Implementation of Health Information Systems at Health Centres

and Health Offices in Ciamis District

Wawan Ridwan

, Lukman Hakim, Gurendro Putro, Ristrini Ristrini, Rustika Rustika

and Dede Anwar Musadad

National Research and Innovation Agency, Bogor, Indonesia

Keywords: Community Health Centres, Health Information System, HIS Implementation.

Abstract: The Indonesian Ministry of Health recently introduced the health information system (HIS) to record and

report health programs, including at community health centres (CHCs) and the district health office.

Therefore, this study aimed to examine the implementation of HIS in CHCs and the Ciamis District Health

Office. This was a descriptive quantitative study with a secondary data analysis approach. The data used were

obtained from Risfaskes results, HIS implementation documents, and HIS staff information. Subsequently,

analysis was carried out using Wallace Foundation guidelines in Workbook B; Secondary Data Analysis. The

analysis showed that HIS had been implemented in 37 CHCs and the Ciamis District Health Office. However,

some CHCs had not consistently implemented all HIS applications as intended. The flow of data and

information between CHCs and the district health office and from the district health office to higher levels

lacked a one-data and one-door system due to variations in the implementation across different programs and

fields. The implementer of HIS was the personnel assigned to each health program that used the system. Some

CHCs had not implemented the use of HIS in the Ciamis District. Furthermore, the existence of this HIS had

not been able to facilitate the work and burden of CHCs.

1 INTRODUCTION

The health sector has rapidly implemented and

developed information and communication

technology (ICT), as evidenced by the widespread

adoption of e-health in various countries. WHO

defines e-health as the cost-effective and secure use

of information and communications technologies in

support of health and health-related fields, including

healthcare services, health surveillance, health

literature, and health education, knowledge and

research. Furthermore, e-health is characterized by

the utilization of ICT to enhance the flow of

information through electronic channels, thereby

strengthening health services and the management of

healthcare systems. This concept is not only related

to the technical aspects but also encompasses

attitudes and mindsets that extend beyond the

purview of local and national healthcare services,

such as regional and world interests (Union 2012).

In Indonesia, the adoption of e-health is marked

by the establishment of a health information system

(HIS). This concept is defined as an intricate

arrangement that encompasses data, information,

indicators, procedures, devices, technology, and

human resources (HR). The components are

intricately linked and managed using an integrated

approach to guide actions or decisions geared towards

supporting health development (Menkes RI 2014)

HIS is a pivotal component of the healthcare

infrastructure of a country and it affects the prevailing

government system. Furthermore, HIS serves as the

backbone of e-Health, as it involves systematic and

integrated management of health data and

information at all levels of government to improve

healthcare services provided to the community

(Soemitro 2016). Information systems can be defined

as organizational frameworks that incorporate a blend

of people, facilities, technology, media, procedures,

and controls. These elements work together to

establish communication channels, process routine

transactions, ensure signal management, manage

internal and external events, and provide a foundation

of information for intelligent decision-making

(Vondewi, R 2010). The development process

involves the creation of a new system to completely

replace the old variants or improve the existing

Ridwan, W., Hakim, L., Putro, G., Ristrini, , Rustika, and Musadad, D. A.

Implementation of Health Information Systems at Health Centres and Health Ofﬁces in Ciamis District.

DOI: 10.5220/0012898800004564

Paper published under CC license (CC BY-NC-ND 4.0)

In Proceedings of the 5th International Conference on Social Determinants of Health (ICSDH 2023), pages 56-69

ISBN: 978-989-758-727-6; ISSN: 2975-8297

variants (Kinasih 2011). Several reports have shown

that the implementation of HIS still faces various

problems, including unintegrated and uncoordinated

data and information management activities. These

conditions often lead to overlapping data collection

and processing activities, both at the centre and in the

regions (Rondo, Pelealu, and Maramis 2013).

The development of the Ministry of Health's HIS

began in 1982 with the establishment of the Data

Collection and Processing Division within the

Planning Bureau (now the Data and Information

Center) (Soemitro 2016). At this time, there were 3

(three) managerial models, namely (1) manual

management by recording and reporting using

computerized management, which was mainly

carried out with computer devices, either by using

management information system (SIM) applications

or ordinary electronic office applications. However, it

lacked support from online internet networks

connecting the district/city and the provincial health

office, as well as national health data banks, (3) online

computerized HIS management, which was mostly or

entirely carried out with computer devices, using SIM

applications. It was connected online through the

internet network to the district and the provincial

health office, and national health data banks, to

facilitate communication and data synchronization

(Menkes RI 2012).

One of the healthcare facilities that has embraced

e-Health is CHCs (Puskesmas), leading to the

implementation of the Puskesmas Management

Information System (SIMPUS) at this level. SIMPUS

is designed to provide information that aids the

decision-making process in carrying out Puskesmas

management and achieving its target activities.

Furthermore, it takes the form of web-based software

that is connected to the system in the health

department (Perwira 2012). The use of SIMPUS by

employing ICT holds the potential to significantly

enhance the operational capabilities of community

health centres (CHCs). The system empowers

puskesmas to efficiently coordinate both public

health efforts (UKM) and individual health efforts

(UKP) by prioritizing promotive and preventive

initiatives, to elevate the level of public health

(Menkes RI 2014).

The use of manual systems within certain CHCs

has led to the occurrence of various problems. In the

handling of patient data, there has been a notable

prevalence of errors during processing (registration

data, examination data, referral data, and laboratory

data). Moreover, the patient service process has been

hindered by slow data retrieval within the registers.

