PERANCANGAN APLIKASI
ELECTRONIC MEDICAL RECORD
(EMR) PADA INSTALASI RAWAT INAP
BERBASIS WEB
Moh. Muttaqin1, Eko Handoyo, S.T, M.T2, Aghus Sofwan, S.T, M.T2
Abstrak
Pelayanan medik dewasa ini membutuhkan sistem yang lebih efektif dan efisien, baik dalam
penggunaan waktu, tenaga maupun sarana. Dalam pengelolaan rekam medik, kenyataan masih
umumnya penggunaan rekam medik manual yang dinilai tak lagi andal menangani data medik
melahirkan ide konversi rekam medik manual kertas ke rekam medik elektronik karena efektivitas dan
efisiensinya.
Penelitian ini bertujuan menciptakan aplikasi rekam medik elektronik yang lebih dikenal
sebagai EMR (Electronic Medical Record) dari rekam medik kertas di Instalasi Rawat Inap Rumah
Sakit Umum Ananda Salatiga. Rekam medik elektronik dirancang dengan membuat form-form isian
catatan-catatan medik dalam proses perawatan pasien selama dirawat. Data-data medik ini kemudian
disimpan dalam basis data sistem dan dikelola secara digital. Setiap kali pengisian data medik pada
form-form tertentu, sistem akan menghasilkan kode yang membawa informasi khusus.
Pada akhirnya, sistem akan menghasilkan deret kode ICD (International Statistical
Classification of Diseases and Related Health Problems) dari kode-kode yang dihasilkan pada
pengisian form-form catatan medik. Deretan kode-kode ini mampu menggambarkan perkembangan
kondisi pasien dan penanganan medik yang diberikan selama perawatan. Data-data medik yang
tersimpan dapat ditampilkan kembali dalam bentuk catatan medik digital.
1
Mahasiswa Jurusan Teknik Elektro UNDIP
2
Staf Pengajar Jurusan Teknik Elektro UNDIP
registrasi
jenis penyakit. terapi awal perawatan awal
dapat disebut deret kode ICD. Satu deret kode penyelesaian administrasi
manajemen RM
kemungkinan untuk setiap kasus rawat inap. Gambar 1 Diagram use case sistem EMR.
Perancangan Sistem
Sistem dirancang berbasis web dengan
menggunakan bahasa pemrograman web PHP
4.4.0 dan basis data MySQL 4.0.25.
Perancangan dilakukan berdasarkan diagram-
diagram pemodelan dan dioperasikan pada Gambar 6 Hasil pembangkitan kode ICD berdasarkan
HTTP server Apache. penyakit.
Pengujian Sistem
Pengujian sistem yang dilakukan secara
menyeluruh ditekankan pada aspek-aspek
kebutuhan, kegunaan dan keamanan. Di sisi
kebutuhan, sistem mampu melakukan reduksi
operasi, otomatisasi pengisian dan
menghindari pengisian ganda. Beberapa meminimalisasi kesalahan pengisian. Fasilitas
konfirmasi juga dilakukan untuk pemeriksaan juga dimiliki sistem untuk
memeriksa data masukan tertentu agar diisi V. PENUTUP
dengan data yang seharusnya. Kebutuhan Kesimpulan
akan kemudahan akses, pencatatan digital dan Beberapa hal yang dapat disimpulkan dari
pencarian cepat juga dapat diterapkan. Di sisi perancangan aplikasi Electronic Medical
kegunaan, fungsi-fungsi rekam medik telah Record (EMR) pada instalasi rawat inap
terpenuhi oleh sistem. Rekam medik berbasis web ini adalah sebagai berikut.
elektronik tidak hanya menawarkan 1. Sistem EMR instalasi rawat inap ini
pencatatan dan melihat catatan, bahkan dapat adalah bagian integral dari rangkaian
menjadi data aktif yang digunakan untuk pencatatan medik di rumah sakit.
berbagai keperluan sesuai ketentuan yang 2. Sebagaimana tercantum dalam tujuan
ada, sebagaimana tuntutan pengembangan penelitian, sistem EMR rawat inap ini
fungsi rekam medik. Kegunaan yang cukup telah mencapai tujuannya melakukan
siginifikan adalah bagaimana kode ICD dapat digitalisasi atas catatan medik kertas
dibangkitkan dengan mudah dari begitu yang ada di instalasi rawat inap dan
banyak kemungkinan pilihan, akurat dalam menjadi sistem yang andal dalam
waktu yang sangat singkat. Di sisi kemanan, kecepatan akses, kecermatan
rekam medik elektronik jauh lebih baik di penyampaian dan meningkatkan
banding rekam medik konvensional. Hak efisisensi kerja petugas medik yang
pengisian dan melihat diatur dengan baik menggunakannya.
