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IT) practices in the Indonesia health referral system
Informatics in Medicine Unlocked 17 (2019) 100263
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The Information System/Information Technology (IS/IT) practices in the Indonesia health referral system Putu Wuri Handayani a, *, Ave Adriana Pinem a, Fatimah Azzahro a, Achmad Nizar Hidayanto a, Dumilah Ayuningtyas b a b
Faculty of Computer Science, University of Indonesia, Indonesia Faculty of Public Health, University of Indonesia, Indonesia
A R T I C L E I N F O
A B S T R A C T
Keywords: Health referral Health referral information system Primary care Hospitals Indonesia
Purpose: The purpose of this study is to understand how Information System/Information Technology (IS/IT) is used to support the health referral system in Indonesia. Method: This study uses a qualitative approach, with case studies at the Ministry of Health of the Republic of Indonesia (MOH) as the sector regulator, the Social Security Agency for Health (BPJS-K) as the Indonesian government body in organizing a health insurance program for all Indonesian citizens, and hospitals as the health providers in the DKI Jakarta Province. The 33 respondents involved in this study are policy makers, medical personnel who use the health referral information system, such as doctors, nurses and administrative staff, and application developers who develop and deploy the applications for health referral. Results: The study reveals that most of the health facilities and providers in the DKI Jakarta Province have used health referral information systems, even if the system is not fully integrated or does not have a complete set of features. All of the relevant stakeholders should be able to manage the technical and non-technical problems in the health referral information system. Strong integration and well-structured planning in IS/IT application could reduce the queuing processes in health facilities. Conclusions: Based on this study, MOH as the health regulator should draft regulation(s) that defines the health data dictionary as a reference for interface between health referral applications developed by each health facility or regional government. In addition, the chairperson of health facilities providers should have a strong leadership commitment and good coordination with other health facilities in performing the usage of health referral in formation systems.
1. Introduction The Indonesian Government has launched a National Health Insur ance (NHI) health program in which all citizens are facilitated in obtaining healthcare access. NHI is one platform for the implementation and development of health efforts within the National Health System (NHS). As part of the NHS implementation plan, a division of tasks among health facilities, or a so-called referral system, is required to obtain high-quality health services that are both effective and efficient. According to the Ministry of Health of the Republic of Indonesia (MOH), both effectiveness and efficiency can be achieved if a referral system is organized with the aim of providing quality health services; this way, service goals can be achieved with minimal cost [1,2,6]. Of particular
importance are reducing the waiting time in the referral process and reducing the number of unnecessary transfers, because the required service can be handled by the original health services facility, either with the help of available cutting-edge or low-cost technology. To date, MOH only regulates the health referral systems of individual health services, as set out in Law No. 40 of 2004 on Guarantee System National Social and implementing Regulation of MOH Number 001 of 2012 regarding Individual Health Service Referral Systems (MOH Regulation 001/2012). Based on MOH Regulation 001/2012, the health referral system is defined as a health service arrangement that regulates the delegation of duties and responsibilities of health services on a reciprocal basis, either vertical or horizontal. Based on this definition, the health referral system is required for all patients who participate in
* Corresponding author. Faculty of Computer Science, Jalan Kampus UI, Depok, West Java, 16424, Universitas Indonesia, Indonesia. E-mail addresses: [email protected] (P.W. Handayani), [email protected] (A.A. Pinem), [email protected] (F. Azzahro), [email protected] (A.N. Hidayanto), [email protected] (D. Ayuningtyas). https://doi.org/10.1016/j.imu.2019.100263 Received 26 August 2019; Received in revised form 30 October 2019; Accepted 31 October 2019 Available online 12 November 2019 2352-9148/© 2019 Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
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health insurance or social health insurance and or receive care from any healthcare provider. Starting from January 1, 2014, the Social Security Agency for Health (BPJS-K) was appointed as the sole implementing body established by the government to organize a health insurance program for all Indonesian citizens. To date, the current referral system in Indonesia is still ineffective because of the visible accumulation of patients in the hospitals compare to first-level health facilities. Most of the patients do not seek treatment within the first-level health facilities due to management of patient file administration, which is still done manually. The issues could be handled properly if each health facility were to be using an integrated Information System/Information Technology (IS/IT), so that the health services could be provided to the patient optimally. By using IS/IT, in tegrated with health facilities’ information systems (e.g., a community health center system, hospital information system, or referral system application [P-Care] from BPJS-K), healthcare facilities could more quickly and readily access patient medical records, ensuring that the decision to refer a patient could be made quickly, and adjusted to the availability of personnel and medical equipment at the referral health care facilities. Until now, there has been limited research examining the health referral systems and the utilization of IS/IT to support these systems. This study has as a purpose, to understand how the IS/IT is utilized to support the health referral system in Indonesia. Bossyns and Lerberghere viewed a non-optimal health referral system in Nigeria, but focused more on the interaction between health workers and patients, and whether these interactions can be an impediment in running a tiered referral system [3]. A study by Akande examined the health referral system in Nigeria, showing that highly skilled workers and adequate equipment are needed for the implementation of the referral system [4]. Pembe et al. evaluated the effectiveness of the maternal referral system in the rural district of Rufiji in Tanzania [5]. Health referral system research conducted in Indonesia has been limited and still focuses on the use of health referral systems in hospitals; however, no studies have been undertaken at first level health facilities (FKTP). Furthermore, the Indonesian health system is unique and has limitations in terms of the facilities and health personnel availability. It also has a decentralized and tiered health system; therefore, the utilization of IS/IT has been one of the health reform initiatives in Indonesia, although the implementa tion is not yet optimal. The research question therefore arose: how is IS/IT used in health facilities to support the health referral system in Indonesia? The remainder of this paper is organized as follows: Section 2 re views the existing literature, and Section 3 explains the conceptual model. Section 4 describes the research methodology. The results and discussion of this research are subsequently presented in Section 5 and Section 6, respectively. Section 7 explores the implications of this research, and the final section, Section 8, discusses conclusions and recommendations for future work related to this research.
