Download - Standar Informatika Kesehatan Gcos
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Terminology, Vocabulary and Standards in Health Informatics
Anis FuadMinat Sistem Informasi dan Manajemen Kesehatan (SIMKES)Program Studi S2 Ilmu Kesehatan MasyarakatFakultas Kedokteran UGMEmail: [email protected] http://anisfuad.blog.ugm.ac.id
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Model status asuhan keperawatan berbasis komputer
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Atau sudah berupa rekam medis multimedia (filmless)
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TeleCare
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Lingkup manajemen data rumah sakitManajemen data
Rumah sakit
Gudang
data
Pertukaran informasi kesehatan
Aplikasi jaringanServer
Pembayar
Lab
Resep
Order dokter
Rawat jalan Surveilans &kesmas
Akses dan penggunaan data
Rumah sakit
dokter
Labs
KesehatanMasyarakat
Pembayar
• Pemberian hasil• Transfer dokumen yg aman• Rekam medis elektronik•
• Pemberian hasil• Transfer dokumen yg aman• Rekam medis elektronik• CPOE (computerized•Physician order entry)•
• Hasil laboratorium
• Surveilans• Kondisi yg wajib dilaporkan• Hasil
• Transfer dokumen yang aman
• Data klinis yang diidentifikasi Peneliti
PayerPayer
Akses yangaman
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Ditjen Yanmed, Dinkes Prop; Kab/Kota
Tanggal 5Bulan Berikut
SETIAP BULANRL6DATA PELAPORAN INFEKSI NOSOKOMIAL RUMAH SAKIT
DATA INFEKSI NOSOKOMIAL
Dinkes Prop; Kab/KotaDinas Kesehatan Setempat
Tanggal 15Bulan Berikut
BULANANRL2cDATA STATUS IMUNISASI
DATA MORBI-DITAS
Ditjen Yanmed, Dinkes Prop; Kab/Kota
Tanggal 15 Juli dan 15 Januari
SEMESTER30 Juni dan 31 Desember
RL4DATA KETENAGAAN RUMAH SAKITDATA KETENAGAAN
Ditjen Yanmed, Dinkes Prop; Kab/Kota
Tanggal 15 JanuariTAHUNAN31 Desember
RL4aDATA INDIVIDUAL KETENAGAAN (RUMAH SAKIT VERTIKAL DEPKES)
Dinkes Prop; Kab/KotaDinas Kesehatan Setempat
Tanggal 15Bulan Berikut
BULANANRL2b1DATA KEADAAN MORBIDITAS PASIEN RAWAT JALAN SURVAILANS TERPADU DI RUMAH SAKIT
Ditjen Yanmed, Dinkes Prop; Kab/Kota
Tanggal 15Bulan Keempat
TRIWULAN1/I s/d 31/XII
RL 2bDATA KEADAAN MORBIDITAS PASIEN RAWAT JALAN RS
Ditjen Yanmed, Dinkes Prop; Kab/Kota
Tanggal 15Bulan Keempat
TRIWULAN1/I s/d 31/XII
RL 2aDATA KEADAAN MORBIDITAS PASIEN RAWAT INAP RS
Dinkes Kab/KotaDinas Kesehatan Setempat
Tanggal 25Bulan Sampling
TRIWULAN(Sampling 10 Hari)
RL 2.1RL 2.2RL 2.3
DATA INDIVIDUAL MORBIDITAS PASIEN RAWAT INAP-Pasien Umum-Pasien Obstetri-Bayi Baru Lahir/Lahir Mati
Ditjen Yanmed, Dinkes Prop; Kab/Kota
Tanggal 15Januari
TAHUNAN31 Desember
RL3DATA DASAR RUMAH SAKITDATA DASAR
KETERANGANJADUAL PELAPORANPERIODE PELAPORANKODENAMA FORMULIRJENIS DATA
Ditjen Yanmed, Dinkes Prop; Kab/Kota
Tanggal 15 JanuariTAHUNAN31 Desember
RL5DATA PERALATAN
MEDIK RUMAH SAKIT
Dinkes Prop; Kab/KotaDinas Kesehatan Setempat
Tanggal 15Bulan Berikut
BULANANRL2a1DATA KEADAAN MORBIDITAS PASIEN RAWAT INAP SURVAILANS TERPADU DI RUMAH SAKIT
DATA PERALATAN
Ditjen Yanmed, Dinkes Prop; Kab/Kota
Tanggal 15Bulan Keempat
TRIWULAN1/I s/d 31/III
