Medical Record and Health Information Three-Year Program in Indonesia

Gemala Hatta

Introduction

Indonesia is located between Asia and Australia, with 17,000 islands and 210 million people. The country declared its independence in 1945 after being colonized for three and a half centuries by the Dutch (including 10 years by England) and three and a half years by Japan. There are around 983 hospitals and 7800 health centers in Indonesia.

The first school in medical record and health information (MRHI) was a three-year program, opening in 1989. I pioneered its establishment, which was formed under a private management institution. This school was known as the School of Medical Record Administration (MRA). Eight years later, the second school was established in 1997 under the School of Public Health, University of Indonesia; then, followed by another opening of 5 new schools in 1998 and 10 new schools between 1999 and 2003. These schools are located in 9 of 32 provinces. Presently, there are already 17 MRHI schools of with 3-year programs available in Indonesia. From all of those schools, only two of them belong to self-supporting government universities, the rest are run by private institutions.

The Role of the Department of Health (DOH)

At the Central Education and Training for Health Personnel (Pusdiknakes), which is under the Department of Health, a curriculum guide on a 3-year Medical Record and Health Information program (known as APIKES) was formulated around 1997 with the reference to the MRA curriculum that I designed for the first MRA school in 1989. Compared to the MRA curriculum, the new curriculum guide formulated by the Pusdiknakes team added many subjects mandated by the Department of Education, thus reducing the lecturing hours of certain important subjects, such as medical terminology, coding, computer software of epinfo, biostatistics/statistics, etc. Based on this new MRHI curriculum guide, Pusdiknakes openly offered private entities the opportunity to establish MRHI schools in Indonesia. Pusdiknakes believes private entities can fulfill the Indonesian needs for health personnel, especially in MRHI. As a result, many private entities from various provinces in Indonesia opened MRHI schools using the new MRHI curriculum guide made by Pusdiknakes. Most of these private entities who own MRHI schools are business-oriented people with no or very little health background and rest are doctors or retired nurses. These business people regard the new health school of MRHI as a potential source of profit. As a result, there were rapid increases in the numbers of new MRHI schools being opened, especially within the 5-year period of 1997-2002.

Quality Problem with MRHI Schools

Most of these private entities that opened MRHI schools obtained their operating license easily with loose educational quality control from the provincial area. So far, most of the lecturers of MHRI schools are nurses, a few doctors, or medical record personnel from hospitals who do not have any basic formal education in MRHI. When they train the students, it is merely based on their experiences. Moreover, most of the MRHI schools have insufficient computer labs and offer limited practical work (clinical practice) in hospitals. Reference materials in the Indonesian language are limited. Most of the MRHI schools prefer searching for materials from the existing limited sources--papers from various medical record seminars or training sessions.

In 1991, the DOH published a medical record technical guide book, known as the "yellow book." The content is a compilation of several papers edited or taken from the 1980s, eight-week training program from the DOH team on medical record management. Other references are old copies of Medical Record Quarterly Journal (1981-1989), which was published by the Medical Record Committee under the Jakarta Metropolitan Health Department. Most of these MRHI schools do not have journals in English or textbooks on medical record or health information management. Some of the MHRI school directors have never heard of "the bible" textbook by Edna K. Huffman.

To my knowledge, there is only one MRHI school in Padang (West Sumatera) whose owner and director regularly download materials from AHIMA's Web site or other sources and translate them into the Indonesian language for their students.

Staff at another MRHI school in the middle of Java constantly search for materials through the Internet. Unfortunately, the other 15 schools are a mixture of those who do not open the Internet or the hardly open it. In addition, English language remains a problem among the lecturers and students.

The Indonesian Professionals on Medical Record and Health Information Organization (PORMIKI), which was established in 1989, regarded the educational system as detrimental to the quality of MRHI professional candidates. During several audiences with the Minister of Health and the Directorate General of Medical Care, PORMIKI appealed to the government to control the quality of the new MRHI schools, including the curriculum and number of new MRHI schools in Indonesia.

DOH and the MRHI Professional

National Curriculum on MRHI

In 2002, after reviewing the previous Pusdiknakes MRHI curriculum, the National Curriculum on MRHI for 3-year programs was set up by the Pusdiknakes team, including representatives of PORMIKI. The curriculum consists of 5 groups with a total of 110 credit hours for 6 semesters (3-year program). One credit hour (CH) equals 50 minutes. One CH equals one hour/week during one semester (five months). Each year has two semesters. The first year consists of 43 CH, the second year has 39 CH, and the third year has 28 CH.

The curriculum has 54 subjects and is divided into 5 lecturing groups.

1. Supporting subjects to Personality Development (Pengembangan Kepribadian) consists of 7 subjects with a total study weight of 14 CH per semester. The 7 subjects are Religion Education, National Principles (Pancasila), Citizenship (Kewarganegaraan), Indonesian Language, English I, English II, English III.
2. Supporting subjects to Basic Sciences (Keilmuan dan Keterampilan) consist of 13 subjects with a total study weight of 27 CH per semester. The 13 subjects are Biomedic I (biology and human genetics), Biomedic II (Anatomy), Biomedic III (Physiology), Biomedic IV (Pathology), Biomedic V (Pharmacology), Medical Terminology I, Medical Terminology II, Laboratory Terminology, Biostatistics, Public Health Administration, Introduction to Health Management, Principles of Accounting, and Public Health Science.
3. Supporting subjects to Professional Skills Development (Keahlian Berkarya) consist of 20 subjects with a total study weight of 39 CH per semester. The 20 subjects are Basic and History of Medical Record, Medical Record Management (archive) and Content, Medical Record Systems in Healthcare Delivery, Information Systems in Medical Record Department, Management of the Medical Record Department, Problem Oriented Medical Record, Epidemiology, General Coding, Morbidity Coding I, II, Mortality Coding, Demography and Environmental, Introduction to Computer Application I, II, Hospital Statistics and Medical Care, Programming I, II, Epi Info, Management Information System, and National Health Information System.
4. Supporting subjects to Behavior Development (Perilaku Berkarya) consist of 8 subjects with a total study weight of 16 CH per semester. The 8 subjects are Applied Psychology, Ethics and Professional Ethics, Public Health Education, Public Relation/Customer Service, Mathematics, Ergonomics and Planning in the Medical Record Department, Health Law, Research Methodology.
5. Supporting subjects to Coordination Skill (Berkehidupan Bermasyarakat) consist of 6 subjects with total study weight of 14 CH per semester. The six subjects consist of Practical Clinics.

