International Journal of Engineering Business

and Social Science

Vol. 2 No. 04, March-April 2024, pages: 1114-1122

e-ISSN: 2980-4108, p-ISSN: 2980-4272

https://ijebss.ph/index.php/ijebss

Implementation of Electronic Medical Record System in Indonesia

Viewed from the Perspective of Legal Certainty

Novianti

, Handar Subhandi Bakhtiar

Universitas Pembangunan Nasional, Jakarta, Indonesia

E-mail: no[email protected]m

, handar_subhan[email protected]

Corresponding Author: noviantievi0[email protected]m

Keywords

Abstract

Electronic Medical

Records, Health Service

Facilities, Electronic

Systems, Minister Of

Health Regulation

Number 24 Of 2022

The implementation of Electronic Medical Records (EMR) is a critical component of

this transformation, aiming to transition health records from paper to electronic

form, with the government emphasising the need for secure data management, as

outlined in the Regulation of the Minister of Health of the Republic of Indonesia

number 24 of 2022. The purpose of this study is to analyse the implementation of the

Electronic Medical Record System in Indonesia, which has one important and

strategic aspect, namely its existence as one of the pillars of health technology

transformation in realising national health and as a condition for indicators of

realising people's welfare mandated in the Preamble of the 1945 Constitution as a

national goal. Its implementation is regulated according to the applicable laws and

regulations in Law No. 17 of 2023 concerning Health and specifically in Minister of

Health Regulation No. 24 of 2022 concerning Medical Records. The method used is

Normative Juridic. As part of the health service system, the role of the Electronic

Medical Record System is very strategic in the quality of health services. The

successful implementation of the Electronic Medical Record System greatly

influences the quality of health services. This will boil down to the regulation

regarding the Electronic Medical Record. Currently, the laws governing RME are Law

Number 17 of 2023 concerning Health and Minister of Health Regulation Number 24

of 2022 concerning Medical Records. In both regulations, it is regulated on the

Implementation of Medical Records; it is formulated that Medical Records are one of

the implementations of the pillars of health transformation in the realisation of state

goals mandated in the 1945 Constitution, significantly improving the nation's health

through a sustainable Electronic Medical Record system. Although various obstacles

were found in implementing the RME, one was related to the electronic medical

record system used, and the other was related to the security and confidentiality of

patient health data. The conclusion of this study will further examine the

implementation of the Electronic Medical Record System, which is still experiencing

problems regarding the security and confidentiality of Electronic Medical Record data

in Indonesia.

for possible open-access publication

under the terms and conditions of the Creative Commons Attribution (CC BY SA)

license (https://creativecommons.org/licenses/by-sa/4.0/).

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1 Introduction

Health is a healthy condition, physically, mentally, spiritually and socially, that enables everyone to live

productively socially and economically (Kolib, 2020b). Improving health services aims to increase awareness, comfort,

and the ability of every citizen to live a healthy life to realise an optimal degree of health as one of the components

of general welfare in the Preamble to the Constitution of the Republic of Indonesia in 1945. Every doctor and dentist

as medical personnel, as well as all health workers and health service facilities, must follow applicable standards,

policies and procedures in carrying out medical activities so that the public can obtain medical services professionally

and safely. One of them is to actively participate in implementing medical records, which have now switched to

electronic systems (Sutton et al., 2020).

The laws and regulations governing the implementation of Medical Records in Indonesia are regulated

through Law Number 17 of 2023 concerning Health and Minister of Health Regulation Number 24 of 2022 concerning

Medical Records (Asyfia et al., 2023). In implementing Electronic Medical Records in Indonesia, there are still

problems, such as using Electronic Systems for Medical Records, which must guarantee the confidentiality and

security of medical record data. The electronic medical record system must be able to provide data assurance and

protection. This guarantee is in the form of confidentiality, integrity and availability (Kolib, 2021). This is related to

the obligations owned by Health Facilities, which must maintain the confidentiality of the contents of the Patient's

Medical Record (Kusumah et al., 2022).