These challenges can be addressed through the use of

SIMPUS, which leverages computer technology in

processing data. The advantages of this system

include expediting services, enhancing information

accuracy, swift data searches, quicker report

generation, and uniformity of information system,

leading to improved healthcare service (Wibisono

and Munawaroh 2012). SIMPUS incorporates a

standardized data structure for reporting across health

centres at the district/city level. This standardized

approach offers the dual benefits of swiftness and

precision in data and information processing (Wijaya,

Ifada, and Jauhari 2009).

Apart from SIMPUS, other HISs have also been

implemented at CHCs, including (1) health centre

records consisting of 4 items, (2) primary care

(Pcare), (3) health facilities information system

(HFIS), (4) BPJS non-capitation claims, and (5)

Puskesmas report, consisting of 7 items

(Balitbangkes, 2019). Several studies have shown

that the comprehensive adoption of SIMPUS remains

uneven across different CHCs due to challenges

encountered in various regions. Consequently,

various puskesmas still opt for the traditional

approach of data reporting, using manual procedures.

A review of the implementation of the computer-

based SIMPUS showed that its application yielded

considerable benefits. These include enhanced

performance, and accuracy, as well as time and

energy efficiency but some individuals considered its

implementation an additional workload for officers

(Putri 2013). This challenge can be addressed by

assigning special personnel with appropriate

expertise, namely information technology to manage

the application (Abdul 2003). The existing personnel

at Puskesmas conform to the stipulation of Law No.

36 of 2014 concerning Health Workers, which consist

of health workers and assistants, as well as non-health

workers who perform administrative duties.

The achievement of health program objectives,

which encompass indicators of life expectancy,

mortality, morbidity, and nutritional status of the

community, hinges on the establishment and

development of District ICIS, tailored to align with

the principle of centralization or regional autonomy

in the healthcare domain. The implementation of

district HIS holds immense significance, as it serves

as a mechanism for furnishing indicators that measure

the realization of a healthy district, while also serving

as a fundamental framework for health-oriented

regional development. Anticipated outcomes from

the data and information produced by the HIS include

bolstering the formulation of regional development

plans, providing analytical insight to support budget

Implementation of Health Information Systems at Health Centres and Health Ofﬁces in Ciamis District

allocation, aiding resource development, and guiding

policymakers during decision-making.

The management of HIS at the Ciamis District

Health Office is carried out by the Planning

Subdivision of the Information Program and Public

Relations Subdivision. One of their key

responsibilities is to collect, process, and present data,

information, programs, and activities within the

Health sector. HIS activities are also carried out by

program implementers in certain regions. Meanwhile,

HIS management at CHCs is entrusted to the

discretion of the head of each Puskesmas (Dinas

Kesehatan Kabupaten Ciamis 2019).

The mandatory adoption of HIS in Indonesia

commenced with the Regulation of the Minister of

Health Republic of Indonesia Number 18 of 2022

concerning the implementation of one health sector

data through HIS (Kemenkes RI 2022). The World

Health Organization (WHO) defines e-health as the

cost-effective and secure use of ICT to support

health-related fields, including health services,

surveillance, literature, education, knowledge, and

study. Clear evidence exists on the growing impact of

e-Health on the delivery of healthcare services across

the work in terms of improved delivery, effectiveness,

and responsiveness to the needs and expectations of

the community (WHO Eastern Mediterranean 2023).

Therefore, this study aims to develop policy

recommendations for the implementation of HIS to

support electronic recording and policy reporting at

CHCs and the Ciamis District Health Office..

2 METHOD

This was a descriptive quantitative study, with a

secondary data analysis approach. The data used were

obtained from Health Facility Research (Risfaskes),

HIS implementation documents, and a dataset on HIS

staff. Furthermore, the secondary data consisted of

the results of the 2019 Risfaskes in Ciamis District,

documents on the implementation of HIS and the

types of HIS that had been implemented, personnel

implementing HIS, and personnel with educational

background or information technology training.

Confirmation was carried out on the implementation

of HIS at several CHCs and the Ciamis District

Health Office. This process was expected to provide

information on the operation of HIS, including the

data flow system from the Puskesmas to the health

office.

Analysis was carried out using the Wallace

Foundation guidelines in Workbook B; Secondary

Data Analysis, and the results were presented in a

tabular form.

3 RESULTS

3.1 General Data of Ciamis District

Ciamis was one of the districts in West Java Province,

consisting of 27 sub-districts, 258 villages, and 7

villages. Furthermore, its geographical position was

at the coordinates of 1080 20' to 1080 40' East

Longitude and 70 40' 20" to 70 41' 20" South Latitude

(BPS Ciamis, 2019).

Table 1. General Description of Ciamis District.

Indicators Numbers/Values

Total Area

1.434 Km

Number of Subdistrict

27 Sub-distric

Number of Villages

265 Villa

Total Population

1.418.301 Peoples

Number of Households

496.893

Households

Average Souls/Households

2,9 Souls/

Households

Population Density per km

989,1 Soul/K

Dependent Load Ratio

45,6 Per 100

productive

opulation

Sex Ratio

100,7

Population 15 Years Old

1.156.401 Peoples

Population 15 years old

with no primary school

certificate

263.875 Peoples

Ciamis district had a land area of 1,433.10 km

with a total population of 1,418,301 people from

406,893 households in 2019 (DHO Kab Ciamis,

2020). This indicated that the population density was

989.1 people per km2, with a household density of 2.9

people per household. Among 1,156,401 individuals

aged >15 years, a total of 263,875 (22.82%) did not

have a primary school certificate, while 991,107

people (77.18%) had a certificate. The highest level

of education possessed by individuals aged >15 years

was elementary/middle school education, namely

597,117 people (60.25%), with the least being a

master's or doctoral degree among 1,747 people

(0.18%). The results showed that there was no data on

vocational high school graduates, as shown in Table

ICSDH 2023 - The International Conference on Social Determinants of Health

Figure 1. Administrative Map of Ciamis District.