RL1DATA KEGIATAN RUMAH SAKITDATAKEGIATAN
Types of hospital reporting to Gov
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Hospital reporting scheme
Military Hosp
private
Provincial Health Office
District HealthOffice
MOH
R.S
DEPKES, PEMDA
R.S
ABRI/DEP.LAIN/BUMN
R.S
S W A S T A
RL1;RL2a;RL2b;RL3;RL4;RL5;RL6
RL1;RL2a;RL2b;RL3;RL4;RL5;RL6
RL1;RL2a;RL2b;RL2a1;RL2b1;RL2c; RL2.1;RL2.2;RL2.3;RL3;RL4;RL5;RL6
RL1;2a;2b;3;4;5;6
RL1;2a;2b;3;4;5;6
RL4a (Khusus RS Vertikal Depkes)
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Database DHF Sleman
Database DHF Kota Yogya
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Data Types
Teks
Numerik
Signal
Terstruktur
KodeKode standar
NLP
Interpretasi
Image
Simbol
Je
genomik
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Wireless WideArea Network in Wonosobo district
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Standar pelayanan kesehatan
• Standar pelayanan medis clinical guideline
• Standar mutu pelayanan ISO• Standar sistem informasi rumah sakit? standar informatika kesehatan
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The nice thing about standard is…There are so MANY to choose from
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Ketiadaan standar akan menghambat pelayanan kesehatan
Ketiadaan standar akan menghambat pelayanan kesehatan yang efektif dan efisien berbasis IT
Ketiadaan standar akan menghambat komputerisasi secara luas
&
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Standar informatika kesehatan
• Berbagai tujuan– Transaksi keuangan, klaim asuransi, data
klinis, data demografis, images, alat kedokteran, .....dll.
• Berbagai organisasi pengembang standar (SDO = standard development organization)– WHO, ANSI, ISO (TC215),CEN (TC251), IEEE,
ASTM, HL7, DICOM (ACR-NEMA), berbagai perhimpunan profesi dokter .... dll.
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Standar informatika kesehatan (lanj)
• Standar istilah, kode dan perbendaharaan kata (vocabulary)– Berbagai kode yang mewakili istilah medis– misalnya ICD, SNOMED, LOINC…dll.
• Standar pertukaran data– Memungkinkan pertukaran data antar berbagai sistem
yang berbeda baik di dalam maupun antar rumah sakit
– misalnya. HL7, CCR, DICOM…dll.
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Standar informatika kesehatan bersifat nasional dan lokal• Kepmenkes 844/2006 tentang Kode Kesehatan
memuat:– Kode identifier rumah sakit, puskesmas– Kode obat– Kode alat/inventory – Kode wilayah– Belum memuat standar data klinis yang rinci
• Kode lokal dalam aplikasi komputer (software)• Berbagai format output/laporan berbasis kertas
(SP2RS)
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Terdapat di http://www.depkes.go.id/downloads/844-2006.pdf
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dari Integrasi ke Interoperabilitas
“interoperabilitas adalah kemampuan sistem teknologi informasi dan aplikasi software yang berbeda untuk saling berkomunikasi, tukar menukar data secara akurat, efektif, konsisten dan menggunakan informasi yang telah dipertukarkan.”
