Standard, Integrasi dan Interoperabilitas

dalam Informatika Kesehatan

Guardian Y. Sanjaya
Departemen Kebijakan dan Manajemen Kesehatan
FK-KKMK UGM
Outline
• Definisi interoperabilitas
• Kenapa standar dan interoperabilitas
• Konsep pertukaran data kesehatan (HIE)
• Interoperabilitas menggunakan FHIR (protokol pertukaran data) dan
kebutuhan standar data
• Strategi untuk mendorong interoperabilitas dan peluangnya
What is interoperability?
• Interoperability is ability of two or more systems or components to
exchange information and to use the information that has been
exchanged (IEEE 1990)
• Technical interoperability
• Semantic interoperability
• Process interoperability
• Clinical interoperability
Interoperabilitas
• Kemampuan antar sistem yang berbeda untuk komunikasi dan
pertukaran informasi secara akurat, efektif dan konsisten serta
menggunakan informasi tersebut.
• Antar sistem di dalam organisasi kesehatan (EMR)
• Antar sistem lintas organisasi kesehatan (EHR)
• Kebutuhan interoperabilitas
• Arsitektur interoparabilitas (OpenHIE)
• Penggunaan standar data kesehatan (terminologi dan klasifikasi)
• Protokol komunikasi/standar message (FHIR)
Where interoperability being used?
• Requests for tests and investigations
• Prescriptions for medicines and treatment.
• Orders for nursing care, equipment, meals and transport.
• Test reports.
• Administration notifications for changes in patient details and scheduling.
• Letters from one clinician to another such as referral, clinic and discharge
letters.
• Transfer and merging of medical records.
• Aggregate information for management, audit and monitoring.
• Commissioning, billing and accountancy.
 Potential benefit of interoperability

https://vigyanix.com/blog/healthcare-interoperability-opportunities-challenges-solutions/
www.healthinformaticsforum.com
Tantangan Data dan Sistem Kesehatan
Petabytes Data Kesehatan dihasilkan setiap hari

Data kesehatan diproduksi

270 Juta masyarakat 1 berukuran besar setiap hari
Indonesia mempunyai data
medis dalam bentuk digital dan
kertas Data tidak terstandar dan tidak
2 terintegrasi
Lebih dari 60,000 fasilitas
kesehatan memproduksi data
Beberapa data yang sama
kesehatan baik digital maupun kertas
3 dikumpulkan oleh sistem/aplikasi
yang berbeda-beda
Terdapat 400+ aplikasi
kesehatan milik
pemerintah Pusat dan Sulit dilakukan Interoperabilitas
Daerah 4 dan Integrasi Data Kesehatan
Nasional

Data kesehatan dari alat

Kebijakan kesehatan
kesehatan berbasis IOT tidak 5 belum berbasis data
terintegrasi dan tersebar
Mengapa perlu interoperabilitas?
• Berapa banyak sistem informasi kesehatan di tempat kita?
• Berapa banyak vendor dan organisasi kesehatan bekerja pada sistem
informasi kesehatan?
• Apakah fasilitas kesehatan telah mengadopsi rekam kesehatan
elektronik?
• Berapa banyak sumber daya yang terbuang akibat duplikasi
pengumpulan data?
• Dapatkah interoperabilitas meningkatkan kualitas pelayanan dan
keselamatan pasien?
Permenkes 24 tahun 2022 – Rekam Medis
• Sistem Elektronik yang digunakan dalam penyelenggaraan Rekam Medis
Elektronik harus memiliki kemampuan kompatibilitas dan/atau
interoperabilitas.
• Interoperabilitas mengacu kepada standar sistem elektronik yang
diselenggarakan oleh Kementerian Kesehatan (SatuSehat)
• Sistem Elektronik harus mengacu kepada variabel dan meta data yang
ditetapkan oleh Kementerian Kesehatan (ex: kf/a, SNOMED-CT)
• Rekam Medis Elektronik yang disimpan oleh Fasilitas Pelayanan Kesehatan
harus terhubung/terinteroperabilitas dengan platform layanan
interoperabilitas dan integrasi data kesehatan yang dikelola oleh
Kementerian Kesehatan.
 MEMBERSHIP
HEALTH
HIS FACILITY BPJS
Social
Kes SEP Individual
Health
REGISTRY Insurance Data
PRIMARY Faskes CLINIC P-CARE
CARE Faskes
Healthcare
Faskes
Facility

