Improving Patient Safety and Hospital Service Quality Through Electronic Medical Record: A Systematic Review

To understand the Electronic medical records (EMR) role in improving patient safety and hospital’s service quality. Articles that included and assessed for the eligibility in this review was an article that show an effect of patient’ safety, and product quality in hospital in correlation on using EMR. The most important function of EMR implementation is to improve patient safety in hospital, in addition to reducing cost. EMR reduce excess cost of Hospital Acquired Condition (HAC) by 16%, reduce death due to HAC by 34%. Doctor and nurse’s belief that the quality of patient data is better when EMR are easier to use and suit with their dialy routine. EMR can improve patient safety, but its use require some skills in technology so it won’t turn to harm patients’ safety. The implementation EMR requires the ability of skilled human resources in using technologies, computer and programs.


INTRODUCTION
Electronic health records (EHRs) are promoted due to their capacity to reduce clinicians' workloads, costs and errors (The Office of the National Coordinator for Health Information Technology 2013). Paper based reporting has many disadvantages, including manual data entry and requiring manual processing.
Accordingly, a systematic review on electronic patient record system for patient safety become important to be known the extent to which it is implemented. Thus, the purpose of this study was to examine the literatures on patient safety reporting based on electronic system review the finding systematically, and assess the implementation of this measurement.

THEORETICAL REVIEW
Hospitals as health centers are required to provide comprehensive services for patients. Patients need health services that guarantee the safety and no errors occur. One of quality assurance services by improving patient safety. Patient safety is a system that makes patient more secure, including risk assessment, identification, risk management, reporting and analysis of incidents, learning ability of incidents and follow-up and implementation of solutions for the answer to the risks and prevention of clarity caused by mistakes due to the action or unnecessary actions.
Efforts to improve the safety of patients is by using the utilization of electronic medical records in the hospital as a system. Electronic medical records are beneficial to patients because they improve efficiency in the healthcare process. For dministrative personnel, the use of electronic medical records can retrieval and access patient information. Doctors and health workers also get the benefit from providing health services for the convenience of accessing patient information that ultimately helps in improving patient safety and clinical decision making such as diagnosis, therapeutic therapy, allergic reactions and drug duplication. Aspects of efficiency and the use of electronic medical records impact in reducing the operating costs and increased revenues in health care facilities, especially for hospitals.
Up The system of incident report is important for collecting and reporting adverse patient occurrences, such as medication errors and equipment failures (WHO, 2008). Therefore, the electronic data is hoped to help detect, manage, and learn from potential safety events in near real-time. The systems can be programmed to automatically detect easily overlooked and underreported errors of omission, such as patients who are overdue for medication monitoring, patients who lack appropriate surveillance after treatment, and patients who are not provided with follow-up care after receiving abnormal laboratory or radiologic tests results (Sittig & Singh., 2012).

RESEARCH METHODOLOGY
Using Proquest search engine, with a keywords "electronic medical record" resulting 7089 documents. More keyword were added "patient safety" and "hospital", result narrow into 1061 documents. Using filter by year between 2014-2017 and journal type of document, the result became 74 documents. After reading the title and abstract we select 8 documents, 3 documents were selected by full text review and assessed for eligibility.
Using Oxford search engine we found 24050 documents with a keywords "electronic medical record. When we add keyword "Patient safety" and "hospital" the result narrow into 4901 documents. After limiting the year of document between 2014-2017 and type of document is journal, the result naroow into 297. By reading the title and the abstract, 18 documents were selected, 10 document selected by full text review and assessed for eligibility.
Articles that included and assessed for the eligibility in this review was an article that show an effect of patient safety in hospital in correlation on using electronic medical record (EMR), it including some effect on medication error, prescribing error, error in the use of EMR that potentially endanger patient safety.

RESULTS AND DISCUSSION
In most US Hospitals, the use of EMR devided into basic and comprehensive EHR systems. A hospital with at least a basic EHR system reported full implementation of the following 10 computerized function: patient demographic, physician notes, nursing assesments, patien problem list, medication list, discharge summaries, radiology reports, laboratory reports, diagnostic test results, and order entry for medications. A hospital with comprehensive EHR system reported all basic function, along with 14 additional function. Those additionals are: support for advance directives, order entry for lab reports, radiology tests, consultation requests, nursing orders, ability to view radiology images, diagnostic test images, consultant reports, clinical decision support, clinical reminders, drug allergy results, drug-drug interactions, drug-lab interaction, and drug dosing support. (Adler-Milstein et al., 2017). In the documentation input of EMR often to use keyboard and mouse (KBM) and speech recognition (SR). But KBM is more effective and potential patient harm chance increase when using SR (Hodgson, Magrabi and Coiera, 2017)

Reaction Patterns of Doctors and Nurses to the Use of EMR/HER
In the use of EMR, the doctor and nurses belief that that the quality of the patient data is better when EMR are easier to use and better aligned with their dialy routine. Other factor that influence the willingnes of doctors and nurses to use EMR are support from the IT departement, more bottom-up communicaton, more innovative culture, more authentic leadership, etc. (Lambooij, Drewes and Koster, 2017).