Electronic Systems in the implementation of Electronic Medical Records can be in the form of Electronic

Systems in the form of Electronic Systems developed by the Ministry of Health, Health Service Facilities themselves,

or Electronic System Operators through cooperation (Putri & Mulyanti, 2023). Such are the complex challenges for

RME implementation; it is necessary to conduct a readiness assessment before RME implementation. This is the most

important step to take before implementation. The readiness assessment will help identify processes and priority

scales and assist in establishing operational functions to support the optimisation of EMR implementation

(Venkatraman & Sundarraj, 2022). The study's results (Ulfa & Yuspin, 2023) mentioned that information technology

(IT) offers many advantages compared to the use of paper for storing and retrieving patient data. However,

implementing RME has several challenges, including infrastructure and structure problems, information technology

problems, lack of need assessment, cultural problems, and high costs of software, hardware, and data exchange

standards. Therefore, it is necessary to conduct a readiness assessment before the implementation of RME by

referring to the legality of preparation for the implementation of Electronic Medical Records in management

information in Health Service Facilities, namely with the existence of Minister of Health Regulation no. 24 of 2022

(Kolib, 2020a).

The preparatory evaluation of the implementation of electronic medical records should be thorough and

include human resources, organisational work culture, governance, leadership, and infrastructure. All of these

elements will support the implementation of operational functions to optimise the implementation of RME (Adha et

al., 2023). The technology system element that supports electronic medical records plays an important role in the

success of the implementation of RME in Fasyankes. However, incomplete preparation is an obstacle to this success.

The obstacles to the RME system include the electronic system used and the readiness of human resources and

infrastructure (Bakhtiar & Syaid, 2022). The important role of medical records is not only for patients as owners of

medical record content but also for organisers, namely health service facilities that carry out the work. Medical

records have a role in legal protection for patients and health facilities, especially if law enforcement officials open

the medical records in court. So that the implementation of this RME can provide legal certainty for health facilities

and patients. However, with the complex obstacles experienced, the author is interested in making a study entitled

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"The Implementation of Electronic Medical Record Systems in Indonesia Viewed from the Perspective of Legal

Certainty."

This research aims to understand how the Electronic Medical Record (EMR) System is operated in health

facilities and to convey the readiness of health facilities to implement the system according to Minister of Health

Regulation No. 24 of 2022. This research aims to gain an in-depth understanding of the EMR operational process in

Health Facilities, including collecting, storing and accessing patient data. Apart from that, this research also aims to

assess the extent to which health facilities are ready to adopt an EMR system, including aspects of infrastructure

readiness, human resources and compliance with applicable regulations.

2 Materials and Methods

Research methods are the science of the levels that must be passed in the research process or science related

to scientific methods to find, develop and prove the truth of knowledge. The research method used in this study is

normative research, which is research conducted using library legal materials or secondary data that may include

primary, secondary and tertiary legal materials. For Research Approach The approach used in this study is juridical

normative research with a statutory approach (statute approach) and a case approach (case approach). The legal

approach is carried out by reviewing all laws and regulations relevant to the legal issues being handled.

The case approach is carried out by examining cases related to issues faced in the implementation of

legislation and having permanent legal force in the form of what happened in Indonesia. The analytical technique

used in this study is descriptive research; descriptive research techniques explain a legal event or condition. A legal

event is an event with legal aspects that occur in a certain place and at a certain time. Descriptive analysis techniques,

when viewed from the point of view of the form, are diagnostic research, which is an intended investigation to obtain

information about the causes of the occurrence of a symptom or several symptoms, which aims to find facts (fact-

finding) followed by finding a problem (problem finding) which then leads to problem identification (problem

identification).

The source of the data in the form of legal materials used in this study is primary legal material, including basic

regulations, laws and regulations, non-codified legal materials, jurisprudence and treaties. In this case, Health Law

Number 17 of 2023 concerns Health and Minister of Health Regulation Number 24 of 2022 concerns Medical Records.

