Hospital Digital Maturity Assessment

Electronic Medical Records Adoption

​
DMA Team
Outline
• Background
• Purpose of digital maturity assessment
• Method of assessment
• Assessment results
• Recommendation
• Conclusion
Background
Digital health transformation
ICT Infrastructure and Information Systems

Data standard and interoperability

Regulation and policy

Governance
Consideration of digital maturity assessment
• Supporting digital health
Digital health
transformation
transformation in Indonesia
(SatuSehat)
• Self-assessment and immediate
Electronic results and feedback
Stakeholders Medical
engagement Records
Adoption • Capability for continues improvement
of digital maturity and electronic
medical records implementation.
MoH Strategic Planning
and National Regulation
• Community engagement and support
(PERSI and PORMIKI)
Purpose of the digital maturity assessment
• Assess the current state of digital technology adoption in hospital level
to improve the quality and efficiency of medical services.
• Identify challenges of digital health implementation in hospital level and
develop recommendations on digital health adoption, strategy and
investment priorities.
• Provide tool for benchmarking the adoption of digital innovation in
hospital level
• Engage community and professional association for the assessment and
improvement of digital maturity at hospital level.
Method of maturity assessment
 Assessment protocol

Pilot Test Analisa Data

• Development 5 • Electronic format
scale self- DMA
assessment • Involving hospitals • Involving all hospital • Descriptive
• Improving • Improving response analytics
instrument rate
• Include EMR instrument • Supervision and • Data quality
validation analysis

Instrument Hospital DMI

Hospital DMI Assessment
Mapping of digital maturity parameters
EMR Duncan et
Components NHS HISMM
Adoption al
Systems and IT Infrastructure   V V V
Interoperability V V V  
Governance, management, strategy   V V V
People, skill and behavior   V V  
Data analytics V   V V
Information security, privacy and
V   V V
confidentiality

Electronic medical records for patient center

V V V V
care
Self-assessment questionnaire and scale

7 components (including EMR

adoption)

HISMM-based 69 questions (5 likert scale) for DMI,

Questionnaire 28 Checklist questions for EMR

5 level DMI and 7 stage of EMR

adoption
Projection Analysis for DMA Level and EMR stage
DMA Level* Description EMR Adoption** Description

Level 1 Ad Hoc and Fragmented Stage 0 There is no EMR in place

Level 2 Foundation Initiation Stage 1 Patient registration and admission

Level 3 Formed with authority Stage 2 Patient assessment, Electronic prescription,

Discharge Summary, and Test results
Level 4 Collaborative Managed
Stage 3 Drug dispensing, Terminology Standard
Level 5 Optimal and Integrated (Diagnosis, procedure and test)
Stage 4 Order Entry (including lab test), LIS,
Radiology interpretation, interoperability
Notes: standard
* Use all components. Answers in each questions are converted Stage 5 Nursing documentation, Basic Clinical
to 5 incremental scale. It assumes that a higher option indicates Decision Support Systems, PACS in
radiology department, medical reconsiliation
the lower option has been exceeded
Stage 6 Advanced clinical decision support systems,
** Only component VII.C.x.x being used in the calculation EMR personal health records
adoption in form of Checklist (yes/no answer)
Stage 7 Complete PACS systems
Instrument validation and refinement

• DHIS2
• Expert MoH, Province
Internal Electronic platform
meeting Pilot Test and District
Team • Spreadsheet level Form • Technical
support
Socialization and • Hybrid meeting
distribution self- • Inviting all
assessment hospital
representatives in
collaboration with
PERSI
Recommendations to complete self-assessment
1. Unit IT/HIS as the person in charge
2. Study the hospital's digital maturity assessment instrument
3. Identification of stakeholders for further consultation
(clinicians, users, managers, other units)
4. Provide several relevant documents such as regulations,
reports, hospital profiles, technical guidelines, strategic plan
documents, SOPs and others.
5. Complete a self-assessment with other stakeholders (internal
meeting or joint workshop) by choosing the conditions most
suitable for the hospital.
Monitoring and supervision
• Coordination with Directorate General Healthcare Services (Yankes)
• Circular letter from the Secretary General of MoH to all hospitals and
health offices (Bidang Yankes)
• Site visit and coordination in several provinces in Indonesia
• Reminder that facilitate by the Hospital Association (PERSI) and
PORMIKI
 Data Analysis Strategy