3.2 Health Care Facilities

Health service facilities in Ciamis District in 2019

consisted of 7 types, namely General Hospitals,

Inpatient Puskesmas, Non-Inpatient Puskesmas,

Mobile Puskesmas, Puskesmas Pembantu,

Pharmacies, and Village Health Posts (Poskesdes),

while there were no Special Hospitals, as shown in

Table 2.

Table 2. Health Service Facilities in Ciamis District.

Indicators

Numbers/

Values

Unit

General Hos

ital 4 Hos

ital

ecialized Hos

ital 0 Hos

ital

Inpatient Community

Health Centre

29 CHCs

Non-Inpatient Health

Centre

17 CHCs

Mobile Health Centre 75 Mobile-CHCs

Sub-Community Health

Centre

85 Sub-CHCs

Pharmac

135 Pharmac

Village Health Post

(

VHP

)

139 VHP

Based on Government Regulation No. 47/2016 on

health service facilities, a health service facility was

a tool and/or place used to organize healthcare efforts,

including promotive, preventive, curative, and

rehabilitative. These efforts were often carried out by

the central and regional governments, and/or

community.

3.3 Human Resources (HR)

The number of health HR in CHCs, hospitals, UPTD

Pharmacy, Labkesda, and health offices in Ciamis

District in 2019 was 1,837 people, which were

classified into 12 groups. Furthermore, there were 25

specialist doctors, 78 general practitioners, 13

dentists, 1 specialist dentist, 827 nurses, 461

midwives, 90 public health workers, 38

environmental health workers, 45 nutritionists, 32

medical laboratory experts, 70 other biomedical

techniques, 11 physical therapists, 88 medical

technicians, and 58 pharmaceutical workers, as

shown in Table 3.

The ratio of HR at the 37 CHCs in the region was

highest for the midwife at 26.09 people per 100,000,

followed by nurses at 20.59 people per 100,000. The

smallest ratios were observed in physical therapists at

0.35 people per 100,000 and dentists at 0.71 people

per 100,000, as shown in Table 4.

Implementation of Health Information Systems at Health Centres and Health Ofﬁces in Ciamis District

Table 3. Number of Health HR in Ciamis District.

No Type of Health Worker

Hospital

Technical Implementation Unit

(UPTD) Pharmacy & Regional

Health Laborator

Head

Office

CHCs Total

1 S

ecialist Docto

25 0 0 0 25

2 General Practitione

29 1 4 44 78

3 Dentist 3 0 0 10 13

4 Specialist Dentist 1 0 0 0 1

5 Nurse 535 0 0 292 827

6 Midwife 91 0 0 370 461

7 Public Health 6 0 8 76 90

8 Environmental Health 3 0 2 33 38

9 Nutrition 10 0 2 33 45

10 Medical Laborator

ert 20 0 0 12 32

11 Biomedical En

ineerin

35 0 0 35 70

12 Ph

sical Thera

ist 6 0 0 5 11

13 Medical Technician 27 0 0 61 88

14 Pharmac

40 0 0 18 58

Total 831 1 16 989 1.837

Table 4. Number and Ratio of Medical Staff, Midwives, and Nurses to Population at Puskesmas in Ciamis District.

The number of HR assigned to 37 CHCs (20

treatment and 17 non-care Puskesmas) was 869

people, consisting of 13 sub-groups. The prevalent

types of HR were midwives, namely 370 individuals

or an average of 10 people per health centre, followed

by nurses, with 292 individuals or an average of 7.89

people per health centre. The last type of HR was

physical therapists, namely 5 people or an average of

0.14 people per health centre. Furthermore, the types

of HR whose average per Puskesmas was less than 1

were dentists (0.27), followed by environmental

health workers (0.89), nutritionists (0.89), medical

laboratory experts (0.32), biomedical engineering

experts (0.95), physical therapists (0.14), and

pharmacist (0.49).

The ratio of HR in 37 health centres in Ciamis

District was highest for midwives at 26.09 people per

100,000 population and nurses at 20.59 people per

100,000 population. Meanwhile, the smallest ratios

were physical therapists at 0.35 people per 100,000

population and dentists at 0.71 people per 100,000

population, as shown in Table 4.

Based on the results of confirmation at the Ciamis

District Health Office, the number of non-health HR

on duty in 2019 was 381 people, including 48 and 333

individuals at the health Office and CHCs,

respectively.

No Type of Health Worker

Inpatient Community

Health Centre

Non-Inpatient Health

Centre

Total Ratio

Total Average Total Average

1 General Practitioner

24 1,2 20 1,18 44 3,1

2 Dentist

6 0,3 4 0,24 10 0,71

3 Nurse

174 8,7 118 6,94 292 20,59

4 Midwife

181 9,05 189 11,12 370 26,09

5 Public Health

39 1,95 37 2,18 76 5,36

6 Environmental Health

18 0,9 15 0,88 33 2,33

7 Nutrition

19 0,95 14 0,82 33 2,33

8 Medical Laboratory Expert

7 0,35 5 0,29 12 0,85

9 Biomedical Engineering

22 1,1 13 0,76 35 2,47

10 Physical Therapist

5 0,25 0 0,00 5 0,35

11 Medical Technician

34 1,7 27 1,59 61 4,3

12 Pharmacy

7 0,35 11 0,65 18 1,27

536 - 453 - 989

ICSDH 2023 - The International Conference on Social Determinants of Health

In terms of the type of knowledge at the

undergraduate level, a total of 15.62% of the samples

were graduates in other fields, with an average of 1.41

people per Puskesmas. Furthermore, 6.97% were in

economics with an average of 0.62, 5.11% in

management with an average of 0.46, 3.00% were in

informatics with an average of 0.27, 2.40% were in

administration with an average of 0.22, 0.60% were

in law with an average of 0.05 people per Puskesmas,

and 0.30% were in education with an average of 0.03.