INDIVIDUAL SIHA
HRIS SITT
PRACTICE
SI STBM KARTINI

INA-CBGs DHIS2
MoH Data Source
KOMDAT SIP
E-LOGISTIK HIS
SI GIZI
SURVEILANCE

REPORT Lainnya REGISTRY

Aggregate
Lainnya
Lainnya
Others Data
VITAL STATISTIC
 SIM BPJS dan SIM Faskes (SIMRS, SIMPUS)

CLIENT Membership
P-CARE
PHC REGISTRY verification
SYSTEMS Information
exchange CARD ID
WEB SERVICE
REFERRAL ID

WEB SERVICE PRIVATE

PUBLIC
CARD ID
REFERRAL ID
SEP SYSTEM
Admission registry
SIKDA SIMPUS
WEB SERVICE HOSPITAL
HOSPITAL

CLAIM
HOSPITAL
SYSTEMS
e-Puskesmas OTHERS SYSTEMS
SYSTEMS
SEP ID

INA-CBGs (DRG)
SUPPLY DATA
Kerangka Interoperabilitas Sistem Informasi

Standar Data dan Kodifikasi

FHIR sebagai standar

protokol pertukaran data

Sistem Elektronik yang

digunakan oleh berbagai
stakeholder
SATUSEHAT : Indonesia’s Health Data Interoperability Platform
Collaboration : SATUSEHAT connect everyone to benefit everyone

Government
Patient/User

● Personal Health Record Integrated dashboard for

● Health Promotion evidence based policy and
● Personalized Education SATUSEHAT data driven decision-making
● Wearable Devices
Integration Terminology Precise and Up-to-date
FHIR API
● etc Server
information for detecting,
predicting, prescription any
Developer health problem and support One Health
Master Data
Hub health resilience system Data
Dashboard

Health Facilities
Integration Target
Health Industry (Ecosystem)
10K 5K+ Insight sharing and utilization to strengthening collaboration
Puskesmas 11K+
+
(Posyandu included) Clinics
Independent
Physician Practices
Insurance
Health-Tech Pharmacy
Company

~3K 1,4K 30K Laboratorium Biotech Lab etc.

Hospitals Laboratoriums
Pharmacies
+

SATUSEHAT : Indonesia’s Health Data Interoperability Platform DTO-Pusdatin Kemenkes. 2023. Evolving Healthcare Data Strategy kemkes.go.id
FHIR sebagai standar protokol pertukaran data
• FHIR (Fast Healthcare Interoperability Resources) Specification, which
is a standard for exchanging healthcare information electronically
• Electronic health records must be available, discoverable, and
understandable.
• To support automated clinical decision support and other machine-
based processing, the data must also be structured and standardized
• FHIR can be used as a stand-alone data exchange standard, but can
and will also be used in partnership with existing widely used
standards.
Standard Development Organization (SDOs)
• IHTSDO  SNOMED-CT
• Regenstrief Institute  LOINC
• WHO  WHO International Family of Classification
• HL7
• DICOM
• NLM  RxNorm
SATUSEHAT Data Standardization and Management
Master Data Management to build reliable data ecosystem for further use

Patient Data (Master Patient Index)
● Product data specially designed as a standard for patient data
to be validated by National Civil Registry for data related to
demographics
● Can be used as the main standard for patient data by all
Health Service Facilities in Indonesia via SATUSEHAT
Data on Medical Devices and Medicines (KFA
Dictionary)
● Data product designed as Master data for
Pharmacy, Drugs, and Medical Devices collected
from various data sources as reference standards
for drug data (active substance content, size,
volume, etc.) and medical devices

Health Facilities Data Financing Data

● Master data specially designed as a standard for Health
Service Facility data which consists of 35 types of healthcare
facilities.
● This data is compiled based on various sources such as
Healthcare Workers Information System, Online Hospital,
SIMADA, and others
● The data product is designed as a Financing
Master data that can be used by all Health
Facilities and can be used as a standard for the
preparation of cost formats for services, actions,
and others.

