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Republic of Indonesia
Ministry of Health
Center for Data and Informa:on

The Indonesia Health Informa:on Architecture

Jakarta - 2016
 The Indonesia
Health Informa:on Architecture

Republic of Indonesia, Ministry of Health

The Indonesia Health Informa:on Architecture
Na9onal document,
@2016 Copyright: Center for Data and Informa9on, Ministry of Health Republic of Indonesia

Main author : Daryo Soemitro

Contribu9on : Didik Budijanto, PaIselano Robert Johan, Oscar Primadi,
Yudianto Singgih, Boga Hardhana
WHO Country Office for Indonesia
Editorial : Salma Burton (Team Leader, Health System Unit, WHO Indonesia)
Mark Landry (Regional Advisor Health SituaDon and Trend, WHO-SEARO),
Alvin Marcelo (AeHIN’s CEO),
Boonchai KijsanayoDn (AeHIN, Co-Chair),

Disclaimer
The author is consultant of Center for Data and Information, MoH and is himself alone responsible for the content
expressed in the Draft for refined by the eHealth FGD, which do not necessarily represent the views, decisions, or
policies of the Center for Data and Information, MoH.
No potenDal conflicts of interest were disclosed.
TABLE OF CONTENT

Foreword ......................................................................................................................iii
Acknowledgement .........................................................................................................v
Reviews And Comments From The e-Health Expert ......................................................vii
AbbreviaCons ...............................................................................................................ix
ExecuCve Summary .......................................................................................................1
1. IntroducCon .............................................................................................................7
Background .....................................................................................................................7
Current Indonesia’s Healthcare Status And IDHIS Profile ...............................................8
Basic Reference of IDHIS Development ........................................................................13
Challenges ....................................................................................................................15
Response ......................................................................................................................17
2. NaConal Vision For IDHIS ........................................................................................19
Vision, Mission and Strategic Goal ...............................................................................19
IDHIS Vision .............................................................................................................19
IDHIS Mission ..........................................................................................................19
Strategic Goals ........................................................................................................19
Key Principle .................................................................................................................19
ImplicaNons of the vision for stakeholders ..................................................................21
3. IDHIS Strategy ........................................................................................................23
Key Strategic Principles ................................................................................................23
Strategic Work Streams ................................................................................................25
Strategic ObjecNves (SOs) and IniNaNves .....................................................................26
IDHIS FoundaNons ...................................................................................................26
IDHIS SoluNons ........................................................................................................28
Change and AdopNon .............................................................................................33
IDHIS Governance ...................................................................................................34
4. IDHIS Enterprise Architecture .................................................................................37
Development Methodology ..........................................................................................37
Guiding Principle ..........................................................................................................38
Reducing Risk of Failure ..........................................................................................39
Strengthening Success Factors ...............................................................................42
Enterprise Architecture ................................................................................................44
Framework Viewpoint .............................................................................................44
The execuNve perspecNve ......................................................................................47
MoH and Stakeholder Network RelaNon ................................................................51
Standards and Interoperability .....................................................................................54
DefiniNon .................................................................................................................54
Levels of Requirements ...........................................................................................57

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 Challenges to healthcare interoperability ...............................................................58
Levels of interoperability ...................................................................................59
Dimensions of interoperability ..........................................................................60
NaNonal Health NormaNve Standard Framework (NHNSF) ..........................................61
Reasoning ................................................................................................................61
AssumpNons of the NHNSF and the general philosophy .........................................63
NHNSF Governance and Processes .........................................................................64
5. Roadmap ...............................................................................................................67
ExsisNng CondiNon .......................................................................................................67
Health InformaNon Exchange .................................................................................67
Referral System Networking ...................................................................................69
Puskesmas InformaNon System ..............................................................................71
Subject Priority .............................................................................................................72
Proposed Roadmap ......................................................................................................74
Strategical Approach ...............................................................................................74
Milestone and Target ..............................................................................................76
6. Monitoring and EvaluaCon (M&E) ..........................................................................81
7. RecommendaCon ...................................................................................................83
Appendices ..................................................................................................................85
Appendix A: NaNonal context for eHealth development: summary ............................85
Appendix B: IDHIS EnNty ...............................................................................................86
Appendix C: Building Blocks of The Indonesian Health InformaNon System ................87
Appendix D: WHO Country CooperaNon Strategy Agenda 2013-2017 ........................88
Appendix E: The Roadmap for Health Measurement and Accountability ....................90
Appendix F: Asia eHealth InformaNon Network Strategic Plan: 2012 – 2017 ..............92
Appendix G: Proposal for the eHealth NaNonal CoordinaNng Body (eHNCB) ..............94
Appendix H Government’s project success and failure ................................................98
References .................................................................................................................101

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FOREWORD

Daryo Soemitro
MoH’s Chief ICT Consultant

The Indonesian Ministry of Health recognizes the potenNal of informaNon and

communicaNon technology (ICT) in transforming healthcare delivery by enabling informaNon
access and supporNng healthcare operaNons, management, and decision making. However,
the Indonesia health sector is characterized by a fragmented landscape of ICT pilot projects
and numerous data and health informaNon system (HIS) silos with significant barriers to the
effecNve sharing of informaNon between healthcare parNcipants. Although the government,
partners, and private insNtuNons are conNnuing to invest in various ICT iniNaNves, without
some form of a naNonal plan and coordinaNon, there is a real risk of conNnued duplicaNon,
ineffecNve expenditure, and the creaNon of new soluNons that cannot be integrated or scaled
across the conNnuum of care.
Based on the ICT environment and enabling environment for eHealth, the naNonal context
can be described in the following way.
✴ Experimenta;on and early adop;on, where both the ICT and enabling environments are at
an early stage
✴ Developing and building up, where the ICT environment grows at a faster rate than the
enabling environment
✴ Scaling up and mainstreaming, during which the enabling environment matures to
support the broader adopNon of ICT.
The current situaNon of Indonesia based on naNonal context group at this stage is classified as
Developing and Building up country, where the ICT environment grows at a faster rate than
the enabling environment. It means that the ICT use has rapidly developed while the enabling
environment is sNll on slowly progressing.
In 2016 the Ministry of Health (MoH) has to adjust the organizaNonal structure corresponding
PresidenNal Decree No. 35 of 2015 concerning changes in the organizaNonal structure of the
MoH. This situaNon resulted in policy changes regarding health system, programs, acNviNes,
financing and deployment of human resources. The NaNonal Health InformaNon Strategy
(NHIS), which have been planned in 2015 by PusdaNn (Central for Data and InformaNon),
have also to be re-evaluated and re-designed to align with the new naNonal health programs
of MoH.
To ensure proper governance in the management of health informaNon in the country, the
review process of the NHIS should follow a parNcipatory approach driven by strategic
objecNves of the eHealth NaConal CoordinaCng Body (eHNCB). An iniNaNve to establish the
eHNCB is in process; the MoH conducted a series of naNonal consultaNons that included

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health sector professionals, partners, faith-based organizaNons, nongovernmental
organizaNons (NGOs), and other stakeholders.
In this transiNonal situaNon, the need for guidelines, which provide the basic informaNon
concerning the direcNon of Indonesian Health InformaNon System (IDHIS) development and
the ICT strategy for supporNng the health sector transformaNon, has been prepared based on
the consideraNon of the government. This technocraNc document need to be reinforced the
framework and revitalized its contents by the eHNCB, once established. The IDHIS plans
should be made in collaboraNon with all relevant stakeholders to ensure greater success in
achieving the IDHIS vision. The final result of this document afer finalizing by the eHNCB is
expected to be used as guidelines for:
1. To outline the policies, strategies, organizaNon, and acNon plan for the Health InformaNon
Management for the health sector of the country.
2. To be used as the reference document and basis for planning and implementaNon of
programs and acNviNes related to health informaNon management in MoH and other
health related agencies, Non-governmental OrganisaNon (NGOs) and private sectors.
3. To provide a plagorm to bring together various stakeholders involved in health and health
related informaNon to share a common vision and goals.
The strategy will address some of the key challenges experienced during HIS implementaNon
before 2016, that include a shortage of qualified healthcare professionals at all levels of the
health system; limited access to health faciliNes and health professionals due to poor
infrastructure, inefficiencies of the healthcare system, poverty, and ignorance.
This document, The Indonesia Health InformaNon Architecture, is a preliminary document,
which will publish as PusdaNn official document afer legally approved by the Ministry.