National Alliance for Health Information Technology (NAHIT), 2005http://www.nahit.org/cms/index.php?option=com_content&task=view&id=220&Itemid=115
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Adopsi standar informatika kesehatanoleh Depkes AS
• March 21, 2003– HL7, NCPDP, IEEE 1073, DICOM, LOINC
(results)
• May 6, 2004– HL7 vocabularies, SNOMED-CT,
LOINC (orders), HIPAA code sets, FDA drug names and codes, RxNORM, NDF-RT, EPA substance registry system, HUGN
http://www.whitehouse.gov/omb/egov/gtob/health_informatics.htm
Messaging Formats
Terminologies
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Standar pertukaran data
• Standar format pesan– Data administratif - X12 – Data klinis - HL7– Gambar medis - DICOM– Data peresepan obat - NCPDP– Data alat medik - IEEE 1073
• Arsitektur dokumen• Template medis• User Interface• Patient Data Linkage
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HL-7
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HL7
• HL7 = Health Level 7• ANSI Standards Development Organization (1994)• Menentukan transaksi pertukaran data kesehatan
– Meliputi: Registrasi pasien, ADT (Admission Discharge Transfer), asuransi, biaya, order, hasil pemeriksaan lab, observasi, penjadwalan
• Not-for-profit, volunteer– Provider, vendor, asuransi, kelompok pemerintah, konsultan,
dll
• Komite teknis, Special Interest Group
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Contoh pesan hasil laboratorium menggunakan HL7
• MSH Segment - Message Header• PID Segment - Patient ID• OBR Segment - Observations Report ID• OBX Segment - Observation/Result
MSH|^~\&||CDB||||ORU^R01|K172|P<cr> PID|1|0123456‑1||ROBERTSON^JOHN^H|||||||9821111<cr> OBR|5|2740X^OE|BC402^MIC|87186^Antibiotic MIC|R|198703281230 |19870329080<cr>OBX|1|ST|28-1^AMIPICILLIN:SUSC:PT:ISLT:QN:MIC^LN||<2|ug/ml||S|||F<cr>OBX|2|ST|60-4^CARBENICILLIN:SUSC:PT:ISLT:QN:MIC^LN||<16|ug/ml||S|||F<cr>OBX|3|ST|267-5^GENTAMICIN:SUSC:PT:ISLT:QN:MIC^LN||<2|ug/ml||S|||F<cr>
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CDA: A Document Exchange Specification
• This is a CDA
• and this
• and this
• and this
• and this
• and this
• and this
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Consult
CDA: electronic documents
• eDocuments for Interoperability– Many CDA documents comprise an individual
electronic medical record– Key component for local, regional, national electronic
health records– Gentle on-ramp to information exchange
• Everyone uses documents• EMR compatible, no EMR required• All types of clinical documents
CDA Health chart
CCD
PathRadiology
Discharge
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Sample CDA
• Header• Body
● Readable: required● Computable: optional
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CDA Header: Metadata
• Identify– Patient– Provider– Document type...
• Sufficient for– Medical records management– Document management– Registry/repositoryg– Record locator service– Store, query, retrieve
required
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CDA Body: Human-readable report
• Any type of clinical document– H&P– Consult– Op note– Discharge Summary...
• Format: tif, PDF, HTML, XML:– Paragraph– List– Table– Caption– Link– Content– Presentation required
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CDA Body: Machine Processible
– Model-based computable semantics:• Observation
• Procedure
• Organizer
• Supply
• Encounter
• Substance Administration
• Observation Media
• Region Of Interest
• Act
Optional
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CDA: Incremental Computability
• Standard HL7 metadata
• Simple XML for point of care human readability
• RIM semantics for reusable computability (“semantic interoperability”)
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Incremental Semantic Interoperability
• Patients transfer between providers with vastly different IT capabilities
• Need to support information requirements at point of care– Full EMR adoption… not predictable based on past
adoption curves
• Assume gradually rising, but still heterogeneous levels of sophistication– Data formats (imaging, text, XML)– Coded data (metadata, basic structure, simple results
reporting, complex clinical statements)
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DICOM
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DICOM
