Evaluasi Evaluasi Penerapan SNOMED CT, LOINC dalam FHIR di RSUD Prof.Dr. Margono Soekarjo Purwokerto: -

Suryani Lena; Ari Sukawan; Barsasella; Nurmalawati Kusumah; Isnanto; Dimas Ari Wibowo; Sulistyaningsih; Sukma Yudiriantiari; Sucipto; Probo Wiyatno; Ahadia Dini Yunisiar

doi:10.37160/jremikes.v4i1.720

Authors

Suryani Lena Poltekkes Kemenkes Tasikmalaya
Ari Sukawan Poltekkes Kemenkes Tasikmalaya
Barsasella Poltekkes Kemenkes Tasikmalaya
Nurmalawati Kusumah Poltekkes Kemenkes Yogyakarta
Isnanto RSUD Prof. Dr. Margono Soekardjo Purwokerto
Dimas Ari Wibowo RSUD Prof. Dr. Margono Soekardjo Purwokerto
Sulistyaningsih RSUD Prof. Dr. Margono Soekardjo Purwokerto
Sukma Yudiriantiari RSUD Prof. Dr. Margono Soekardjo Purwokerto
Sucipto RSUD Prof. Dr. Margono Soekardjo Purwokerto
Probo Wiyatno RSUD Prof. Dr. Margono Soekardjo Purwokerto
Ahadia Dini Yunisiar RSUD Prof. Dr. Margono Soekardjo Purwokerto

DOI:

https://doi.org/10.37160/jremikes.v4i1.720

Keywords:

Code, Evaluation, FHIR, LOINC, SMOED CT

Abstract

The Systematized Nomenclature of Medicine–Clinical Terms (SNOMED CT) has introduced new concepts related to COVID-19, leading to a reduction of 1.5 minutes in disease coding time per health record and a slight increase in coding accuracy. This improvement stems from effective medical terminology mapping with SNOMED CT, one being in the hospital. The Prof. Dr. Margono Soekarjo Regional General Hospital (RSUD) in Purwokerto, is a government-owned hospital accredited with an "A" grade and has implemented standards such as ICD-10, ICD-9-CM, SNOMED CT, and KFA. This aims analyzes the procedural flow, concepts, and challenges in implementing. Using qualitative descriptive methods, the study involved observations and in-depth interviews with seven informants. Results that indicate from 2018 to 2024, data standards have been updated, involving eight IT personnel and various healthcare staff like all HIM officers, physician, nurses, laboratory, nutrition, pharmacy and finance officers. A total of 300,000 ICD-10 and ICD-9 CM codes have been mapped within the FHIR EMRRI in SIMRS. To enhance effective mapping, more detailed diagnostic enforcement is necessary. The Ministry of Health, in collaboration with Satu Sehat and BPJS, is expected to support the optimal use of new data standards, improving healthcare service quality.

References

Abhyankar S, J Daniel, L Bonnie, W Connie (2018), Letter to the Editor—Comments on the Use of LOINC and SNOMED CT for Representing Nursing Data, International Journal of Nursing Knowledge, NANDA International Inc, Volume 29, No.2, 82.

Butcher R (2014), Combined Utilization of SNOMED CT with LOINC for Comparative Effectiveness Research, Medicine, Computer Science, Corpus ID: 52203496.

Bhattacharyya, S. (2016). Introduction to SNOMED CT. Singapore: Springer.

Bienteck A, Boeker M, Schulz S (2018), NPU, LOINC, and SNOMED CT: a comparation of terminologies for laboratory results reveals individual advantages and a lack of possibilities to encode interpretive comments, Medicine, Computer Science, DOI: 10.1515/LABMED-2018-0103, Corpus ID: 81243453.

Dhakal S, Burrer S, Winston C, Dey A, Ajani U, Groseclose S (2015), Coding of Electronic Laboratory Reports for Biosurveillance, Selected United States Hospitals, 2011, Online J Public Health Inform, Jul 1;7(2):e220, doi: 10.5210/ojphi.v7i2.5859. eCollection 2015.