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ACKNOWLEDGEMENT

Anonym
Ministry of Health, Head of Pusda;n

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REVIEWS AND COMMENTS FROM THE e-HEALTH EXPERT

Boonchai Kijsanayo;n MD., PhD.

Thai Health Informa;on Standards Development Center (THIS)
Health System Research Ins;tute, Na;onal Health Building,
88/39 Tiwanon 14 Road, Muang District, Nonthaburi 11000 Thailand
Office phone: +66 2832 9216, Mobile phone: +66 89 7914120
Web Page: www.this.or.th, email: [email protected], [email protected], Skype name: kijs0001

Dear Dr.Daryo
Thank you very much for the file. Again. congraturaNon for the work, I think it is one of the
good country's works that other Asia member countries can learn. Is it OK to share the
document in AeHIN's repository as an arNfact that people can benefit from the work.
InteresNngly, our AeHIN's CEO, Dr.Alvin has several interesNng comments on the draf. Below
is his comments
"Here are my comments. I will leave it up to you to forward to MOH Indonesia.
1. The document is comprehensive and all-encompassing. Congratula;ons.
2. It is a good founda;onal start for the na;onal eHealth strategy of MOH Indonesia. The
phases (page 75 onwards) is consistent with the AeHIN Na;onal eHealth Capacity
Roadmap (see aaached). Elements of the WHO-ITU Na;onal eHealth Strategy Toolkit are
used extensively.
3. The EA methodology or framework selected is the Reference Model for Open Distributed
Processing. This is an acceptable methodology and is mature.
4. The principles listed are also relevant. However, we should reference the ac;vity from
which these were elicited. The na;onal eHealth strategy is a mul;-stakeholder exercise
and will quickly become very complex the more players come in (esp private sector). The
principles will be the ones that will keep the stakeholders together so they should be
disseminated as widely as possible with their acceptance.
5. Thank you for ci;ng the AeHIN Strategy.
6. Most important comment is how the other agencies (Ministry of ICT, Finance, Social
Protec;on) par;cipate in the eHealth program. Will they be part of the governance
structure? Will they have a role somewhere and if yes, what will those be?
7. The Asia eHealth Informa;on Network has a Regional Enterprise Architecture Council for
Health who we will make available to MOH Indonesia in case they will need assistance."

Regards

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ABBREVIATIONS

AAAT Agency Assessment and ApplicaNon of Technology. [BPPT]

API AcNvity Performance Indicator (Indicator Kinerja Kegiatan [IKK])
BDEHRH Board of Development and Empowerment on Human Resources for Health.
[BPPSDMK]
BPR Business Process Reengineering
CCS Country CooperaNon Strategy
CDI Center for Data and InformaNon
CHS Community Health Service (Upaya Kesehatan Masyarakat [UKM])
DGDPC Directorate General of Disease PrevenNon and Control
DGIS Directorate General’s InformaNon System
DGPH Directorate General of Public Health
DGPMD Directorate General of PharmaceuNcal and Medical Devices
DHIS District Health InformaNon System
DHO District Health Office
eHNCB eHealth NaNonal CoordinaNng Body
EA Enterprise Architecture
EHR Electronic Health Record
EIS ExecuNve InformaNon System
EMR Electronic Medical Record
ERP Enterprise Resource Planning
HA Health Authority
Health-BPJS Social Security Management Agency for the Health Sector
HIE Health InformaNon Exchange
HIS Health InformaNon System
Hos-MIS Hospital Management InformaNon System
HR Human Resources
HRHIS Human Resources Management InformaNon System
ICT InformaNon and communicaNon Technology
IDHIA Indonesian Health InformaNon Architecture

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IDHIF Indonesian Health InformaNon Framework
IDHIS Indonesian Health InformaNon System (two digit country code for
Indonesia : ID [ISO 3166-2])
IDSRS Indonesian Surveillance and Response System
IHE IntegraNng the Healthcare Enterprise
IHS Individual Health Service (Upaya Kesehatan Perorangan [UKP])
IHWA Indonesian Health Workers Assembly (Majelis Tenaga Kesehatan Indonesia
[MTKI])
IM InformaNon Management
IMC Indonesia Medical Council (Konsil Kedokteran Indonesia [KKI])
IS InformaNon System
Log-MIS LogisNc Management InformaNon System
MIS Management InformaNon System
MNCH Maternal, Newborn, and Child Health
MoEd Ministry of EducaNon
MoH Ministry of Health
MoHA Ministry of Home Affairs
MoNDP Indonesian Ministry of NaNonal Development Planning. [BAPPENAS]
MoR Ministry of Religion
NeHST NaNonal eHealth Strategy Toolkit (WHO-ITU)
NGO Non-Governmental OrganizaNons
NHIS NaNonal Health InformaNon Strategy
NHNSF NaNonal Health NormaNve Standard Framework
NIHRD NaNonal InsNtute for Health Research and Development [LITBANGKES]
NPC NaNonal Pharmacy Comminee (Komite Farmasi Nasional [KFN])
NSPK Nomenklatur, Standar, Pedoman dan Kebijakan (Nomenclature, Standard,
Guideline and RegulaNon)
PHO Provincial Health Office
PMO Project Management Office
PPI Program Performance Indicators (Indikator Kinerja Program [IKP])
PusdaNn Central Data And InformaNon Unit of MoH
Puskesmas Pusat Kesehatan Masyarakat (Primary Health Care)
RCH ReproducNon and Child Health
SGIS Secretariat General InformaNon System
SOP Standard OperaNng Procedure

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SWIS Social Welfare InformaNon System
UHC Universal Health Coverage
WASH Water, SanitaNon and Hygiene
WMS Warehouse Management System

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EXECUTIVE SUMMARY

The Health InformaNon Architecture is a direcNonal document that describes Indonesia’s

long-term vision for Indonesian Health InformaNon System (IDHIS), with a strong focus on
tangible benefits and deliverables for the next five years.
In 2016, in the early stages of implementaNon of health development that has been drafed
as acNviNes, indicators, targets, funding and framework of the regulaNons as outlined in the
PusdaNn AcNon Plan AcNviNes (RAK) 2015-2019, the Indonesian government made a policy of
reorganizaNon in all ministries and agencies. PusdaNn also changed the organizaNonal
structure, the various duNes and funcNons should be adapted to the new organizaNonal
structure. It has an impact on various aspects of governance and policy in health programs at
the central as well as local government, governance and requirements in ICT also need to be
adjusted.
In this transiNonal situaNon, the need for guidelines, which provide the basic informaNon
concerning the direcNon of IDHIS development and the ICT strategy for supporNng the health
sector transformaNon, is sNll required by the majority health related stakeholders.
Responding to these challenges, the MoH has made a technocraNc concept of the Indonesia
Health InformaNon Architecture (IHIA) with the aim to be used as a temporary reference. This
technocraNc document need to be reinforced the framework and revitalized its contents by
the eHealth NaNonal CoordinaNng Body (eHNCB), once established. The IDHIS plans should be
made in collaboraNon with all relevant stakeholders to ensure greater success in achieving
the IDHIS vision.
This document, The Indonesia Health InformaNon Architecture, is a preliminary document,
which will publish as an official document by the Indonesian MoH afer it has been approved.

Vision:
By 2025, IDHIS will enable a safe, high quality, equitable, efficient, and sustainable health
system for the Indonesia people by transforming the way informaNon is used to plan,
manage, deliver and monitor health services.