Benefits of EMR/HER
One of the most important function of EMR implementation is to improve patient safety in hospital, in addition to reducing hospital cost. EMR reduce excess cost of Jurnal Administrasi Rumah Sakit Indonesia/Volume 6 Number 1 Firdaus, Improving Patient Safety and Hospital Service Quality Through Electronic Medical Record: A Systematic Review Hospital Acquired Condition (HAC) by 16%, and reduce death due to HAC by 34% (Encinosa, 2012). In comunication between prescribers an pharmacists, EMR reduce the incorrect dose and clarification (Singer and Fernandez, 2015).While in acupuncture unit, EMR are useful in enhancing the security of accupunture measures in terms of accessing instruction and monitoring the patient's reaction to treatment (Li et al., 2011).EMR also simplify us to trace down the patient allergic history. In some study we can track down patient's allergic history against beta lactam through hospital EMR (Moskow et al., 2016). Base on interviewing physician using EMR, the use of EMR could make acces to patient medical history easier, saves time, improve error awareness in medication, prevent administration of allergic drugs, and improve ordering accuracy (Holden, 2011).

Weakness of EMR/HER
As well as benefits, EMR also contributes some errors that threat patient safety such as inability to use Computerized Provider Order Entry (CPOE) properly can lead to prescribing errors (Brown et al., 2016) and delay in medication (Amato et al., 2016). In other articles other EHR-related Safety concern can occur in other situation like: mismatch between information needs and content display, and one component of the EHR is unexpectedly affected by condition another component like transition of patients between wards not reflected in EHR, resulting in missed medication or orders (Meeks et al., 2014). During the downtime period of EHR, wether it planned (eg; regular maintenance, updates of the software, etc) or unplanned (eg; equipment failure, cyber attacks, etc) have the potential in serious patient safety risk like: specimen misplaced or mislabeled, delay medication, placement of medication order disrupted, etc (Larsen et al., 2017) The use of Electronic Medical Record (EMR), which is the changing of conventional medical record usage to new technology based on computerization requires high consideration in planning and organizing. For details the benefits of using EMR in health services. Medical records as notes and important documents containing the overall record of the condition and development of the patient' s health should be accountable by the healthcare provider involved in providing services to the patient The use of medical records manually in the form of paper records has a problem that is long in searching the data or provide information when needed immediately and difficulty for collecting patient data is complex and fragmented. While the EMR describes the patient' s health condition record in electronic format, and can be accessed by computer from a network with the main purpose of providing or improving the care and health services are efficient and integrated. In addition to the use of manual medical records, the use of telephones and conversations is an important facility for discussion and exchange of information to make patient service decisions. But after using the EMR, the health operator of medical record involved in the care of the patient simply sees the EMR to get a patient's medical summary and quickly make a decision. The benefits of EMR can be felt both by the health operator of medical record as health providers as well as for patients to obtain safety during receiving services In most US Hospitals, the use of EMR devided into basic and comprehensive EHR systems. A hospital with at least a basic EHR system reported full implementation of the following 10 computerized function: patient demographic, physician notes, nursing assesments, patien problem list, medication list, discharge summaries, radiology reports, laboratory reports, diagnostic test results, and order entry for medications. A hospital with comprehensive EHR system reported all basic function, along with 14 additional function. Those additionals are: support for advance directives, order entry for lab reports, radiology tests, consultation requests, nursing orders, ability to view radiology images, diagnostic test images, consultant reports, clinical decision support, clinical reminders, drug allergy results, drug-drug interactions, drug-lab interaction, and drug dosing support. (Adler-Milstein et al., 2017). In the documentation input of EMR often to use keyboard and mouse (KBM) and speech recognition (SR). But KBM is more effective and potential patient harm chance increase when using SR (Hodgson, Magrabi and Coiera, 2017)

Reaction Patterns of Doctors and Nurses to the Use of EMR/HER
In the use of EMR, the doctor and nurses belief that that the quality of the patient data is better when EMR are easier to use and better aligned with their dialy routine. Other factor that influence the willingnes of doctors and nurses to use EMR are support from the IT departement, more bottom-up communicaton, more innovative culture, more authentic leadership, etc. (Lambooij, Drewes and Koster, 2017).