Secondary legal materials are those that explain primary legal materials. Tarsier legal materials provide instructions

and explanations for primary and secondary legal materials. Secondary legal materials are materials that provide

explanations of primary legal materials such as draft laws, legal writings in books, magazines, journals, newspapers,

and internet media, and the results of research and scientific works of scholars. Tertiary legal materials, namely legal

materials, provide guidance and explanation for primary legal materials and secondary legal materials, such as

encyclopedias (legal) dictionaries.

For Data Collection Methods, in this study, the author uses a type of data collection tool, namely through

interviews and literature studies, which are all efforts made by researchers to collect various information relevant to

the topic or problem that will or is being researched, such as various kinds of scientific books, research reports,

scientific essays, theses and dissertations, regulations, statutes, yearbooks, encyclopedias, and other written sources,

both printed and electronic.

3 Results and Discussions

Medical Record Regulation in Indonesia

Management Information Systems in Health Care Facilities were created not only to maximise the old

governance but also to update and create new technical data flows that are more effective and efficient. In addition,

a system of data processing procedures that are more systematic, simple, informative and effective information

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distribution is created (Karmadi et al., 2023; Pujihastuti & Hastuti, 2021). In administrative terms, the benefit of

electronic medical records is that they store electronic information regarding health status and health services

provided by healthcare facilities that patients have obtained. The benefits of using medical records with electronic

systems are also useful for doctors and health workers to find and open access to information about patients. This

helps medical personnel and health workers make clinical decisions and establish diagnoses for patients.

Obligation Recording medical records is done by doctors and dentists who perform medical actions on

patients. So, according to the regulations, there is nothing that can be used as a reason for doctors not to record

medical records. Implementing the Electronic System of Medical Records solves various problems in healthcare

facilities. One of these problems is that the space for storing medical records must be large as new patient visits at

the health facility increase, medical record files are lost, the release of medical record data is needed, and many more

problems are faced. SIM, or Management Information System in the form of an electronic system of medical records,

provides operational benefits that can facilitate the process of extracting patient data, as well as practical and

minimal errors in document storage. so that, in this case, it does not require a lot of space; the time to find medical

record data is short, and all the necessary health data can be fulfilled and read in RME, which can improve the quality

of service.

The regulations governing the implementation of Medical Records in Indonesia are Law Number 17 of 2023

concerning Health in articles 296 to 300 and Regulation of the Minister of Health of the Republic of Indonesia Number

24 of 2022 concerning Medical Records. Both regulations seek to be the legal basis or legality for implementing

medical records, especially those held electronically. So, with this policy, health service facilities (Fayankes) must run

an electronic patient medical history recording system. Minister of Health Regulation No. 24 of 2022 has regulated

three new things. These three things are electronic medical record systems, electronic medical record management

activities, and electronic medical record data protection. Law number 17 of 2023 article 300, paragraph 2, regarding

the integration of medical records with the national health information system launched by the government, namely

in the form of the Satu Sehat program, requires the implementation of Electronic Medical Records, which the system

must be able to guarantee the security, confidentiality, integrity and availability of Medical Record data. Therefore,

article 3 and Article 9 of the Minister of Health Regulation Number 24 of 2022 concerning Medical Records emphasise

the obligation of Fasyankes to run an Electronic System in the Implementation of Medical Records at Fasyankes.

Article 22, paragraph 1 of the Minister of Health Number 24 of 2022 stipulates the Cooperation Agreement that

Fasyankes can carry out with Electronic System Operators (PSE). The Electronic System used in implementing Medical

Partners electronically is also required to have compatibility and interoperability capabilities.