sustainable manner, the mapping of referral areas in each level of the referral system and national reference system must first occur, with reference system units included therein [7]. The task of mapping the referral system at the regency/municipal level is the responsibility of the Regional Health Office, BPJS-K, and its network (i.e., branch offices), while the task of mapping the referral system at the provincial and higher levels is assigned to the Provincial Health Office and MOH, and especially the Directorate of Referral Health Development [7]. In the DKI Jakarta Province, based on the Regulation of the Governor of DKI Jakarta No. 189 of 2015, the regulation is formulated as the legal basis and reference for health service facilities in carrying out the regionali zation of health referral systems in the relevant region. The objective of this regulation is to develop the regionalization of a tiered referral sys tem, to improve the quality and reach of referral health services in hospitals, and to even out the distribution of referral health services. Based on the Practical Guide to the Tiered Referral System issued by MOH, the referral system in Indonesia has been arranged in a tiered form, comprised of first-, second-, and third-level health services; as such, its application does not stand alone but is part of an interconnected system [[6]8]. Table 1 describes the classification of each healthcare facility. Further, based on MOH Decree No. 28 of 2014 regarding Guidelines for Implementation of National Health Insurance Program, health fa cilities are divided into two facility levels: First Level Health Facility (FKTP) and Advanced Level Health Facility (FKRTL). FKTP includes primary healthcare centers (Puskesmas or Pusat Kesehatan Masyarakat), physician private practices, dentists, primary or equivalent clinics, and class D hospitals or equivalents. FKRTL includes primary or equivalent clinics, general hospitals, and special hospitals. FKRTL is distinguished into second-level health facilities (healthcare facilities generally located in the Provincial Region, such as a provincial general hospital) and third-level health facilities (healthcare facilities generally located in the capital city, such as a central general hospital). 3. Methods This research is a qualitative study (case study research) using in terviews to collect data. The research phase starts from identifying problems, literature review, sample construction, instrument prepara tion, conducting face-to-face interviews, and analyzing the interview data. The bulk of this research was performed in health facilities in the North Jakarta region of DKI Jakarta Province, because the health referral system processes from FKTP to FKRTL have been continuously conducted in the North Jakarta region compared to other regions in the DKI Jakarta Province. The research is performed based on a preliminary interview with the Head of the Data and Information Section of DKI Jakarta Province. After the preliminary interview, we developed in struments for structured interview to the respondents, as suggested by the Head of the Data and Information Section of DKI Jakarta Province. Interviews were performed using the same interview questions with health referral system regulators, as well as users and managers of the health referral applications, with 33 people interviewed in total. The person being interviewed is selected based on the direction from the relevant head of government institutions on the basis of their expertise, knowledge, and scope of their works or their position which is most relevant to this study. The list of respondents involved in describing the health referral system is set out in Table 2. Data was collected from February 16, 2017 to May 4, 2018 (16 months). Further, based on the health profile of DKI Jakarta Province in 2014, the hospital bed ratio to 1000 residents in DKI Jakarta was 2:3, means that there were 2 beds per 3000 residents, which is above the ratio for national coverage (1:7). The highest ratio was in Central Jakarta region (6:7) while the lowest ratio is in Kepulauan Seribu (Thousand Island) region of (0:6). Based on the data, the health referral system process has been fully conducted in the North Jakarta region and this study selected four FKTPs and two FKRTLs in handling many referral patients. To
2. Literature review: Indonesia health referral system regulatory framework The health referral system in Indonesia is subject to regulations is sued by the government. Based on MOH Regulation 001/2012, the health referral system is defined as a health service arrangement that regulates the delegation of duties and responsibilities of health services on a reciprocal basis, either vertical or horizontal, which must be carried out by those who participate in health insurance or social health in surance and by all health facilities. The general objective of individual healthcare referral systems is the execution of individual health referral procedures, following the quality and patient safety standards of the reference criteria, at individual health service facilities of all levels in Indonesia [7]. According to the Guidelines of the National Referral System, to be able to establish a personal referral system in a good, steady, and 2
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Table 1 Healthcare Facility Classification [7]. Referral Level
Duties of Healthcare Facilities
Healthcare Facilities
Responsible for Monitoring and Evaluation
First-level healthcare facilities
Able to provide first-rate medical services performed by a doctor/ dentist and specifically able to provide psychological, neonatal, and maternal services, in certain conditions assisted by a midwife.
1. 2. 3. 4.
Second-level healthcare facilities
Able to provide specialist personal health services.
Third-level healthcare facilities
Able to provide sub-specialist health care.
1. Class D or C hospitals 2. Non-educational class B hospitals, governmentowned hospitals, and army forces/police/state/ privately owned hospitals 1. Class B education/class A hospital in the province 2. Class A hospitals (general referrals/general national in cities)
1. Head of Regency/ Municipality Health Office 2. Professional organization of regency/municipality branch 1. Head of Provincial Health Office 2. Provincial branch professional organization 1. Directorate of Referral Health Promotion 2. Directorate General of Health Efforts 3. Professional organizations 4. Educational institutions
Community health centers Primary clinics (government and private) Private practices of doctors/dentists Primary hospitals
and the health personnel available at each hospital”. In other words, for emergency referrals, administrative and/or geographical boundaries can be ignored because the important thing is that the patient receives prompt and appropriate care within a very decisive period (i.e., the “golden period”). According to the Director of Dr. Wahidin Sudir ohusodo Hospital and the Head of Medical Services of Tugu Koja General Hospitals, communication in emergency referrals is very important; because the referral process must begin and end with communication. Emergency referrals are performed by transferring patient identity data, diagnoses, and necessary actions that need to be performed for the relevant patient. To accelerate the health referral service process, MOH has developed three referral applications, BPJS-K has developed nine referral applica tions, and the Provincial Health Office of DKI Jakarta has developed one referral application. In general, the features required for the health referral system consist of the following:
obtain a comprehensive knowledge of the health referral system, this study also included interviews with the health regulators (i.e., MOH) and referral application developers who have successfully deployed the health referral applications in Indonesia, to understand the lessons learned by the developers when they deployed the health referral ap plications. The duration of interview was between 30 min and 1 h for each interviewee, and there were one to two iterations when conducting interviews in each case study, to enable researchers to discover and discuss all information related to the processes of the health referral system. The results of the interview were recorded with an audio recorder, transcribed and coded by the researcher for each important point throughout the interview. In relation to the ethics of this study, we have obtained approval from MOH (the Directorate of Referral Health Services and the Data and Information Center), BPJS-K, Provincial Health Office of DKI Jakarta Provinces, relevant health care centers, hospitals and interviewees that the result from this study will be pub lished. In addition, all participants have provided their consent to be interviewed for this study and approved that the results of interview will be published in a journal or publication. Table 3 shows the interview key point of questions. We used content analysis to organize and elicit meaning of interview data and draw conclusion from it. Content analysis is a widely used qualitative research method for studying documents and communica tion objects, which might include texts in various formats, audio, video or picture [12]. The results of the analysis are grouped with the results, namely (1) the actual processes carried out in the health referral system, (2) the support of IS/IT on the health referral system and (3) the prob lems that occur in the health referral system.
1. Patient, medical personnel and health facility profile information as well as patient medical resume; 2. Schedule information of physician polyclinic service in hospital by date, day, and hour; 3. Room availability information; 4. Reservation/appointment booking service of polyclinic doctor or booking room in hospital; 5. Confirmation of patient referral patients at the hospital; and 6. Reports related to patient referrals. Based on interviews with all the respondents, there are still dupli cation functions performed in more than one application. For example, both the Online Referral Service System (SPRO) and Integrated Referral System (SISRUTE) can be used to perform scheduling and patient registration to the intended outpatient installations. Then, integration methods performed between the BPJS-K’s applications are done using web services. Health facilities in Indonesia use different health appli cations, resulting in a complex integration mechanism. The complica tion arises because there is no standard reference that can be used, as well as strong coordination between the central regulator and the local facilities, and as such, there is no SI/IT plan in place to allow for synergy between the healthcare regulators and providers. The lack of coordi nation also makes it difficult to achieve a standardization in health data between the various parties. In addition to the complexity of integration between applications, each health facility requires IT staff who can support the maintenance of these applications. However, many health facilities do not have permanent IT staff due to limited budget. Table 4 explains the summary of results. Based on input from all respondents and analyzing the results, the following list of actions need to be made a priority to resolve all
4. Results Referral flow consists of vertical referrals, back referrals, and hori zontal referrals between hospitals in the same class or between units in one hospital (e.g., referring patients from emergency departments to inpatient units). Vertical referrals are made from the health facility of a lower class to a health facility that has a class at least one level higher than that of the referrer health facility. In contrast to vertical referrals, back referrals are done from a health facility of a higher class to one of a lower class. Finally, horizontal referrals occur between units in one hospital and between hospitals of the same class. Based on the Head of Medical Services of Tugu Koja General Hospital, all referral flows are performed by sending patient identity data, the reason for the referral, the follow-up treatment, and the medical resume. The Head of Public Relations of BPJS-K said that “specifically for emergency referrals, a tiered referral mechanism is not necessary and that the selection of hospitals for the referred patient is adjusted according to the patient’s level of severity, the appropriate facilities needed to provide care, 3
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Table 2 Respondent demographics.
