Outpatient Electronic Medical Record Adoption Level at Prambanan Regional General Hospital

Erlinda Nuraini; Anton Kristijono; Nita Budiyanti; Syarah Mazaya Fitriana; Yalid Fattah Nurbuwana

Authors

Erlinda Nuraini Poltekkes Kemenkes Yogyakarta
Anton Kristijono Rekam Medis dan Informasi Kesehatan, Poltekkes Kemenkes Yogyakarta, Indonesia
Nita Budiyanti Rekam Medis dan Informasi Kesehatan, Poltekkes Kemenkes Yogyakarta, Indonesia
Syarah Mazaya Fitriana Rekam Medis dan Informasi Kesehatan, Poltekkes Kemenkes Yogyakarta, Indonesia
Yalid Fattah Nurbuwana RSUD Prambanan, Daerah Istimewa Yogyakarta, Indonesia

Keywords:

Electronic Medical Record, O-EMRAM, EMR Adoption, Outpatient Digital Maturity

Abstract

Digital health transformation mandates Electronic Medical Record (EMR) implementation, yet outpatient EMR adoption at RSUD Prambanan based on the Outpatient Electronic Medical Record Adoption Model (O-EMRAM) remains undetermined. This study aimed to describe outpatient EMR implementation across O-EMRAM levels 0–7 and determine the adoption level. A descriptive qualitative case study design was used. Data were collected through semi-structured interviews with five informants, non-participatory observation, and document review, with validity tested via technical and source triangulation. Results showed levels 0–4 fully met, including near-complete digitalization, authority-based access with BPJS eligibility verification via VClaim, a centralized CDR integrating laboratory, pharmacy, and radiology, real-time clinical documentation with e-prescribing, and CPOE, basic CDSS, structured SOAP documentation, and external electronic reporting. At level 5, the SAPA portal was active but usage data were unavailable; level 6 saw disease recapitulation and the PERSADIA program running but lacked advanced CDSS; level 7 achieved SATUSEHAT integration and mature governance but not paperless operations or a clinical analytics dashboard. The 2025 Digital Maturity Index (DMI) assessment showed a total score of 4.62/5.00, with an EMR component score of 4.21/5.00. Outpatient EMR adoption at RSUD Prambanan is concluded to be level 4, with a clear pathway toward optimal digital maturity.

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