Mission:
IDHIS is easily accessed at any Nme anywhere to support the transformaNon of the health
system of Indonesia to achieve improved health and social welfare of all ciNzens.

Strategic Goals
Strategic goals describe health outcomes in qualitaNve terms that reflect a realisNc focus
of the Ministry and its direcNon for achieving the IDHIS mission and vision.

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 1. Enable electronic access to appropriate healthcare services for paNents within
remote, rural, and disadvantaged communiNes.
2. Make paNent care safe and effecNve by ensuring that the correct informaNon is
available in a Nmely manner, where it is needed and to whom it is needed.
3. Enable the health sector to operate more effecNvely as a connected system,
overcoming fragmentaNon and duplicaNon of service delivery.
4. Support improved mulN-way communicaNon and sharing of informaNon among
clinicians, paNents, and caregivers within the health sectors and across partner
agencies.
5. Support evidence-based policy, investment, and research decisions through access to
Nmely, accurate, and comprehensive reporNng of healthcare system informaNon.
6. Enable more efficient use of healthcare resources through replacing paper-intensive
processes and providing bener informaNon management.

Key Principle
In developing IDHIS through a parNcipatory mulN-sectorial cooperaNon, which involves
intellectual property and the use of individual data, the eHNCB team members will respect
to the following principles:
1. Holding full ownership and responsibility for IDHIS iniNaNves, including intellectual
property ownership;
2. Taking an incremental and iteraNve approach – build on what already exists in both
the public and private sectors and fill the gaps where necessary;
3. Establishing coordinaNon mechanisms within the country and between countries in
the Region, to improve the effecNveness of IDHIS at all levels, for the required
iniNaNves: (i) integraNon between systems; and (ii) enforcement of common
standards, norms, terminology and systems across the country and the Region;
4. Pursuing a collaboraNve approach by leveraging partnership between the private
sector, nongovernmental organizaNons, government departments, other country
governments, and research organizaNons;
5. ProtecNng informaNon security, confidenNality and paNent privacy at all Nmes;
6. Considering available open-source soluNons for cost effecNveness;
7. RespecNng culture, ethics, rules, regulaNons and principles embedded in naNonal HIS
management;
8. Informing and imparNng knowledge to country governments, local organizaNons and
relevant health-care workers, to enable ownership and comprehension;
9. Enabling paNents to parNcipate in their health-care choices and facilitaNng “user-
driven health care”.

Key Strategic Principles

There are several key principles that underpin and inform the proposed strategy and
approach.

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✴ NaConal infrastructure - Deliver core elements of enabling IDHIS infrastructure once,
rather than duplicaNng development costs and efforts and increasing the likelihood of
rework
✴ Stakeholder engagement - AcNvely engage key health care stakeholders in the design
and delivery of IDHIS soluNons
✴ Incremental approach - Build of long term naNonal HIS capability in an incremental
and pragmaNc manner, focusing iniNal investment in those areas that that deliver the
greatest benefits for consumers, care providers and health care managers
✴ Recognising different starCng points - Balance acNve support for care providers with
less developed capability, while not constraining the ability for more advanced
parNcipants to progress
✴ Leverage - More effecNvely leverage and scale IDHIS acNvity across the country
✴ Balancing alignment and independence - Drive alignment of naNonal HIS acNviNes
whilst not unnecessarily limiNng the ability of health care parNcipants and vendors to
implement locally relevant soluNons
✴ Relevant skills - Ensure sufficient numbers of skilled pracNNoners are available to
support delivery of the naNonal HIS Strategy.

Strategic Work Streams

In order to address these principles four major strategic streams of acNvity have been
idenNfied.
✴ FoundaCons - Establishing the core foundaNons for electronic informaNon exchange
across the health sector. This work stream is fundamental as without the basic ability
to securely share health informaNon there will effecNvely be no naNonal HIS capability.
✴ IDHIS SoluCons - SNmulaNng the delivery of IDHIS soluNons to the key users of health
informaNon. This work stream will facilitate the delivery of specific compuNng systems
and tools to address the high priority needs of consumers, care providers and health
care managers.
✴ Change and AdopCon - Fostering consumer, care provider and health care manager
adopNon of IDHIS. The aim of this work stream is to focus effort on achieving a ‘Npping
point’ of stakeholder adopNon of IDHIS soluNons as quickly as required.
✴ Governance - Ensuring the effecNve leadership, coordinaNon and oversight of the
IDHIS work program. This work stream focuses on the establishment of appropriate
IDHIS governance structures and mechanisms.

Strategic ObjecCves (SOs) and IniCaCves

The following are the IDHIS SOs, built around the four strategic work stream (noted above)
that are necessary to achieve the IDHIS vision and long-term health sector business goals.
✴ IDHIS FoundaCons
The IDHIS FoundaNons pillar’s SOs focus on implemenNng the basic infrastructural
building blocks required to enabling the effecNve electronic sharing of informaNon
across the Indonesia health sector.

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 SO ICT Strategic Objective HIS Foundation Target Outcome
SO.1 Establish eHealth standards, rules, and protocols Informa;on exchange and protec;on.

SO.2 Establish comprehensive health facility, provider, Meets stakeholders’ needs.

and client registries with complete and current
informa;on
SO.3 Enhance ICT infrastructure and services Improve communica;on and informa;on
sharing across the health systems and at
all levels

✴ IDHIS SoluCons
The IDHIS SoluNons pillar’s SOs focus on implemenNng the specific electronic systems
and tools to address the high-priority needs of consumers, care providers, and
healthcare managers that improve efficiency and effecNveness.

SO ICT Strategic Objective Health Service Target Outcome

SO.4 Strengthen an electronic HR system improve HR planning and management at all levels
SO.5 e-learning and digital resources. CPD of healthcare workers
SO.6 Strengthen disease preven;on, Early detec;on and rapid repor;ng and response
surveillance, and control
SO.7 Strengthen electronic HMIS Support evidence-based health care and decision-
making.
SO.8 Enable electronic delivery and Reduce child mortality; maternal mortality; and the
interven;ons of health services burden of HIV/AIDS, TB, malaria, and non-
communicable diseases.
SO.9 Enable an electronic logis;cs and Availability of adequate quality and quan;;es of
supplies system health commodi;es at the point of service to meet
pa;ent demand
SO.10 Enable electronic financial Effec;ve collec;on, alloca;on, and use of health
management financial resources at all levels
SO.11 Enable electronic communica;on Improve quality of referral system service.
and informa;on sharing mechanism
for the referral system
SO.12 Enable electronic management of Improve access and quality of service delivery.
social welfare services, beneficiaries,
and providers
SO.13 Establish an electronic water, Support evidence-based planning and investment in
sanita;on and hygiene (WASH) service delivery
management informa;on system
SO.14 Establish telehealth services Enable electronic delivery of quality health care to
individuals in remote areas lacking needed exper;se.

✴ Change and AdopCon

The Change and AdopNon pillar’s SO focuses on what needs to be done to encourage
and enable parNcipants in the healthcare system to adopt IDHIS soluNons and change
their work pracNces to be able to use these soluNons effecNvely.

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 SO Governance Aspects Change and Adoption Target Outcome
SO.15 Establish a comprehensive Promote and enforce the development and use of IDHIS
change and adop;on strategy solu;ons for public and private ins;tu;ons at all levels.

✴ IDHIS Governance
The IDHIS governance strategic objecNves focus on establishing the appropriate IDHIS
governance to provide leadership, coordinaNon and oversight to ensure successful
delivery of IDHIS

SO Organizational Aspects Governance Target Outcome

SO.16 Establish and ins;tu;onalize an Ensure effec;ve management and oversight of IDHIS
IDHIS governance structure Strategy implementa;on.

ImplementaCon:
The Ministry adopts enterprise architecture (EA) as a framework to guide the
development and implementaNon of the integrated Indonesian Health InformaNon
System (IDHIS). The final document, acNon plan and implementaNon of the IDHIS Strategy
will be organized by eHNCB, once established.