Table 3 Interview key point of questions.
No.
Name of Health Facility
Position of Respondent
Number of Respondents
1.
Directorate of Referral Health Services with the MOH
Section Head of Referral Service Management Staff of Referral Service Management Staff Section of Planning and Development of Medical Services Referral Application Coordinator at the Referral Service Information Center Head of Sub Directorate of Integrated Emergency Services Head of Information System Development Division Data Center and Information Center staff Head of Public Relations Department Staff of Information Management and Documentation Officer Si Jari Emas Application Developer SMSBunda Business Development Director Section Head of FKRTL Health Services Division Section Head of FKTP Health Services Division Head of Data and Information Section IT staff Head of Health Services Section Staff of Health Services Section Online referral staff General practitioners of polyclinics who actively use referral applications Head of Individual Services Division IT Analyst Referral Operator Staff Elderly Polyclinic Doctor (person in charge of Referral Application) Head of Individual Services Division Reporting and Procurement Section staff BPJS-K Application Operator Head of Implementation Unit of Emergency and Outpatient Head of Education and Training Section Head of Medical Services Head of Hospital Information System Director of Koja Public Hospital Administration and Reporting Staff of Hospital Information System Installation Director
1
2.
Data and Information Center of the MOH
3.
BPJS-K
4.
Si Jari Emas and SMSBunda Application Developer
5.
Health Office of DKI Jakarta Province Health Services Division
6.
North Jakarta Health Office
7.
Koja Primary Health Care Center
8.
Cilincing Primary Health Care Center
9.
Kelapa Gading Primary Health Care Center
10.
Penjaringan Primary Health Care Center
11.
Tugu Koja General Hospital
12.
Koja Public Hospital
13.
Dr. Wahidin Sudirohusodo Public Hospital
No
Respondents
Key Point of Questions
1.
Health regulators (MOH, BPJS-K, Provincial Health Office of DKI Jakarta Province, North Jakarta Health Office)
2.
Health facilities (Kelapa Gading Primary Health Care Center, Koja Primary Health Care Center, Cilincing Primary Health Care Center, Penjaringan Primary Health Care Center, Tugu Koja General Hospital, Koja Public Hospital, Dr. Wahidin Sudirohusodo Public Hospital)
3.
Health referral application developers (Si Jari Emas and SMSBunda Application Developer)
� Regulation used as a basis for implementing health referral systems in Indonesia � Supports provided by health regulators to health facilities in running referral systems (e.g., the support of referral applications, human resources, and so on) � Requirements needed to run a health referral system and IS/IT to support the health referral system (e.g., the applications used, users using the health referral system, integration of the referral application with other related application, and so on) � Problems faced in the health referral system � Main features developed in the referral application � Issues occurred in the health referral application
2 1 1 1 2
2
2
Table 4 Summary of results.
4
Analysis
Results
Actual health referral system activities in health facilities Health referral system strength
� Vertical referrals, back referrals, and horizontal referrals are conducted in health facilities All relevant stakeholders have already used the online health referral information system � duplication functions performed in more than one application � complex integration mechanism due to the different referral applications used in health facilities � lack of IT resources in the health facilities
Health referral system weakness
2
2
2
� �
2
� 3
2
�
2
�
2
�
�
problems and achieve successful execution of health referral systems: � Relevant regulation(s) for the implementation of health referral systems (e.g., the regionalization of referral regions, the creation of clinical pathways, the development of a referral system data
�
4
dictionary). In addition to health facilities, the referral network also needs to be connected to the ambulance system and blood bank. Strong leadership from regulators and health facilities. The development of applications tailored to user needs that can be easily integrated with other related applications. The involvement of local stakeholders in various ways in the devel opment of an integrated, comprehensive referral system. The engagement of end users in the design and the systematic use of their feedback to revise the system and improve the user experience, as this is helpful in ensuring that the features of the system meet their needs. Determination of Service Level Agreements (SLA) for referral appli cations that must be mutually agreed upon between regulators and health service facilities to ensure standardization in providing services. An understanding of participant and health services facility re quirements in the tiered health referral system as well as patient education for the re-control of chronic diseases, which can be used for referral. The readiness of supporting facilities and infrastructure, such as Internet communication networks and integrated health applications. The availability of online communication and data networks in FKTPs as well as in FKRTLs and the smooth access to communication and data networks as the foundation of the online health referral systems. The commitment and discipline of FKTPs and FKRTLs in conducting service entries in the health referral application and carrying out all
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of the provisions and regulations set by the health referral system regulator. � Coordination with regency health offices and related health facilities in improving the availability of communication and data networks in non-sustainable areas or no jurisdictions. � Conducting IT governance in each health facility. � The readiness of human resources personnel who know and under stand IT/IS in helping with the development and support of health referral applications.
issue in the current health referral system is that regionalization is too rigid and hospital classification in each regency has been incomplete, so that referrals are highly dependent on doctor diagnoses. 6. Implications The results of this study could theoretically enrich previous research in providing knowledge related to the health referral systems in devel oping countries with limited health personnel and health infrastructure. This study also determined the factors required for the success of health referral systems. This study has implications for regulators (i.e., MOH, Health Office and BPJS-K) where regulators must prepare relevant regulation(s) regarding IS/IT for supporting the health referral system. Health facilities also need to develop applications tailored to the needs of users that can be easily integrated with other related applications, need to ensure the readiness of supporting facilities and infrastructure, and need IT governance in each health facility. In addition, patients also need to have awareness of the tiered health referral system.
