Analisis Kesiapan Penerapan Rekam Medis Elektronik Menggunakan Penilaian CCCEAR di Puskesmas Wonogiri II

Ardiyana Nur Aida, Dr. Savitri Citra Budi, SKM., M.P.H.

2023 | Tugas Akhir | D4 MANAJEMEN INFORMASI KESEHATAN

Latar Belakang : Seiring perkembangan zaman dan teknologi menyebabkan adanya perubahan rekam medis konvensional menjadi rekam medis elektronik. Perubahan kebijakan tersebut diatur dalam Peraturan Menteri Kesehatan Republik Indonesia Nomor 24 tahun 2022. Dalam hal ini, Puskesmas Wonogiri II belum sepenuhnya menerapkan RME. Penerapan RME hanya dilakukan pada bagian registrasi pasien, informasi klinis, input data klaim dan transfer data RM. Dengan adanya perubahan kebijakan tersebut, yang menyatakan bahwa seluruh fasyankes harus sudah siap menerapkan RME maka penelitian ini perlu dilakukan untuk melihat kesiapan Puskesmas dalam menerapkan RME.

Tujuan : Mengidentifikasi kesiapan Puskesmas Wonogiri II dalam penerapan RME menggunakan penialaian CCCEAR (California Community Clinic HER Assessment Readiness) yang terdiri dari 7 variabel diantaranya, SDM, Infrastruktur TI, Perencanaan dan Kebijakan, Alokasi Anggaran, Struktur Organisasi, Manajemen Informasi, dan Dukungan Pemerintah.

Metode : Metode penelitian ini menggunakan jenis penelitian kualitatif dengan rancangan studi kasus dekriptif. Subjek penelitian ini dipilih dari segi pengguna RME. Objek penelitian ini yaitu kesiapan penerapan RME di Puskesmas Wonogiri II. Serta penilaian kesiapan menggunakan instrumen CCCEAR (California Community Clinic HER Assessment Readiness) yang dimodifikasi sesuai kebutuhan puskesmas.

Hasil : Berdasarkan hasil penilaian terhadap 7 variabel, diperoleh skor pada SDM 9 (Cukup Siap), Infrastruktur TI 6 (Cukup Siap), Perencanaan dan Kebijakan 2 (Belum Siap), Alokasi Anggaran 4 (Cukup Siap), Stuktur Organisasi 3 (Belum Siap), Manajemen Informasi 5 (Cukup Siap), Dukungan Pemerintah 2 (Belum Siap).

Kesimpulan : Analisis kesiapan penerapan RME diperoleh skor 29 dari 100. Hal ini menunjukkan bahwa Puskesmas Wonogiri II dalam kategori belum siap menerapkan RME.

Background: With the advancement of time and technology, there has been a transition from conventional medical records to electronic medical records. This policy change is regulated in the Indonesian Ministry of Health Regulation Number 24 of 2022. In this context, Puskesmas Wonogiri II has not yet fully implemented EMR. The implementation of EMR is currently limited to patient registration, clinical information, claims data input, and medical record data transfer. With the presence of this policy change, which mandates that all healthcare facilities (fasyankes) must be ready to implement EMR, conducting this research is necessary to assess Puskesmas's readiness in adopting EMR.

Objective: Identifying the readiness of Puskesmas Wonogiri II in implementing Electronic Medical Records (EMR) using the CCCEAR (California Community Clinic EHR Assessment Readiness) assessment, which consists of 7 variables including Human Resources, IT Infrastructure, Planning and Policy, Budget Allocation, Organizational Structure, Information Management, and Government Support.

Method: This research method utilizes qualitative research with a descriptive case study design. The research subjects are selected based on the RME users. The research object is the readiness of RME implementation at Puskesmas Wonogiri II. The assessment of readiness is conducted using a modified version of the CCCEAR (California Community Clinic EHR Assessment Readiness) instrument, tailored to the needs of the health center.

Results: Based on the assessment results of the 7 variables, the scores obtained are as follows: Human Resources the score 9 (Moderately Ready), IT Infrastructure the score 6 (Moderately Ready), Planning and Policy the score  2 (Not Ready), Budget Allocation the score 4 (Moderately Ready), Organizational Structure the score 3 (Not Ready), Information Management  the score 5 (Moderately Ready), Government Support the score 2 (Not Ready).

Conclusion : The analysis of the readiness for the implementation of EMR obtained a score of 29 out of 100. This indicates that Puskesmas Wonogiri II falls into the category of not being ready to implement EMR.

Kata Kunci : Kesiapan, RME, Penerapan, CCCEAR.