Grouping: geographic are, hospital characteristics (class, type,

accreditation, HIS status, etc)
General analysis:
Response rate by group,
completeness,
participations rate by
gender
DMI: Calculate average score (1-5) from the total 69 questions
EMR: highest number based on complete shorted of 28
Comparison DMI level with checklist answers
Internal data: DMI dan
RME, external data: RS
Online, DMI Macro.
Descriptive analysis: average score of components, sub-
components and parameters by selected group
Grouping by geographic regions
Data external validation
• It was predicted that self-assessment would face several challenges (low
response rate, completeness and quality of collected data
• The assessment following several data quality checks
• Completeness (inclusion criteria)
• Consistency of hospital DMI level/ RME stage with hospital
characteristics
• Consistency of hospital DMI level and RME stage
• Consistency of hospital DMI level and DMI sub-national Level
Assessment Results
Response rate
Target self-assessment DMI (n=3,052)
100% 100
90% 90
80% 80
70% 70
60% 60
50% 50
40% 40
30% 30
20% 20
10% 10
0% 0
L O G BI AN TA AT R G LI AN TA AT LU AT AU R AU AT AH AH EN RA RA EH AT AN KU RA RA AH RA R AT UA
N M U N A I U I U
TA ITU JA LAT AR AR TIM PU - B LAT AR AR KU AR - R TIM R AR NG NG NT TA TA AC AR LAT LU GA TA NG TA TIM AR AP
N
O L - E AK I B A M 51 SE JAK A B NG N B 14 N AN A B TE TE - BA SI U U U 11 - A B SE - MA NG N U I TE A U A A B - P
R BE 15 S GY ES W - LA TA LAU AR AN WA 36 E UK R 1
O A N O W JA 8 A KI AW - B E T A N W
E
ER SI 81 I T TA ES TER GA APU 9
G A R D J N A PU GG NT JA L T N
- GK T I Y LA 5 - 1 TE 1 - 2 - 17 IMA LA MA A WE ES MA AW MA NG - P
75 A N A N D U 3 A 3 3 IM E N A - U M A I L
B IM 4- -S M A L A L K E IM 33
- T L - S 2- S U L
U L AW AL SU SU TE 92
U - K 21 SA KA 8 - U - K 2 - 2 - SA
AN AL 3 76 -S -K 4 71 1 3 -S S
U - K 6 6 1 6 U - 7 3 - 65 7 1 N U
A 3 1 - N 62 7 4 -
L 6 2 3
P U 5 5
E
-K
19

Complete Incomplete Null Percentage

Participation rate of self-assessment

680; 40%

1029; 60%

Male Female
Hospital information systems (HIS) status
HIS Status* Level 1 Level 2 Level 3 Level 4 Level 5

Unknown 3 24 29 4

HIS - Front Office 19 104 69 9 1

HIS - Front Office, Back Office 28 209 313 112 5

HIS does not exist 15 17 7 2

HIS is not working 3 13 4

Grand Total 68 367 422 127 6

* Data acquired from RS Online in December 2022
HIS = Hospital information systems
Total sample eligible n=969
Hospital digital maturity index (n=973)
Hospital class and digital maturity index (n=973)
Le
vel
4;
12
9; Level 5; 5;
Level 1; 68;
13 1% 7%
%

Le
vel
2;
36
1;
Le 37
vel %
3;
41
0;
42
%
DMI and hospital ownership (n=973)
Hospital Ownership* Level 1 Level 2 Level 3 Level 4 Level 5
BUMN   5 3   
Kementerian Lain   5 4 2
Kemkes   4 16 8 1
Pemkab 31 97 47 14 2
Pemkot 3 20 18 5
Pemprop 7 44 31 8 1
POLRI 1 3 7 2
Swasta 17 120 203 66
Swasta Non Profit 7 51 72 19 1
TNI 2 12 9 5
Grand Total 68 361 410 129 5

