Readiness of Application of Electronic Medical Records in Health Services ( Literature Study )

Background: Information and Communication Technology is advancing rapidly and has a major impact on all life, especially in the health sector, especially medical records. This is manifested in the Electronic Medical Record (EMR), which has now been further developed into an Electronic Health Record (EHR). This technology is used to replace or complement paper medical records. The purpose of this literature study is to determine the readiness to apply electronic medical records in health services. Methods: This study uses a literature study obtained from searching scientific research articles from the 2010–2020 range.


INTRODUCTION
Along with the advancement of Information and Communication Technology (ICT) which brings a major impact toward all lines of life, notably to the health area especially in medical records, it is resulted an advanced technology called as Electronic Medical Records (EMR). EMR is part of Electronic Health Records (EHR) that has been widely used by several hospitals in various parts of the world to replace or complement the paper-based medical records (Triyanti E, 2018) Electronic Medical Records (EMR) is not only used by the developed countries, but also by the developing countries which starting to adopt the electronic systems to gain effectiveness and efficiency in health services. Although those developing countries are still fully concerned with the handling of various infectious and contagius diseases, yet an effective and efficient health service documentation process is highly required (Wirajaya MKM, Dewi NMUK, 2020). In Indonesia, the development of EMR holds no specific regulation yet. However, the support in 2008's Electronic Information and Transaction Law (UU ITE) and 2008's Minister of Health Regulation (PERMENKES) Number 269 regarding the legitimacy of EMR as legal evidence provides a bright hope toward the development of EMR in Indonesia.
The development of EMR cannot be avoided and also has to be accepted by the whole medical record users consisting of medical recorders, doctors, nurses and other health workers. The advantages of using EMR are including more structurally stored data and much easier and faster process of data searching (Sabarguna BS, 2008). The advantages of electronic medical records will provide many benefits toward more effective and efficient medical record management. In health services by hospital, every treatment performed to the patients from the first day hospitalized until their home return is written in a medical record book. According to the Indonesian Minister of Health Regulation Number 269 (PERMENKES RI No.269/MENKES/PER/III/2008), medical records are files containing records and documents regarding the patient identity, examination results, treatment, and other actions and services provided to the patient. Electronic Medical Records (EMR) is the electronic version of paper medical records, which transfers records or forms previously written on paper into a computer. EMR has been widely used in hospitals around the world as a substitute or complement to paper-based medical records. In Indonesia, EMR is known as RME (Electronic Medical Record). Along with its development, EMR has become the heart of information in services of both Hospital Management Information System (SIMRS) and Public Health Center Management Information System (SIMPUS) (Triyanti E, 2018).
EMR is a life long patient medical record in electronic format about his/ her health information, written by one or more health workers in an integrated manner in every meeting between health workers and patients. EMR can be used by accessing computers from a network, with the main purpose of providing or improving an efficient and integrated health care and service (Perry&Potter, 2009). A computer-based medical record is an electronic repository of information about the health status and health services obtained by patients throughout their lives, stored in such way to serve various authorized medical record users (Triyanti E, 2018).
The data collected by the Ministry of Health through the Hospital Information System (SIRS) -a guideline for hospitals to fulfill their routine records and reports -until the end of November 2016, it is known that 1,257 hospitals from 2,588 hospitals in Indonesia already functioning SIMRS, indicating the percentage of active users around 48%. Furthermore, there are 128 hospitals (5%) not functioning SIMRS or already have one yet inactive, while hospitals with no SIMRS are around 425 hospitals (16%). Nevertheless, there are still 28% or 745 hospitals give no report regarding SIMRS, whether they already have SIMRS or not (Herlyani E, Koten B, Ningrum BS, 2020).
From a previous research, it is known that the Regional Public Hospital (RSUD) of Yogyakarta City is ready enough to develop the Electronic Medical Records/ EMR based on the EHR and Assessment by the Doctor's Office Quality Information Technology (DOQ-IT) DOQ- ). Yet, there are still many aspects that must be fulfilled to support the successful implementation of EMR at the hospital . Meanwhile, at Wonotirto's Public Health Center, Blitar, the Public Health Center Management Information System (SIMPUS) is not yet applied. SIMPUS is also a program of health information system that provides information about all public health conditions at a local level (at Public Health Center or locally called as Puskesmas), starting from the patient personal data, medicine availability as well as the patient treatment data (Pratama MH, Darnoto S, 2017).
After being assessed with the DOQ-IT method regarding the implementation of SIMPUS, Wonotirto's Public Health Center is at range II with score 53, which means that the Health Center is quite ready fulfilling some parameter of SIMPUS's implementation readiness (Erawantini F, Deharja A, Yusfitasari Y,2016). Although the development of EMR is not as easy as imagined, it will bring more benefits in the future. According to Richard (2012), one of the benefits of using EMR is the provision of good services, low financing and competitive advantages in the future.
In assessing the readiness of EMR implementation in health services, the research will use the DOQ-IT (Doctor's Office Quality Information Technology) method, which using a score in its assessment. And the higher the score, the better the readiness of health services in implementing the EMR. The use of EMR requires careful preparation, and in the assessment of its implementation readiness, there are four parameters that must be prepared including human resources, infrastructure, work culture, and leadership governance. Hence, this research is intended to examine "The Readiness of Electronic Medical Records (EMR) Implementation in Health Services".