5. Discussion According to Gillies et al., integrated health systems are widely considered to provide superior performance in terms of quality and safety because of effective communication and standardized protocols, although these outcomes have not been fully demonstrated [10]. Health referral systems must also be developed in an integrated manner; thus, the operation of an integrated health system requires leadership with vision as well as an organizational culture that is congruent with the vision [9,11,12]. Developing integrated health referral systems is time consuming, complex, and costly; therefore, health regulators should have a clear IS/IT strategic plan and standards so that health facilities can have access to standard data, eliminating duplicate applications that have the same functionalities. For example, SPRO and SISRUTE, developed by the Health Office of DKI Jakarta Province and MOH, respectively, have a similar functionality for referring patients that could be homogenized into a single application. To date, in Indonesia, there is an awareness within regulator and health facilities about using IS/IT to support the health referral system, and there is not such a reliance on highly skilled workers and equipment as there is in Nigeria [4]. The execution of a health referral system re quires the Puskesmas Information System (PIS) for FKTPs and the Hos pital Information System (HIS) for FKRTLs as a backend support to health referral applications. The PIS and HIS must be integrated so they can facilitate the exchange of patient data. These conditions can bring health facilities closer to the community as they improve the account ability of the referral data. However, because there is no comprehensive coordination between the regulators and implementers of the health referral system, there are still many duplicate functions in various health applications, increasing the complexity of the integration between the health applications in each health facility. To date, MOH also does not have a data dictionary related to the development of PIS/HIS and health referral applications, so there is no standard data that can be excluded from health referral applications that have been developed to date. These conditions make it difficult to integrate data between health fa cilities and regulators. Furthermore, the health referral system in Indonesia includes verti cal and horizontal patient references (i.e., internal and external), spec imen referrals, and expert referrals [7]. Currently, however, based on interviews with the Head of the Referral Health Service Section and the Directorate of Referred Health Services with the MOH, the development of health referral applications still focuses only on individual referral systems. Moreover, it has not yet been implemented for community health business referrals. In the future, a health referral system should be developed in an automated manner based on severity levels, and in a manner that is integrated between services and health facilities. The addition of features that can cover the entire health referral process is indispensable for the successful execution of a health referral system. Issues have arisen for implementing the health referral system in the certain areas of Indonesia because such areas do not have Internet access or electricity yet. Therefore, regulators and health facilities need to conduct comprehensive planning related to the health referral systems by not only providing access to online health referral systems but also by developing methods of conducting referrals offline. In addition, based on interviews with the FKTP Section Head of the Health Services Divi sion at the Provincial Health Office of DKI Jakarta Province, another
7. Conclusion and future work This research discusses the use of IS/IT in support of health referral systems. To support the health referrals system in Indonesia, health fa cilities may develop their own referral health applications, even though regulators have also developed reference applications that can be used by health facilities. However, because such applications cannot be in tegrated with other related applications, no unified health referral sys tem has been created to accommodate all of the needs in the health referral process. In addition, there are some health facilities that resist using applications, and instead refer manually even though they already have a system. Using IS/IT can facilitate better access to and sharing of patient information between health facilities to accelerate services. In addition to technical factors in the application, non-technical factors are also very influential to the success of the health referral system. The limitation of this research is that it only focused on the North Jakarta region, where the health referral system has been continuously applied with support from IS/IT in Indonesia. The results of this study can be used to examine the factors related to the acceptance of health referral systems and related analysis of success factors in the utilization of mo bile applications to support the health referral process. In addition, this research can be used as a reference in developing health referral appli cations that can meet the overall needs of the health referral process. Summary points Summary of previous studies: � Most of the research regarding health referral system still focus on the referral systems in hospitals � To date, there has been limited research examining the imple mentation of health referral information systems and the utilization of IS/IT to support the health referral systems Summary of this study: � This study aims to analyze the practices of IS/IT in the health referral system in primary care and hospitals in Indonesia � This study revealed that most health facilities have implemented the health referral information system � Stakeholders should manage the technical and non-technical issues � Using the implementation of IS/IT, health facilities could reduce the patient queuing processes Ethical statement Regarding the ethics of this study, we have obtained approval from 5
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the following individuals and facilities:
Acknowledgements
� MOH: allowed to conduct interviews with the Directorate of Referral Health Services on February 16, 2017 and the Data and Information Center on May 9, 2017. � BPJS-K: consent given in letter number 3184/VIII.2/0317, dated March 14, 2017. � Provincial Health Office of DKI Jakarta: consent from the Head of Health Resources Section given in letter number 703/SDK/VI/2017 and letter number 500/SAK/V/2017. � North Jakarta Health Office and Kelapa Gading Primary Health Care Center: issued a license to perform an interview from the One Stop Service Integrated Service (PTSP) of North Jakarta, reference num ber 78/16.1/31.72/-1.862.9/2017. � Koja Primary Health Care Center: given consent from the PTSP of North Jakarta Municipality, reference number 109/16.1/31.72/1.862.9/2017. � Cilincing Primary Health Care Center: given consent from the PTSP of North Jakarta Municipality, reference number 110/16.1/31.72/1.862.9/2017. � Penjaringan Primary Health Care Center: given consent from the PTSP of North Jakarta Municipality, reference number 113/16.1/ 31.72/-1.862.9/2017. � Tugu Koja General Hospital: given consent from the PTSP of North Jakarta Municipality, reference number 74/16.1/31.72/-1.862.9/ 2017. � Koja Public Hospital: given consent from the PTSP of North Jakarta Municipality, reference number 75/16.1/31.72/-1.862.9/2017. � Dr. Wahidin Sudirohusodo Public Hospital: given consent from the PTSP of South Sulawesi Municipality, reference number 4524/S.02/ PTSP/2018.
We want to convey our gratitude to the support of Faculty of Com puter Science, Universitas Indonesia through the internal publication grant. References [1] Kementerian Kesehatan Republik Indonesia. Pedoman Sistem Rujukan Nasional. Jakarta, Indonesia: Direktorat Jenderal BUK (Bina Upaya Kesehatan) Kementerian Kesehatan Republik Indonesia; 2012. [2] Primasari KL. Analisis Sistem Rujukan Jaminan Kesehatan Nasional RSUD Dr. Adjidarmo Kabupaten Lebak. J Administrasi Rumah Sakit Indones (ARSI) 2015;1 (2):78–86. [3] Bossyns P, Lerberghe W. The weakest link: competence and prestige as constraints to referral by isolated nurses in rural Niger. Hum Resour Health 2004;2:1–8. [4] Akande TM. Referral system in Nigeria: study of a tertiary health facility. Ann Afr Med 2004;3(3):130–3. [5] Pembe AB, Carlstedt A, Urassa DP, Lindmark G, Nystr€ om L, Darj E. Effectiveness of maternal referral system in a rural setting: a case study from Rufiji district, Tanzania. BMC Health Serv Res 2010;10:326. [6] Luti I, Hasanbasri M, Lazuardi L. Kebijakan Pemerintah Daerah dalam Meningkatkan Sistem Rujukan Kesehatan Daerah Kepulauan Di Kabupaten Lingga Provinsi Kepulauan Riau. J Kebijakan Kesehat Indones 2012;1(1):24–35. https:// doi.org/10.22146/jkki.v1i1.3072. [7] Direktorat Jenderal Bina Upaya Kesehatan Kemenkes RI. Pedoman Sistem Rujukan Nasional. Indonesia: Direktorat Jenderal Bina Upaya Kesehatan Kemenkes RI; 2012. [8] Kesehatan BPJS. Panduan Praktis Sistem Rujukan Berjenjang. Indonesia: BPJS Kesehatan; 2014. [9] Handayani P, Sandhyaduhita P, Hidayanto A, Pinem A, Fajrina H, Junus K, et al. Integrated hospital information system architecture design in Indonesia. In: Iyamu I, Tatnall A, editors. Maximizing healthcare delivery and management through technology integration. Hershey, PA: IGI Global; 2016. p. 207–36. [10] Gillies RR, Chenok KE, Shortell SM, Pawlson G, Wimbush JJ. The impact of health plan delivery system organization on clinical quality and patient satisfaction. Health Serv Res 2006;41:1181–99. [11] Suter E, Oelke ND, Adair CE, Armitage GD. Ten key principles for successful health system integration. Healthc Q 2009;13:16–23. [12] Hsieh HF, Shannon SE. Three Approaches to qualitative content analysis. Qual Health Res 2005;15(9):1277–88.
Declaration of competing interest The authors declare that they have no potential conflicts of interest.
