EHR 2 Support and Continuity of EHR implementation

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Support and Continuity of EHR implementation

Guardian Y. Sanjaya gysanjaya.blog.ugm.ac.id

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Outline

• Konsep EHR di fasilitas pelayanan kesehatan

• Kunci sukses implementasi EHR

• Penguatan EHR di fasilitas pelayanan kesehatan

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Organizational model of healthcare services

Essential Public Health management function

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IT sebagai strategi

• To support business and clinical decisions

• To make effective use of emerging technologies

• To enhance organization’s image

• To promote satisfaction of market and regulatory requirements

• To be cost‐effective

• To provide a safer environment for customer

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Penerapan IS/IT melalui kosep EHR

• An EHR is a computerized health record used to capture, store, access and share summary information for a patient between health‐care organizations and providers.

• Examples of information include demographics, medical history, medication and allergies, immunizations, discharge summaries and other summary information.

• Typically, EHRs are developed to support the provision of care across health‐sector or geographical boundaries. They may also be used by individuals and their caregivers to take a more active role in the

management of their own health.

WHO‐ITU. 2012. National eHealth Strategy Toolkit

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Tujuan Penggunaan EHR

• Tujuan Primer

• Ketersediaan informasi yang sifatnya longitudinal

• Komunikasi antar provider terkait patient care

• Tujuan Sekunder

• Medikolegal

• Quality management

• Education

• Research

• Public and population health

• Policy development

• Health service management, billing, finance and reimbursment

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PELAYANAN PASIEN MASUK -Registrasi -Admisi masuk -Scheduling dan appointment

Sarana Pelayanan Rekam Medis. Ex. Pelaporan Rutin

Sarana Pelayanan Perencanaan dan Pengelolaan Anggaran. Ex: Pengadaan Sarana Pelayanan Supply chain: Ex: obat dan perbekalan kesehatan Sarana Pelayanan Aset dan inventori barang

Sarana pelayanan keuangan dan akuntansi Sarana pelayanan sumber daya manusia

Kegiatan Utama

PELAYANAN MEDIS

•Rawat Inap

•Rawat Jalan

•IGD

•Layanan Khusus (Kanker, Stroke, Jantung, dll)

PEMERIKSAAN PENUNJANG MEDIS

•Patologi Klinis

•Radio- diagnostic

•Patologi Anatomi

•Forensik

PENATALAK- SANAAN MEDIS

•Operasi

•Persalinan

•Rehabilitasi medis

•Pemberian obat-obatan (Farmasi)

PELAYANAN PASIEN KELUAR

•Billing

•Resume Medis

•Klaim

NILAI TAMBAH

¾Cepat

¾Efisien

¾Kualitas Kegiatan Pendukung

Identifikasi proses bisnis di Fasilitas Kesehatan

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Registrasi Admisi Rawat Jalan

Rawat Inap Laboratorium Kamar Operasi

Discharge Radiologi

Registrasi Admisi Manajemen

Bed

Dokumentasi Klinis, Order Entri, Clinical Decision Support Systems

Pharmacy Information

System Billing System – Receivable System

Datawarehouse

Discharge Financial, Accounting & Budgeting

Supply Chain Management

Business Intelligence Clinical Intelligence

Front Office

Monitoring Perencanaan dan Penyerapan Anggaran melalui proses pengadaan

Back Office

Arsitektur sistem informasi di Rumah Sakit

Data Mining

Lab Information

System

Digital Imaging

System

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Key Success Factors of ICT

implementation in Healthcare

Organization

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Tantangan Penggunaan EHR

Jha et al, 2009. Use of electronic health records in U.S. hospitals.