Based on the results, there were also non-health

HR who had attended informatics courses, namely

0.30% with an average of 0.03 people per Puskesmas.

The most common type of HR was elementary/junior

high/senior high school graduates, namely 65.77%

with an average of 5.92 people per health centre. This

condition was similar in the health office, where the

majority of the samples were other (47.92%),

economics (2.08%), management (6.25%), non-

informatics, administration (4.17%), law (2.08%),

and non-education graduates, as well as those who

attended informatics courses. The most common type

of HR in health offices was elementary/junior

high/senior high school graduates, namely 47.92%, as

shown in Table 5.

Table 5. Non-Health HR in Health Center and Health Office Ciamis District.

3.4 HIS Implementation

Based on data from the Balitbangkes Data

Management Laboratory from the 2019 Rifaskes

results, activities at the Puskesmas supported by HIS

application could be divided into 6 groups, namely:

a. Puskesmas Management, consisting of 3

applications, namely the SIMPUS, SP2TP/SP3,

and e-Puskesmas.

b. HISDA application.

c. ASPAK.

d. Disease case/health status data, consisting of 10

applications, namely SITT, SIHA, SIHEPI, SI

PTM, SI PD3I, SISMAL, SI STBM, E-PPGBM,

KS, and SKDR.

e. Primary Care Application (Pcare).

f. HFIS application.

g. BPJS non-capitation claims, consisting of (1)

Pap smear/IVA claims, (2) Primary/promotive

screening, (3). First-level hospitalization (RITP),

(4) Obstetrics and neonates, (5) Ambulance

Claims, and (6) Other claims.

h. Puskesmas Report, consisting of:

(1) Monthly Report on Morbidity Data (LB1)

(2) Monthly Report on Drug Usage and Request

Sheet (LPLPO or LB2)

(3) Monthly Report on Nutrition, MCH,

Immunization, P2M (LB3)

(4) Monthly Report of Puskesmas Activity Data

(LB4)

(5) Annual Report of Basic Health Center Data

(LT1)

(6) Annual Report of Puskesmas Personnel

Data (LT2)

(7) Annual Report of Puskesmas Equipment

Data (LT3).

i. Medical record application.

No Types of Non-Health HR

CHCs Health Office Total

Total %

Average/

Health Cente

Total % Total %

1 Bachelor of Administration 8 2,40 0,22 2 4,17 10 2,62

2 Bachelor of Economics 23 6,91 0,62 1 2,08 24 6,30

3 Bachelor of Mana

ement 17 5,11 0,46 3 6,25 20 5,25

4 Bachelor of Informatics 10 3,00 0,27 0 0,00 10 2,62

5 Bachelor of Law 2 0,60 0,05 1 2,08 3 0,79

6 Bachelor of Education 1 0,30 0,03 0 0,00 1 0,26

7 Other Bachelo

52 15,62 1,41 18 37,50 70 18,37

8 Informatics Course 1 0,30 0,03 0 0,00 1 0,26

10 Elementar

/Secondar

/Hi

h School 219 65,77 5,92 23 47,92 242 63,52

Total 333 - - 48 - 381 -

Implementation of Health Information Systems at Health Centres and Health Ofﬁces in Ciamis District

Table 6. Number of Health Centers Based on the Availability of HIS Ciamis District.

No HIS Implementation System

Recordin

stem

Electronics

& Manuals

Manuals Not in Use Total

1. Health center management

a) SIMPUS

b) SP2TP/SP3

c) e-Puskesmas

2. HISDA 5 7 1 24 37

3. ASPA

18 18 1 0 37

4. Disease Case Data/Health Status

a) SITT

b) SIHA

c) SIHEPI

d) SI PTM

e) SI PD3I

f) E-ISMAL

g) SI STBM

h) E-PPGBM

i) KS

)

SKDR

Table 7. Number of HIS Implementation Activities at Puskesmas Ciamis District.

No HIS Implementation System Activity Period

Number of

Activities/ CHCs

Total

CHCs

Number of

Activities

Health center management

a) SIMPUS

b) SP2TP/SP3

c) e-Puskesmas

Monthly

12 times

264

300

336

0.36

0.41

0.23

HISDA Monthly &

Incidental

13 times 13 169 0.60

ASPAK Incidental - 37 444 0.60

Disease Case Data/Health Status

a) SITT

b) SIHA

c) SIHEPI

d) SI PTM

e) SI PD3I

f) E-ISMAL

g) SI STBM

h) E-PPGBM

i) KS

j) SKDR

Monthly

Incidental

12 times

420

444

360

444

384

276

396

444

336

0.57

0.60

0.49

0.60

0.54

0.37

0.54

0.60

0.46

Pcare Monthly 12 times 37 444 0.60

HFIS Monthly 12 times 37 444 0.60

BPJS Non-Capitation Claims

a) Pap smear/IVA

b) RITP

c) Obstetrics and neonates

d) Ambulance Claims

e) Other Claims

Incidental

117

13,620

33,574

961

64,690

0.16

18.46

45.46

1.30

8.77

CHCs report

a) LB1

b) LPLPO or LB2

c) LB3

d) LB4

e) LT1

f) LT2

g) LT3

Monthly

Yearly

12 times

1 time

444

0.60

0.05

ICSDH 2023 - The International Conference on Social Determinants of Health

No HIS Implementation System Activity Period

Number of

Activities/ CHCs

Total

CHCs

Number of

Activities

Medical records (electronic and combined) Dail

292 times 37 10,804 14.64

Total 132.002

The implementation of each HIS application did

not have the same operational period, where some

were daily. In the case of medical records, some of

them were monthly, annual, monthly and annual, and

incidental.