In accordance with the national curriculum, the Pusdiknakes team has set up the Role, Function, and Competency Standard for MRHI professional.

The term of a professional in MRHI applies only to someone who has passed the three years of MRHI school.

Roles and Issues on Functional Position of MRHI Professional

Roles of the MRHI Professional

The four roles of the MRHI professional, according to the Pusdiknakes team, are ordinary staff (pelaksana), manager (pengelola), educator (pendidik), and co-research partner (mitra peneliti). Besides the four roles, there is also a lengthy description of the eight functions and five broad competencies for MRHI professionals.

Career Development Reflected in Functional Position

To raise the career development of government employees who work as MRHI professionals in government hospitals (or in a few private institutions), effective 2003, DOH formulated a career development plan called the Functional Position (Jabatan Fungsional). The system has three ranking levels based on the length of service as a public servant. These are Pelaksana, Pelaksana Lanjutan, and Penyelia, which start from the rank of II C, or recent graduate from MRHI school, up to III d, nearing retirement.

In the Functional Position system, each rank category is divided into level of competency with associated compensation. Each year, the work performance of a MRHI professional will be reviewed and analyzed by the health institutions where he/she works, based on the performance matrix created by the DOH team. If the person is performs well after four years, his/her position will be raised to a higher rank. This means he/she will face other tasks or similar jobs with associated levels of difficulties/complexities. Under certain circumstances, instead of waiting for four years, a person who has been on the last rank for two years may be granted a special one-level rise.

What About the Nondegree MRHI Employee in Public Hospitals?

There are many Medical Record Department (MRD) personnel in government hospitals that have served their whole career in MRD, but never have had the chance to study MRHI in a formal three-year program. Only few of them have attended any or some sort of MR training(s) and/or seminar(s) or joined the special eight-week training course on MR management (during the 1980's). These MRD personnel who are considered nondegreed and labeled as nonprofessional should receive separate education/training. This has not yet been formulated by either the DOH or PORMIKI.

Authorities Did Not Work Fast Enough--MRD Employees in Public Hospitals Missed the Opportunity of a Lifetime

By the end of May 2003, DOH asked the provincial authorities (PA) to inform the government hospitals in their area about the new Functional Position (Jabatan Fungsional) system for medical record personnel (released in December 2002). PA should ask hospitals to report the names of the nondegreed MRD personnel by September 2003. In return, these nondegreed MRD personnel would be given an exception clause (pemutihan), allowing them to receive additional salary even though they are classified as a nondegreed MRHI group. All names received after the pemutihan period would be regarded as latecomers and therefore should take formal MRHI study in a three-year program.

Unfortunately, the passing of information on the pemutihan period from the local PA to provincial hospitals (that employed the nondegree public servant MRD personnel) was somehow missed. As a result, there were many hospitals that did not receive the news, and the nondegree MRD personnel missed this opportunity. As a result, many complaints rise to the surface. Presently, several education solutions are being discussed for the benefit of these "missed" nondegree MRD personnel.

Later on, every professional organization (in this case, PORMIKI) will be asked by the government to evaluate the competencies and certification of the professionals. But, this system has still a long way to go.

Constraints on HRIM Schools

• Difficulties in following the national curriculum of 2002 on MRHI.
  Even though the national curriculum on MRHI of 2002 has been released, in reality, many schools run their own curriculum and are still a long way from reaching the mandated function or competency.

• Inadequate facilities for conducting proper MRHI subjects.
  Insufficient libraries, limited access to foreign publication materials, lack of computer labs.

• Qualified lecturers are scarce and learning materials are limited to the local needs or to a lecturer's knowledge and capability. As a result, the curriculum, the content, depth of learning subjects, and the way materials are presented varies greatly.

• Brief clinical hours for the students due to budget constraints.

• Lack of hospital preparation for having mentors ready on-site for guiding the students. There are gaps between theory and reality in practical work.

• Foreign language barrier among the students and the lecturers, resulting in inaccessibility to materials in English including Internet resources.

• Limited qualified MRHI personnel available in government hospitals: a challenge for the MRHI schools.

In sum, professionals in MRHI are limited in Indonesia. Most new schools have not produced any graduates, while previous graduates from the older schools tend to work in private health institutions and a few in insurances, IT consultancy companies (for a better salary), or they have left the profession. As a result, government hospitals mostly employ the nondegree MRHI personnel.

Recommendations

To address the above constraints, there must be several actions:

• Encourage the establishment of an information center for MRHI schools-- circulating current important news, such as the latest relevant reference materials and other important issues.
• Create Indonesian language training materials in MRHI subjects.
• Provide professional guidance on conducting training for the trainers (TOT) and standardization for MRHI educator. This program has never been done, and it should be carried out by the DOH and PORMIKI or other related health organizations.
• Offer nondegree MRHI employees, especially in the government hospitals, the opportunity for further study through distant learning programs on MRHI.
• Unqualified MRHI schools should be controlled, evaluated, re-programmed, or closed by provincial authorities and/or by the DOH.