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Yoon et al, 2012. Adoption of electronic health records in Korean tertiary teaching and general hospitals

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• Human Barriers (Healthcare Professionals)

• Financial Barriers (Money and Funding)

• Legal and Regulatory Barriers (Laws and Policies)

• Organizational Barriers (Hospital Management)

• Technical Barriers (Computers and IT)

• Professional Barriers (Working at Hospitals)

Khalifa, 2013. Procedia Computer Science

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Inokuchi R, et al, 2014. Motivations and barriers to implementing electronic health records and ED information systems in Japan

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Tantangan Adopsi & Implementasi EHR

Tantangan (Yoon et al. 2012; Jha et al. 2009) Isu

The amount of capital needed to purchase and implement an EHR system Biaya Investasi Uncertainty about return on the investment (ROI) in an EHR system Expected benefit Concerns about the ongoing cost of maintaining an EHR system Biaya Pemeliharaan Finding an EHR system that meets the organization’s needs Software

Resistance to implementation from physicians Sosio‐teknis

Lack of adequate IT staff SDM khusus IT

Concerns about lack of future support from vendors for upgrading and maintaining the system Kontrak Vendor

Concerns about illegal record tampering or “hacking” Keamanan

Lack of interoperable IT systems in the marketplace Pertukaran data

Concerns about inappropriate disclosure of patient information Keamanan

Disruption in clinical care during implementation Pelayanan

Resistance to implementation from other providers Socio‐teknis

Lack of capacity to select, contract for, and implement an EHR system Manajemen TI

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Faktor Pendukung Penggunaan EHR

Jha et al, 2009. Use of electronic health records in U.S. hospitals.

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Faktor Pendukung Penggunaan EHR

• Clinical documentation

• Shortened time for clinical documentation

• CPOE

• Shortened time for imaging and laboratory orders

• CDSS

• Improved medical safety

• Others

• Shortened time for overall medical care

• Improved access to previous patient information

• Improved providing explanations to patients

• Improved sharing patient information

Inokuchi R, et al, 2014. Motivations and barriers to implementing electronic health records and ED information systems in Japan

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Strengthening EHR in

Healthcare Organization

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eHealth framework

Governance and culture

IT committee

Organization structure

Organization culture

Partnerships (vendor, consultant)

Strategy and Investment

IT Strategic Planning

Financial Support

Capacity building

Service and application

HIS Services

Application

Standard

Infrastructure

Hardware

System architecture

Legislation, Policy

Regulation

User manual, guideline,

SOP

Workforce

IT Team

IT Champion

Users

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Kesuksesan Adopsi SIM Faskes

Lingkungan (Makro) Organisasi

Faskes (Meso)

Sistem Informasi

(Mikro)

Software, hardware, brainware Penggunaan SIM (pemeliharaan,

dukungan teknis) Manfaat SIM Pengguna SIM di Faskes Organisasi dan budaya kerja

Strategi implementasi SIM Kebijakan dan regulasi SIM Standar data dan pelayanan

Pembiayaan dan insentif

Tren pasar (teknologi, ekonomi, politik)

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Mikro Level

HIS Quality HIS Use

Makro Level Meso Level

Net Benefit

Healthcare Standard

Legislation, Policy, Governance

Funding, Incentive

Social, Political

& Economic Trends Implementation

Organization People

System Quality

Information Quality

Service Quality

Use

User Satisfaction

Productivity Access Care Quality

Benefit Evaluation Framework

Lau et al. 2012. Impact of electronic medical record on physician practice in office settings: a systematic review

Direct Influence

Direct Effect

Variabel Kesuksesan Adopsi SIM Faskes

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Micro Level (IT Unit, Application and Infrastructure)

• System quality factors

• EHR functional standard

• Compliance to terminology standard

• the availability of templates

• interface design, and

• technical performance

• Information quality factors

• the organization (IT Unit, activity and management)

• accuracy

• completeness and

• accessibility of the patient record

• Security, privacy and confidentiality of data

• Service quality factors

• Training

• Technical support

• System backup and

• Unexpected downtime

• Infrastructure and network

• Information retrieval (Datawarehouse to support decision making)

• Health information exchange

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Micro Level (Benefit)

• Use

• Intent (e.g. quality improvement versus record keeping)

• Actual strategies for optimal/appropriate use

• Usage patterns that emerged over time

• Satisfaction

• Ease of use,

• Better interaction

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Micro Level (Benefit)

• Care Quality

• patient safety,

• care effectiveness

• quality improvement

• guideline compliance

• Productivity

• care efficiency

• better coordination, and

• net cost including billing,

• Cost saving (staffing)

• maintenance costs

• Access

• Communication

• Patient acceptance

• Patient choice

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Meso Level (Health Care Organizatio

• People

• Personal characteristics and expectations such as prior EMR experience of the users