Due to various reasons, a proportion of health

centres in the Ciamis district have not implemented

all HIS applications. The results also showed that

some HISs were manual, electronic, and a mixture of

electronic and manual.

The least used application was HISDA, which was

used by 13 CHCs, accounting for 35.14% of the total

population. Among these Puskesmas, the availability

of data was carried out electronically by 5 of them

(13.51%), a mixture of electronic and manual by 7

(18.91%), and manually by 1 (2.70%).

The most widely used HIS applications were

ASPAK, SIHA, SI PTM, E-PPGBM, and KS, which

were used by all CHCs (100%). Among HIS

applications, none of them were carried out

electronically.

The most highly used electronic applications were

ASPAK and E-PPGBM by 18 Puskesmas (48.65%).

Meanwhile, the least used was HISDA, namely 5

Puskesmas (13.51%).

In the implementation of HIS (Table 7), some

CHCs did not record all HIS applications. Among

those using the recording system, some of them were

online, offline, or a mixture of online and offline.

The application with the least online recording

system was ASPAK, which was used by 36

Puskesmas. The results showed that none of the

Puskesmas had an online recording system is online,

with 17 (47.22%) being offline and 19 (52.78%) not

using any system, as shown in Table 8.

In 2018, the types of HIS applications carried out

by 37 health centres in Ciamis District were recorded

at 30 items, with the total number or frequency of

activities being 132,002, as shown in Table 7.

Based on the number of activities, the 5 items of

HIS activity types with the highest number of

activities were (1) obstetric and neonate claims,

namely 33,574 times (45.50%) by 35 Puskesmas, (2)

RITP claims, namely 13,620 times (18.46%) by 20

Puskesmas, (3) Electronic and combined medical

records were 108,04 times (14.64%) by 37

Puskesmas, (4) BPJS non-capitation claims for other

claims were 6,469 times (8.77%), and (5) BPJS non-

capitation for ambulance claims were 961 times

(1.30%) by 15 Puskesmas.

In terms of groups, the 5 HIS items with the

highest number of activities were (1) BPJS non-

capitation claims, namely 112,962 times (85.58%) by

37 Puskesmas, (2) medical records, namely 10,804

times (8.18%) by 37 Puskesmas, (3). Disease Case

data was performed 3,948 times (2.99%) by 33 health

centres, (4) Health centre reports were carried out

1,887 times (8.18%) by 37 health centres, and (5)

health centre management was performed 900 times

(0.68%) by an average of 25 health centre, as shown

in Table 2.

The calculation of the number of medical record

activities using HIS was based on the assumption that

each working day was carried out 1 time per

Puskesmas. The working days in Ciamis District were

6 days per week, and in a year, it was 52 weeks x 6

days - 20 national holidays and public holidays, to

give 292 working days. The number of medical

record activities carried out in Ciamis District in 2019

was 10,804.

In providing services in the building, some CHCs

did not have an inter-room computer network. The

2019 Rifaskes results showed that 17 of them

(45.95%) had the networks, 15 (40.54%) experienced

a total absence, and 5(13.51%) did not use computers.

Patient medical records in 23 CHCs (62.16%)

were in the form of family folders, and the remaining

14 (37.84%) were in other forms. In inpatient

registration, a total of 10 (27.02%) were online, and

the remaining 27 (72.98%) did not apply for

registration, as shown in Table 8.

Table 8. Computer Network System in Providing Indoor Services and Online Patient Registration at Puskesmas Ciamis

District.

No Activities

Yes No

Total % Total %

1. Using computers in in-building services 32 CHCs 86.49 5 CHCs 13.51

2. Computer networks exist between rooms in the building 17 CHCs 45.95 15 CHCs 40.54

3. The online patient registration system 10 CHCs 27.02 27 CHCs 72.98

Implementation of Health Information Systems at Health Centres and Health Ofﬁces in Ciamis District

The results showed that 16 activity items must be

implemented at the district health office and

supported by the HIS application, namely HISda, data

communication (komdat), health office management

information system (SIM DHO), SIMPUS,

SP2TP/SP3, e-Puskesmas, ASPAK, SITT, SIHA,

SIHEPI, SI PTM, SIPD3I, SISMAL, SI-STBM,

EPPGBM, and SKDR. A total of HIS data on 10

items that had been implemented were available,

namely Komdat, e-Puskesmas, ASPAK, SITT, SIHA,

SIPTM, SISMAL, SI-STBM, and EPPGBM.

Furthermore, the results showed that 2 of them were

still manual (SIHEPI and SIPD3I), while HISDA,

SIM DHO, SIMPUS, and SP2TP/SP3 had no dataset.

Among the data available, only 1 HIS activity (10%)

was available electronically, namely, ASPAK and the

remaining 9 were a combination of electronic and

manual, as shown in Table 9.

In the 10 HIS items, 3 activities (30%) used online

recording systems, namely ASPAK, SISMAL, and

SI-STBM, and the remaining 7 used a combination of

online and offline recording.

System developers were 70% MOH, 20% health

office, and 10% private developers, while the data

storage was 99% MOH servers and 10% non-

government servers, as shown in Table 9.

Based on the confirmation results at the 4 CHCs

and the Ciamis District Health Office, until 2020,

there were no issued regional policies from the local

government or health office regarding the

implementation of HIS in healthcare programs.

Therefore, the use of the program was considered the

main tasks and functions (tusi) of the implementation

unit and the duties of each officer. For example, if the

HIS application was related to nutrition, then the

person in charge of the EPPGBM also had the

responsibility of monitoring the nutrition program.