Health Human Resources Data Service Data

● Specially designed data product as a standard data index for ● Data products that are designed as Service Master
health workers combined from various data sources for health data that can be used by all Health Facilities and
personnel (Name, STR, SIP, etc.) can be used as service coding standards.

18
SATUSEHAT : Indonesia’s Health Data Interoperability Platform DTO-Pusdatin Kemenkes. 2023. Evolving Healthcare Data Strategy kemkes.go.id
 Terminology Standard Used in SATUSEHAT

ICD-10 ICD-9-CM LOINC DICOM SNOMED CT

Laboratory,
Medical Procedures
Diagnosis Radiology Test and Health Digital Clinical Terms
and Actions
Standard Examination Imaging Standard
Standard
Standard

19 19
SATUSEHAT : Indonesia’s Health Data Interoperability Platform DTO-Pusdatin Kemenkes. 2023. Evolving Healthcare Data Strategy kemkes.go.id
 Stages of Use Cases in SATUSEHAT

Use Case 1 Use Case 2 Use Case 3

Medical procedures, vital

Patient registration/visit and Medication prescription and
conditions, diet
diagnosis dispensing

Use Case 4 Use Case 5 Use Case 6

Allergies, other physical
Laboratorium conditions, conditions leaving Radiology and Other
the hospital, education, follow- Observations
up plans

SATUSEHAT : Indonesia’s Health Data Interoperability Platform DTO-Pusdatin Kemenkes. 2023. Evolving Healthcare Data Strategy. Presentation
20
kemkes.go.id
Interoperabilitas menggunakan FHIR
1. Identifikasi Sistem informasi yang perlu interoperabiltias
2. Melakukan pemetaan struktur rekam medis dengan FHIR dan Gap
analysis antara standar data dan FHIR resource
3. Mengidentifikasi FHIR resource yang akan digunakan dan strukturnya (ex:
Patient, encounter, organization, condition, observation, procedures and
medication)
4. Melakukan pemetaan antara FHIR resource dengan data yang diperlukan
5. Membuat profil interoperabilitas berdasarkan resource dan extention
yang diperlukan ke dalam FHIR server
6. Mengembangkan FHIR Server (dengan profiling yang sudah dipetakan)
7. Melakukan pengujian Post dan Get dari Client (Ex: SIMPUS dan SIMRS)
2. Pemetaan struktur data - Ilustrasi
Anamnesis Data Structure
• Pasien mengeluh mata • Clinical and disorder
merah sebelah kanan, nyeri • Red eye (Code: 703630003)
pada bola mata, bengkak, • Periorbital pain (Code: 86260003)
gatal, mengeluarkan cairan • Periorbital edema (Code: 49563000)
kental dan lengket pada
• Itching of eye (code: 162288000)
pagi hari
• Dischrage from eye (code: 246846008)
• Sticking of eyelids due to discharge from eyes (Code:
246846008)
• Structure of the Right eye region (Code: 18944008)
2. Data Element Group Mapping
Data Element Group
Data Kunjungan
Data Sosio-demografi
Informasi Fasilitas Kesehatan
Penanggung Jawab Pelayanan
Clinical Information – Anamnesis
(Subjective)
Clinical Documentation – Clinical
Finding (Objective)
Clinical Documentation – Lab Results
Clinical Documentation – Medication
Clinical Documentation – Medical
Procedure
Clinical Documentation – Diagnosis
Tindak Lanjut
FHIR Resources Example of Data Elements
Episode of care Date of admission, service unit
Patient Resources Full name, date of birth, age in year, address
Organization Resources Health Facility Name, Health Facility Code, Type of
Health Facility
Practitioner Resources Doctor name, Physician’s ID
Condition Resources Chief complain, history taking
Observation Resources Body temperature, systolic and diastolic blood
pressure
Observation Resources Lab code, lab name, lab value result
Medication Resources Drug name, drug strength, route, frequency
Procedure Resources Procedure code, Procedure name
Condition Resources ICD-10 code, ICD-10 name
Care Plan Resources Patient referral
3. FHIR Resource Mapping

