Designing Minimum Data Set and Data Model for Electronic Health Record Systems in Indonesia

This study aimed to design a minimum data set (MDS) and Data Model for electronic health record system (EHRS) in Indonesia. The content of the MDS in this study is different from the MDS from the results of the study in other advanced countries. The technical preparation of the MDS in this study follows the medical service process provided to patients from the time they first enter the hospital until they complete receiving services at the hospital with the aim that the MDS designed is aligned with real-world hospital workflows. The initial stage of this research began by identifying data elements through literature reviews sourced from medical record documents of general hospitals and psychiatric hospitals in Indonesia, papers regarding minimum data set in other advanced countries, websites, and clinical guidelines. The Delphi technique was employed to validate the identified data elements through a survey of medical experts. A questionnaire was designed to determine data elements in both administrative and clinical departments. There were 5 and 21 data classes agreed upon by experts in the administrative and clinical sections with 28 and 858 data elements, respectively. This MDS could be a reliable tool for data standardization in EHRS that can improve the quality of data and medical services in hospitals. The designed data model consist of conceptual, logical and physical component. This MDS and data model can facilitate system developers to build physical EHRS database and health surveillance center for more efficient health data management.