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1. INTRODUCTION

1.1. Background
Good health informaNon systems are crucial for addressing health challenges and improving
health service delivery in developing countries. However, the quality of the data produced by
such systems is ofen poor and the data are not used effecNvely for decision-making.
Although there has been increasing internaNonal anenNon to the need to develop strong
health informaNon systems, it has proved difficult to do so for several reasons, including
fragmentaNon and lack of coordinaNon of health programmes and insistence by internaNonal
agencies on maintaining their own verNcal systems; lack of shared data standards; unrealisNc
ambiNons; inability of system developers to handle complex organizaNonal, social and
cultural issues; and problems of sustainability. The Health Metrics Network, established in
2005, has been instrumental in addressing the problem of fragmentaNon in health
informaNon systems through its technical framework, which promotes a data warehouse
approach to informaNon system integraNon and in creaNng global consensus on the need for
all actors to join forces and work towards integrated systems. [1][2]
The MoH has recognized the ICT potenNal to support and reform the quality of the health
service delivery. However, the rapidness of the ICT use in districts and health faciliNes in
order to make evidence-based decisions has created difficulNes to compile relevant and
accurate data quickly and easily. The MoH is trying to solve the problem of separate health
informaNon systems in use throughout the country (both paper-based and electronic paNent
medical record system) to become integrated naNonal health informaNon system.
In planning for the more systemaNc and expanded applicaNon of IDHIS to the health sector in
Indonesia, it is important to understand the organizaNon of the healthcare system within the
country.

IT Governance
๏ Structuring informaNon systems in the health sector by the MoH has been iniNated
since 1982 by the work unit equivalent third echelon, namely Unit Data CollecNon and
Processing in the Planning Bureau. In line with efforts to improve the quality and use of
data as well as the needs of the organizaNon, in 1985 Health Data Centre (Pusdakes)
was created and inaugurated as a working unit, equivalent echelon II. In 2010 the
name Pusdakes was converted into Center for Data and InformaNon (PusdaNn), which
serves to more complex data management and health informaNon. PusdaNn has
responsible to develop and design naNonal regulaNons and norms, standards and
guideline of informaNon systems for health, including naNonal strategic planning and
roadmap to strengthen the Indonesia HIS (IDHIS). The appropriate architecture design

1 Framework and standards for country health information systems / Health Metrics Network, World Health Organization. 2nd ed, WHO-2008
2 Jørn Braa,a Arthur Heywooda & Sundeep Sahaya: Improving quality and use of data through data-use workshops: Zanzibar, United Republic
of Tanzania. Bull World Health Organ. 2012 May 1; 90(5): 379–384. doi: 10.2471/BLT.11.099580

7
 of naNonal HIS developed to translate the roadmap of the development on integrated
naNonal HIS.
๏ The MoH has also established the HIS Steering Comminee, which composed of experts
from various insNtuNons / sectors related to health informaNon systems, to oversee
government regulaNons, guidance and HIS strategic planning and roadmap.

Important policy changes

๏ The decentralizaNon of various authoriNes, from the central government to provincial
governments which came into force in 2004, among others [3]
• providing public infrastructure;
• handling the field of health;
• providing educaNon and allocaNon of human resources potenNal;
• alleviaNon social problems across districts / ciNes;
Not all the components of IDHIS were implemented as iniNally envisaged, because of
varying degrees of capabiliNes at provincial levels. Furthermore, the Provinces
procured systems that were neither compaNble nor interoperable with each other.
๏ In 2016, in the early stages of implementaNon of health development that has been
drafed as acNviNes, indicators, targets, funding and framework of the regulaNons as
outlined in the PusdaNn AcNon Plan AcNviNes (RAK) 2015-2019, the Indonesian
government made a policy of reorganizaNon in all ministries and agencies. PusdaNn
also changed the organizaNonal structure, the various duNes and funcNons should be
adapted to the new organizaNonal structure. It has an impact on various aspects of
governance and policy in health programs at the central as well as local government,
governance and requirements in ICT also need to be adjusted. The existence of "HIS
Steering Comminee" (forerunner to proposed eHealth NaNonal CoordinaNng Body
[eHNCB]) needs to realign to fit the needs of the environment. SystemaNc HIS needs to
improve in order to achieve the sustainable integrated HIS. CoordinaNon and bridging
mechanism should be agreed upon data sharing at naNonal level among government,
private sector and public to assure the accountability.

1.2. Current Indonesia’s Healthcare Status And IDHIS Profile

Indonesia is yet to achieve the health-related MDG goals parNcularly Goals 4 and 5. Emerging
and re-emerging communicable diseases place immense strain on health systems, so
concerted efforts are required to respond rapidly to urgent needs and to strengthen the
development of effecNve disease control programmes including zoonoNc diseases. It has
been realized that while emphasizing improved access to services, equal anenNon also needs
to be given to ensure quality, comprehensive and integrated health services for women,
children and adolescents. NutriNon, a criNcal common factor in both mortality and morbidity,
remains a key public health problem; further triggered by inadequate food safety and quality.

3 Act No. 23 of 2014 on Local Government

8
Public health risks posed by tobacco, unhealthy diets, lack of physical acNvity, unsafe water,
inadequate sanitaNon, traffic congesNon, and use of solid fuels for cooking; place further
demands on the need for integrated health promoNon and healthy sevngs.
The linkage between climate change and human health requires increased advocacy, and the
health sector needs to be bener prepared to miNgate and adapt to climate change effects
and impacts. Building on the experience gained during the emergency response to the
tsunami and subsequent quakes, it is equally important to further develop naNonal capacity
for emergency preparedness and response to public health needs.
With a myriad of challenges in health sector that arise in the diversity of Indonesia (below
figure), it can be predicted that the use of ICT in Indonesia clearly quite promising and
requires short-cut innovaNon.

Population Availability of ICT

infrastructure, ICT
human resources,
quality of public
services and economic
Islands growth rate varies
from one place to
another.
ICT promises to
Tribes overcome the digital
divide, improving the
quality of services,
increase economic
Local Languages growth, and maintain
the sovereignty of the
Republic of Indonesia.

Figure 1-1. Diversity of Indonesia [4 ]

To enrich the IDHIS, it is important to understand the organizaNon of the healthcare system
within the country and some related health aspects.
✴ The organizaNonal structure of Indonesia’s administraNve is divided into 34 provinces
and 516 districts/ciNes with 9756 primary care centers (Puskesmas). Each province has
local policy in health planning and implementaNon and districts have semi-autonomy
authority. The administraNve authority is an important point to take into account when
planning the deployment of HIS throughout the country.
✴ The public health system has been idenNfied as entrepreneurial system and it is
parNally financed and delivered through public health care faciliNes consisNng of
health centers and public hospitals. Health centers provide various public health and
primary health care to a defined community, usually a sub-district level. There are
currently more than 7,000 health centers and more than 21,000 sub-health centers
throughout Indonesia. Public hospitals, providing secondary and terNary care, consist
of four types (1) Type D hospitals (less than 50 beds) with four specialist: an internist,
an ob-gyn, a surgeon, and a pediatrician) provide basic secondary care at district level,
(2) type C hospitals (50-100 beds with more than four types of specialists) serve

4 Ibenk Dwi Anggono: eGovernment Indonesia Update 2015 - 2019. Ministry of Communication Technology, the Republic of Indonesia