Patient Organization Condition Practitioner

Observation

Service
Request

Medication

Procedures

Episode of Care
Care Plan

Jenis kunjungan, Tanggal

kunjungan, tanggal keluar
4.a. Data Element Maping - Example
Data Element Group Data Element FHIR Resource Description
Sosio-demography Nama Lengkap Patient.name.given HumanName
Sosio-demography Nomor Induk Kependudukan Patient.identifier Identifier
Sosio-demography Jenis Kelamin Patient.sex Patient gender
Sosio-demography Tanggal Lahir Patient.dateBirth Date
Sosio-demography Alamat Patient.address.line Address
Anamnesis Keluhan Utama Condition Chief complaint
Pemeriksaan Fisik Suhu tubuh Observation Body temperature
Pemeriksaan Fisik Tekanan Darah Sistolik Observation Sistolik
Terapi Obat Medication Drug name and Code
Terapi Frekuensi Pemberian Obat Medication Frequency of consumption
Diagnosa Diagnosis Diagnosa.condition Diagnosa ICD-10
Diagnosa Tipe Diagnosa Diagnosa.type Masuk|Kerja|Akhir
 4b. Data Value Mapping Example
V- V-
HDD_dataVa PCare_dataVal PCare_dataValueN
dataElement HDD_DataValueName Claim_dataV Claim_dataValu FHIR_dataValueCode FHIR_dataValueName
lueCode ueCode ame
alueCode eName
Jenis Kelamin 0 Tidak diketahui unknown Unknown
Jenis Kelamin 1 Laki-laki 1 Laki-laki male Male
Jenis Kelamin 2 Perempuan 2 Perempuan female Female
Jenis Kelamin 3 Tidak dapat dikategorikan
Jenis Kelamin 9 Tidak Berlaku
Jenis Kelamin other Other
Status Pernikahan 1 Belum Kawin 1 Belum kawin U unmarried
Status Pernikahan 2 Kawin 2 Kawin M Married
Status Pernikahan 3 Cerai Hidup 3 Cerai D Divorced
Status Pernikahan 4 Cerai Mati W Widowed
Status Pernikahan 9 Tidak terdefinisi UNK unknown
Status Pernikahan I Interlocutory
Status Pernikahan L Legally Separated
Status Pernikahan P Polygamous
Status Pernikahan S Never Married
Status Pernikahan T Domestic partner
Status Pernikahan A Annulled
 4c. Clinical term mapping
No Terminologi Kelompok Komponen code name source
2 Batuk Keluhan Utama Condition 49727002 Cough SNOMED-CT
3 Pilek Keluhan Utama Condition 82272006 Common cold SNOMED-CT
4 Nyeri otot Keluhan Utama Condition 68962001 Muscle pain SNOMED-CT
5 Nyeri tenggorokan Keluhan Utama Condition 162397003 Pain in throat SNOMED-CT
6 Sakit kepala Keluhan Utama Condition 25064002 Headache SNOMED-CT
7 Sesak nafas Keluhan Utama Condition 267036007 Dyspnea SNOMED-CT
8 Nyeri sendi Keluhan Utama Condition 57676002 Joint pain SNOMED-CT
9 Mual Keluhan Utama Condition 422587007 Nausea SNOMED-CT
10 Muntah Keluhan Utama Condition 422400008 Vomiting SNOMED-CT
11 Diare Keluhan Utama Condition 62315008 Diarrhea SNOMED-CT
12 Fatigue Keluhan Utama Condition 8422900 Fatigue SNOMED-CT
79 Angka lekosit Lab Observation 6690-2 Leukocytes [#/volume] in Blood by Automated count LOINC
80 Angka trombosit Lab Observation 777-3 Platelets [#/volume] in Blood by Automated count LOINC
Hematocrit [Volume Fraction] of Blood by Automated
81 Hematokrit Lab Observation 4544-3 count LOINC
82 Tes torniquet Lab Observation 38520-3 Capillary fragility [Presence] LOINC
Albumin/Protein.total in Serum or Plasma by
83 Protein darah Lab Observation 13980-8 Electrophoresis LOINC
Rapid Diagnostic Test Dengue virus IgG and IgM [Identifier] in Serum, Plasma
84 (RDT) Dengue Lab Observation 75223-8 or Blood by Rapid immunoassay LOINC
10 Hematocrit [Volume Fraction] of Blood by Automated
5 Hematokrit Lab Observation 4544-3 count LOINC
5. FHIR Profiles (https://simplifier.net/)
Message Protocol (FHIR)
{
"resourceType": "Patient", • Struktur informasi/ messege
"id": "2380927",
"identifier": [ untuk setiap aktivitas
{
"use": "official", • Pasien baru
"type": {
"coding": [ • Admisi pasien
{
"code": "NIK", • Pemeriksaan fisik
"display": "Nomor Induk Kependudukan"
} • Hasil pemeriksaan penunjang
]
},
• Diagnosis
"value": "000019993005"
},
• Tindakan medis
"gender": "female",
• Obat
"birthDate": "1999-05-30",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/patient-birthPlace",
"valueAddress": {
"district": "Madiun"
}
}
6-7. Skenario Interoperabilitas (Ex: SIMPUS dan
SIMRS)
SIM Lainnya
Lab