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Contents lists available at ScienceDirect
Informatics in Medicine Unlocked journal homepage: http://www.elsevier.com/locate/imu
The Information System/Information Technology (IS/IT) practices in the Indonesia health referral system Putu Wuri Handayani a, *, Ave Adriana Pinem a, Fatimah Azzahro a, Achmad Nizar Hidayanto a, Dumilah Ayuningtyas b a b
Faculty of Computer Science, University of Indonesia, Indonesia Faculty of Public Health, University of Indonesia, Indonesia
A R T I C L E I N F O
A B S T R A C T
Keywords: Health referral Health referral information system Primary care Hospitals Indonesia
Purpose: The purpose of this study is to understand how Information System/Information Technology (IS/IT) is used to support the health referral system in Indonesia. Method: This study uses a qualitative approach, with case studies at the Ministry of Health of the Republic of Indonesia (MOH) as the sector regulator, the Social Security Agency for Health (BPJS-K) as the Indonesian government body in organizing a health insurance program for all Indonesian citizens, and hospitals as the health providers in the DKI Jakarta Province. The 33 respondents involved in this study are policy makers, medical personnel who use the health referral information system, such as doctors, nurses and administrative staff, and application developers who develop and deploy the applications for health referral. Results: The study reveals that most of the health facilities and providers in the DKI Jakarta Province have used health referral information systems, even if the system is not fully integrated or does not have a complete set of features. All of the relevant stakeholders should be able to manage the technical and non-technical problems in the health referral information system. Strong integration and well-structured planning in IS/IT application could reduce the queuing processes in health facilities. Conclusions: Based on this study, MOH as the health regulator should draft regulation(s) that defines the health data dictionary as a reference for interface between health referral applications developed by each health facility or regional government. In addition, the chairperson of health facilities providers should have a strong leadership commitment and good coordination with other health facilities in performing the usage of health referral in formation systems.
1. Introduction The Indonesian Government has launched a National Health Insur ance (NHI) health program in which all citizens are facilitated in obtaining healthcare access. NHI is one platform for the implementation and development of health efforts within the National Health System (NHS). As part of the NHS implementation plan, a division of tasks among health facilities, or a so-called referral system, is required to obtain high-quality health services that are both effective and efficient. According to the Ministry of Health of the Republic of Indonesia (MOH), both effectiveness and efficiency can be achieved if a referral system is organized with the aim of providing quality health services; this way, service goals can be achieved with minimal cost [1,2,6]. Of particular
importance are reducing the waiting time in the referral process and reducing the number of unnecessary transfers, because the required service can be handled by the original health services facility, either with the help of available cutting-edge or low-cost technology. To date, MOH only regulates the health referral systems of individual health services, as set out in Law No. 40 of 2004 on Guarantee System National Social and implementing Regulation of MOH Number 001 of 2012 regarding Individual Health Service Referral Systems (MOH Regulation 001/2012). Based on MOH Regulation 001/2012, the health referral system is defined as a health service arrangement that regulates the delegation of duties and responsibilities of health services on a reciprocal basis, either vertical or horizontal. Based on this definition, the health referral system is required for all patients who participate in
* Corresponding author. Faculty of Computer Science, Jalan Kampus UI, Depok, West Java, 16424, Universitas Indonesia, Indonesia. E-mail addresses: [email protected] (P.W. Handayani), [email protected] (A.A. Pinem), [email protected] (F. Azzahro), [email protected] (A.N. Hidayanto), [email protected] (D. Ayuningtyas). https://doi.org/10.1016/j.imu.2019.100263 Received 26 August 2019; Received in revised form 30 October 2019; Accepted 31 October 2019 Available online 12 November 2019 2352-9148/© 2019 Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
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health insurance or social health insurance and or receive care from any healthcare provider. Starting from January 1, 2014, the Social Security Agency for Health (BPJS-K) was appointed as the sole implementing body established by the government to organize a health insurance program for all Indonesian citizens. To date, the current referral system in Indonesia is still ineffective because of the visible accumulation of patients in the hospitals compare to first-level health facilities. Most of the patients do not seek treatment within the first-level health facilities due to management of patient file administration, which is still done manually. The issues could be handled properly if each health facility were to be using an integrated Information System/Information Technology (IS/IT), so that the health services could be provided to the patient optimally. By using IS/IT, in tegrated with health facilities’ information systems (e.g., a community health center system, hospital information system, or referral system application [P-Care] from BPJS-K), healthcare facilities could more quickly and readily access patient medical records, ensuring that the decision to refer a patient could be made quickly, and adjusted to the availability of personnel and medical equipment at the referral health care facilities. Until now, there has been limited research examining the health referral systems and the utilization of IS/IT to support these systems. This study has as a purpose, to understand how the IS/IT is utilized to support the health referral system in Indonesia. Bossyns and Lerberghere viewed a non-optimal health referral system in Nigeria, but focused more on the interaction between health workers and patients, and whether these interactions can be an impediment in running a tiered referral system [3]. A study by Akande examined the health referral system in Nigeria, showing that highly skilled workers and adequate equipment are needed for the implementation of the referral system [4]. Pembe et al. evaluated the effectiveness of the maternal referral system in the rural district of Rufiji in Tanzania [5]. Health referral system research conducted in Indonesia has been limited and still focuses on the use of health referral systems in hospitals; however, no studies have been undertaken at first level health facilities (FKTP). Furthermore, the Indonesian health system is unique and has limitations in terms of the facilities and health personnel availability. It also has a decentralized and tiered health system; therefore, the utilization of IS/IT has been one of the health reform initiatives in Indonesia, although the implementa tion is not yet optimal. The research question therefore arose: how is IS/IT used in health facilities to support the health referral system in Indonesia? The remainder of this paper is organized as follows: Section 2 re views the existing literature, and Section 3 explains the conceptual model. Section 4 describes the research methodology. The results and discussion of this research are subsequently presented in Section 5 and Section 6, respectively. Section 7 explores the implications of this research, and the final section, Section 8, discusses conclusions and recommendations for future work related to this research.