In carrying out a cooperation agreement, one requirement to choose a PSE is to register the Electronic System

used at the Ministry of Health. The system (Yunisca et al., 2022) used by health facilities is an integrated system that

will also be integrated with the national health system in the future, namely the One Healthy Program. The Ministry

of Health of the Republic of Indonesia is transforming the digitalisation of health services through the SATUSEHAT

program, a platform for data connectivity, analysis, and services to support integration between applications and

health service facilities (fasyankes). Later, patients will not need to fill out new forms when moving Health Care

Facilities repeatedly. With the SATUSEHAT Program, patients can get information about their health condition more

clearly and transparently. Through the Ministry of Health, the Government of the Republic of Indonesia continues to

make efforts to achieve the target of Implementing Electronic Medical Records (RME) by the Minister of Health

Regulation (PMK) Number 24 of 2022 concerning Medical Records.

The Ministry of Health of the Republic of Indonesia created this integration platform through a long process.

The process starts with planning, polls from experts, and alpha and beta phase trials with participants from various

institutional backgrounds. For example, hospitals, laboratories, pharmacies, independent clinics, practitioners, and

academics. According to existing data, there are 792 hospitals, clinics and puskesmas that have been incorporated

into the SATUSEHAT platform and continue to increase in number where the public can open access in

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https://satusehat.kemkes.go.id/platform/healthcare-list. This step is one of the movements of accelerating

technological transformation to achieve health data, where this system also provides convenience in utilising

accurate and efficient data. This aligns with health transformation in pillar six, namely health technology

transformation.

The obstacles and problems when implementing an electronic system of medical records are related to

systems that must have interoperability with variables that are mandatory by the provisions of the Ministry of Health

of the Republic of Indonesia, which often do not meet the needs of variables that become standard formats in

medical records by applicable laws and regulations, namely the Decree of the Minister of Health Number HK.01.07 /

MENKES / 1423 / 2022 concerning Variable Guidelines and Meta Data on Electronic Medical Record Administration.

This Decree of the Minister of Health was determined with the consideration that in the implementation of electronic

medical records, an electronic system that has compatibility and interoperability capabilities between one electronic

system and another electronic system and different electronic systems is needed to be able to work in an integrated

manner to communicate or exchange data with one or more other electronic systems. This requires that the

electronic system on electronic medical records used must refer to variables and metadata set by the Ministry of

Health. One of the obstacles is the unfulfilled element of interoperability, resulting in hampered medical record

implementation activities and incomplete input. This has an impact on the availability of incomplete data in the RME.

The readiness of human resources, which makes inputs, includes all medical personnel and health and non-health

workers involved in RME activities. EMR officers often do not have sufficient ability and knowledge to input Electronic

Medical Records. So that the data inputted is incorrect, inaccurate, and complete. The role of Management includes

leadership in determining the system used.

The electronic system used can come from Fasyankes, the Ministry of Health, or from entering into a

cooperation agreement with PSE (electronic system operator). The cooperation agreement with PSE is currently the

choice of most health facilities in Indonesia. Choosing a PSE that fulfils government requirements regarding the

electronic medical record system is the duty of health facilities to be able to carry out electronic medical record

implementation activities according to laws and regulations. PSE that can meet the needs of Fasyankes in terms of

selecting medical record metadata variables, the system is considered capable of meeting the elements of

compatibility and interoperability. It is digitally integrated with other devices and systems. The implementation of

the Electronic Medical Record System in Health Service Facilities consists of patient registration, distribution of

electronic medical record data, filling in clinical information, processing of Electronic Medical Record information,

Covering data for financing claims, storage of Electronic Medical Records, quality assurance of Electronic Medical

Records, transfer of contents of Electronic Medical Records (Putri & Mulyanti, 2023). All of these implementation

activities require an RME system whose compatibility and interoperability can ensure data security and

confidentiality. An RME system that can meet metadata variables according to the Ministry of Health regulations can

be used to guarantee that the data meets interoperability and compatibility requirements and is in line with the

government program, namely SATUSEHAT.