Benefits of EMR/HER
One of the most important function of EMR implementation is to improve patient safety in hospital, in addition to reducing hospital cost. EMR reduce excess cost of Hospital Acquired Condition (HAC) by 16%, and reduce death due to HAC by 34% (Encinosa, 2012). In comunication between prescribers an pharmacists, EMR reduce the incorrect dose and clarification (Singer and Fernandez, 2015).While in acupuncture unit, EMR are useful in enhancing the security of accupunture measures in terms of accessing instruction and monitoring the patient's reaction to treatment (Li et al., 2011).EMR also simplify us to trace down the patient allergic history. In some study we can track down patient's allergic history against beta lactam through hospital EMR (Moskowet al., 2016). Base on interviewing physician using EMR, the use of EMR could make acces to patient medical history easier, saves time, improve error awareness in medication, prevent administration of allergic drugs, and improve ordering accuracy (Holden, 2011). One of the most important function of EMR implementation is to improve patient safety in hospital, in addition to reducing hospital cost. EMR reduce excess cost of Hospital Acquired Condition (HAC) by 16%, and reduce death due to HAC by 34%. In the use of EMR, the doctor and nurses belief that that the quality of the patient data is better when EMR are easier to use and better aligned with their dialy routine. Overall, benefits of Electronic Medical Record (EMR) application leads to improved service quality. An important issue in quality improvement is currently oriented to Patient Safety (PS) which has 6 advantages: 1. Accuracy of patient identification 2. Improved effective communication 3. Increased safety the drugs that needed to the patients 4. Certainty of precise location, precise procedure, precise patient surgery 5. Decreased the risk of infection in health services 6. Decreased the risk of the patients falls All components of hospital services must understand and work with the purpose of maintaining patient safety. This is crucial, given the various mistakes that can occur in the service process: drug delivery; surgical procedures; radiology services; laboratory services; diagnostic determination and in the transfusion process

Weakness of EMR/EHR
As well as benefits, EMR also contributes some errors that threat patient safety such as inability to use Computerized Provider Order Entry (CPOE) properly can lead to prescribing errors (Brown et al., 2016) and delay in medication (Amato et al., 2016). In other articles other EHR-related Safety concern can occur in other situation like: mismatch between information needs and content display, and one component of the EHR is unexpectedly affected by condition another component like transition of patients between wards not reflected in EHR, resulting in missed medication or orders (Meeks et al., 2014). During the downtime period of EHR, wether it planned (eg; regular maintenance, updates of the software, etc) or unplanned (eg; equipment failure, cyber-attacks, etc) have the potential in serious patient safety risk like: specimen misplaced or mislabeled, delay medication, placement of medication order disrupted, etc (Larsen et al., 2017) Jurnal Administrasi Rumah Sakit Indonesia/Volume 6 Number 1 Firdaus, Improving Patient Safety and Hospital Service Quality Through Electronic Medical Record: A Systematic Review a. Information Security Given that a service is a system with various subsystems and complex parts, then the element of information becomes very important, moreover to avoid the mistakes mentioned above. In this case fasyankes shall ensure security in data storage systems and access systems of medical records of patients. With EMR, obviously very helpful.
b. Avoid the Mistake of Patient Identity Transfusion error is 49% because blood is given to the wrong patient, wrong identification. The use of EMR allows hospitals to store electronic data each patient is equipped with a self-image, for helping afoid the mistake of patients data because the same of the name and date birth.
c. Management of Utilitization With EMR, the patient' s medical history record will be stored well and can not be erased from the system. In addition, the process of care and treatment is done in a transparent, meaning that this system can avoid excessive medical therapy that is not as needed. This will support utilization management as the cost of unnecessary care and treatment becomes a disadvantage for the patient d. Time Efficiency Order-Taker system in EMR can reduce the energy and cost in delivering information between service sections. Patients and their families do not need to manually carry out the forms (lab checks) and sheets (lab results, radiology and prescriptions). More convenient, no hassle and without having to queue for each time will take medical action or take medication e. Continuous History The EMR system allows online and integrated databases in spite of different urban hospital locations.
Older patients do not need to register as new patients, but simply by showing a medication card or mentioning the medical record number at another online hospital. This makes it easier for patients and doctors to continue treatment wherever the patient is

Conclusion
Electronic Medical Record is a systematic collection of electronic patient-based medical information that is connected and integrated with the information system in the hospital network. Given the importance of medical records, there is a need for progress in that.
Recording of medical records digitally must be known how to record system and need to be developed in order to advance health service more effective and efficient so that can decrease the number of medical record data errors.
Electronic Medical Record is able to store patient data in large numbers using only portable computer devices.
In addition, electronic medical records may provide warnings if medical personnel wrongly administer the drug or there is drug reactions. Electronic Medical Record becomes an important part in patient safety. Electronic medical record is capable of storing multimedia medical data that can be accessed anytime, anywhere, and is very useful in storing data in the long term.

Recommendation
From all the explanation, the advice that can be given based on this study is electronic Medical Record is very useful for health care facilities, for the implementation requires the ability of skilled human resources in using information technology-based resources, computer devices and programs, each user must be able to apply the computer device, then the support of all parties needed to be able to achieve the purpose of utilization of electronic medical records, both in terms of human resources and funds. The cognitive change of medical personnel in using EMR for patient safety purposes revealed in this study trough interview method, either in the form of positive things, such as faster search and negative things such as "copy-paste" a data.
1. EMR has both advantage and disadvantage. 2. (+)Advantage : easy to acces patient medical history, saves time, improves error awareness, improve ordering accuracy, prevent administration of allergic drugs, etc. 3. (-)Disadvantage : requires many steps and numerous clicks, allergy warning require response before order can be completed,