* Data acquired from RS Online in December 2022

DMI and Hospital Accreditation (n=973)
Hospital
Level 1 Level 2 Level 3 Level 4 Level 5
Accreditation*
Tidak Terisi 6 25 28 5 
Lulus Perdana 15 79 47 8
Proses Akreditasi 10 18 20 4
Tingkat Dasar 8 24 13 5
Tingkat Madya 12 50 33 11 1
Tingkat Utama 6 46 37 9 1
Tingkat Paripurna 11 119 232 87 3
Grand Total 68 361 410 129 5
* Data acquired from RS Online in December 2022
DMI and hospital information systems source
(n=973)
HIS Source* Level 1 Level 2 Level 3 Level 4 Level 5
Unknown 11 19 10 1 
Kerjasama Operasional 20 128 146 42 1
Kombinasi 3 46 90 15
Membeli Sistem Jadi 9 33 32 9 1
Mengembangkan sendiri 7 32 71 46 2
Menggunakan Open Source 18 103 61 16 1
Grand Total 68 361 410 129 5
* Data acquired from RS Online in December 2022
HIS = Hospital information systems
 Average DMI sub-national and Hospital Level
2.8
Jawa-Bali

2.6

2.4 NTB-NTT-Maluku-Maluku Utara

a. PAPUA
DMI Rumah Sakit

Sulawesi
2.2 Sumatera
b. MALUKU-NTT-NTB
2 Kalimantan c. SULAWESI
d. KALIMANTAN
1.8 Papua e. SUMATERA
1.6 f. JAWA-BALI
1.4

1.2

1
1 1.2 1.4 1.6 1.8 2 2.2 2.4 2.6

DMI Sub-nasional*
Stage of RME Adoption
Response rate RME
Target self-assessment RME (n=3,052)
100% 100.0
90% 90.0
80% 80.0
70% 70.0
60% 60.0
50% 50.0
40% 40.0
30% 30.0
20% 20.0
10% 10.0
0% 0.0
B I A N L O A T T A T A N G A LI U R N G LU A T A T A U A U A N U R A H A T R A E N A H A T E H R A A N R A R A A H K U U R R A A T U A
M I I
J A AT TA AR AR AR TU - B IM PU KU AR AR R - R AT IM NG AR TA NT NG AR AC TA AT TA GA NG LU IM TA AR AP
I
- EL ON I B AK AK L 51 A M G B B AN 4 EL N T E B I U BA E B - U EL U G E A A T U B - P
T
5
1 S R ES I J Y B E N
W - LA BE WA RA AU
1 S A T N T A 1 A N T M A
N O W K OG A A A A T A TA ES 6 - N ER 1 KU SI S ER TE SI 1 - AR TAN PU 91
A W 3 T T A U
TA - G LA - D I Y GK - J 18 7 - - J GG UL N W
ER MA JA AN LA A AL WE AT ES AW
I E 8 G N A
G
N 5
A 7 SU 3 - D AN 1 3 5 1 2
3 EN KE
P T -
A LI 3 LIM SU
N
A UM M A M W L E N IMA - P
M
I S - L U T A L 92
L IM - 4 B T - U
M A 3 A -
K L - 8 2 U - S LA S U A
76 3 K S S -K
K A AN S A 21 - S 4-
1
- 71
- K A 13 3
- 12 SU 2 -
U
3
- A U N
U
1 6 6 6
62 7 4
- 7
- N 65
6 L - 7
P U 52 53
E
-K
1 9