9
 secondary and terNary care for a larger district, (3) type B hospital (between 100-400
beds with variety of specialists) providing referral care of more advances at provincial
level, and (4) type A hospital (up to 1,500 beds) designed to provide top (naNonal)
referral care.
✴ In the era of Universal Health Coverage, the health insurance regulaNon has been
mandated that public health care faciliNes are charged based on the number of
services received by the paNents (subsidized fees for services system). The paNent
charges at health centers and at third class room of public hospitals are heavily
subsidized (about 50-80% of the paNents fees are subsidized indirectly through publicly
set fees). These are the poorest that have free healthcare but minimum access to
health resources.
✴ The investment within countries is insufficient. There has not been adequate naNonal
and internaNonal financing directed toward building sustainable and comprehensive
informaNon systems. Ofen paper-based systems conNnue to be used, and are used
only for reporNng purposes, with the result that much data from naNonal systems are
of low quality.
✴ The current IDHIS data collected is based on formats developed for a manual system of
data collecNon. The various programs at MoH, in recognizing the need for more
informaNon for their respecNve program monitoring and evaluaNon developed their
own reporNng systems for specific purposes. This has resulted in the use of data sets
which are non-standardised, where the data definiNon used were different and values
varied. Hence the same data element means differently in different formats making
data analysis difficult due to inconsistency of data, quesNonable data integrity and
different data definiNons.
✴ The investment in naNonal data collecNon and analysis is inefficient. Donor-specific
programs have prioriNzed the producNon of quality data for their own indicators.
Investments have been ad hoc, fragmented, and targeted at unsustainable pilots,
stand-alone surveys, and one-off impact evaluaNons. Investments in informaNon
systems are ofen not responsive to local needs or geared to improving services.
Currently, many local governments do not make enough budget allocaNon to finance
the development of informaNon systems. Conversely, many healthcare faciliNes
provide a budget for the development of informaNon systems as an investment to get
the data and informaNon to bener health. Weaknesses in leadership and governance
within the government system, being one of the causes fragmentaNons of the system.
✴ In view of the different types of informaNon collected in different format, or same
informaNon being collected in different format, there is a considerable degree of data
inconsistency collected by various agencies. Ministries of Health, Indonesia Central
Bureau of StaNsNcs, and civil registraNon, the backbone of data producNon and
management, lack of required capacity, standardized tools, and resources. Low-quality
data is frequently used to make decisions.
✴ The access to and usability of data are Limited. Bener quality of data, bener
informaNon of health data is ofen not available and inaccessible for public
consumpNon. The lack of transparency and inadequate use of ‘open data’ by
government means civil society actors cannot undertake the analysis to challenge or

10
 verify results produced by government. The introducNon of (ICT) provides many
opportuniNes, but too ofen results in data that is not used for improving clinical care
and facility management. Conflict and emergency situaNons provide parNcular
challenges.
✴ The current system of collecNng informaNon from private sector is inadequate and less
saNsfactory in the analysis of the country profile. There is a need to improve the
reporNng system from private sector through enforcement of the Private Health Care
FaciliNes and Services Act. In addiNon there is a lot of health and health related
acNviNes done by NGOs for which there is no formal way of reporNng.
✴ The quality of informaNon pertaining to medical diagnosis is far from saNsfactory.
Presently there is inadequate training for staff in coding, disease classificaNon and
record management. There is also a need to train doctors in documenNng accurate
informaNon to facilitate diagnosis coding.
✴ The manpower in measurement and accountability are ofen not sufficiently trained
and incenNvized to uNlize health data for responding to gaps in services or local
inequiNes in health. With the high turnover of staff, who are already trained, it will
influence to the quality and sustainability on recording, data collecNon, reporNng and
analysis of data. The tasks are limited to producNon of reports for Health
Management.
✴ Infrastructure and network required for supporNng communicaNon and connecNvity
are inadequate in terms of coverage and its capability. Currently lease lines are used to
connect MOH with state office and the other faciliNes are connected through dial-up
lines. This has resulted in the system being slow, unreliable and also incurs addiNonal
operaNonal cost and has caused non compliance at the operaNonal level.
A more detailed analysis of the current strengths, weaknesses, opportuniNes, and threats
(SWOT) in the health sector Ned to ICT capability:

Strengths
1. Existence of the Act on InformaNon and Electronic TransacNons [5 ], the Act No. 14 of
2008 on Public InformaNon [6] as well as regulaNon of the President of the Republic of
Indonesia on NaNonal Health System and Indonesian Government RegulaNon on
Health InformaNon Systems [7]
2. Existence of poliNcal will by the government of Indonesia to advocate healthcare
reform and the use of ICT to improve the efficiency and efficacy of the healthcare
system [8]
3. Existence of insNtuNons and agencies that are responsible for provision of various
services (Agency for Development and Empowerment of Human Resources - MoH
[BPPSDMK], Health Research and Development Agency - MOH [Litbangkes], Ministry
of Internal Affairs, Health - NaNonal Social and Healthcare Security [Health-BPJS],

5 Act No. 11 of 2008 on Information and Electronic Transactions

6 Act No. 14 of 2008 on Public Information
7 Government Regulation No. 46 Year 2014 on Health Information Systems
8 Regulation of the Minister of Health of the Republic of Indonesia Number 192 of 2012 on the Roadmap Action Plan Strengthening Health
Information Systems Indonesia

11
 Agency Assessment and ApplicaNon of Technology [BPPT], Non-Governmental
OrganizaNons [NGOs], etc.) with their own data and informaNon systems
4. Existence of naNonal e-Government strategy coordinated by the Indonesian Ministry
of NaNonal Development Planning (BAPPENAS) that recognizes IDHIS as a priority
area
5. Existence of primary health care informaNon systems as reporNng mechanism to
naNonal programs
6. Existence of partnership between MoH and nine State UniversiNes in Indonesia to be
a Center of Excellence
7. Existence of healthcare applicaNon developers who are already working with a wide
range of primary care centers
8. Existence of guideline from various official internaNonal organizaNon (WHO [9 ], ITU
[10], ISO [11].

Weaknesses
1. Lack of a IDHIS governance structure to guide the development of IDHIS across the
health sector
2. Absence of IDHIS strategy to guide implementaNon of IDHIS iniNaNves
3. Lack of integrated naNonal control to the implementaNon of rule and guideline, which
already establish.
4. Lack of availability of proper informaNon sharing systems within and outside the
health sector
5. Lack of reliable health informaNon/data collecNon and sharing among health
providers
6. Lack of guidelines on research and use of data/ informaNon
7. Lack of compliance with IDHIS standards and systems interoperability
8. Inadequate integraNon of IDHIS skills into exisNng health professional training
curricula
9. Lack of biomedical and medical informaNcs experts and trained ICT professionals
10. Inadequate ICT infrastructure throughout the health sector

OpportuniCes
1. Existence of Healthy Indonesia program with a family approach conducted by Ministry
of Health
2. IniNaNve by Ministry of CommunicaNon and InformaNon Technology (MoCIT) to
establish naNonal internet bandwidth to support data exchange and communicaNon to
the isolated / remote areas

9 Framework and standards for country health information systems / Health Metrics Network, World Health Organization. 2nd ed, WHO-2008
10 National eHealth Strategic Toolkit. © World Health Organization and International Telecommunication Union 2012
11 ISO/TR 14639-2 (2014) Health Informatics—Capacity-Based eHealth Architecture Roadmap—Part 2: Architectural Components and Maturity
Model. International Standards Organisation, Geneva. http://www.iso.org/iso/catalogue_detail?csnumber=54903

12
 3. IniNaNve by the Ministry of Internal Affairs to establish NaNonal IdenNficaNon Cards
4. Existence of donor-supported programs/ projects
5. Existence of public-private partnerships to support IDHIS development projects
6. Availability of new technologies such as mHealth

Threats
1. Lack of IDHIS governance structure to guide and maintain the sustainability of the
development of HIS across the health sector
2. Financial constraints
3. Inadequate applicaNon of informaNon security and system interoperability standards
on shared networks
4. Absence of legal frameworks/legislaNon to support IDHIS development
As a summary, currently there is no accurate staNsNcs show the exisNng naNonal health
profile and qualified health workers in the Indonesia health sector, leaving Indonesia with a
different complexity of health service problem as well as severe human resources problem in
the health sector. This crisis, together with other challenges facing the Indonesia health
sector, calls for the immediate formulaNon and implementaNon of an IDHIS strategy as a way
of supporNng progress in the Indonesia Health Program