sustainable manner, the mapping of referral areas in each level of the referral system and national reference system must first occur, with reference system units included therein [7]. The task of mapping the referral system at the regency/municipal level is the responsibility of the Regional Health Office, BPJS-K, and its network (i.e., branch offices), while the task of mapping the referral system at the provincial and higher levels is assigned to the Provincial Health Office and MOH, and especially the Directorate of Referral Health Development [7]. In the DKI Jakarta Province, based on the Regulation of the Governor of DKI Jakarta No. 189 of 2015, the regulation is formulated as the legal basis and reference for health service facilities in carrying out the regionali zation of health referral systems in the relevant region. The objective of this regulation is to develop the regionalization of a tiered referral sys tem, to improve the quality and reach of referral health services in hospitals, and to even out the distribution of referral health services. Based on the Practical Guide to the Tiered Referral System issued by MOH, the referral system in Indonesia has been arranged in a tiered form, comprised of first-, second-, and third-level health services; as such, its application does not stand alone but is part of an interconnected system [[6]8]. Table 1 describes the classification of each healthcare facility. Further, based on MOH Decree No. 28 of 2014 regarding Guidelines for Implementation of National Health Insurance Program, health fa cilities are divided into two facility levels: First Level Health Facility (FKTP) and Advanced Level Health Facility (FKRTL). FKTP includes primary healthcare centers (Puskesmas or Pusat Kesehatan Masyarakat), physician private practices, dentists, primary or equivalent clinics, and class D hospitals or equivalents. FKRTL includes primary or equivalent clinics, general hospitals, and special hospitals. FKRTL is distinguished into second-level health facilities (healthcare facilities generally located in the Provincial Region, such as a provincial general hospital) and third-level health facilities (healthcare facilities generally located in the capital city, such as a central general hospital). 3. Methods This research is a qualitative study (case study research) using in terviews to collect data. The research phase starts from identifying problems, literature review, sample construction, instrument prepara tion, conducting face-to-face interviews, and analyzing the interview data. The bulk of this research was performed in health facilities in the North Jakarta region of DKI Jakarta Province, because the health referral system processes from FKTP to FKRTL have been continuously conducted in the North Jakarta region compared to other regions in the DKI Jakarta Province. The research is performed based on a preliminary interview with the Head of the Data and Information Section of DKI Jakarta Province. After the preliminary interview, we developed in struments for structured interview to the respondents, as suggested by the Head of the Data and Information Section of DKI Jakarta Province. Interviews were performed using the same interview questions with health referral system regulators, as well as users and managers of the health referral applications, with 33 people interviewed in total. The person being interviewed is selected based on the direction from the relevant head of government institutions on the basis of their expertise, knowledge, and scope of their works or their position which is most relevant to this study. The list of respondents involved in describing the health referral system is set out in Table 2. Data was collected from February 16, 2017 to May 4, 2018 (16 months). Further, based on the health profile of DKI Jakarta Province in 2014, the hospital bed ratio to 1000 residents in DKI Jakarta was 2:3, means that there were 2 beds per 3000 residents, which is above the ratio for national coverage (1:7). The highest ratio was in Central Jakarta region (6:7) while the lowest ratio is in Kepulauan Seribu (Thousand Island) region of (0:6). Based on the data, the health referral system process has been fully conducted in the North Jakarta region and this study selected four FKTPs and two FKRTLs in handling many referral patients. To
2. Literature review: Indonesia health referral system regulatory framework The health referral system in Indonesia is subject to regulations is sued by the government. Based on MOH Regulation 001/2012, the health referral system is defined as a health service arrangement that regulates the delegation of duties and responsibilities of health services on a reciprocal basis, either vertical or horizontal, which must be carried out by those who participate in health insurance or social health in surance and by all health facilities. The general objective of individual healthcare referral systems is the execution of individual health referral procedures, following the quality and patient safety standards of the reference criteria, at individual health service facilities of all levels in Indonesia [7]. According to the Guidelines of the National Referral System, to be able to establish a personal referral system in a good, steady, and 2
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Table 1 Healthcare Facility Classification [7]. Referral Level
Duties of Healthcare Facilities
Healthcare Facilities
Responsible for Monitoring and Evaluation
First-level healthcare facilities
Able to provide first-rate medical services performed by a doctor/ dentist and specifically able to provide psychological, neonatal, and maternal services, in certain conditions assisted by a midwife.
1. 2. 3. 4.
Second-level healthcare facilities
Able to provide specialist personal health services.
Third-level healthcare facilities
Able to provide sub-specialist health care.
1. Class D or C hospitals 2. Non-educational class B hospitals, governmentowned hospitals, and army forces/police/state/ privately owned hospitals 1. Class B education/class A hospital in the province 2. Class A hospitals (general referrals/general national in cities)
1. Head of Regency/ Municipality Health Office 2. Professional organization of regency/municipality branch 1. Head of Provincial Health Office 2. Provincial branch professional organization 1. Directorate of Referral Health Promotion 2. Directorate General of Health Efforts 3. Professional organizations 4. Educational institutions
Community health centers Primary clinics (government and private) Private practices of doctors/dentists Primary hospitals
and the health personnel available at each hospital”. In other words, for emergency referrals, administrative and/or geographical boundaries can be ignored because the important thing is that the patient receives prompt and appropriate care within a very decisive period (i.e., the “golden period”). According to the Director of Dr. Wahidin Sudir ohusodo Hospital and the Head of Medical Services of Tugu Koja General Hospitals, communication in emergency referrals is very important; because the referral process must begin and end with communication. Emergency referrals are performed by transferring patient identity data, diagnoses, and necessary actions that need to be performed for the relevant patient. To accelerate the health referral service process, MOH has developed three referral applications, BPJS-K has developed nine referral applica tions, and the Provincial Health Office of DKI Jakarta has developed one referral application. In general, the features required for the health referral system consist of the following:
obtain a comprehensive knowledge of the health referral system, this study also included interviews with the health regulators (i.e., MOH) and referral application developers who have successfully deployed the health referral applications in Indonesia, to understand the lessons learned by the developers when they deployed the health referral ap plications. The duration of interview was between 30 min and 1 h for each interviewee, and there were one to two iterations when conducting interviews in each case study, to enable researchers to discover and discuss all information related to the processes of the health referral system. The results of the interview were recorded with an audio recorder, transcribed and coded by the researcher for each important point throughout the interview. In relation to the ethics of this study, we have obtained approval from MOH (the Directorate of Referral Health Services and the Data and Information Center), BPJS-K, Provincial Health Office of DKI Jakarta Provinces, relevant health care centers, hospitals and interviewees that the result from this study will be pub lished. In addition, all participants have provided their consent to be interviewed for this study and approved that the results of interview will be published in a journal or publication. Table 3 shows the interview key point of questions. We used content analysis to organize and elicit meaning of interview data and draw conclusion from it. Content analysis is a widely used qualitative research method for studying documents and communica tion objects, which might include texts in various formats, audio, video or picture [12]. The results of the analysis are grouped with the results, namely (1) the actual processes carried out in the health referral system, (2) the support of IS/IT on the health referral system and (3) the prob lems that occur in the health referral system.
1. Patient, medical personnel and health facility profile information as well as patient medical resume; 2. Schedule information of physician polyclinic service in hospital by date, day, and hour; 3. Room availability information; 4. Reservation/appointment booking service of polyclinic doctor or booking room in hospital; 5. Confirmation of patient referral patients at the hospital; and 6. Reports related to patient referrals. Based on interviews with all the respondents, there are still dupli cation functions performed in more than one application. For example, both the Online Referral Service System (SPRO) and Integrated Referral System (SISRUTE) can be used to perform scheduling and patient registration to the intended outpatient installations. Then, integration methods performed between the BPJS-K’s applications are done using web services. Health facilities in Indonesia use different health appli cations, resulting in a complex integration mechanism. The complica tion arises because there is no standard reference that can be used, as well as strong coordination between the central regulator and the local facilities, and as such, there is no SI/IT plan in place to allow for synergy between the healthcare regulators and providers. The lack of coordi nation also makes it difficult to achieve a standardization in health data between the various parties. In addition to the complexity of integration between applications, each health facility requires IT staff who can support the maintenance of these applications. However, many health facilities do not have permanent IT staff due to limited budget. Table 4 explains the summary of results. Based on input from all respondents and analyzing the results, the following list of actions need to be made a priority to resolve all
4. Results Referral flow consists of vertical referrals, back referrals, and hori zontal referrals between hospitals in the same class or between units in one hospital (e.g., referring patients from emergency departments to inpatient units). Vertical referrals are made from the health facility of a lower class to a health facility that has a class at least one level higher than that of the referrer health facility. In contrast to vertical referrals, back referrals are done from a health facility of a higher class to one of a lower class. Finally, horizontal referrals occur between units in one hospital and between hospitals of the same class. Based on the Head of Medical Services of Tugu Koja General Hospital, all referral flows are performed by sending patient identity data, the reason for the referral, the follow-up treatment, and the medical resume. The Head of Public Relations of BPJS-K said that “specifically for emergency referrals, a tiered referral mechanism is not necessary and that the selection of hospitals for the referred patient is adjusted according to the patient’s level of severity, the appropriate facilities needed to provide care, 3
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Table 2 Respondent demographics.