Implementation of RME System in Indonesia

The Ministry of Health of the Republic of Indonesia, on August 31, 2022, stipulated the Regulation of the

Minister of Health of the Republic of Indonesia Number 24 of 2022 concerning Medical Records. So, enacting this

regulation revokes the Regulation of the Minister of Health of the Republic of Indonesia Number 269 / MENKES / PER

/ III / 2008 of 2008 concerning Medical Records. The things that underlie the revocation of the previous Minister of

Health. Some of these are as follows: 1.) There are developments in science and technology, health service needs

and legal needs in the community so that Permenkes Number 269 / MENKES / PER / III / 2008 2008 is no longer by

this; 2.) The transformation of digitalisation of health services underlies the development of digital technology in

society 3.) Electronic medical records must prioritise the principles of security and confidentiality of data and

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information in the electronic medical record management system. Minister of Health Regulation Number 24 of 2022

is used as the legal basis for the legality of the implementation of RME. Three new things are regulated in general

terms, Minister of Health Regulation Number 24 of 2022. These three things are electronic medical record systems,

electronic medical record implementation activities, security and electronic medical record data protection. There

are several ways to implement an electronic medical record system: an electronic system developed by Fasyankes

himself, an electronic system developed by the Ministry of Health of the Republic of Indonesia, an electronic system

developed by an Electronic System Operator that has been registered in the health sector at the Ministry of

Communication and Information Technology of the Republic of Indonesia. In its implementation, the electronic

system used is required to have the ability to conform one electronic system to another electronic system and the

ability of different electronic systems to be integrated in carrying out communication or data exchange with other

electronic systems. When preparing to implement Minister of Health Regulation Number 24 of 2022, it is considered

necessary to develop the use of RME, including 1. The number of health human resources in each unit is added,

where each will have a special responsibility to input RME 2. Increasing the number of IT human resources who have

the task of maintaining and maintaining the continuity of the RME 3 Information System network system. Additional

internet capacity in the health facility environment 4. Increase the number of hardware devices to optimise the use

of RME 5. Optimising the RME information system to improve patient service security arrangements and protect

medical record data to organise EMR.

Regulated in the Regulation of the Minister of Health of the Republic of Indonesia Number 24 of 2022, which

consists of ownership and content of RME, security and protection of electronic medical record data and regarding

the confidentiality of the contents of electronic medical records, waiver of rights to the contents of electronic medical

records and the retention period of electronic medical records. The ownership and content of RME are two

ownerships, namely belonging to health care facilities and belonging to patients. Healthcare facilities are responsible

for loss, damage, falsification and use by persons or entities who do not have rights to such medical record

documents. If patients obtain consent, it can be conveyed to the next of kin or other parties. Fasyankes' obligations

in organising medical records as stated in the Regulation of the Minister of Health of the Republic of Indonesia

Number 24 of 2022 explain several things, including: 1.) This regulation provides obligations for all health service

facilities to organise electronic medical records no later than December 31, 2023, including independent practices

carried out by health workers and medical personnel. The Ministry of Health, through the Director General of Health

Services, has the authority to provide administrative sanctions and conduct written reprimands and

recommendations for the revocation or revocation of accreditation status for healthcare facilities found to have

violations. This legal obligation is strengthened by legal sanctions aimed at realising legal certainty. However, legal

practicality should also be considered.

This must be a consideration due to the geographical factors of Indonesia, which are very wide, varied, and

compounded. The situation in the field and the situation and condition of health workers and medical personnel on

duty in all regions to remote parts of Indonesia who have limitations in infrastructure must be considered by the

Ministry of Health, especially regarding internet and computer networks. 2.) The authority of the Regulation of the

Minister of Health of the Republic of Indonesia Number 24 of 2022 to the Ministry of Health related to the data and

content of electronic medical records and electronic medical record implementation systems. Healthcare facilities

must have open access and be integrated into all contents of electronic medical records for the Ministry of Health.

