Chapter 18

Electronic Health Record

Ahmad Said & Cendra Devayana Putra

A. Overview of Electronic Health Record

During today’s technological advances, information spreads quickly
and becomes an advantage for people who use it. Moreover, technol-
ogy is used to disseminate useful information to the community, one
of which is in the world of health. Health information available in
hospitals is very important for public safety. Therefore, it is neces-
sary to have a health information system such as electronic health
records. Electronic Health Records (EHRs) can be broadly defined
as representing longitudinal data (in electronic format) that are col-
lected during routine delivery of healthcare (Jackson et al., 2016).
Electronic Health Records (EHRs) provide opportunities to enhance

A. Said & C. D. Putra

Universiti Sains Malaysia, e-mail: ahmad_said@ymail.com

© 2022 Overseas Indonesian Student's Alliance & BRIN Publishing

Said, A., & Putra, C. D. (2022). Electronic health record. In R. Trialih, F. E. Wardiani, R.
Anggriawan, C. D. Putra, & A. Said (Eds.), Indonesia post-pandemic outlook: Environment and
technology role for Indonesia development (321–330). DOI: 10.55981/brin.538.c499 321
ISBN: 978-623-7425-85-4 E-ISBN: 978-623-7425-89-2
 patient care, embed performance measures in clinical practice, and
facilitate clinical research (Cowie et al., 2017).
Legally, the data in the EHRs is a legal record of patient services
and the hospital has the right to store such data. EHRs generally con-
tain demographic, vital statistics, administrative, claims, clinical, and
patient-centered data. EHRs can be accessed and owned by patients
and the data can be used in other healthcare centers for subsequent
treatment purposes. EHRs emerged largely to improve healthcare
quality and capture billing data. EHRs may be used to assess study
feasibility, facilitate patient recruitment, streamline data collection,
and conduct entirely EHR-based observational, embedded pragmatic,
post-marketing randomized registry studies, or comparative effective-
ness studies. EHRs are mostly used for observational studies, safety
surveillance, clinical research, and regulatory purposes.

B. The Benefits
There are several benefits of using EHRs: general benefit, operational
benefits, and organizational benefits. For the general benefits, EHRs
will improve the professionalism and performance of hospital man-
agement. Stakeholders such as patients will enjoy the convenience,
speed, and convenience of health services. Furthermore, EHRs makes
each unit work according to its functions, responsibilities, and au-
thorities. Operational Benefits, when EHRs are implemented, at least
four operational factors will be felt. The first factor is the completion
speed of administrative tasks. This speed has an impact on increasing
work effectiveness. The second is the accuracy factor, especially data
accuracy. In the past with manual systems, people had to check one file
at a time, but now with the manual system. For example, if the same
patient is registered twice at different times, the system will reject it.
EHRs will warn if the same action for the same patient is recorded
two times. This keeps the data more accurate and more thorough.
The third is the efficiency factor. Because the speed and accuracy of
data increases, the time needed to do administrative work is reduced
considerably so that employees can focus more on their main work.

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Fourth is the ease of reporting, the number of reporting cases could
be more because the data is in non-physical form.
Organizational Benefits, because Hospital Information System
(HIS) requires discipline in data entry, timeliness and correctness
of data, the work culture that previously suspended such things has
changed. For example, a drug prescription written in the EHRs will be
very much needed by the drug department, while all actions taken at
the hospital will be required. So EHRs create increased coordination
between units. Often people claim that with the computerization of
administrative costs increased.
In Indonesia, EHRs have been used since the late 2000s. The use
of technology in the health care system in Indonesia was initially
limited to recording patient data. In addition, EHRs are also used in
communication and exchange of information between health facilities,
such as in Central Java, where each puskesmas (Public Health Center)
can access integrated electronic medical records to track the history
of patients who come for treatment. Not infrequently patients have
to undergo various examinations from the beginning again because
of the unavailability of health data first.

C. Function
Accordingly, an EHRS system should offer the following basic func-
tions. First, Health Information and Data. It should store and provide
access to patient’s health information such as patient’s history, aller-
gies, laboratory reports, diagnosis, current medications, and so on
to healthcare providers for appropriate clinical decisions for better
patient care. It should integrate data from various sources and make
it available to the people involved in patient care. The second is to
Replicate the Workflow. It should be able to work in sync with the
original workflow of the healthcare organization. The third is Efficient
Interaction. It should be able to work effectively, saving care providers’
time by keeping things concise.

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 Fourth is Clinical Decision Support (CDS). It should support
the provision of reminders, prompts, and alerts. Such features help
improve clinical and preventive practices and reduce the frequency of
adverse events. Fifth is Patient Support. It should empower patients
to access their health information, enabling them to be involved in
their healthcare. Sixth is Messaging and Data Processing Capability.
It should allow an exchange of data in known/standard formats for
the interoperability of healthcare applications.
Additionally, it should enable the processing of incoming data in
known/standard formats. Seventh is Administrative Tools. It should
provide administrative tools, such as scheduling systems, to improve
clinical practices’ efficiency and timely patient services.