1.3. Basic Reference of IDHIS Development

In line with the WHO-ITU eHealth Strategy Toolkit [WHO and ITU, 2012], the IDHIS use the
toolkit, which offers a framework and method for the development of a naNonal eHealth
vision, acNon plan and monitoring framework. All governments that are developing or
revitalizing a naNonal eHealth strategy can be applied to the development of IDHIS, whatever
the level of IDHIS maturity is.
Established
ICT environment

Mainstreaming

Scale up
Developing
and building up

Emerging Established
enabling II. III.
enabling
envirenment envirenment
Early adop>on
for eHealth I. for eHealth

Experimenta>on

Emerging
ICT environment

Figure 1-2. National context for eHealth development

13
Based on the ICT environment and enabling environment for eHealth, the naNonal context
can be described in the following way: (see Appendix A)
I. Experimenta;on and early adop;on, where both the ICT and enabling environments
are at an early stage
II. Developing and building up, where the ICT environment grows at a faster rate than the
enabling environment
III. Scaling up and mainstreaming, during which the enabling environment matures to
support the broader adopNon of ICT.
A naNonal plan for a country in stage I should focus on creaNng an enabling environment by
making the case for eHealth, creaNng awareness and establishing a foundaNon for
investment, workforce educaNon and adopNon of eHealth in priority systems and services.
There is a common misconcepNon that countries can ‘leapfrog’ to more advanced eHealth
systems without creaNng such an enabling environment, but in reality such acNons will lead
to innovaNons in ICT that will remain isolated and only have a limited impact on health [WHO
and ITU, 2012].
A naNonal plan for a country in stage II should focus on strengthening the enabling
environment for eHealth, creaNng legal certainty, establishing the policy context for
delivering eHealth and idenNfying the standards to be adopted to ensure that building ever-
larger silo systems is avoided. The major drivers for eHealth in stage II is access to care and
quality of care [WHO and ITU, 2012].
In stage III the commercial ICT market is well established with larger internaNonal and local
vendors. Drivers for eHealth in this stage are cost and quality. A naNonal plan for a country in
stage III should focus on [WHO and ITU, 2012] [12]:
✴ Interoperability and adopNon of standards.
✴ Providing incenNves for innovaNon and integraNon of eHealth into core services.
✴ IdenNfying funding for medium-to-long term implementaNon.
✴ Responding to the expectaNons of ciNzens for more efficient, effecNve and
personalized services.
✴ Using data and informaNon for public health planning, policies for privacy and security
of informaNon.
✴ Undertaking monitoring and evaluaNon to ensure that eHealth delivers according to
health prioriNes.
Indonesia is currently somewhere between stages I and II, therefore according to the NeHST
[WHO-ITU], it should focus in strengthening infrastructure; establishing core services and
plagorms; engaging investors; making the case for eHealth, as well as strengthening and
linking core systems; creaNng a foundaNon for investment; ensuring legal certainty;
strengthening the IDHIS enabling environment. (table below)

12 National eHealth Strategic Toolkit. © World Health Organization and International Telecommunication Union 2012

14
 Table 1-1. Context and focus of eHealth strategy
Context Example Focus Example AcCon
I. ExperimentaCon Strengthen • Create awareness of eHealth; highlight outcomes of
and early adopCon infrastructure; establish successful pilots and proof-of-concept projects
core services and • Make the case for eHealth investment in priority areas
plagorms; engage
investors; make the case • Establish iniNal mechanisms for naNonal eHealth
for eHealth. governance, coordinaNon and cooperaNon
• Establish a foundaNon for investment, workforce educaNon
and adopNon of eHealth in priority systems and services
II. Developing and Strengthen and link core • Establish eHealth data and interoperability standards, and
building up systems; create a associated compliance and accreditaNon mechanisms
foundaNon for • Establish the policy context to support investment in and
investment; ensure legal adopNon of ICT in health services
certainty; strengthen the
eHealth enabling • Address legislaNve requirements and barriers (e.g. data
environment. protecNon and privacy)
• Implement changes to educaNon and training programmes
to improve eHealth workforce capability and capacity
• Secure long-term funding for investment in naNonal
eHealth infrastructure and services
• Establish naNonal eHealth planning processes, which have
broader cross-sectoral stakeholder representaNon and
parNcipaNon
III. Scale up and Focus on scale up and • Ensure broad adopNon of standards by health ICT vendors
mainstreaming integraNon of services; • ConNnue development of data and interoperability
cost-effecNveness of standards to support broader and deeper types of health
investments; incenNves informaNon flows
for quality and broader
adopNon; policies for • Create incenNves for integraNon of eHealth into core health
privacy, security, services
innovaNon. • Provide educaNon and awareness programmes to health-
care providers and ciNzens
• Respond to expectaNons of ciNzens for more efficient,
effecNve and personalised services
• Leverage emerging health informaNon data sources to
support public health planning, management and
monitoring
• Undertake evaluaNon and monitoring to ensure that
eHealth delivers according to health prioriNes

1.4. Challenges
The strategy in strengthening health services consist of five transformaNon prioriNes [13 ] that
refer to easily accessible integrated health services, centered around the paNent who moves
seamlessly from primary care to acute hospitals and back again. The programme also calls for
standards-based performance management and measurement throughout the health service.

13 Moeloek NF, Minister of Health: Pembangunan Kesehatan Menuju Indonesia Sehat. National Health Work Meeting, Central Regitan,
Denpasar, February 15, 2015

15
 Strategy in Strengthening Health Services

Improvement Quality Regionalization Strengthening Intersectoral

access Improvement Referral DHO/PHO Support

Fulfilling the needs Regional and Regulatory

Provision NSPK / SOP Provincial Referral Socializa8on
of the labor System Support
Increasing primary Improving the ability Na8onal Referral Infrastructure
care facili8es of health workers Advoca8ng Support
System
Fulfilling the needs Primary Physician
of the suppor8ng Services Program Capacity Building Funding Support
infrastructure
Innova8ons services Accredita8on Program
in remote and very of Primary healthcare
Remote Facili8es

Figure 1-3. Strategy in Strengthening Health Service

While MoH sNll have to rearrange various aspects of policies, acNviNes and assignments in the
new organizaNonal structure, the challenges facing from the healthcare industry is sNll
growing:
✴ Expanding numbers of electronic systems/applicaNons in use within and across
organizaNons,
✴ Growing volume and variety of data and informaNon,
✴ Expanding uses of healthcare informaNon,
✴ ProliferaNon of medical devices creaNng data for which reliable integraNon into
systems / applicaNons is essenNal,
✴ State of interoperability across devices and systems, and
✴ Reliability of shared and exchanged informaNon.
In order for IDHIS to successfully respond to the needs of the strategy in strengthening health
services, technical standards are required to ensure regional compaNbility, interoperability,
open architecture, modularity and capacity for upgrade. Regional IDHIS standards should
enable the procurement and implementaNon of affordable, cost-effecNve, accessible
technology that complies with these standards and is contextualized to the country as well as
regional context. There are several specific ICT challenges that must be overcome.
1. Keep the technology simple, relevant, and local.
2. Build on what is there (and being used).
3. Involve users in the design (by demonstraNng benefit).
4. Strengthen capacity to use, work with, and develop effecNve ICTs.
5. Introduce greater monitoring and evaluaNon, parNcularly parNcipatory approaches.
6. Include interoperability strategies in the design of ICT projects.
7. ConNnue to research and share learning about what works, and what fails.
An assessment to idenNfy these challenges has to be carried out through key stakeholder
consultaNon. The assessment include an invesNgaNon of the current ICT services and
infrastructure in the country, how data in the health system are collected and managed,
referral ambiguiNes that result in loss of paNents’ follow-up, best pracNces for monitoring and
evaluaNon (M&E), and the informaNon pathway for a network of service providers who could
be bener supported through ICT.

