EHR is a home-grown hospital information system with a capacity for non-clinical (administration, billing) and clinical [(Electronic Medical Record (EMR), Computerized Physician Order Entry (CPOE)] processes. Founded in 1896, RSUPNCM is one of Indonesian oldest hospitals and acts as the central tertiary referral center in the country. In the earlier adoption of the EMR system, the hospital was limited to entering information in offline mode. In 2006, the HIS (administration and billing modules) was integrated into the EMR systems, which allowed information to be processed online.
After three years of significant progress, RSUPNCM administrators adopted the EMR—integrated with an inpatient and outpatient CPOE module—across the entire hospital system. The information recorded on the EMR covers patients’ demographic profile, medications and allergy history, immunization status, and supporting examination result such as laboratory, radiology, EKG, etc. The CPOE obliges all physicians working at the hospital to order medications electronically. This module is part of a clinical decision support software (CDSS) solution as well.
The system has significantly reduced medical errors, especially those where pharmacists were unable to interpret doctors’ handwriting on prescriptions. High compliance with the system has been observed and attributed to RSUPNCM’s status as a teaching hospital, where the majority of its staff and medical doctors are completing medical residencies and are up-to-date on the newest technology.