• Digital Imaging and Communications in Medicine
• Standards Committee– Vendors: Philips, Siemens, GE Medical
Systems, IDX, Heartlab, Eastman Kodak …– Users– General Interest
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Terminologi Kesehatan
NANDA
NOCOmaha
NIC DSM
LOINC
MedDRASNOMED
-CT
Read Codes
NHSCTV3
Gabrieli
ICD-9-CM
ICD-9
ICD-10
ICD-10-PCS
HCPCS
MEDCIN
SNOMED-RT
NDF-RT
ICFNDC
CPT-4
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HIPAAhealth insurance portability accountability act
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ICD-9-CM International Classification of Diseases, 9th Edition, Clinical Modification
CPT-4 Current Procedural Terminology, 4th Edition
HCPCS Healthcare Common Procedure Coding System
CDT-2 Code on Dental Procedures and Nomenclature, 2nd Edition
ICD-9-CM International Classification of Diseases, 9th Edition, Clinical Modification
Standar yang dianut oleh HIPAA
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ICD-9-CM
• ICD-9-CM berbasis pada ICD-9• ICD: International Classification of Diseases
– World Health Organization (WHO) – Tujuan:
• kode dan klasifikasi mortalitas berdasarkan sertifikat kematian• Promosi komparabilitas internasional
– ICD-10 (since Jan. 1, 1999), WHO copyright
• ICD-9-CM: International Classification of Diseases, Clinical Modification– National Center for Health Statistics (NCHS)– Tujuan:
• Kode dan klasifikasi morbiditas pasien rawat jalan (outpatient)– Dapat didownload, diupdate setiap tahun
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ICD-9-CM
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NDC
• NDC = National Drug Code• Drug Listing Act of 1972
– Dimandatkan oleh FDA (Badan POM AS)– Untuk peresepan dan sebagian obat bebas yang tersedia di AS
• Memuat formulasi, route, packaging, perusahaan• Contoh kelas NDC
ADRENAL CORTICOSTEROIDSTOPICAL STEROIDSCEPHALOSPORINSQUINOLONES / DERIVATIVESDISORDERS, ACID/PEPTICANTIDEPRESSANTS
ANTIDIARRHEALSSEDATIVES / HYPNOTICSDERMATOLOGICSANTIVIRALSCNS, MISCELLANEOUSAMINOGLYSIDES
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NDCSearch Page
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NDCQuery
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NDC Results
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NCVHS Terminologi Utama
SNOMED-CT Systematized Nomenclature of Human and Veterinary Medicine, Clinical Terms
LOINC Logical Observations Identifiers, Names, and Codes
RxNORM (“normalized” notations for clinical drugs)
SNOMED-CT Systematized Nomenclature of Human and Veterinary Medicine, Clinical Terms
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UNII Unique Ingredient Identifier
MedDRA Medical Dictionary for Drug Regulatory Affairs
MEDCIN Medicomp Systems Inc.
ISBT International Society for Blood Transfusion
DSM-IV Diagnostic and Statistical Manual for Mental Disorders
UNII Unique Ingredient Identifier
NCVHS Terminologi tambahan
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SNOMED-CT
• Systematized Nomenclature of Medicine - Clinical Terms– Rilis pertama Feb. 2002
• Kolaborasi AS dan Inggris – AS: College of American Pathology (CAP)
• SNOP, SNOMED 2, SNOMED International, SNOMED-RT
– Inggris: National Health Service (NHS)• Read 4-byte set, 5-byte set, Read 2, Clinical Terms Version
3
• Isi– 325.000 konsep, 800.000 descriptions,950.000 relasi
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SNOMED - Axes
D - DiseasesC - DrugsF - FunctionL - Living OrganismsX - ManufacturersG - ModifiersM - MorphologyJ - OccupationsA - Physical AgentsP - ProceduresS - Social ContextT - Topography
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SNOMED - contoh
"D3-15000" "01" "Myocardial infarction, NOS" "(T-32020) (M-54700)""D3-15000" "02" "Infarction of heart, NOS" "(T-32020) (M-54700)""D3-15000" "02" "Cardiac infarction, NOS" "(T-32020) (M-54700)”"D3-15000" "02" "Heart attack, NOS” "(T-32020) (M-54700)""D3-15010" "01" "Microinfarct of heart” "(T-32000) (M-54701)”"C-C137A" "01" "Bufferin Analgesic Tablets""C-C137B" "01" "Bufferin Analgesic Caplets""M-54700" "01" "Infarct, NOS"“M-54700" "02" "Infarction, NOS""M-54700" "05" "Infarcted""M-54701" "01" "Focal infarct""M-54701" "02" "Microscopic infarct""S-10120" "01" "Mother, NOS"
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LOINC
• Logical Observation Identifier Names and Codes