Complete Incomplete Null Percentage

 Hospital EMR Stage (n=772)
100%
90%
80%
70%
60%
50%
40%
Stage 6
30% Stage 5
Stage 4
20%
Stage 3
10% Stage 2
0% Stage 1
A T I A T A I T T A A A T A A T A Stage 0
EH AR RA IAU MB TAN U LU NG NG IAU RT RA AH RT UR TEN AL RA UR RA AH TAN UR AR AR AH TAN AR ALO RA KU AR PU RA SI
C R A U U R G IM B I M G IM G T U E
- A UT BA 4 - - J ELA GK MP LIT AN AKA BA EN AKA A T AN 51 - BA T BA EN ELA T UT I UT EN ELA GG ON I BA AL UT - PA BA ON
11 RA RA 1 15 S EN LA BE U I J WA A T Y W - B A RA N T S AN N S I T S E N R S - M U 1 A
E E A B - A K G A 6 A R A T A N N T TA E S I T O E 1
S K 9 PU IND
- A L A W O J 3 G G N T A N N W A E I G W 8 U
AT A
T
T ER 17 18 GK PU - D - J JA I Y 5 - G NG MA AN NT IMA A LA AW W ES 5 - LA
E AL - PA
M UM 1 2 - 3 N M M
S U S M
A AN - KE 3 3 33 - D T E TE LI IM MA AL LI SU UL LA AW 7 SU 2
- 92
- - U B 3 4 A K A L L I K A - S S U L - 8
1 K
12 13 -S AN 2 SA US 1 - - KA KA 4 - 5 - 71 72 - 3 - SU 76
U 6 -
16 U
-N 3-
N 6 62 3 - 6 7 4
LA 6 7
P U 52 5
E
-K
19
 Proportion of RME stage by hospital class

100%
90% 6; 1% 5; 1%

80%
70%
137; 18% Stage 0
60% 171; 22% Stage 1
50% Stage 2
Stage 3
40% 139; 18% Stage 4
30% Stage 5
243; 31% Stage 6
20%
10% 7
0% 1;
Class A Class B Class C Class D D PRATAMA 9
%
Stage 0 Stage 1 Stage 2 Stage 3 Stage 4 Stage 5 Stage 6
DMI and RME Stage (n=772)
Hospital Digital Maturity
Index by Components
 DMI Level by Components (n=973)
• In average DMI level
I. Hospital Information Systems and Infrastructure
was 2.63
4 • HIS infrastructure and
VII. EMR and Patient Center Care
3
II. Standards and Interoperability
human resource, skills
2
and HIS usage were
1
perceived higher
0
compare to other
VI. Information security, privacy and data confidentiality III. Management and governance
componenents

V. Human resources, skills and usage IV. Data analysis

4.00
Digital maturity index by geographic area

3.00

I. Hospital Information Systems and In-

frastructure

II. Standards and Interoperability

2.00 III. Management and governance

IV. Data analysis

V. Human resources, skills and usage

VI. Information security, privacy and

1.00 data confidentiality

0.00
1. Sumatera 2. Jawa-Bali 3. Kalimantan 4. Sulawesi 5. NTB-NTT-Maluku 6. Papua
Component I. Information
systems and ICT Infrastructure
Information systems and ICT Infrastructure maturity by province
Average sub-component I

I.A. Front Office

4
I.F. IS Resource Planning I.B. Back Office
3

I.E. Interoperability Services and Routine Reporting I.C. ICT Quality

I.D. ICT Service Quality

 Sub-components I by geographic region
6

5 5
5 4.774.87 4.874.93 4.924.92 4.92
4.79 4.74

4
4
3.44
3.01 3.07 3.07 3.1
3 2.72 2.74
2.62 2.69
2.45
2.33
2.17
2

0
1. Sumatera 2. Jawa-Bali 3. Kalimantan 4. Sulawesi 6. NTB-NTT-Maluku 7. Papua

I.A. Front Office I.B. Back Office I.C. ICT Quality

I.D. ICT Service Quality I.E. Interoperability Services and Routine Reporting I.F. IS Resource Planning
Average parameters
6

5 4.77 4.62
3.95
4 3.64
3.38
2.91 3.09 3.03
3
2.16 2.31 2.21
2 1.79

0
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Component II. Standards and
Interoperability
Standard and interoperability
 Sub-components II by geographic region
3.5
3.24
3.1
3 2.91
2.81
2.71
2.5
2.5 2.38
2.23 2.25
2.01 2.01
2
1.75

