EVALUASI REKAM MEDIS ELEKTRONIK DI PUSKESMAS KULON PROGO

LAILI RAHMATUL ILMI, Dr. dr. Wahyudi Istiono, M. Kes dan dr. Lutfan Lazuardi., M.Kes., PhD

2017 | Tesis | S2 Ilmu Kesehatan Masyarakat

Latar belakang: RME di Puskesmas Kulon Progo memberikan manfaat bagi layanan kesehatan untuk meningkatkan kualitas pendokumentasian rekam medis. Beberapa Puskesmas di Kulon Progo mulai menggunakan RME untuk mengkoodinasikan layanan kesehatan pada suatu kelompok. Semua data pasien pada implementasi RME dapat digunakan sebagai sistem pelaporan petugas kesehatan secara baik untuk meningkatkan kualitas layanan kesehatan. Tujuan: menganalisis kualitas data RME di empat Puskesmas Kulon Progo Subjek dan metode: Penelitian ini menggunakan metode deskriptif analisis dengan pendekatan ekploratif sekuensial menggunakan data primer dari responden dan data sekunder dari data RME di empat puskesmas di Kulon Progo periode Januari sampai dengan Maret 2017. Hasil: Secara statistik aspek hubungan antara variabel memiliki korelasi yang kuat antara organization dan people (r = 0,617; p = 0,0001), korelasi antara organization dan implementation cukup kuat (r = 0,487; p = 0,003), korelasi cukup kuat antara organization dan completeness (r = 0,592 ; p = 0,004), korelasi organization dan quality of data sangat lemah (r = 0,352 ; p= 0,035) korelasi antara completeness dan quality data cukup kuat (r= 0,539 ; p =0,0001), korelasi implementation dan completeness cukup (r=0,424; p-value = 0,049). Manfaat RME bagi pengguna langsung dirasakan baik dan masih dalam tahap basic, bagi pengguna tidak langsung membantu pengambilan keputusan. Diperlukan sosialiasi dan belum semua puskemas ada SOP terkait prosedur penggunaan, pengisian dan melengkapi RME untuk meningatkan mutu RME. Tampilan dan susunan RME belum sepenuhnya mengacu kepada regulasi yang berlaku. Rata-rata data RME di empat puskesmas data administrasi lengkap lengkap dan akurat (95%). Data sosial lengkap (85%).Menariknya kategori data diagnosis lengkap (65%) dan kategori data vital sign lengkap (24%). Kesimpulan: Implementasi RME dan SDM belum cukup mendukung meningkatnya kuaitas data RME. Diperlukan peran dan dukungan orgnisasi yang mendorong SDM untuk meningkatkan kualitas pengisian demi kelengkapan data RME

Background.Electronic medical record (EMR) have the advantage to facilitate the improvement of the quality of medical documentation. Some primary health centers at Kulon Progo district have started to implement the EMR to facilitate the health care to the community. All patients data from EMR system and will be used as a reporting system to the health offices as well as to improve the quality of the medical services. Objectives.To analysed the quality data from EMR four primary health centers at Kulon Progo. Metode.This is a descriptive analytical method with explanatory sequential approach that used the secondary data from EMR in four primary health centers in Kulon Progo District were collected during January to March 2017. Result. The EMR system from four primary health centers were analysed for the completeness. The results suggest that the administrative data are the most complete among other category, which reach 96% followed with social data on the second place with 87%. Interestingly, the diagnosis data and the vital sign data that are considered very important are very low with only 65% and 24% respectively. To support quality of EMR data needed Organization and user�s support to complete the data. Conclusion.The results suggest that although they already used the EMR, the quality of the data especially related to the clinical data were still low. The implementation of the EMR seems still focus on administrative area rather then clinical aspects. Thus the completeness of the clinical data needs to be improved in order to allow them to facilitate the better health care.

Kata Kunci : EMR, data quality, information system, primaty care