• Personal expectation (time investment in exchange for the benefits expected from the system)

• Roles and Responsibility (IT champions and staff participation, shift in tasks e.g. documentation by staff vs.

physicians)

• IT Staff (CIO, System analyst, network administrator, database administrator, help desk)

• Organization

• Strategy of EHR adoption

• Structure/processes and culture that supported EMR adoption/use

• EMR‐practice fit (e.g. hybrid EMR/paper systems), and

• EMR‐supported office and workflow design such as the placement of computer screens in consult rooms

• Implementation Factor

• Introduction of an EMR into the practice was planned and carried out as a priority project with dedicated time and resources (IT Strategic Planning)

• Maturity model of EHR adoption

• IT project management

• HIS‐Practice Fit

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Makro Level (Environment)

• Healthcare standard

• data content standard

• Established practice guidelines, and

• legal documentation requirements that affected EMR design/performance and user behaviours

• practice standards for clinical guidelines [60], professional scope of practice [32] and medico‐

legal requirements [55,56] that governed EMR use

• Funding and Incentive

• pay for performance and fee‐for‐service that encouraged EMR use and

• incentive programs in the form of subsidies to purchase/adopt EMR systems

• Legislation‐policy‐Governance

• Legislative act

• Regulation‐policy

• Government body

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Apa yang perlu diperkuat?

• Bagaimana tatakelola SIK yang diharapkan

• Apakah sudah memiliki komite TI? Apakah organisasi sudah memiliki fungsi CIO? Apakah pengambilan keputusan TI sudah mengikuti SIM Plan?Apakah ada standar tatakelola TI (SOP, Guideline)?

• Infrastruktur apa yang diperlukan?

• Apakah sudah memiliki data center? Jumlah komputer terpenuhi? Jaringan yang digunakan? Pengaturan keamanan (fisik)? Bagaimana dengan disaster plan?

• Aplikasi apa yang akan dipakai (ditambah)?

• Modul front office? Modul backoffice? Modul surveilans? Public portal?

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Governance and Culture

• IT committee

• Dibentuk untuk memastikan keterlibatan berbagai pihak (tidak berperan langsung)

• Lebih ke arah strategi politis (wakil direktur bidang tertentu, perwakilan bagian/program)

• Pengambil keputusan

• Top management

• Middle management: bagian keuangan, bagian Pelayanan, Penunjang Medis dan Komite Medis dan Keperawatan

• Low Management: Kepala ruang, Kepala Seksi

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Contoh tatakelola: Struktur Organisasi TI/SI

• Secara struktural, perlu unit yang menaungi sistem informasi (Di Bawah Bidang

Perencanaan).

• Memiliki tim khusus didedikasikan untuk penyelenggaraan SI di organisasi

Direktur Rumah Sakit

Bidang Perencanaan

Bidang Penunjang

Bidang Pelayanan

Seksi Informasi Manajemen dan

Humas

Seksi Medical Record dan Perencanaa

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Direktur Utama

Wadir Yan‐Medik Wadir Operasional

Wadir SDM &

Diklat

Wadir Keuangan&Aset

Ka. Unit SI/TI

Administrasi dan Logistik

DivisiData Center, Infrastruktur dan Jaringan

Divisi Analisa Kebutuhan dan desain

Divisi

Pengembangan Sistem Informasi

Divisi

Implementasi Sistem

Informasi

Divisi Analisis Data dan Informasi Komite SI/TI

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Struktur Organisasi Terkait Sistem Informasi

Functional IT leadership Group-wide IT Structure/architecture

CENTRALIZED DECENTRALIZED

Unresponsive No SBU ownership of systems

Doesn’t meet every SBU’s need

No SBU control of central

overheadcosts

Scale economics

Control standards Critical mass of skills

SBUs have ownership Users control IT priority

Responsive to SBU’s need

Excessive overall cost to group

Variable standards of IT competence Reinvention of wheels No synergy

Pooled experience Synergy

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Organization Culture

• Model kekeluargaan, kesetiaan dan tradisi

• Mementingkan keutuhan dan moral

Budaya Clan

• Dinamis, bersifat entrepreneur, dan kreatif

• Komitmen untuk bereksperimen dan berinovasi

Budaya Adhocracy

• Formal dan terstruktur

• Aturan‐aturan dan kebijakankebijakan formal mempersatukan organisasi

Budaya Hierarchy

• Berorientasi pada hasil/pencapaian

• Reputasi dan keberhasilan (share market)