There must be a balance with great responsibility because, until now, personal data protection in Indonesia has been

categorised as still weak, and there are frequent leaks. Medical secrets are not only personal data that must be

safeguarded but also a basis and philosophical basis for health workers and medical personnel in carrying out their

profession. In this case, there needs to be regulations that have legal force regarding medical secrets through

harmonisation or synchronisation. Through the Regulation of the Minister of Health of the Republic of Indonesia

Number 24 of 2022 as legal protection in implementing electronic medical records.

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Legal protection is comprehensive and must be explained and disseminated again through broad regulations

(for example, SOPs / Standard Operating Procedures or RME Implementation Manuals). This aims to prevent

misunderstanding of the provisions of the Regulation of the Minister of Health of the Republic of Indonesia, number

24 of 2022. Law Number 24 of 2022 concerning Medical Records must have the basis of the Principle of Legal

Certainty, where the principle in the rule of law prioritises the basis of legislation, decency, and justice in every policy

of the state administrator. This principle has the will to respect the rights that a person has obtained based on the

decisions of state administrative bodies or officials. This principle is important because it guarantees clarity from this

law; it explains that electronic medical records in the RME Implementation System have clarity and legal protection

for patients regarding medical record data so that with this, data confidentiality is maintained and not leaked. The

absence of RME in service has legal consequences relating to 1. Insurer RME 2. Sanctions for violation of the

provisions of the RME. Fasyankes' RME is responsible for the integrity and continuity of services, and evidence of

Fasyankes includes primary clinics for all efforts to heal patients. Health workers or health facilities must organise

medical or electronic medical records correctly and are responsible for confidentiality. Therefore, Fasyankes that do

not carry out electronic medical records may result in administrative sanctions if the unavailability of medical record

facilities may be subject to criminal law. Civil sanctions may be imposed if there is incompleteness in conducting

electronic medical records. The opening of electronic medical records legally has criminal, civil, and administrative

legal consequences.

4 Conclusion

The assessment of readiness for the implementation of RME in health facilities in terms of human resources

is almost entirely not ready due to the need for special staff responsible for the implementation of RME. The staff

must have the competence to master information systems with the assistance of information technology experts.

The assessment of the readiness of the implementation of RME in terms of organisational work culture is considered

quite ready. Still, almost all of them do not have SOPs and RME workflows that are not ready for planning. The

assessment of readiness for implementing RME in terms of infrastructure is partly not ready; this is assessed from

the unavailability of adequate software and computers. Minister of Health Regulation Number 24 of 2022 is the legal

basis or legality in terms of organising electronic medical records. In general, three new things are regulated in the

Minister of Health Regulation Number 24 of 2022: electronic medical record systems, electronic medical record

implementation activities, security and electronic medical record data protection. The Regulation of the Minister of

Health of the Republic of Indonesia Number 24 of 2022 regulates the following: ownership and content of electronic

medical records; Security and protection of electronic medical record data, including the confidentiality of the

contents of electronic medical records, waiver of rights to the contents of electronic medical records and the period

of storage of electronic medical records.

To improve the quality of health services in healthcare facilities in the face of technological advances, it is

expected that all health service facilities in Indonesia can make more mature preparations from the aspects of Human

Resources, Organizational Unit Culture and Infrastructure that can provide support for the implementation of

Electronic Medical Records. This can maximise the development of the RME information system for Health Service

Facilities. And indirectly, Fasyankes is required to know how the legality and management of Electronic Medical

Records must be maintained from the aspect of confidentiality and has the aim that these health workers can be

utilised optimally and sustainably in increasing the competence of human resources who are broad-minded in

technology so that the target of advancing health facilities is achieved and the development of information through

the Medical Records System but must always pay attention to several things such as the possession and content of

electronic medical records; Security and protection of electronic medical record data including the confidentiality of

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the contents of electronic medical records, waiver of rights to the contents of electronic medical records and the

period of storage of electronic medical records.

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