• Tujuan– Membuat identifier universal (nama dan kode) yang
nantinya akan digunakan dalam pesan HL 7 dan DICOM
• Tanpa lisensi dan fee• Besar
– 32,000 observasi
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Struktur dasar LOINC
Field Contoh
Komponen Potassium, hepatitis C antigen
Properti Substance concentration, volume rate
Waktu Point in time, 24 hr
Sampel Urine, serum, plasma
Skala Quantitative, ordinal, nominal, narrative
Field Contoh
2951-2 SODIUM:SCNC:PT:SER/PLAS:QN
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• Unified Medical Language System• National Library of Medicine (NLM)• Purpose
– Mempermudah kemampuan program komputer untuk memahami makna istilah biomedis dan menggunakannya untuk mengintegrasikan berbagai informasi kepada pengguna (1993)
– Mempermudah pengembangan sistem komputer yang dapat memahami/ “understanding” bahasa biomedis dan kesehatan (2004)
• UMLS Knowledge Sources– Metathesaurus, Semantic Network, Specialist Lexicon
UMLS
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UMLS
• Cakupan– Kombinasi berbagai vocabulary
• Ukuran– 1 juta konsep, 2.8 juta nama, 100+ sumber
• Nama dan hubungan• Organisasi berdasarkan konsep• Makna
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Referensi tentang standar
• National Library of Medicine– http://www.nlm.nih.gov/index.html
• Unified Medical Language System– http://www.nlm.nih.gov/research/umls/umlsmain.html
• NCVHS– http://ncvhs.hhs.gov
• LOINC– http://www.regenstrief.org/loinc
• SNOMED-CT– http://snomed.org/snomedct/index.html
• National Health Information Infrastructure; Standards and Standards Organizations
– http://aspe.os.dhhs.gov/sp/nhii/standards.html• NDF-RT; VA Drug Demonstration Project
– http://mmr.afs.apelon.com/va/about/ndfrt_files/frame.htm
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Manfaat
IntegrasiInteroperabilitasKonsistenDuplikasiSesuai dengan karakteristik perkembangan SIMRS
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Implikasi bagi pengembangan sistem informasi kesehatan
• Persyaratan standar informatika kesehatan harus dipenuhi oleh aplikasi sistem informasi– Standar nasional– standar internasional
• Menyesuaikan antara kebutuhan lokal/nasional dengan internasional
• Penguatan peran pemerintah, vendor (yang banyak terlibat di lapangan), pengguna (rumah sakit/puskesmas/dinas kesehatan), akademisi (penelitian, pengajaran, adopsi)
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Kapan kita berbicara mengenai standar
• Sistem informasi sudah menjadi kebutuhan
• Telanjur memiliki sistem yang tidak interoperabel satu sama lain
• Regulasi sistem informasi rumah sakit
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Gambaran umum penggunaan kode/klasifikasi
Diagnosis
Laporan radiologi
Pemeriksaan fisik
Ringkasan pasien keluar
Riwayat pasien
Obat
Tidak terkode, Belum
terstruktur
Kode lokalKode universal
Then (1993)
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Harapan perkembangan berikutnya..
Diagnosis
Laporan radiologi
Pemeriksaan fisik
Ringkasan pasien keluar
Riwayat pasien
Obat
Tidak terkode, Belum
terstruktur
Kode lokalKode universal
Then (1993)
Tidak terkode,
terstruktur
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Memilih standar
1. Adopsi– Membayar lincense fee – beberapa– Tanpa lisensi – ICD-10, WHO ATC, LOINC
2. Mengembangkan sendiri– Membutuhkan tim peneliti yang kuat– Sharing data antar lembaga lokal
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Thailand health coding center
1. Menyusun kesepakatan standar2. Pemeliharaan standar kode3. Training coders4. User support5. Penelitian dan pengembangan kode baruberdiri 2006 di bawah Depkes Thailand
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Upaya bersama
• Pemerintah– Regulasi– Sumber dana
• Rumah sakit– Think Big, start small
• Industri– Adopsi standar dalam pengembangan dan inovasi
software
• Akademik– Adaptasi standar internasional ke lokal (translasi) – Apa yang bisa dan yang tidak bisa (lesson learnt)
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Kesimpulan
• Tidak ada monopoli sistem informasi• Diperlukan standar informatika kesehatan• Memasukkan persyaratan standar
informatika kesehatan dalam master plan SIM RS
• Regulasi tentang standar informatika kesehatan
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Terima kasih