The person in charge of the SI-STBM application also

had the role of supervising the environmental health

program. These decisions depended on the policy of

the head of the Puskesmas, issued by the decision

letter.

Based on Rifaskes 2019 data, among 37 CHCs in

Ciamis District, a total of 24 (64.86%) had special

personnel, who were assigned to be responsible for

recording, while the remaining 13 (35.14%) did not

assign any personnel. The person in charge was only

saddled with an additional task but still had the main

responsibility of supervising the program

implemented by Puskesmas. Based on educational

background among 24 staff, 3 (12.5%) had an

education in medical records and health information

(RMIK) or health information (Infokes), while the

remaining 21 (87.5%) had a variety of backgrounds,

such as midwives, nurses, public health,

environmental health, and nutrition (Table 10).

Table 9. HIS Implemented by Health Office Ciamis District.

Health Information

Sistem Types

Availability

Recording

System

Developer

Data Storage

(Server)

1. HISDA - - - -

2. Data Communication

(Komdat) Application

Electronics & Manuals Online & Offline Health Ministry Health Ministry

3. SIM Health Office - - - -

4. SIMPUS - - - -

5. SP2TP/SP3 - - - -

6. e-Puskesmas Electronics & Manuals Online & Offline Private Non-Government

7. ASPAK Electronics Online Health Ministry Health Ministry

8. SITT Electronics & Manuals Online & Offline Health Office Health Ministry

9. SIHA Electronics & Manuals Online & Offline Health Ministry Health Ministry

10. SIHEPI Manuals - - -

11. SI PTM Electronics & Manuals Online & Offline Health Office Health Ministry

12. SIPD3I Manuals - - -

13. SISMAL Electronics & Manuals Online Health Ministry Health Ministry

14. SI-STBM Electronics & Manuals Online Health Ministry Health Ministry

15. EPPGBM Electronics & Manuals Online & Offline Health Ministry Health Ministry

16. SKDR Electronics & Manuals Online & Offline Health Ministr

Health Ministr

ICSDH 2023 - The International Conference on Social Determinants of Health

Table 10. Person in Charge of Recording and Reporting at Puskesmas Ciamis District.

No Person in Charge of Recording and Reporting at the Health Center

There is a Person in Charge of

Recording and Reporting

Yes No Total

1. Special personnel assigned to be responsible for recording and reporting

at CHCs

24 CHCs 13 CHCs 37 CHCs

2. Educated in RMIK or Infokes 3 CHCs 21 CHCs 24 CHCs

The flow of data and information in the

implementation of HIS in the Ciamis District was still

carried out partially, without the use of a single data

system tailored to the tasks of implementing each

program. Furthermore, data flow links were also

performed separately for each program. The flow of

a program at the Puskesmas was connected to the

same program at a higher level, and other programs

had different links.

4 DISCUSSIONS

In 2019, the overall HR at the Puskesmas in Ciamis

District, specifically medical personnel (general

practitioners and dentists), nurses, and midwives did

not meet the targets set 10 years ago (2010). The

targets were 30 general practitioners per 100,000

population, 11 dentists per 100,000 population, 75

midwives per 100,000 population, and 158 nurses per

100,000 population (BPPSDM, 2019). Based on the

results, the ratio of general practitioners, dentists,

nurses, and midwives was less than 26.9 per 100,000

population (less than 89.67%), 10.29 per 100,000

population (less than 93.55%), and 137.41 per

100,000 population (less than 86.97%), and 48.91 per

100,000 population (less than 65.21%).

Compared to the minimum standards of staffing

by the Annex of Permenkes No. 75 of 2014 (averaged

including the category of rural areas) in both

treatment and non-treatment Puskesmas, some health

HR had not met the requirement. The standards in the

treatment health centre were (1) 2 doctors or primary

doctors, (2) 1 dentist, (3) 8 nurses, (4) 7 midwives, (5)

1 community health worker, (6) 1 environmental

health worker, (7) 1 medical laboratory technologist,

(8) 2 nutrition workers, (9) 1 pharmaceutical worker,

(10) 2 administrative personnel, and 1 staff.

Meanwhile, the standards in the non-care health

centre were (1) 1 doctor or primary doctor, (2) 1

dentist, (3) 5 nurses, (4) 4 midwives, (5) 1 community

health worker, (6) 1 environmental health worker, (7)

1 medical laboratory technologist, (8) 1 nutritionist,

(9) 1 pharmaceutical worker, (10) 2 administrative

personnel, and 1 staff 1 person (Ministry of Health,

2014). These results indicated that in the treatment

health centre, general practitioners, dentists,

environmental health workers, medical laboratories

technologists, nutritionists, and pharmaceutical

workers were still lacking by 0.8, 0.7, 0.1, 0.65, 0.05,

and 0.65 persons per health centre, respectively. The

results also showed that nurses, midwives, and

community health workers had reached the minimum

standard of 0.7, 2.05, and 0.95 persons per health

centre, respectively. In non-care health centres,

general practitioners met the minimum standard of

0.18 per health centre, followed by nurses (1.97),

midwives (7.12), and community health workers

(1.18). Dentists, environmental health workers,

medical laboratory technologists, nutritionists, and

pharmaceutical workers were still lacking by 0.76,

0.12, 0.71, 0.18, and 0.35 people per health centre,

respectively.

Health workers at Puskesmas, specifically

doctors, midwives, and nurses were also given other

responsibilities as implementers of programs, which

were often related to their profession. This was

because Puskesmas was a health service facility used

to organize healthcare efforts, including promotive,

preventive, curative, and rehabilitative, with the

function of organizing public (UKM) and individual

(UKP) health efforts (Menteri Kesehatan 2014).