berdasarkan type user, namun tetap tidak 3. Sistem EMR rawat inap ini
merusak interaksi yang tinggi antar tenaga mengakomodasi 7 user (resepsionis,
medik dalam proses perawatan pasien. perawat IGD, dokter IGD, perawat
Melakukan peniruan dan pemalsuan yang bangsal, dokter bangsal, petugas
diatasnamakan pada petugas medik lain juga administrasi dan petugas rekam
lebih sulit dilakukan. Untuk melindungi medik) dari 5 unit pelayanan medik
pasien, sistem juga dibekali mekanisme dalam instalasi rawat inap (unit
mencatat setiap tindakan medik yang registrasi, IGD, unit bangsal, unit
diberikan, sehingga jika terjadi malpraktik, administrasi dan unit rekam medik).
maka bukti-bukti kesalahan penanganan akan 4. Keluaran sistem masih dapat dijadikan
terekam dengan jelas. bahan bagi laporan catatan medik
berikutnya, khususnya ICD.
Pengujian Penerimaan 5. Sistem EMR rawat inap ini telah
Pengujian penerimaan telah menunjukkan menerapkan kode ICD versi terbaru
hasil bahwa sistem telah lengkap, sesuai yaitu kode ICD 10 yang bersumber
dengan kebutuhan yang menjadi dasar dari Dinas Kesehatan Jawa Tengah.
perancangan dan dapat diterima oleh user
yang selanjutnya akan menggunakannya, Saran
yaitu petugas-petugas medik di instalasi rawat Untuk mengembangkan sistem EMR
inap. Pengujian lapangan dilakukan oleh user ini lebih lanjut, terdapat beberapa saran
sebenarnya dari berbagai unit, meliputi unit sebagai berikut.
registrasi, IGD, bangsal, administrasi, rekam 1. Perancangan di bagian bangsal masih
medik ditambah bagian umum, di Instalasi bersifat umum (sesuai dengan format
Rawat Inap Rumah Sakit Umum Ananda rekam medik kertas yang
Salatiga. didigitalisasi). Hal ini masih dapat
dikembangkan mengingat kekhususan
tiap spesialisai penyakit yang
diklasifikasikan dalam bagian-bagian,
misalnya Anak, penyakit dalam, THT
dan mata.
2. Pengintegrasian dengan unit
pelayanan medik lain dalam rumah
sakit yaitu rawat jalan (poli), sistem
internal laboratorium, sistem internal sistem internal OK (kamar bedah), dapat
radiologi, sistem internal apotek, dilakukan jika sistem untuk unit-unit
tersebut telah dirancang. Installation”, International Graduate
3. Sistem masih dapat dikembangkan Conference on Engineering and
misalnya dengan memasukkan pasien Sciences, D35: Computing and
dan penjenguk sebagai user, selain itu Information Technology, 2008.
aplikasi juga masih dapat [9] Nugroho, Adi., Rational Rose untuk
dikembangkan dalam hal pengaturan Pemodelan Berorientasi Objek,
keuangan. Cet.I.17, 39-40, 51-52, 61, 92, 110.
Informatika, Bandung, 2005.
DAFTAR PUSTAKA [10] Nugroho, Bunafit., Database Relasional
dengan MySQL, Ed.1.1-4. Andy
[1] Ginsburg, Mark., “Pediatric Electronic Offset, Yogyakarta, 2005.
Health Record Interface Design: The [11] Nugroho, Bunafit., Trik dan Rahasia
PedOne System”, in Proceedings of Membut Aplikasi Web dengan PHP,
The 40th Hawaii International Cet. I, Ed.1.47. Gava Media,
Conference on System Sciences, Yogyakarta, 2007.