Budaya Market

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Dokumen IT Plan: Rencana Strategis dan Road Map SI/TI

• Rencana organisasi dalam jangka waktu tertentu sebagai panduan dalam melakukan aktivitas dan operasional SI/TI

• Menggambarkan Misi, Visi dan Tujuan organisasi

• SI/TI sebagai bagian dari Renstra yang kemudian dijabarkan dalam

Road Map SIK

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Kenapa perlu SIM Plan

• Rumah sakit merupakan “Information intensive domain”

• Penggunaan TI untuk mengelola data tidak terhindari

• Kesesuaian antara rencana kegiatan SIM dengan rencana strategis organisasi (strategic allignment)

• Mengantisipasi resiko yang mungkin timbul dalam implementasinya (Menjaga konsistensi)

• Perubahan organisasi

• Perubahan kebijakan

• Perubahan posisi

• Alat kontrol dan parameter yang efektif untuk mengkaji performa dan keberhasilan implementasi teknologi informasi

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Resiko implementasi SIM

• Ketidaksesuaian antara kebutuhan bisnis dengan sistem informasi yang dibangun;

• Banyak aplikasi yang tambal sulam, sehingga tidak bisa saling berkomunikasi antara satu dengan yang lain;

• Investasi yang dikeluarkan tidak memberikan manfaat seperti yang diharapkan;

• Kualitas sistem informasi tidak sesuai dengan standar industri yang semestinya.

Indrajit, 2008. Penyusunan Master Plan

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Aplikasi dan Standar

Pengembangan Keunggulan Kelemahan

Outsource -Instant

-Brand name

-Mahal

-Susah dimodifikasi (closed code)

In-house -Sesuai bisnis proses -Lama

-Sistem analist yang handal

Mix -Customable - SDM yang

‘mumpuni’

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Standard data

https://wiki.ohie.org/display/documents/OpenHIE+Architecture

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Infrastruktur TI/SI

• Hardware

• High‐cost

• Initial investment

• Maintenance

• Perlindungan fisik

• User manual dan SOP

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Infrastruktur SIMRS

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Legislation, policy, and compliance

• UU no 44 tahun 2009 tentang rumah sakit

• Pasal 7 ayat 1 ‐‐> “...prasarana...”

• Pasal 11 ayat 1 ‐‐‐> “j. Sistem informasi dan komunikasi”

• UU ITE tahun 2008 terkait transaksi elektronik

• PP nomor 82 tahun 2012 tentang penyelenggaraan sistem dan transaksi elektronik

• PP no 46 tahun 2014 terkait sistem informasi kesehatan

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Human resource: unit SI/IT RS

• Survey TRIBAL 2009 (Inggris)

• 1 tenaga SIM : 52 Tenaga Non SIM

• Komposisinya dapat dilihat pada grafik

berikut ^5%

28%

4% 5%

9%

35%

14%

Senior manager Health Records Knowledge Management ICT

Clinical Coders Information Management Clinical Informatics

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Layanan SI/TI

Analisa

• Identifikasi kebutuhan

• Sosialisasi dan Advokasi

Pengembangan

• Sistem analist

• Hard coding

Implementasi

• Penyesuaian proses bisnis &

Operasional

• Pelatihan &

pendampingan

• Pemeliharaan

Analisa Data dan Informasi untuk Mendukung Keputusan

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Kesimpulan

• Dukungan pimpinan dan staf fasilitas kesehatan (tatakelola)

• Alokasi anggaran (investasi awal maupun rutin)

• Peraturan internal (SOP, Guideline, master data tarif)

• Master plan IT rumah sakit

• Ketersediaan sumber daya manusia khusus untuk mengelola SI/TI

• Kepala SI/TI rumah sakit

• Programmer

• Network administrator

• Database administrator

• Infrastruktur pendukung EHR

• Komputer server dan client (sesuai kebutuhan)

• Jaringan yang menghubungkan semua potensi komputer client