The implementation of all healthcare efforts

required coordination with all stakeholders in the

working area to prevent and reduce risks faced by

individuals, families, groups, and communities based

on the principles of the healthy paradigm. The

confirmation at the sample Puskesmas revealed that

most of these activities were carried out by medical

personnel, midwives, nurses, and management

personnel. Apart from health workers, the facility also

consisted of non-health staff who must support

administrative activities, financial administration,

information systems, and other operational activities

(Menteri Kesehatan 2014).

The HIS was developed to support the seven

national healthcare subsystems, namely (1) health

efforts, (2) health study and development; (3) health

financing; (4) health HR; (5) pharmaceutical

preparations, medical devices, and food; (6) health

management and regulation; and (7) community

Implementation of Health Information Systems at Health Centres and Health Ofﬁces in Ciamis District

empowerment (Daryo Soemitro, 2016). The

implementation of this program was expected to

make the recording and reporting activities at the

Puskesmas become an interrelated unit. In its

application, the use of ICT was a necessity because

HIS increased along with efforts to improve the

quality, efficiency, and effectiveness of management

and implementation of health development.

At present, the frequency of ICT activities is very

high, including in Ciamis District. According to

Rifaskes 2019 data, the frequency of HIS

implementation at Puskesmas during 2018 in 9

activity items, namely Puskesmas management (25),

HISDA (13), ASPAK (37), disease case data (33),

Pcare (37), HFIS (37), BPJS non-capitation claims

(19), Puskesmas reports (37) and medical records

(33) was 132,002 times (Table 7.9) or 452 times per

working day. The confirmation from 4 Puskesmas

showed that the application of ICT could enhance

performance, increase accuracy, and reduce the time

required (time and energy efficiency). However, the

large amount of applications and the high frequency

of ICT activities increased the burden on employees,

including health workers. This was because there was

no officer specifically handling HIS and the

implementation process was complex.

One of the consequences of this situation was that

some CHCs in the Ciamis District could not

implement all SIMPUS items. Rifaskes 2019 data

showed that among 37 Puskesmas, 22 (54.46%)

implemented SIMPUS, and only 7 had electronic

information. The report also revealed that only 5 of

them used online recording systems. Several HIS

applications have been implemented by all facilities,

such as ASPAK, SIHA, SI PTM, E-PPGBM, and KS.

Meanwhile, HISDA had the lowest implementation,

namely 13 Puskesmas, accounting for 35.13% of the

total population. In the availability of information,

some of the facilities used electronic approaches, with

ASPAK and E-PPGBM being the most used

applications by 18 CHCs (48.65%). Based on the

results, HISDA had the lowest usage by only 5

facilities (13.51%). The most common use of the

online recording system was observed in KS by 17

samples (45.95%), and the least was HISDA with

only 3 samples (8.11%). ASPAK was not carried out

using online recording by any of the facilities.

HIS must be managed at the central and regional

levels (provincial and district/city), as well as in

health care facilities by their respective authorities.

This arrangement aimed to (1) ensure the availability,

quality, and access to health information, (2)

empower the participation of the community,

including professional organizations in the

implementation of HIS, and (3) achieve the

implementation of the HIS within the scope of the

national health system, specifically through

strengthening cooperation, coordination, integration,

and synchronization (Kemsekneg 2014).

The management of HIS in districts/cities was

carried out by structural or functional work units that

organized government affairs in the health sector. The

activities carried out included managing health data

and information at the district/city scale, in the form

of (1) requesting health data and information from

parties related to HIS management, (2) collecting

and/or combining routine and non-routine datasets

from sources, (3) processing health data, (4). storing,

maintaining, and providing health data and

information reserves, (5) providing feedback to

sources, (6) conducting data analysis as needed, (7)

disseminating health information using electronic

and/or non-electronic media, (8). sending health data

and information needed in the management of

provincial and national HIS, and (9) implementing

guidance and facilitating the development of HIS in

first-level facilities. Meanwhile, the management of

the program in health facilities was carried out by the

HIS manager in each health facility (Kemsekneg

2014). This regulation implied that the management

of HIS at the district level and health facilities must

be carried out by a special unit or team or officer who

performed these activities. The aim was to facilitate

the management of data and information, as well as

their flow to various levels. The approach was also

used to ensure that all components of the HIS were

implemented properly. Therefore, data and

information managed in the HIS application at the

health facility level were only issued and received by

the manager (one door), while the source of data was

from program implementers at the health facility.

Feedback from higher-level ICT managers

(district/city, provincial and central) was received by

other managers and then channelled to the relevant

people. The management of the HIS at the district/city

level must also be carried out by a special unit to

ensure that all data and information flow only entered

and were issued by the unit. Data from health

facilities were forwarded to the relevant field or

section, while data inputted for reporting and

feedback were obtained from the relevant field or

section. This type of ICT management helped to

ensure that there was only one data (one data) at the

health facility or district level because it was only

managed by one unit. Furthermore, this situation

facilitated data management, which could be used as

a basis for making decisions or policies as a follow-

up to information received.

ICSDH 2023 - The International Conference on Social Determinants of Health

One-stop HIS management by using ICT was the

national e-health strategy, which was a

comprehensive approach to planning, developing,

implementing, and evaluating the use of ICT in the

health sector. The aim was to provide a reference for

the government, professional/community

organizations, academics, practitioners, and other

stakeholders in carrying out e-health planning,

development, implementation, and evaluation

(Permenkes RI 2017). Furthermore, the optimal use

of ICT in the implementation of HIS was an aspect of

the application of the Electronic-Based Government

System (SPBE). The SPBE approach was defined as

the administration of government that used ICT to

provide services to users (Peraturan Presiden RI

2018).