IEEE 2007, pp. 1530-1605. [12] Sanjoyo, Raden., Aspek Hukum Rekam
[2] Hakim, Lukmanul., Membongkar Trik Medis,
Rahasia Para Master PHP, Cet. I. http://www.yoyoke.web.ugm.ac.id,
Lokomedia, Yogyakarta, 2008. D3 Rekam Medis FMIPA
[3] Hanafiah, M. Jusuf dan Amri Amir., Universitas Gadjah Mada
Etika Kedokteran dan Hukum [13] Rusli, Arsil, dkk., Manual Rekam
Kesehatan, Ed.3, Penerbit Buku Medis, Konsil Kedokteran
Kedokteran EGC. Indonesia/Indonesian Medical
[4] Harlan, Johan., Dari Rekam-Medik council, Jakarta, 2006
Kertas ke Rekam-Medik Elektronik, [14]---, ICD, http://id.wikipedia.org/wiki/icd.htm
Presentasi, Pusat Studi Informatika
Kedokteran, Universitas Gunadarma, BIODATA PENULIS
Jakarta, Tanpa Tahun.
[5] Infokez., Sejarah dan Perkembangan Moh. Muttaqin, dilahirkan di
ilmu Rekam Medis, Langsa, pada tanggal 10
http://www.infokez.wordpress.com / Agustus 1986. Mahasiswa
Sejarah & Perkembangan ilmu Teknik Elektro Universitas
Rekam Medis « Line Of Diponegoro ini mengambil
Infokez.htm, Juni 2008 konsentrasi Informatika dan
[6] J. Kairouz, A. Lam, A.S. Malowany, Komputer.
F.A. Carnevale, R.D. Gottesman., “A
Moh. Muttaqin3, Eko Handoyo, S.T, M.T4, Aghus Sofwan, S.T, M.T2
Abstract
Nowadays, medical caring need more effective and efficient system, in time, personnel and
facility using. The fact that medical record still operates in manual papered medical record which
appraised unreliable anymore to handle the medical data, issued idea to convert papered medical
record to the electronic one, because of its effectiveness and efficiency.
The goal of this research is to create the electronic medical record or known as EMR, form
the papered medical record in Ananda Hospital Stayed Nursing Installation. This EMR designed by
creating forms that recorded medical data during the patient curing process. Then, the data stored and
managed digitally. For each medical data in several forms noted, the system will resulting a code that
tell a special information.
At last, this system produce the ICD (International Statistical Classification of Diseases and
Related Health Problems) code stream consist of codes resulted in medical record forms filling. This
stream describe the patient conditions development during the curing process. The stored medical
data can be represented as digital medical record.
3
UNDIP Electrical Engineering Student
4
UNDIP Electrical Engineering Lecturer
VIII. DESIGNING
System Modeling
To facilitate system designing, the system
first describe into model using UML (Unified
Modeling Language) that performed in Figure 2 Medical record staff activity diagram.
several kind of modeling diagrams. The use
case diagram is a modeling diagram describe The sequence diagram is a diagram
relation among actors and use cases[9] in describing the sequence detail of each activity
EMR operation procedure. Use case diagram performed in the activity diagram as the order
for EMR system shown in Figure 1 below. of time or chronologically.[9] An important
activity in medical record operation is the
informasi
ICD stream code generation activity for the
penjenguk
resepsionis patient who had finished his stayed nursing
dokter igd
perawat igd
process. This activity done by the medical
registrasi
record staff and can be performed in two
terapi awal perawatan awal different modes. First mode is ICD stream
code generation based on the disease which
the patient diagnosed. Sequence diagram for
pasien
terapi intensif
this mode is shown in Figure 3. The rest mode
perawatan intensif
penyelesaian administrasi
is ICD stream code generation based on the
patient guarantor. Sequence diagram for this
dokter bangsal
perawat bangsal last mode shown in Figure 4.
petugas administrasi
Object1 generate_icd.php list_icd2.php
icd_penyakit.php
open
simpan rekam medik
lihat
view
manajemen RM
System Designing
This system designed web based, using
PHP 4.4.0 as the web programming language
and MySQL 4.0.25 as its database. The
designing processed according to the Figure 6 Testing result of ICD stream code generation
modeling diagrams and run on HTTP server based on patient disease diagnosed.
Apache.
