas 89, atau sesuai ketentuan berlaku)
5. Nomor telepon
6. Nomor fax
7. Alamat email
8. Nomor Induk Kependudukan (NIK)
47
Anonimitas (lanjutan) :
9. Nomor rekam medis
10. Nomor asurasi
11. Nomor akun/ keanggotaan
12. Nomor sertifikat/ lisensi
13. Nomor dan jenis kendaraan
14. Identitas alat yang digunakan/ nomor seri
15. Alamat Universal resource locations (URL's)
16. Alamat Internet protocol addresses (IP's)
17. Identitas biometrik (sidik jari, warna mata, pola suara, pola wajah, dsb)
18. Foto wajah, termasuk gambar yang bisa dibandingkan
19. Semua nomor identitas unik, karakteristik, atau kode lainnya
48
Standardisasi
Text, Istilah
Gambar,
Diagnosis,
Suara, Format
Video, dsb Singkatan Tindakan,
data Obat,
dsb
TT, LD, HP,
Perinatal,
Neonatal,
Proses/
Pasien RI, Simbol
Keluar, dsb Rumus Hasil pemeriksaan
fisik, Lab, Farmasi,
dsb
Satuan
49
page 50
page 51
page 52
page 53
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57
Teknologi
bukan PESAING
(jangan bersaing),
tapi PENDAMPING karir
(mari bersanding). Takeaway
Messages
Education
is an investement.
Contoso
Pharmaceuticals
page 58
Terima Kasih
dr. Rano Indradi S, M.Kes
08112702894
Contoso
Pharmaceuticals
page 59

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Fitur-Fitur

Rekam Medis Elektronik

dr. Rano I Sudra, M.Kes

S3 – Candidate Doctor Ilmu Hukum (Hukum Kesehatan)

• Sudra, Rano I. 2020. Harmonization of Regulations Related to the Medical Record

An electronic health record

• “a longitudinal collection of electronic health information for

• Immediate electronic access to person- and population-level

• Provision of knowledge and decision-support systems that

• Support for efficient processes for health care delivery.”

Cloud Storage Retention

Audit Trail RoI/ HIE

Regulasi Pemberdayaan Human

Tantangan & Peluang Contoso

Rekam Medis Elektronik

Fitur Dasar RME

Lengkap saja tidak cukup !

Sistem penunjang pengambilan keputusan

Kita membutuhkan RME

Fitur Penting RME

Fitur Penting RME

Fitur Penting RME

Status Gyn Rwyt alergi obat Indikasi

Kodefikasi Interaksi Obat

Data Standards • Disease Classification

Information • Healthcare Content

Entity/Person • Patient Identifier

Privacy and • Anonymization and

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