Direktur Jenderal Pelayanan Medik (1996) Keputusan Direktur Jenderal Pelayanan Medik Nomor : Hk.00.05.1.4.00744, Tentang : Penggunaan Klasifikasi Internasional Mengenai Penyakit Revisi Kesepuluh (ICD-10) Di Rumah Sakit, Jakarta, 1.

Dwi N, Nurul A (2022), Tinjauan Penyebab Pengembalian Klaim BPJS Kesehatan Pasien Rawat Inap, Jurnal Rekam Medis dan Informasi Kesehatan, Volume 5 No 2, Oktober, DOI: https://doi.org/10.31983/jrmik.v5i2.9244, 81-2.

Fung, K. W. (2019). Using SNOMED CT – Encoded Problems To Improve ICD-10-CM Coding – A Randomized Controlled Experiment. Int J Med Inform, 19-25.

Haffer N, Thun S (2021) Postcoordination of LOINC Codes in SNOMED CT, German Medical Data Sciences: Bringing Data to Life, doi:10.3233/SHTI210045, 25.

Kemenkes RI (2023), Surat Edaran Nomor Hk.02.02/d/7093/2023 tentang Penyelenggaraan Rekam Medis Elektronik yang terinteroperabilitas dengan platform Satu Sehat.

Menkes RI (2020) Keputusan Menteri Kesehatan Republik Indonesia Nomor : HK.01.07/Menkes/312/2020, Tentang Standar Profesi Perekam Medis Dan Informasi Kesehatan, Jakarta, 10-18.

Menkes RI (2022), Keputusan Menteri Kesehatan Nomor Hk.01.07/Menkes/1423/2022, tentang Pedoman Variabel Dan Meta Data Pada Penyelenggaraan Rekam Medis Elektronik, Jakarta.

Lena D, Lazuardi L (2017), Evaluasi Konversi ICPC-2 dari ICD sebagai Upaya Peningkatan Kualitas Pelayanan Puskesmas, Journal of Information Systems for Public Health, Vol. 2, No. 1, April 2017, 36-46.

Masturoh, I., & Nauri, A. (2018), Metodologi Penelitian Kesehatan. Badan Pengembangan Dan Pemberdayaan Sumber Daya Manusia Kesehatan.

Muinga N, Magare S, Monda J, English M, Fraser H, Powel J, Paton C, (2020), Digital Health Systems in Kenyan Public Hospitals: A Mixed-Methods Survey, BMC Medical Informatics and Decision Making, https://doi.org/10.1186/s12911-019-1005-7, 20-22.

Matnew S, Settergren T, Westra B, Pruinelli L (2016), Developing Standardized Physiologic Assessments, Nursing Informatics, IMIA and IOS Press, doi:10.3233/978-1-61499-658-3-1084, 1084.

Rinaldi E, Saas J, Sylvia Thun S (2021), Use of LOINC and SNOMED CT with FHIR for Microbiology Data, German Medical Data Sciences: Bringing Data to Life, IOS Press, doi:10.3233/SHTI210064, 156-161.

Santamaria S, Ashrafi F, Spackman K (2014), Linking LOINC and SNOMED CT: A cooperative approach to enhance each terminology and facilitate co-usage, ICBO 2014 Proceedings, International Health Terminology Standards Development Organisation (IHTSDO), Copenhagen, Denmark, 99.

SNOMED International. SNOMED CT Browser Inrernational Edition 2021. [Online]. Tersedia: https://browser.ihtsdotools.org/?perspective=full&conceptId1=404684003&edition=MAIN/2021-01-31&release=&languages=en

Wager, K. A., Lee, F. W., & Glaser, J. P (2017) Health Care Information System A Practical Approach for Health Care Management. United States of America: John Wiley & Sons.

WHO (2015), International Statistical Classification of Diseases and Related Health Problems Tenth Revision-Fifth edition 2016, WHO, Geneva.