METHODS
The inclusion criteria here refer to the criteria of the selected articles in this research and serve as the research policy. The criteria used are the one published in the period of 10 years (2010-2020). The languages used are Indonesian and English. Subjects/ Population include Doctors, Nurses, medical record officers, IT team and some people related to the use of medical records in hospitals. The type of article used is the original article, in the form of full text article publication. The theme of the article covers the scope of readiness, implementation, electronic medical records in health care centers (hospitals, health centers, and clinics), by applying DOQ-IT theory. The keyword used by the authors in looking for the research articles is "Readiness, DOQ-IT". In this searching process, the authors use several portals, such as Google scholar, Garuda, Neliti, One Search, and university portals that provide RMIK (Medical Records and Health Information) education. From the process, it is found from Google Scholar: 113 results, Garuda: 32 results, Neliti: 1 result, One Search: 4 results. Then, the articles obtained are selected by looking at the entire text, resulting in 10 articles. The process of the selection can see in the

RESULTS
The results of the literature study on the Readiness of EMR Implementation in Health Services by using 10 journals can be seen in the Table 1. From the 10 journals, it can be explained that the readiness in implementing EMR is influenced by several factors, including the following in Table 2. The result of the readiness of health facilities in implementing EMR can be seen in the Table 3.

DISCUSSION
Information and communication technology has rapidly developed in various areas, including in the health area, one of which is the Electronic Medical Record (EMR). The completion of EMR management has begun to be implemented in several hospitals / health centers in Indonesia. As complex as the challenges for implementing EMR are, it is necessary to conduct an assessment regarding to the readiness before implementing EMR. This is the most prominent step to take before the implementation itself. The assessment of readiness will help in identifying the processes and the priority scales, and also assist the establishment of operational functions to support optimization of EMR implementation. The process of analyzing the readiness of EMR implementation can be conducted to determine the "road map" and provide an overview of whether to continue with the electronic health record (Pratama A, Sutisna M,2016). To determine the road map and the success of the electronic medical record development program, it is necessary to analyze the readiness of human resources, organizational culture, infrastructure and leadership governance. (DOQ-IT) DOQ-IT, 2009)

Human Resources
The development of EMR will greatly depend on human resources (HR), both as users and as policy makers. According to the 2013 Minister of Health Regulation, information technology (IT)'s human resources for SIMRS consist of staff that at least qualified in the fields of system analysis, programmers, hardware, and network maintenance. And the staff's ability to operate computers is also an important component in supporting the development of EMR (Faida EW, Ali A, 2021).
From Table 2, it can be seen that 60% of the readiness in implementing EMR is influenced by the readiness of of the staff in its implementation. This cannot be separated  (Kusriyanti D, Matuwi B, Supriyantoro, 2021). A good organizational work culture is that the leader is able to move and make policies in the form of SOPs and flows in every procedural activity that needs to be known and carried out by staffs, especially in running electronic medical records (Faida EW, Ali A,2021).
However, some affecting factors on the failure of electronic medical records are influenced by the absence of policies in the development of EMR and there is no plan to implement the EMR system, therefore the implementation of EMR is not ready (Hidayat AR, Sari EW,2017). And other researchers also said that the difficulty for staffs in implementing EMR is the unavailability of instructions in performing EMR (Faida EW, Ali A,2021); (Erawantini F, Deharja A, Yusfitasari Y,2016). It is necessary to make instructions regarding the implementation of EMR that can easily understood by the staffs in accordance with the workflow and SOPs. 3 . The successful implementation of medical records is also influenced by budget readiness, therefore leaders must prepare and plan finances to support the needs of electronic medical records (Hidayat AR, Sari EW,2017).
Other researchers said that the unsuccessful implementation of EMR is influenced by several factors including the absence of a special team (Hidayat AR, Sari EW,2017). the unavailability of regulations regarding the appeal to run EMR (Faida EW, Ali A,2021), the absence of IT management for SIMPUS implementation and the unfitted personnel decree (9). In increasing the success of implementing electronic medical records, hospital leaders must give a socialization to the staffs about the importance of using EMR in the future. 5 From the discussion above, it can be concluded that EMR readiness in health services is categorized as quite ready (50%), very ready (30%), and not ready (20%). The implementation of electronic medical records requires careful preparation. To analyze EMR readiness with the DOQ-IT method, there are 4 components that must be prepared, including: 1. Human resources As many as 60% of HR readiness in implementing electronic medical records is influenced by the readiness of the staffs in implementing EMR. This cannot be separated from the staff's ability to operate computers. Around 30% of hospitals in Indonesia said that most of the staffs could operate computers with a minimum of assistance. Other components affecting the readiness in implementing EMR are also influenced by the availability of IT staffs and a sufficient knowledge.

Organizational Culture
As much as 50% of organizational culture readiness in the implementation of EMR is influenced by the workflow readiness factor or SOP. However, there are some hospitals that are not ready to implement the electronic medical record due to the unavailability of instructions to apply EMR, the absence of policies in the development of the EMR, and no plan to implement the EMR system, therefore the implementation of EMR is not ready yet.

Infrastructure
As much as 50% of infrastructure readiness in implementing EMR is influenced by the availability of adequate facilities for IT consisting of computers, computer networks and support from vendors. All these needs cannot be separated from the financial budget, thus it must be planned and prepared.

Leadership Governance
As much as 40% of the success of the readiness to implementing EMR is influenced by factors of good leadership governance, as well as the leader's understanding of the benefits of implementing electronic medical records that will facilitate the decision making. And the success of the implementation of medical records is also influenced by the readiness of the