Apotek KIA Dashboard

Aggregation and
Data
SIM FASKES
Autentikasi
SIMPUS 1
Mobile
SIMUNDU
FHIR Database Apps Database
(PHR)
BUMILKU

EPPBGM Autentikasi

2
FHIR
Standar
 Isu yang berkaitan dengan standar data kesehatan

• Need for multi-purpose standards and terminologies

• Lack of content in terminology standards
• Gaps in data standards
• Overlapping standards
• Different requirements from different agencies when exchanging data
• Changes in standards
Brooks. 2010. Standards and Interoperability in Healthcare Information Systems: Current Status, Problems, and Research Issue
 Pengembangan standard
1. Ad hoc – when a group of interested people or organizations agree
on a certain specification;
2. Defacto – when a vendor or other commercial enterprise controls
such a large segment of the market that its product becomes the
recognized norm;
3. Government mandate – when the government mandates a
standard;
4. Consensus – when representatives from interested parties work
together and reach a consensus.

Brooks. 2010. Standards and Interoperability in Healthcare Information Systems: Current Status, Problems, and Research Issue
Bagaimana mencapai interoperabilitas?
Regulatory frameworks • Laws and regulation

Information Structure • Standard (terminology, registry)

• Communication networks, Electronic directory, Identification,

Technical Infrastructure Authentication, information structure

Supportive and • Electronic Health records, administrative support systems, national

interoperable ICT Systems patient’s summary, decision support, prescription support

• Access across organization and boundaries

Access information • Accessibility for citizen

Mansoor, Majeed. 2010. Achieving Interoperability among Healthcare Organizations

Peluang interoperabilitas
• Standar terminologi kesehatan mulai dikembangkan (metadata rekam
medis elektronik, kf/a)
• Tersedia standar internasional yang diadopsi (LOINC, SNOMED-CT
• Adanya dukungan kebijakan (SatuSehat, Permenkes)
• Keragaman sistem informasi
• Inisiasi integrasi sistem dan interoperabilitas
Take home message
• Interoperabilitas menjadi kunci penting untuk mengoptimalkan peran
teknologi digital dalam pelayanan kesehatan.
• Interoperabiltias menggunakan standar FHIR yang sudah diadopsi
berbagai negara.
• Standar data kesehatan ditetapkan secara nasional untuk mendukung
interoperabiltias dan masih terus berkembang.
• Masih diperlukan tatakelola terhadap pencapaian interoperabilitas
level nasional.
Terimakasih