1. Significance of EHR
In addition, there is significance in the EHR. First, Ease of Maintaining
Health Information of Patients. The EHR system minimizes the use
using paper in storing data and has good backups, reducing operat-
ing, upgrading, and maintaining costs. Second, Efficient in Complex
Environments. EHRs help improve work processes and efficiency in
healthcare. For example, quickly finding patient data, overcoming
patient problems, and making it easier for researchers to analyze the
efficacy of drugs in patients. Next, Better Patient Care. Most of the
time, multiple healthcare providers are involved in the treatment of
a patient.
Moreover, it enables point-in-time data insertion, retrieval, and
update. Thereby, providing immediate access to patient data from any
specialty center whenever required. Availability of health informa-
tion, such as past medical history, family medical history, and im-
munization through EHR helps take preventive measures and manage
chronic diseases more effectively.
The Fourth is Improve Quality of Care. EHR helps decrease
reporting and charting time during treatment, hence, improving
care quality. EHR also helps improve risk management and accurate
diagnosis, improving the quality of care. Fifth, is Reduce Healthcare

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Delivery Costs. Due to the availability of health information data
from all healthcare organizations, a healthcare provider can refer to
the required test reports, thus avoiding the repetition of expensive
tests. Next is Accelerates Research and Helps Build Effective Medical
Practices. EHR provides an extensive database in one place, promoting
its use for disease surveillance for providing preventive measures. It
also helps analyze treatment patterns of medicine in decision support
with EHR enabling effective medical practices. The last is Better Safety.
An EHR system provides safer patient health records than paper based
system through access, audit, and authorization control mechanisms.

2. Factors Affecting Implementation of EHR

There are also several factors affecting the implementation of EHR.
First, the design of the system needs the involvement of clinical staff
with the to include the organization’s policies and workflow processes.
Then, an EHR system must also meet the privacy and security regula-
tions for health data imposed by regulatory bodies in the country. It
provides assures patients and providers that the health data is securely
stored and privacy is maintained while healthcare applications deliver
appropriate services. Next, the duplication of EHR records of a patient
in the same EHR system is an important issue in EHR usage. In the
process, different organizations assign different identifiers to the same
patient.
EHR system consolidates patients’ healthcare data generated from
various healthcare systems. Hence, it should be capable of integrating
data from all such systems. Additionally, these applications usually
do not consistently use security and data integrity standards. An
EHR system must, therefore, consistently use standards and upgrade
to newly developed standards for addressing these issues. An EHR
system must also carefully handle ethical and legal issues linked to
the accuracy, confidentiality, and access rights of healthcare data.
These include improved quality and patient care, patient safety, more
efficient patient data tracking, improved documentation, and better
audit of accessed information. Indeed, an EHR system also provides

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 some financial ROI, such as increased income with expanded pa-
tient load due to time efficiency and reduced material costs, such
as paper, charts, and printing supplies. Some healthcare providers
find it more difficult and time-consuming to use computers for data
entry than handwriting. Additionally, paper-based records have some
advantages over EHR. Also, reading text on paper is 40% faster than
reading on a computer screen.
The system's speed is reported to be the most important, with
sub-second (screen flips) recommended. Users’ familiarity with
computer systems affects the ease of use, perhaps favoring younger
users in developed countries. When training staff uses EHR system, it
has been reported that educational efforts should ensure that staff
understands why the system is being implemented and how to use
all relevant features. Problems with EHR integration arose when staff
training started too late in the implementation phase. It is important
to address infrastructure issues earlier, such as identifying appropriate
spaces for computer installment and use and ensuring that sufficient
backup and technical support exists in case of computer malfunctions.
Even after the iimplementing EHR system, significant use was still
made of paper documentation. Despite access to computers in these
hospitals, nurses still relied on paper documentation and personalized
scraps of paper to organize nursing activities. Thus documentation
was fragmented (Baumann et al., 2018). However, there are some
evidences from studies that over a more-extended period with full
implementation of the system, documentation time may ultimately
decrease, accompanied by improved work and information flow,
significant decreases in multitasking, and improved patient safety.

