Developing Minimum Data Sets for Indonesian Electronic Health Record System

This study aimed to develop a minimum data set (MDS) for electronic health record system in Indonesia. The content of the MDS in this study is different from the MDS from the results of the study in other developed countries. The technical preparation of MDS in this study follows the process of medical services provided to a patient from the beginning of admission to the completion of receiving services at the hospital. 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 870 data elements, respectively. This MDS could be a reliable tool for data standardization in electronic health record systems that can improve the quality of data and medical services in hospitals. Our data set can be used by the Indonesian health ministry, hospital information system development unit, and health surveillance centres for more efficient management of health data.