System Testing
IX.TESTING System testing executed generally to all
Unit Testing parts of system and focused on the
Unit testing performed for each unit in the requirements, use and security aspects. In the
system. Units are commands or menus. The requirements aspect, the system enabled to
testing executed on login and logout facility, reduce the number operations, automate the
filling and viewing medical note according to filling and avoid its multiplication. Several
the right of each user. The two most automatic confirm facilities available to
important testing is the test to view all the minimize the filling error. Checking facility is
filled medical record and the test to generate also activated in this system to recheck some
the stream of ICD code performed by the inputted data so its must be filled with the
medical record staff. Figure 5 show the page suitable one. The need to ease accessing,
to choose which medical note to view, digital recording and quick searching also
whereas Figure 6 show the testing result of performed finely. In the use aspect, the
generating ICD stream code based on patient medical record functions were fulfilled by the
disease diagnosed. system. Electronic medical record system not
only facilitate to write and view the record,
moreover can be a large number of active
data used for various interest according to the
regulation and medical record function
development manual. A significant advantage
of this system is show on how the ICD stream
code can be generated easily from a large
number of optional possibilities accurately, in
a very short period of time. In the security write and read managed well refer to the user
aspect, the electronic medical record rated type, but not broke the rapid interaction among
better then the conventional kind. The right to medical staff in the patient health care process.
Imitating and counterfeiting action that (registration unit, emergency unit,
aliased to another medical staff is hard to ward, administration unit and medical
execute. To protect the patient, this system record unit).
completed with the documentation of every 9. Output of the system can be reused to
medical action noted so if any malpractice be the raw data for creating another
occurred, the proof of the accident will be medical document note, especially
recorded clearly. ICD.
10. This stayed nursing installation
Acceptance Testing applied the latest version of ICD code,
Acceptance testing show that the system ICD code version 10, released by
is completed and perform according to the Central Java Governmental Health
requirements that being the basis of designing Institute.
process and also accepted by all users operate
the system soon, that is the medical staff Advice
work in stayed nursing installation. Beta test Some useful advice to further more
performing by the real users from various develop this stayed nursing EMR system
units, consist of registration, emergency, noted below.
ward, administration and medical record unit, 4. Ward section designing still created
plus general service unit, in stayed nursing unspecified (it is according to the
installation Ananda General Hospital, format of papered medical record that
Salatiga. digitalized). This section can be
develop to be more specialized for
X. CLOSING each disease general classification e.g.
Conclusion pediatric, internist and ear-nose-throat
Conclusion of this designing a web base clinic, and ophthalmology clinic.
electronic medical record in stayed nursing 5. Integration with another medical
installation mentioned below. serving unit in the hospital, such as
6. This stayed nursing EMR system is an regular health care (polyclinic),
integral part of hospital medical record internal laboratory system, internal
connecting structure. radiology system, internal pharmacy
7. As shown in the research purpose, this system, internal surgery system can be
stayed nursing EMR system had executed if the internal system of
reached its goal to perform these units had been created.
digitalization of the papered medical 6. The system still can be developed e.g
record use in stayed nursing by performing the patient as a user,
installation and became reliable beside in this application also still can
system in accessing speed, accurate in be developed the section of finances
reporting and improve the work management.
efficiency of medical staff who use it.
8. This stayed nursing EMR system REFERENCES
belong to 7 users (receptionist,
emergency nurse, emergency doctor, [1] Ginsburg, Mark., “Pediatric Electronic
ward nurse, ward doctor, Health Record Interface Design: The
administration staff and medical PedOne System”, in Proceedings of
record staff) from 5 medical care units The 40th Hawaii International
in stayed nursing installation Conference on System Sciences,
IEEE 2007, pp. 1530-1605.
[2] Hakim, Lukmanul., Membongkar Trik
Rahasia Para Master PHP, Cet. I.
Lokomedia, Yogyakarta, 2008.
[3] Hanafiah, M. Jusuf dan Amri Amir.,
Etika Kedokteran dan Hukum
Kesehatan, Ed.3, Penerbit Buku Kertas ke Rekam-Medik Elektronik,
Kedokteran EGC. Presentasi, Pusat Studi Informatika
[4] Harlan, Johan., Dari Rekam-Medik Kedokteran, Universitas Gunadarma,
Jakarta, without published year. AUTHOR
[5] Infokez., Sejarah dan Perkembangan
ilmu Rekam Medis, Moh. Muttaqin was born in
http://www.infokez.wordpress.com / Langsa, on Sunday, August
Sejarah & Perkembangan ilmu 10th 1986. Studied in
Rekam Medis « Line Of Diponegoro University, he is
Infokez.htm, Juni 2008 majoring the Electrical
[6] J. Kairouz, A. Lam, A.S. Malowany, Engineering and take the
F.A. Carnevale, R.D. Gottesman., “A specialist in Computers and
Informatics.