Development of Electronic Health Record System Functionality through the Creation of a Central Surgery Module
Downloads
With the advancement of health technology, the use of Electronic Health Records (EHR) systems has become crucial in improving the efficiency and quality of services in various hospital units. However, the adoption of EHR systems is still uneven, especially in developing countries, including Indonesia. At the Pekanbaru Military Hospital, several departments have successfully implemented EHR systems, but the surgical department still uses a paper-based system for medical record keeping. Challenges faced include a lack of infrastructure and technical support. Therefore, the development of a central surgery module within the EHR system at Pekanbaru Military Hospital is necessary to enhance the efficiency and accuracy of medical record-keeping. This study aims to enhance the functionality of the EHR system in managing medical records in the surgical department by developing a central surgery module at the Pekanbaru Military Hospital. The software development methodology used in this study is the Agile model, which includes user requirements analysis, data collection, system implementation, as well as evaluation and validation. The Central Surgery Module that has been developed includes various features such as patient registration for surgery, recording of pre-operative, intra-operative, and post-operative patient data, surgical reports, and integration with laboratory and radiology systems. Through testing conducted using the black box testing technique, the results showed that 93.48% of the system functionality worked well, and using the User Acceptance Testing technique, it was found that 92.5% of the system functionality was acceptable to users.
Emanuel, A. W. R. (2019). Challenges and Proposed Model in Implementing Integrated Medical Record Systems in Indonesia. International Journal of Advanced Science and Technology, 130, 1–10. https://doi.org/10.33832/ijast.2019.130.01
Evans, R. S. (2016). Electronic Health Records: Then, Now, and in the Future. Yearbook of Medical Informatics, S48–S61. https://doi.org/10.15265/IYS-2016-s006
Gianfrancesco, M. A., & Goldstein, N. D. (2021). A narrative review on the validity of electronic health record-based research in epidemiology. In BMC Medical Research Methodology (Vol. 21, Issue 1). BioMed Central Ltd. https://doi.org/10.1186/s12874-021-01416-5
Hreha, K. P., Fisher, S. R., Reistetter, T. A., Ottenbacher, K., Haas, A., Li, C. Y., Ehrlich, J. R., Whitaker, D. B., & Whitson, H. E. (2020). Use of the ICD-10 vision codes to study ocular conditions in Medicare beneficiaries with stroke. BMC Health Services Research, 20(1). https://doi.org/10.1186/s12913-020-05484-z
Jilcha Sileyew, K. (2020). Research Design and Methodology. In Cyberspace. IntechOpen. https://doi.org/10.5772/intechopen.85731
Jung, S. Y., Lee, K., Lee, H. Y., & Hwang, H. (2020). Barriers and facilitators to implementation of nationwide electronic health records in the Russian Far East: A qualitative analysis. International Journal of Medical Informatics, 143. https://doi.org/10.1016/j.ijmedinf.2020.104244
Li, E., Clarke, J., Ashrafian, H., Darzi, A., & Neves, A. L. (2022). The Impact of Electronic Health Record Interoperability on Safety and Quality of Care in High-Income Countries: Systematic Review. In Journal of Medical Internet Research (Vol. 24, Issue 9). JMIR Publications Inc. https://doi.org/10.2196/38144
Liu, Z. Y., & Edye, M. (2020). Implementation of electronic health records systems in surgical units and its impact on performance. ANZ Journal of Surgery, 90(10), 1938–1942. https://doi.org/10.1111/ans.15350
Messina, A. G., Wang, M., Ward, M. J., Wilker, C. C., Smith, B. B., Vezina, D. P., & Pace, N. L. (2016). Anaesthetic interventions for prevention of awareness during surgery. In Cochrane Database of Systematic Reviews (Vol. 2016, Issue 10). John Wiley and Sons Ltd. https://doi.org/10.1002/14651858.CD007272.pub2
Oumer, A., Muhye, A., Dagne, I., Ishak, N., Ale, A., & Bekele, A. (2021). Utilization, Determinants, and Prospects of Electronic Medical Records in Ethiopia. BioMed Research International, 2021. https://doi.org/10.1155/2021/2230618
Outland, B., Newman, M. M., & William, M. J. (2015). Health policy basics: Implementation of the international classification of disease, 10th revision. Annals of Internal Medicine, 163(7), 554–556. https://doi.org/10.7326/M15-1933
Rahmathulla, G., Deen, H. G., Dokken, J. A., Pirris, S. M., Pichelmann, M. A., Nottmeier, E. W., Reimer, R., & Wharen, R. E. (2014). Implementation and impact of ICD-10 (Part II). Surgical Neurology International, 5(SUPPL. 3). https://doi.org/10.4103/2152-7806.137182
Schramm, V. B., Damasceno, A. C., & Schramm, F. (2023). SUPPORTING THE CHOICE OF THE BEST-FIT AGILE MODEL USING FITRADEOFF. Pesquisa Operacional, 43(spe1). https://doi.org/10.1590/0101-7438.2023.043spe1.00264750
Seu, M., Cho, B. H., Pigott, R., Sarmiento, S., Pedreira, R., Bhat, D., & Sacks, J. (2020). Trends and Perceptions of Electronic Health Record Usage among Plastic Surgeons. Plastic and Reconstructive Surgery - Global Open, 8(4). https://doi.org/10.1097/GOX.0000000000002709
Sharma, S., Sarkar, D., & Gupta, D. (2012). Agile Processes and Methodologies: A Conceptual Study. International Journal on Computer Science and Engineering, 4(5), 892–898.
Sohal, K. S., & Shubi, F. (2015). Early Post-Operative Complications in Surgeries Pertaining Oral and Maxillofacial Region in MNH, Tanzania. Surgical Science, 06(10), 470–477. https://doi.org/10.4236/ss.2015.610068
Standar nasional akreditasi rumah sakit (1st ed.). (2017). Komisi Akreditasi Rumah Sakit.
Tilaar, T. S., & Sewu, P. L. S. (2023). Review of Electronic Medical Records in Indonesia and its Developments Based on Legal Regulations in Indonesia and its Harmonization with Electronic Health Records (Manual for Developing Countries). Daengku: Journal of Humanities and Social Sciences Innovation, 3(3), 422–430. https://doi.org/10.35877/454RI.daengku1662
Topaz, M., Shafran-Topaz, L., & Bowles, K. H. (2013). ICD-9 to ICD-10: evolution, revolution, and current debates in the United States. Perspectives in Health Information Management, 10(Spring), 1d. http://www.ncbi.nlm.nih.gov/pubmed/23805064
Wang, C. K., Wang, F. D., Lee, Y. Q., Chen, P. T., Wang, B. H., Su, C. H., Kuo, J. C. C., Wu, C. S., Chien, Y. L., Dai, H. J., Tseng, V. S., & Hsu, W. L. (2022). Principle-Based Approach for the De-Identification of Code-Mixed Electronic Health Records. IEEE Access, 10, 22875–22885. https://doi.org/10.1109/ACCESS.2022.3148396
Woldemariam, M. T., & Jimma, W. (2023). Adoption of electronic health record systems to enhance the quality of healthcare in low-income countries: A systematic review. BMJ Health and Care Informatics, 30(1). https://doi.org/10.1136/bmjhci-2022-100704
Yang, P., Cao, Y., Liu, D., Bai, Y., Pan, F., & Xu, Y. (2014). The effect of electronic medical record application on the length of stay in a Chinese general hospital: a department- and disease-focused interrupted time-series study. Journal of Medical Systems, 38(5). https://doi.org/10.1007/s10916-014-0053-x