1.5

0.5

0
1. Sumatera 2. Jawa-Bali 3. Kalimantan 4. Sulawesi 6. NTB-NTT-Maluku 7. Papua

II.A. Internal interoperability II.B. External interoperability

Average sub-component II and Parameters
4

3.06
3

2.53
2.25
1.98
2

0
II.A. Internal interoperability II.B. External interoperability II.B.1. External Data Exchange Average of II.B.2. Exchange of
Standard Individual Data
Komparasi kematangan standar dan interoperabilitas Mikro
dan Makro Level
3 Jawa-Bali
NTB-NTT-Maluku-Maluku Utara
2.8

2.6 Sulawesi
DMI Rumah Sakit

2.4
Kalimantan Sumatera
2.2

2 Papua

1.8

1.6

1.4

1.2

1
0 0.2 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2 2.2 2.4

DMI Sub-nasional*
Component III. Management
and governance
Management and government maturity by province
Average sub-component III
III.A. IS/IT Strategic Plan

3
2.5
2
1.5
1
0.5
III.D. Information System Investment 0 III.B. IS/IT Governance

III.C. HR at IT Unit
 Sub-components III by geographic region
3.50
3.17

3.00 2.86
2.79
2.722.72 2.66
2.51 2.52
2.50 2.45
2.37 2.36 2.33
2.30
2.19 2.222.22 2.20 2.23 2.17
2.12 2.16
1.99
2.00

1.50

1.00 1.00
1.00

0.50

0.00
1. Sumatera 2. Jawa-Bali 3. Kalimantan 4. Sulawesi 6. NTB-NTT-Maluku 7. Papua

III.A. IS/IT Strategic Plan III.B. IS/IT Governance III.C. HR at IT Unit III.D. Information System Investment
Average parameters of sub-component III
3.5 3.23
2.95 2.97
3
2.69
2.53 2.55
2.5 2.28 2.22
2 1.89

1.5

0.5

0
t t
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Pl on an an of
H ni H
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S tra c G G ul
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I.B. Av
II
Component IV. Data analysis
Data analysis maturity by province
Average sub-component IV and Parameters
3.00

2.50 2.39

1.98
2.00 1.83 1.83
1.67 1.68
1.56
1.50
1.12
1.00

0.50

0.00
s l
l ity m ic ls ls si
s ta ta
ua s te yt i ta ita ly pi da
sy al os
p sp a
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an ho An bi
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a ct at y at h gi
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D ac na
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4 .D da rce
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IV .B
IV
 Sub-components IV by geographic region
3.50

3.00
3.00

2.50
2.28
2.04 2.05
2.00 1.90 1.96 1.86 1.88
1.80
1.72 1.72
1.64
1.50

1.00

0.50

0.00
1. Sumatera 2. Jawa-Bali 3. Kalimantan 4. Sulawesi 6. NTB-NTT-Maluku 7. Papua

IV.A. Data Use and Quality IV.B. Big Data Analysis

Component V. Human
resources, skills and usage
Human resources, skills and usage maturity by province
Average sub-component V

V.A. Digital Literacy

4.00
3.00
2.00
1.00
V.D. Knowledge Management 0.00 V.B. Ease of use and usefulness

V.C. Iinformation systems usage

 Sub-components V by geographic region
4

3.51
3.5 3.33
3.29
3.07 3.07 3.1
2.97
3 2.87 2.83
2.74 2.71 2.76
2.62 2.67
2.55 2.5
2.5 2.37
2.2
2.01 2
2 1.88 1.88 1.83

1.5
1.5

0.5

0
1. Sumatera 2. Jawa-Bali 3. Kalimantan 4. Sulawesi 6. NTB-NTT-Maluku 7. Papua

V.A. Digital Literacy V.B. Ease of use and usefulness V.C. Iinformation systems usage V.D. Knowledge Management
Average parameters of Component V
4.50
3.95 3.96
4.00 3.72
3.50 3.34
3.15 3.15
3.02
3.00 2.87
2.61
2.50 2.36 2.38
2.09
2.00