16
To establish over Nme a dedicated, focused and strongly branded enNty ‘Healthy Indonesia
Program’ to oversee Indonesia’s IDHIS journey and ensure maximum return for Indonesia’s
populaNon wellbeing and economy as a whole, there are some potenNal priority projects,
which should be follows the IDHIS Enterprise Architecture, among others
✴ NaNonal Health IdenNfier Infrastructure.
✴ ePrescribing Systems.
✴ Online Referrals and Scheduling.
✴ Telehealthcare - parNcularly relaNng to the management of chronic diseases.
✴ Development of PaNent Summary Records.
✴ Online Access to Health InformaNon.
✴ NaNonal PaNent Portal.
The process requires simultaneously effort to establish specific funcNonal workstreams
involving all appropriate stakeholders to address the major deployment enablers including;
✴ Appropriate funding models for programs.
✴ Change management and adopNon processes
✴ Healthcare informaNcs resources and the development of appropriate health
informaNcs skills.
✴ A standards-based, mulN-layered informaNon and technical infrastructure to provide a
common plagorm for IDHIS deployments.
✴ Appropriate legislaNon around trust, privacy, security and data protecNon
✴ Public engagement, awareness and uptake.
These challenges and complexiNes underscore the need for informaNon governance, and the
need for their due consideraNon in its adopNon. The adherence to informaNon and
technology standards across healthcare is compelled, as standards are crucial to informaNon
use and exchange given the imperaNves of integrity, security and interoperability.
Governance should be established throughout the organizaNon, uNlizing a collaboraNve
approach, with input of stakeholders, business process owners, and domain experts,
assigning defined roles and responsibiliNes to workforce members. It should be clear where
responsibiliNes reside and how the chain of command builds, implements, and updates the
informaNon governance program.

1.5. Response

The MoH is mandated to be the over-all technical authority on health that provides naNonal
policy direcNon and develop naNonal plans, technical standards and guidelines on health. To
support an appropriate and realisNc health service planning, it needs complete, relevant and
reliable of health data from all health stakeholders
To support the safe and reliable electronic informaNon exchange, comprehensive Indonesian
Health InformaNon System (IDHIS) has to be established for naNonal guideline during the
development of informaNon systems by the Ministry of Health, local government as well as
different stakeholders
The objecNves are aimed at sNmulaNng the electronic exchange of data from paNent files in
the areas of healthcare and health insurance. The plan is based on five pillars:

17
 1. Develop data exchange between caregivers on a common architecture
2. Achieve a greater engagement and bener knowledge of IDHIS by the paNents
3. Develop a terminology of reference
4. Simplify and improve efficiency of administraNve tasks
5. Establish a flexible and transparent governance structure in which all authoriNes and
relevant stakeholders will be involved.
As an iniNal effort to enhance the integraNon between the various health informaNon
systems, the IDHIS is designed, which viewed more from the government side. To achieve the
real condiNons and determine the future health community needs, the technocraNc IDHIS
must be evaluated and refined through a parNcipatory process. This includes a
comprehensive IDHIS plan to guide the planning and implementaNon of IDHIS intervenNons.
To support this purpose, the immediate establishment of eHealth NaConal CoordinaCng
Body (eHNCB) is mandatory for idenNfying prioriNes and direcNng towards ensuring the
achievement of the health system goals of bener health outcomes and responsive health
system. Complete and accurate informaNon is a prerequisite to create an IDHIS roadmaps
that match the reality. The greater the gap between design and reality, the greater the
chance of failure.

lllll

18
2. NATIONAL VISION FOR IDHIS

2.1. Vision, Mission and Strategic Goal

2.1.1. IDHIS Vision

By 2025, IDHIS will enable a safe, high-quality, equitable, efficient, and sustainable health
system for the Indonesia people by transforming the way informaNon is used to plan,
manage, deliver and monitor health services.

2.1.2. IDHIS Mission

IDHIS is easily accessed at any Nme anywhere to support the transformaNon of the health
system of Indonesia to achieve improved health and social welfare of all ciNzens.

2.1.3. Strategic Goals

Strategic goals describe health outcomes in qualitaNve terms that reflect a realisNc focus of
the Ministry and its direcNon for achieving the IDHIS vision and mission.
1. Enable electronic access to appropriate healthcare services for paNents within
remote, rural, and disadvantaged communiNes.
2. Make paNent care safe and effecNve by ensuring that the correct informaNon is
available in a Nmely manner, where it is needed and to whom it is needed.
3. Enable the health sector to operate more effecNvely as a connected system,
overcoming fragmentaNon and duplicaNon of service delivery.
4. Support improved mulN-way communicaNon and sharing of informaNon among
clinicians, paNents, and caregivers within the health sectors and across partner
agencies.
5. Support evidence-based policy, investment, and research decisions through access to
Nmely, accurate, and comprehensive reporNng of healthcare system informaNon.
6. Enable more efficient use of healthcare resources through replacing paper-intensive
processes and providing bener informaNon management.

2.2. Key Principle

In developing IDHIS through a parNcipatory mulN-sectorial cooperaNon, which involves
intellectual property and the use of individual data, the eHNSB team members will
respect to the following principles:

19
 1. Holding full ownership and responsibility for IDHIS iniNaNves, including intellectual
property ownership;
2. Taking an incremental and iteraNve approach – build on what already exists in both the
public and private sectors and fill the gaps where necessary;
3. Establishing coordinaNon mechanisms within the country and between countries in the
Region, to improve the effecNveness of IDHIS at all levels, for the required iniNaNves:
✴ Enable integraNon between systems wherever appropriate.
✴ Enforce common standards, norms and systems across the country.
✴ Establish common data standards and terminology across informaNon systems.
4. Pursuing a collaboraNve approach by leveraging partnership between the private
sector, nongovernmental organizaNons, government departments, other country
governments, and research organizaNons;
5. ProtecNng informaNon security, confidenNality and paNent privacy at all Nmes;
6. Building the capacity and the systems to obtain official health staNsNcs from a single
official source
7. Considering available open-source soluNons for cost effecNveness;
8. RespecNng culture, ethics, rules, regulaNons and principles embedded in naNonal HIS
management;
9. Informing and imparNng knowledge to country governments, local organizaNons and
relevant health-care workers, to enable ownership and comprehension;
10.Enabling paNents to parNcipate in their health-care choices and facilitaNng “user-
driven health care”.
In addiNon to the above principles, the strategy seeks to provide benefits within the six
domains of healthcare quality put forward by the MoH:
✴ Safety: Avoiding harm to paNents from the care that is intended to help them.
✴ EffecCveness: Providing services based on scienNfic knowledge to all who could benefit
and refraining from providing services to those not likely to benefit (avoiding underuse
and misuse, respecNvely).
✴ PaCent-centeredness: Providing care that is respecgul of and responsive to individual
paNent preferences, needs, and values and ensuring that paNent values guide all
clinical decisions.
✴ Timeliness: Reducing waiNng Nmes and potenNally harmful delays for both those who
receive and those who give care.
✴ Efficiency: Avoiding waste, including waste of equipment, supplies, ideas, and energy.
✴ Equitability: Providing care that does not vary in quality because of personal
characterisNcs such as gender, ethnicity, geographic locaNon, and socioeconomic
status.

20
2.3. ImplicaCons of the vision for stakeholders
The IDHIS vision can also be expressed in terms of what it might mean for each of the three
key groups of impacted stakeholders:
✴ Consumers – individuals who receive Indonesian health care services and the friends,
family and carers who are directly involved in the care of the individual
✴ Care Providers – the individuals and organisaNons that provide Indonesian health care
services
✴ Health Care Managers – Indonesian health sector clinical managers, health service
managers, planners, researchers and policy makers.