Table 3 Interview key point of questions.
No.
Name of Health Facility
Position of Respondent
Number of Respondents
1.
Directorate of Referral Health Services with the MOH
Section Head of Referral Service Management Staff of Referral Service Management Staff Section of Planning and Development of Medical Services Referral Application Coordinator at the Referral Service Information Center Head of Sub Directorate of Integrated Emergency Services Head of Information System Development Division Data Center and Information Center staff Head of Public Relations Department Staff of Information Management and Documentation Officer Si Jari Emas Application Developer SMSBunda Business Development Director Section Head of FKRTL Health Services Division Section Head of FKTP Health Services Division Head of Data and Information Section IT staff Head of Health Services Section Staff of Health Services Section Online referral staff General practitioners of polyclinics who actively use referral applications Head of Individual Services Division IT Analyst Referral Operator Staff Elderly Polyclinic Doctor (person in charge of Referral Application) Head of Individual Services Division Reporting and Procurement Section staff BPJS-K Application Operator Head of Implementation Unit of Emergency and Outpatient Head of Education and Training Section Head of Medical Services Head of Hospital Information System Director of Koja Public Hospital Administration and Reporting Staff of Hospital Information System Installation Director
1
2.
Data and Information Center of the MOH
3.
BPJS-K
4.
Si Jari Emas and SMSBunda Application Developer
5.
Health Office of DKI Jakarta Province Health Services Division
6.
North Jakarta Health Office
7.
Koja Primary Health Care Center
8.
Cilincing Primary Health Care Center
9.
Kelapa Gading Primary Health Care Center
10.
Penjaringan Primary Health Care Center
11.
Tugu Koja General Hospital
12.
Koja Public Hospital
13.
Dr. Wahidin Sudirohusodo Public Hospital
No
Respondents
Key Point of Questions
1.
Health regulators (MOH, BPJS-K, Provincial Health Office of DKI Jakarta Province, North Jakarta Health Office)
2.
Health facilities (Kelapa Gading Primary Health Care Center, Koja Primary Health Care Center, Cilincing Primary Health Care Center, Penjaringan Primary Health Care Center, Tugu Koja General Hospital, Koja Public Hospital, Dr. Wahidin Sudirohusodo Public Hospital)
3.
Health referral application developers (Si Jari Emas and SMSBunda Application Developer)
� Regulation used as a basis for implementing health referral systems in Indonesia � Supports provided by health regulators to health facilities in running referral systems (e.g., the support of referral applications, human resources, and so on) � Requirements needed to run a health referral system and IS/IT to support the health referral system (e.g., the applications used, users using the health referral system, integration of the referral application with other related application, and so on) � Problems faced in the health referral system � Main features developed in the referral application � Issues occurred in the health referral application
2 1 1 1 2
2
2
Table 4 Summary of results.
4
Analysis
Results
Actual health referral system activities in health facilities Health referral system strength
� Vertical referrals, back referrals, and horizontal referrals are conducted in health facilities All relevant stakeholders have already used the online health referral information system � duplication functions performed in more than one application � complex integration mechanism due to the different referral applications used in health facilities � lack of IT resources in the health facilities
Health referral system weakness
2
2
2
� �
2
� 3
2
�
2
�
2
�
�
problems and achieve successful execution of health referral systems: � Relevant regulation(s) for the implementation of health referral systems (e.g., the regionalization of referral regions, the creation of clinical pathways, the development of a referral system data
�
4
dictionary). In addition to health facilities, the referral network also needs to be connected to the ambulance system and blood bank. Strong leadership from regulators and health facilities. The development of applications tailored to user needs that can be easily integrated with other related applications. The involvement of local stakeholders in various ways in the devel opment of an integrated, comprehensive referral system. The engagement of end users in the design and the systematic use of their feedback to revise the system and improve the user experience, as this is helpful in ensuring that the features of the system meet their needs. Determination of Service Level Agreements (SLA) for referral appli cations that must be mutually agreed upon between regulators and health service facilities to ensure standardization in providing services. An understanding of participant and health services facility re quirements in the tiered health referral system as well as patient education for the re-control of chronic diseases, which can be used for referral. The readiness of supporting facilities and infrastructure, such as Internet communication networks and integrated health applications. The availability of online communication and data networks in FKTPs as well as in FKRTLs and the smooth access to communication and data networks as the foundation of the online health referral systems. The commitment and discipline of FKTPs and FKRTLs in conducting service entries in the health referral application and carrying out all
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of the provisions and regulations set by the health referral system regulator. � Coordination with regency health offices and related health facilities in improving the availability of communication and data networks in non-sustainable areas or no jurisdictions. � Conducting IT governance in each health facility. � The readiness of human resources personnel who know and under stand IT/IS in helping with the development and support of health referral applications.
issue in the current health referral system is that regionalization is too rigid and hospital classification in each regency has been incomplete, so that referrals are highly dependent on doctor diagnoses. 6. Implications The results of this study could theoretically enrich previous research in providing knowledge related to the health referral systems in devel oping countries with limited health personnel and health infrastructure. This study also determined the factors required for the success of health referral systems. This study has implications for regulators (i.e., MOH, Health Office and BPJS-K) where regulators must prepare relevant regulation(s) regarding IS/IT for supporting the health referral system. Health facilities also need to develop applications tailored to the needs of users that can be easily integrated with other related applications, need to ensure the readiness of supporting facilities and infrastructure, and need IT governance in each health facility. In addition, patients also need to have awareness of the tiered health referral system.