1.50

1.00
0.50

0.00
y r s t s s t t
ac se en se ce s on e rin
g
en en
r U tem m fu en ne pi tiv m
ite IS s e o er
i
fu
l m n ti o e em
ll sy g e p e ha ce on ag ag
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ig ro tio e n
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A
V.
Component VI. Information
security, privacy and data
confidentiality
Information security, privacy and data confidentiality maturity by province
Average sub-component VI and Parameters
4.00

3.00 2.86
2.46 2.60 2.56 2.39
2.15 2.08 2.13
2.00 1.79

1.00

0.00
 Sub-components V by geographic region
3.00
2.68 2.67
2.46 2.47 2.49
2.50
2.34 2.33
2.25
2.11
2.04
2.00
1.74

1.50

1.00 0.88

0.50

0.00
1. Sumatera 2. Jawa-Bali 3. Kalimantan 4. Sulawesi 6. NTB-NTT-Maluku 7. Papua

VI.A. Security and access to patient data VI.B. Information system security procedures
Component VII. EMR and
Patient Center Care
EMR and Patient Center Care maturity by province
Average sub-component V

VII.A. EMR function

4.00
3.00
2.00
1.00
VII.D. Personalized Medicine 0.00 VII.B. Patient Center Care

VII.C. EMR Adoption

 Sub-components VII by geographic region
4
3.7
3.61
3.5
3.5
3.3
3.16 3.1
3 2.86

2.47 2.54
2.5 2.4 2.45
2.37
2.21 2.15 2.21
2.07 2.02
2
1.79 1.75
1.62
1.46
1.5

1 1 1
1

0.5

0
1. Sumatera 2. Jawa-Bali 3. Kalimantan 4. Sulawesi 6. NTB-NTT-Maluku 7. Papua

VII.A. EMR function VII.B. Patient Center Care VII.C. EMR Adoption VII.D. Personalized Medicine
 Average parameters of Component VII
5.00
4.50 4.36 4.36
4.05
4.00
3.50 3.16
3.00 2.75
2.55 2.42
2.50 2.31 2.29
1.97 2.04
2.00 1.88
1.52
1.50 1.33
1.00
0.50
0.00
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Recommendation
• Individual feedback for hospital to provide general recommendation for hospitals
• Supervision and capacity building post self-assessment survey to strengthening the
capacity of hospitals to adopt EMR
• Mentorship program, in collaboration with hospital association (hospital that has
better maturity level become mentor of other hospitals)
• Develop capacity building program for different level of users in hospitals and Health
Offices to improve knowledge, capacity and skills of HIS
Limitation
• It was perceived that the questionnaire too complex. Completion of self assessment
required staff from technical and health background to understand operational
definition of both narrative questions and the possible answers.
• There were technical problems with the electronic survey that probably impact the
low response rate of survey. In addition, area with geographical challenges probably
required direct supervision.
• The low involvement of the health office makes communication mechanisms and
technical support difficult in increasing the response rate and the completeness of
survey amongst the hospitals.
Conclusion
• A digital maturity self-assessment was developed to assess a hospital's digital
capacity.
• There are 2 components relatively better in the hospital, including: Information Systems and
Infrastructure and Human Resources, Skills and Use of information systems
• Standard components and interoperability, management and governance of hospital information
systems, security and confidentiality of data and electronic medical records vary relatively.
• Relative components require a lot of intervention on the data analysis aspect
• Electronic medical records (RME) have been adopted by hospitals, although adoption rates still vary.
Several important modules such as pharmacy, medical support, use of data standards and
interoperability between systems are available.
 THANK YOU

This presentation is made possible by the support of the American people through the United States Agency for
International Development (USAID). The contents are the sole responsibility of the Country Health Information
System and Data Use program and do not necessarily reflect the views of USAID or the United States
Government.