Systemic digital co-creation framework for unified electronic health record implementation: A case study in Indonesia

Implementing a unified Electronic Health Record (EHR) system is critical for modernizing healthcare services, yet involves complexities extending far beyond technological considerations. This study examines Indonesia's national EHR initiative, Satu Sehat, employing Soft Systems Methodology (SSM) to explore implementation challenges and formulate effective strategies thoroughly. Distinctively, this research introduces the Systemic Digital Co-Creation Framework (SDCF), a novel conceptual model developed through the rigorous application of SSM. Unlike previous frameworks that typically focus on singular adoption levels such as patient or organizational adoption, SDCF uniquely integrates multiple perspectives: micro (citizen/patient), meso (healthcare facility), and macro (government) into a holistic, multi-level analysis. Conducted in the Greater Bandung Area, West Java, the study employed qualitative data from two rounds of focus group discussions (FGDs) and in-depth interviews involving six key stakeholders, including healthcare providers, technology vendors, and governmental bodies. Additionally, quantitative data from surveys of 422 patients supplemented these findings. Results underscore that successful unified EHR implementation should be perceived not merely as a technological upgrade but as a catalyst for systemic co-creation, requiring technical, personal, and social enablers to facilitate seamless access, data sharing, and integration. Effective realization requires addressing institutional silos and establishing robust governance and institutional mechanisms, enabling stakeholders to achieve intended outcomes at their respective levels. The proposed framework provides a conceptual lens to understand symbiotic value co-creation where open innovation is fostered through collaborative access, sharing, and integration of health data. This framework offers practical, actionable guidance to policymakers and healthcare leaders, significantly enhancing the likelihood of sustainable implementation. Moreover, the framework is generalizable and applicable to other highly regulated systems beyond healthcare contexts.