In the strategic plan of the Ministry of Health

(Renstra) for the 2020-2024 period, HIS management

was one of the priority programs, intending to

stabilize (1) health information services that were

faster, valid, resource sharing, (2) integrated

electronic-based standard HIS, and (3) the

implementation of HIS in health service facilities.

Furthermore, data flow optimization was carried out,

which involved data reporting from districts/cities

through the Komdat application, reporting from all

source entities, and data bank development. The

fragmentation of the current HIS showed the need to

develop the ONE DATA initiative with a strategy

through the development of one standard, one

standardized metadata, and one portal. The aim was

to improve the integration, interoperability, and use

of government data whose use was not limited to

agencies, but also as a form of fulfilling public

information needs (Kemenkes 2020). In connection

with one data, a regulation had been issued, namely

Presidential Regulation Number 39 of 2019

concerning One Data Indonesia. In this regulation,

Satu Data Indonesia was defined as a government

policy to produce a dataset that was accurate, up-to-

date, integrated, and accountable, as well as easily

accessible and shared between central agencies and

regional agencies. This could be achieved through the

fulfilment of data standards, metadata, data

interoperability, and using reference codes and master

data (Pemerintah Republik Indonesia 2019).

The 2019 Ciamis District Health Profile showed

that the number of Health HR was still insufficient

when compared to the ratio of the population to be

served. This indicates that to prevent an increase in

the burden on HR, the management of HIS at the

Puskesmas was carried out by non-health HR or

others who did not provide direct services to patients

and the number had exceeded the minimum standard.

However, non-health HR with a background in

informatics and informatics courses were few sat

health office and Puskesmas, namely 11 individuals,

which was insufficient to manage HIS. The short-

term countermeasure was to provide courses or

training on informatics, including software,

hardware, network management, and ICT to existing

HR. These individuals were then given the

responsibility of managing the entire ICT by using the

principle of one data in their respective work units.

For the long term, recruitment of non-health HR with

a background in informatics was carried out, both

ASN recruitment and Government Employees with

Work Agreements (PPPK). The type of people

managing the program must be permanent

employees, namely ASN or PPPK. This was to ensure

that they had high responsibility due to employment

status, considering the importance of data and

information management in policy-making. The

approach was expected to help non-health HR support

administrative activities, financial administration,

information systems, and other operational activities

(Menkes RI 2014).

The implementation of data communication in the

HIS must be carried out in an integrated manner. The

aim was to 1) ensure the availability, quality, and

access to priority health data and other data content,

2) optimize the flow of health data from

districts/cities and/or provinces to the ministry or vice

versa, and 3) realize the implementation of an

integrated HIS (Menteri Kesehatan 2014). The MOH

regulation implied that the flow of data and

information from the health centre to the district

health office must be connected to the provincial

health office and the MOH in a network. To support

this policy, a national information system network

(HISNAS) was established, which was an integrated

data communication network infrastructure using a

wide area network (WAN). The WAN was a

telecommunications network that covered a large area

and was used to send information over long distances

between different local area networks (LANs), and

other local computer architectures (Menteri

Kesehatan 2014). The results of the 2017 HIS

evaluation showed that it was "present but

inadequate" for resources (47%), indicators (61%),

data sources (51%), data quality (55%), data use and

dissemination (57%) and "not adequate" for data

management (35%). Based on these results, the

overall HIS still needed to be improved (Menkes RI

2012). A similar situation also occurred at the

Puskesmas and the Ciamis District Health Office,

where the application was not yet interconnected with

the HISNAS Network. To improve the

Implementation of Health Information Systems at Health Centres and Health Ofﬁces in Ciamis District

implementation of HIS, the Indonesian Ministry of

Health developed a Roadmap for the Action Plan to

Strengthen the Indonesian HIS, which in one part

mentioned the national model, namely integrated

HIS. This national model was defined as an

information system that provided an interconnection

mechanism between information sub-systems in

various appropriate ways. Therefore, data from one

system could routinely flow to, go to, or be retrieved

by one or more other system. Integration included

both technical systems (systems that can

communicate with each other) and content (common

data sets). The physical form of integrated ICT was

an information system application that was linked to

other applications.

To implement all ICT applications in Puskesmas

in Ciamis District, it was necessary to improve the

management of ICT at the local level. Improvements

were made to the management of HIS implementing

HR, work units, supporting hardware, data and

information flow system, internet networks,

financing, and regulations or policies on its

implementation issued by the Regent or Head of

SKPD and as well as the head of Fasyankes.

Furthermore, to strengthen the optimization of HIS

with one Puskesmas data and one Ciamis District

Health Office data connected in the HISNAS

Network, it was necessary to establish a one-door

system at the Ministry of Health. This had been stated

in the Roadmap of the Action Plan for Strengthening

the Indonesian HIS, that strengthening the HIS could

be carried out by developing a national model,

namely an integrated HIS. This model was an

information system that provided a mechanism for

interconnection between information sub-systems in

various appropriate ways. The physical form of an

integrated HIS is an information system application

that is linked to other applications. Therefore, data

from one system could routinely flow, go to, or be

retrieved by one or more other systems.

5 CONCLUSIONS

In conclusion, HIS has been implemented in 37 CHCs

and the Ciamis District Health Office, but some of the

CHCs have not routinely used all HIS applications.

The data and information flow from the Puskesmas to

the health office and from the district health office to

a higher level lacked a one-data and one-door system.

This was because each program or field employed its

unique approach, leading to fragmentation and a lack

of integration with the HISNAS Network.

HIS implementers at Puskesmas and the health

office were also in charge of executing health

programs involving HIS applications. Consequently,

for some certain individuals, the implementation of

HIS was considered an additional burden after

carrying out the primary duties and functions.

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Implementation of Health Information Systems at Health Centres and Health Ofﬁces in Ciamis District