5. Discussion According to Gillies et al., integrated health systems are widely considered to provide superior performance in terms of quality and safety because of effective communication and standardized protocols, although these outcomes have not been fully demonstrated [10]. Health referral systems must also be developed in an integrated manner; thus, the operation of an integrated health system requires leadership with vision as well as an organizational culture that is congruent with the vision [9,11,12]. Developing integrated health referral systems is time consuming, complex, and costly; therefore, health regulators should have a clear IS/IT strategic plan and standards so that health facilities can have access to standard data, eliminating duplicate applications that have the same functionalities. For example, SPRO and SISRUTE, developed by the Health Office of DKI Jakarta Province and MOH, respectively, have a similar functionality for referring patients that could be homogenized into a single application. To date, in Indonesia, there is an awareness within regulator and health facilities about using IS/IT to support the health referral system, and there is not such a reliance on highly skilled workers and equipment as there is in Nigeria [4]. The execution of a health referral system re quires the Puskesmas Information System (PIS) for FKTPs and the Hos pital Information System (HIS) for FKRTLs as a backend support to health referral applications. The PIS and HIS must be integrated so they can facilitate the exchange of patient data. These conditions can bring health facilities closer to the community as they improve the account ability of the referral data. However, because there is no comprehensive coordination between the regulators and implementers of the health referral system, there are still many duplicate functions in various health applications, increasing the complexity of the integration between the health applications in each health facility. To date, MOH also does not have a data dictionary related to the development of PIS/HIS and health referral applications, so there is no standard data that can be excluded from health referral applications that have been developed to date. These conditions make it difficult to integrate data between health fa cilities and regulators. Furthermore, the health referral system in Indonesia includes verti cal and horizontal patient references (i.e., internal and external), spec imen referrals, and expert referrals [7]. Currently, however, based on interviews with the Head of the Referral Health Service Section and the Directorate of Referred Health Services with the MOH, the development of health referral applications still focuses only on individual referral systems. Moreover, it has not yet been implemented for community health business referrals. In the future, a health referral system should be developed in an automated manner based on severity levels, and in a manner that is integrated between services and health facilities. The addition of features that can cover the entire health referral process is indispensable for the successful execution of a health referral system. Issues have arisen for implementing the health referral system in the certain areas of Indonesia because such areas do not have Internet access or electricity yet. Therefore, regulators and health facilities need to conduct comprehensive planning related to the health referral systems by not only providing access to online health referral systems but also by developing methods of conducting referrals offline. In addition, based on interviews with the FKTP Section Head of the Health Services Divi sion at the Provincial Health Office of DKI Jakarta Province, another
7. Conclusion and future work This research discusses the use of IS/IT in support of health referral systems. To support the health referrals system in Indonesia, health fa cilities may develop their own referral health applications, even though regulators have also developed reference applications that can be used by health facilities. However, because such applications cannot be in tegrated with other related applications, no unified health referral sys tem has been created to accommodate all of the needs in the health referral process. In addition, there are some health facilities that resist using applications, and instead refer manually even though they already have a system. Using IS/IT can facilitate better access to and sharing of patient information between health facilities to accelerate services. In addition to technical factors in the application, non-technical factors are also very influential to the success of the health referral system. The limitation of this research is that it only focused on the North Jakarta region, where the health referral system has been continuously applied with support from IS/IT in Indonesia. The results of this study can be used to examine the factors related to the acceptance of health referral systems and related analysis of success factors in the utilization of mo bile applications to support the health referral process. In addition, this research can be used as a reference in developing health referral appli cations that can meet the overall needs of the health referral process. Summary points Summary of previous studies: � Most of the research regarding health referral system still focus on the referral systems in hospitals � To date, there has been limited research examining the imple mentation of health referral information systems and the utilization of IS/IT to support the health referral systems Summary of this study: � This study aims to analyze the practices of IS/IT in the health referral system in primary care and hospitals in Indonesia � This study revealed that most health facilities have implemented the health referral information system � Stakeholders should manage the technical and non-technical issues � Using the implementation of IS/IT, health facilities could reduce the patient queuing processes Ethical statement Regarding the ethics of this study, we have obtained approval from 5
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the following individuals and facilities:
Acknowledgements
� MOH: allowed to conduct interviews with the Directorate of Referral Health Services on February 16, 2017 and the Data and Information Center on May 9, 2017. � BPJS-K: consent given in letter number 3184/VIII.2/0317, dated March 14, 2017. � Provincial Health Office of DKI Jakarta: consent from the Head of Health Resources Section given in letter number 703/SDK/VI/2017 and letter number 500/SAK/V/2017. � North Jakarta Health Office and Kelapa Gading Primary Health Care Center: issued a license to perform an interview from the One Stop Service Integrated Service (PTSP) of North Jakarta, reference num ber 78/16.1/31.72/-1.862.9/2017. � Koja Primary Health Care Center: given consent from the PTSP of North Jakarta Municipality, reference number 109/16.1/31.72/1.862.9/2017. � Cilincing Primary Health Care Center: given consent from the PTSP of North Jakarta Municipality, reference number 110/16.1/31.72/1.862.9/2017. � Penjaringan Primary Health Care Center: given consent from the PTSP of North Jakarta Municipality, reference number 113/16.1/ 31.72/-1.862.9/2017. � Tugu Koja General Hospital: given consent from the PTSP of North Jakarta Municipality, reference number 74/16.1/31.72/-1.862.9/ 2017. � Koja Public Hospital: given consent from the PTSP of North Jakarta Municipality, reference number 75/16.1/31.72/-1.862.9/2017. � Dr. Wahidin Sudirohusodo Public Hospital: given consent from the PTSP of South Sulawesi Municipality, reference number 4524/S.02/ PTSP/2018.
We want to convey our gratitude to the support of Faculty of Com puter Science, Universitas Indonesia through the internal publication grant. References [1] Kementerian Kesehatan Republik Indonesia. Pedoman Sistem Rujukan Nasional. Jakarta, Indonesia: Direktorat Jenderal BUK (Bina Upaya Kesehatan) Kementerian Kesehatan Republik Indonesia; 2012. [2] Primasari KL. Analisis Sistem Rujukan Jaminan Kesehatan Nasional RSUD Dr. Adjidarmo Kabupaten Lebak. J Administrasi Rumah Sakit Indones (ARSI) 2015;1 (2):78–86. [3] Bossyns P, Lerberghe W. The weakest link: competence and prestige as constraints to referral by isolated nurses in rural Niger. Hum Resour Health 2004;2:1–8. [4] Akande TM. Referral system in Nigeria: study of a tertiary health facility. Ann Afr Med 2004;3(3):130–3. [5] Pembe AB, Carlstedt A, Urassa DP, Lindmark G, Nystr€ om L, Darj E. Effectiveness of maternal referral system in a rural setting: a case study from Rufiji district, Tanzania. BMC Health Serv Res 2010;10:326. [6] Luti I, Hasanbasri M, Lazuardi L. Kebijakan Pemerintah Daerah dalam Meningkatkan Sistem Rujukan Kesehatan Daerah Kepulauan Di Kabupaten Lingga Provinsi Kepulauan Riau. J Kebijakan Kesehat Indones 2012;1(1):24–35. https:// doi.org/10.22146/jkki.v1i1.3072. [7] Direktorat Jenderal Bina Upaya Kesehatan Kemenkes RI. Pedoman Sistem Rujukan Nasional. Indonesia: Direktorat Jenderal Bina Upaya Kesehatan Kemenkes RI; 2012. [8] Kesehatan BPJS. Panduan Praktis Sistem Rujukan Berjenjang. Indonesia: BPJS Kesehatan; 2014. [9] Handayani P, Sandhyaduhita P, Hidayanto A, Pinem A, Fajrina H, Junus K, et al. Integrated hospital information system architecture design in Indonesia. In: Iyamu I, Tatnall A, editors. Maximizing healthcare delivery and management through technology integration. Hershey, PA: IGI Global; 2016. p. 207–36. [10] Gillies RR, Chenok KE, Shortell SM, Pawlson G, Wimbush JJ. The impact of health plan delivery system organization on clinical quality and patient satisfaction. Health Serv Res 2006;41:1181–99. [11] Suter E, Oelke ND, Adair CE, Armitage GD. Ten key principles for successful health system integration. Healthc Q 2009;13:16–23. [12] Hsieh HF, Shannon SE. Three Approaches to qualitative content analysis. Qual Health Res 2005;15(9):1277–88.
Declaration of competing interest The authors declare that they have no potential conflicts of interest.
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