D. Some Cases Using EHR in Indonesia

Based on research, Budiyanti et al. (2018) talk about the development
of EHR using cloud-based HER. Cloud based-electronic medical
record (cloud-based-EHR) has been developing in Indonesia. These
services have some benefits, such as lower costs, more user-friendly
features, potential for data sharing, and support for clinical decision-

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making. Nevertheless, the implementation has implications for ethical
and legal issues such as data and network security, cloud service
provider, data sharing procedures, and medical privacy.
Research conducted by Andriani et al. (2017) on satisfaction with
EHR implementation at Gadjah Mada University Hospital foundthat
satisfaction with information from EHR had a positive effect on
overall satisfaction with performance expectations and attitudes that
had an impact on overall benefit satisfaction. For further development
of the EHR, the output of the report produced by the EHR needs to
be adjusted to the format of the Ministry of Health. In addition, IT
staff also need to provide training for new employees.
In Indonesia, various techniques are used in the implementation
of EHR. One of them is using data security techniques that can be
done using cryptographic methods, firewalls, access control, and
other security techniques. This method has been proven to be very
promising and successful in keeping privacy and security from EHR
(Ningtyas & Lubis, 2018).
From a legal aspect in Indonesia, there is no special law about
electronic medical records. However, at this moment, preparation for
using EHR can be enforced based on regulations legislation and poli-
cies among others; Law No. 29 of 2004 concerning Medical Practice,
Law No.36 of 2009 concerning Health, Law No. 11 of 2008 concerning
Electronic Information and Transactions, and Regulation of Ministry
of Health (Permenkes) No. 269 of 2008. However, several laws and
regulations governing electronic medical records can be retrieved
show that that EHR can also be used as evidence in court related to
problems in health services (Gunawan & Christianto, 2020).

E. Some Cases using EHR in The World

Baumann et al.’s research (2018) shows that pooled meta-analysis
results indicated that pre-EHR interns had the largest proportion
of total workload spent on documentation tasks, followed by physi-
cians, and nurses who had the smallest proportion out of all hospital

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 staff examined. Post-EHR, physicians had the largest proportion
of total workload spent on documentation tasks, by interns, and
nurses. The large variation in documentation times between studies
could be partly explained by the varying allocation of tasks between
medical staff in different countries. For example, the role played by
nurses in the coordination and planning of patient care may differ
between Europe, Australia, and the US.
Differences in national guidelines around documentation
about patient safety and quality standards and varying definitions
of tasks defined as documentation tasks between studies could also
contribute to variations in results. EHR implementation use of paper
and electronic documentation was frequently observed, suggesting
duplication of work processes. In contrast, full implementation of EHR
for documentation appeared to be associated with decreased time in
documenting. Thus, after an initial transition phase, exclusive utiliza-
tion of electronic records rather than paper records could potentially
lead to a more efficient system, allowing improved information flow
between different disciplines and medical institutions and more time
for direct patient care and communication.
A finding of concern is that over one-fifth of physicians’ and
almost half of the nurses’ workload is spent multitasking in pre-EHR
settings. In addition, physicians were reported to be frequently inter-
rupted in their work. Multitasking and interruptions may adversely
affect patient safety by increasing the possibility of mistakes in docu-
mentation and prescription, staff cognitive overload, and medical er-
rors. Interestingly, time spent multitasking was only 9% for physicians
in the one post-EHR study that examined multitasking.
In the USA, while EHR adoption has increased steadily since
2010, it is unclear how providers that have not yet adopted will fare
now that federal incentives have converted to penalties. Finally, hos-
pitals most often reported up-front and ongoing costs, physician
cooperation, and complexity of meeting meaningful-use criteria as
challenges. Our findings suggest that nationwide hospital EHR adop-
tion is in reach but will require attention to small and rural hospitals

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and strategies to address financial challenges, particularly now that
penalties for lack of adoption have begun (Adler-Milstein et al., 2015).

F. Conclusion and Recommendations

EHR, or electronic health record, is a valuable technology in the medi-
cal field. EHR is beneficial because it allows healthcare workers to
focus more on their work. Doctors who focus on patient diagnosis, for
example, do not need to be bothered with many physical documents
that may differ in type depending on the test site. If doctors must
check document formats, they should focus on this less important
task. The EHR can assist in the standardization of patient reporting.
Several Indonesian hospitals have attempted to deploy EHR. The
use of an EHR has several advantages for hospitals, including lower
costs, more user-friendly features, the ability to share data, and sup-
port for clinical decision-making. However, in Indonesia, the adoption
of EHR technology is not going so well. Data and network security,
cloud service providers, data sharing processes, and medical privacy
were among the ethical and legal challenges. This issue arises because
EHR development in Indonesia is still in its early stages.
Through this chapter we expect a widespread response from
many sectors to ensure that EHR is fully implemented in Indonesia
as soon as possible. We hope all hospitals in Indonesia use EHR since
technology advancements in Indonesia are relatively rapid. To do this,
specifically, we need (1) more operational government legislation
addressing EHR, (2) network cooperation between Internet Service
Provider (ISP), the government, and hospitals, and (3) the realization
of Indonesia’s “Satu Data” dream. "One Data" is a government program
to unify (integrated) data so as to reduce data redundancy, data loss,
and be more structured.

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