Variabel Dan Metadata Rekam Medis Elektronik Sebagai Standar Interoperabilitas Data Kesehatan di Rumah Sakit

Rika  Andriani; Julia  Pertiwi; Arum  Alfitasari; Tri Anita Restu  Salima; Triya  Wijayanti

doi:10.52943/jipiki.v10i2.1946

Authors

Rika Andriani Universitas Veteran Bangun Nusantara
Julia Pertiwi Universitas Veteran Bangun Nusantara
Arum Alfitasari Universitas Veteran Bangun Nusantara
Tri Anita Restu Salima Universitas Veteran Bangun Nusantara
Triya Wijayanti Universitas Veteran Bangun Nusantara

DOI:

https://doi.org/10.52943/jipiki.v10i2.1946

Keywords:

Electronic Medical Records, Interoperability, Metadata, Variabel

Abstract

Electronic Medical Records (EMRs) require interoperability capabilities to effectively integrate with other health information systems. For EMRs integration, it is crucial to adhere to the guidelines outlined in KMK HK.01.07/MENKES/1423/2022. The implementation of EMRs was carried out in 2019 at Hospital X. Until now, Hospital X has not adjusted the EMRs’ variables and metadata. This study aimed to analyze EMRs’ variables and metadata for health data interoperability. This was a quantitative study. Data collection used a documentation study guideline instrument. Data analysis used descriptive statistic. This study showed that variables and metadata from 5 datasets consisting of emergency, outpatient, inpatient, laboratory, and pharmacy datasets, there were 45,3% exist and appropriate; 20% exist and inappropriate, and 34,7% do not exist compared to KMK HK.01.07/MENKES/1423/2022. To improve the quality of EMRs, it is necessary to adjust variables and metadata in accordance with KMK HK.01.07/MENKES/1423/2022; identify users’ data and information needs; and conduct periodic quality audits and evaluations of EMRs.

Downloads

Download data is not yet available.

References

WHO. WHO Guideline: Recommendations on Digital Interventions for Health System Strengthening. Geneva: WHO; 2019.

Kementerian Kesehatan RI. Permenkes No. 24 Tahun 2022 Tentang Rekam Medis. 2022.

Donnelly C, Janssen A, Vinod S, Stone E, Harnett P, Shaw T. A Systematic Review of Electronic Medical Record Driven Quality Measurement and Feedback Systems. Int J Environ Res Public Health 2022;20:200. https://doi.org/10.3390/ijerph20010200.

Senishaw AF, Tilahun BC, Nigatu AM, Mengiste SA, Standal K. Willingness To Use Electronic Medical Record (EMR) System And Its Associated Factors Among Health Professionals Working In Amhara Region Private Hospitals. PLOS ONE 2023;18:e0282044. https://doi.org/10.1371/journal.pone.0282044.

Andriani R, Wulandari DS, Margianti RS. Rekam Medis Elektronik sebagai Pendukung Manajemen Pelayanan Pasien di RS Universitas Gadjah Mada. J Ilm Perekam Dan Inf Kesehat Imelda JIPIKI 2022;7:96–107. https://doi.org/10.52943/jipiki.v7i1.599.

Kavandi H, Al Awar Z, Jaana M. Benefits, Facilitators, and Barriers of Electronic Medical Records Implementation in Outpatient Settings: A Scoping Review. Healthc Manage Forum 2024;37:215–25. https://doi.org/10.1177/08404704231224070.

Gopidasan B, Amanullah S, Adebowale A. Electronic Medical Records – A Review of Cost-Effectiveness, Efficiency, Quality of Care, and Usability. J Psychiatry Spectr 2022;1:76. https://doi.org/10.4103/jopsys.jopsys_17_22.

Kementerian Kesehatan. Surat Edaran Nomor Hk.02.02/D/7093/2023 tentang Penyelenggaraan Rekam Medis Elektronik yang Terinteroperabilitas dengan Platform Satusehat. 2023.

Kementerian Kesehatan RI. Surat Edaran No.HK.02.01/MENKES/1030/2023 tentang Penyelenggaraan Rekam Medis Elektronik di Fasyankes Serta Penerapan Sanksi Administratif. 2023.

Kementerian Kesehatan RI. Keputusan Menteri Kesehatan Republik Indonesia Nomor Hk.01.07/Menkes/1423/2022 tentang Pedoman Variabel Dan Metadata pada Penyelenggaraan Rekam Medis Elektronik. 2022.

Azizah MN. Analisis Kesesuaian Variabel Metadata dengan Formulir Identitas Pasien Rekam Medis Elektronik pada Unit Rawat Jalan di Rumah Sakit Pelni. Politeknik Negeri Jember, 2025.

Ilyas AA, Golo ZA, Retnowati R. Analisis Kesesuaian Variabel dan Metadata Rekam Medis Elektronik: Studi Kasus pada Instalasi Rawat Jalan Rumah Sakit X. J Rekam Medis Dan Inf Kesehat 2023;6:89–97. https://doi.org/10.31983/jrmik.v6i2.10640.

Raharjo SA, Asgiani P, Ningsih KP. Analisis Kesesuaian Variabel Metadata Rekam Medis Pada Data Set Unit Gawat Darurat. Universitas Jenderal Ahmad Yani, 2024.

Fatharanni MO, Ilyas Y. Dampak Penerapan Interoperabilitas Rekam Medis Elektronik di Rumah Sakit: Sebuah Tinjauan Sistematis. J Kesehat Tambusai 2025;6.

Li E, Clarke J, Ashrafian H, Darzi A, Neves AL. The Impact of Electronic Health Record Interoperability on Safety and Quality of Care in High-Income Countries: Systematic Review. J Med Internet Res 2022;24:e38144. https://doi.org/10.2196/38144.