Table 2-1. Current State and Future Expectation

Stakeholder Current State Future State

Group
Consumer • S p e n d N m e r e p e a N n g t h e s a m e • Will have an ability to access their own
informaNon to mulNple care providers health records and maintain a personal
and/or receiving duplicate treatment health diary
acNviNes • Will be supported in the management of
• Poor, and in most cases zero, access to their care through automated monitoring of
personal health informaNon which is their health status and access to individual
stored in mulNple, fragmented silos care plans
across the health system • When consumers interact with the health
• Heavily reliant on individual care system, care providers will know who they
providers for access to reliable health are and have access to relevant details of
informaNon their health information
• Unequal access to health care services, • Will rely on the health system to effectively
parNcularly in remote and rural coordinate their care regimes and treatment
communiNes acNvities
• Largely responsible for coordinaNng their • Will have confidence that their health
own care delivery and acNng as the information is managed securely and
integrator of health care informaNon confidenEally
across the health system • Will have the ability to beGer manage their
• Limited security of personal health own health through access to reliable and
informaNon or ability to control who accredited sources of health informaNon
accesses it • Will have technology enabled access to a
broader and deeper range of health services
from within rural and remote communities

Care • S p e n d N m e c o l l e c N n g c o n s u m e r • Will have access to data that allows them to

Providers informaNon and duplicaNng treatment more effecEvely monitor and evaluate
acNviNes service delivery outcomes
• Risk the occurrence of adverse events • Will be able to electronically interact with
through incomplete informaNon and a consumers regardless of where they are
lack of access to decision support tools at geographically located
the point of care • Will be able to collaborate with other
• Work with incomplete and fragmented professionals by more easily sharing
informaNon when providing care to experNse and evidence
consumers • Will have an integrated and complete view
• Manually coordinate care with other of consumer health informaEon at the point
providers and exchange informaNon in an of care
inefficient, incomplete and ad hoc • Providers’ care decisions will be supported
manner by access to appropriate informaEon
• Limited means to monitor effecNveness sources and decision support tools at the
of service delivery outcomes point of care
• Limited ability to interact with consumers •
remotely

21
 Stakeholder Current State Future State
Group
• Will be able to share informaEon
electronically in a Emely manner across
different geographic locaEons and all parts
of the health sector
• Will be able to electronically order tests,
prescribe medicaEons and refer individuals
to other providers
• Will have easy access to clinical knowledge
and evidence sources to assist with skill
development

Health Care • Limited ability to share clinical and • Will be able to beGer respond in the case of
Managers administraNve management informaNon emergencies through real Nme monitoring
across the health sector of public health indicators
• Rely on incomplete, fragmented and • Will have access to Emely and complete
unNmely informaNon when trying to informaEon about health system activiEes
make decisions and outcomes
• Very difficult to meaningfully understand • Will be able to rapidly assess the naEonal
the naNonal impact of strategic, impact of parEcular treatment regimes via
operaNonal or clinical treatment access to naNonally aggregated clinical
decisions datasets
• Spend Nme trying to collect and manually • Will have a reliable and comprehensive
integrate informaNon from many evidence base to inform and monitor the
different data sources impact of clinical, policy, investment and
administraNve decisions

lllll

22
3. IDHIS STRATEGY

3.1. KEY STRATEGIC PRINCIPLES

There are several key principles that underpin and inform the proposed strategy and
approach.
✴ Stakeholder engagement - AcNvely engage key health care stakeholders in the design
and delivery of IDHIS soluNons
✴ Balancing alignment and independence - Drive alignment of naNonal HIS acNviNes
whilst not unnecessarily limiNng the ability of health care parNcipants and vendors to
implement locally relevant soluNons
✴ Incremental approach - Build of long term naNonal HIS capability in an incremental
and pragmaNc manner, focusing iniNal investment in those areas that that deliver the
greatest benefits for consumers, care providers and health care managers
✴ Recognising different starCng points - Balance acNve support for care providers with
less developed capability, while not constraining the ability for more advanced
parNcipants to progress
✴ NaConal infrastructure - Deliver core elements of enabling naNonal HIS infrastructure
once, rather than duplicaNng development costs and efforts and increasing the
likelihood of rework
✴ Leverage - More effecNvely leverage and scale IDHIS acNvity across the country
✴ Relevant skills - Ensure sufficient numbers of skilled pracNNoners are available to
support delivery of the naNonal HIS Strategy.
To ensure effecNveness and sustainability of IDHIS in Indonesia, the following principles will
guide and underpin the planning and implementaNon of the IDHIS strategy:
3.1.1. Guarantee of pa;ent informa;on rights, integrity, and confiden;ality in line with
emerging public health access needs
The implementaNon and use of IDHIS soluNons must place the highest importance on
the protecNon of paNent health informaNon to ensure privacy and integrity. However,
the protecNon of paNent informaNon has to be balanced with the need for the health
sector to manage public health for all ciNzens, such as noNficaNon of emerging diseases
or related outbreaks
3.1.2. Cost-effec;ve, efficient, and benefit-driven solu;ons in a limited resources environment
that lead to future growth poten;al
IDHIS must be concerned not just about ICT choices, but also about the relaNonship of
ICT choices to the benefits they bring in the health sector. It is not the technology
alone that will bring these benefits; rather it is the health sector business processes
that are changed by leveraging ICT which provide the business value, with the right

23
 level of organizaNonal buy-in. Therefore, the ICT investment and implementaNon shall
be driven by the value they provide to the Indonesia healthcare system and paNent
care.
3.1.3. Exploita;on of exis;ng structures and use of an incremental approach
Realizing an integrated naNonal HIS requires a long-term implementaNon plan that
builds from exisNng soluNons in an incremental and pragmaNc way while focusing in
strategic areas where IDHIS will bring more valuable outcomes and impacts.
3.1.4. Technology development, standardiza;on, and convergence
The themes underpinning developing the technology and standards that support IDHIS
will be the following:
✴ Focus on usability;
✴ Convergence on fewer and more reusable, cost-effecNve ICT systems that are
extensible, scalable, and manageable;
✴ Common standards and terminology across informaNon systems;
✴ Involvement of local partners in development and support of informaNon systems.
3.1.5. Collabora;on and consulta;on with stakeholders
The health sector involves many diverse stakeholders. Therefore, IDHIS
implementaNon requires effecNve collaboraNon and involvement of all the
stakeholders, including early adopters of key acNviNes and decision making in defining
IDHIS soluNons.
3.1.6. Strong leadership and governance mechanism
Successful implementaNon of the IDHIS Strategy depends on a strong leadership and
governance mechanism for planning, direcNng, and monitoring. Although at a higher
level the leadership will be provided through the IDHIS governance structure, a strong
leadership and governance mechanism for individual IDHIS projects is needed to
ensure the expected results are met.
3.1.7. Ensuring availability of local skilled human resources (HR) to ensure sustainability of the
IDHIS solu;ons
Development of IDHIS soluNons is complex and Nme consuming and requires
experienced professionals. Therefore, the development may involve internaNonal
professionals with pracNcal experience to ensure successful implementaNon of the
IDHIS Strategy. However, to ensure sustainability, the first priority should be given to
building local capacity before building more complex IDHIS soluNons.
3.1.8. Ensuring business con;nuity mechanism for implemented IDHIS system
This principle ensures that total cost of ownership is considered in deploying IDHIS
soluNons and a clear mechanism is in place to ensure that expected service levels are
met with minimum interrupNon and no possibility for loss of health informaNon.

24
3.2. STRATEGIC WORK STREAMS

In order to address these principles four major strategic streams of acNvity have been
idenNfied.
✴ IDHIS FoundaCons - Establishing the core foundaNons for electronic informaNon
exchange across the health sector. This work stream is fundamental as without the
basic ability to securely share health informaNon there will effecNvely be no naNonal
HIS capability.
✴ IDHIS SoluCons - SNmulaNng the delivery of IDHIS soluNons to the key users of health
informaNon. This work stream will facilitate the delivery of specific compuNng systems
and tools to address the high priority needs of consumers, care providers and health
care managers.
✴ Change and AdopCon - Fostering consumer, care provider and health care manager
adopNon of IDHIS. The aim of this work stream is to focus effort on achieving a ‘Npping
point’ of stakeholder adopNon of IDHIS soluNons as quickly as required.
✴ IDHIS Governance - Ensuring the effecNve leadership, coordinaNon and oversight of
the IDHIS work program. This work stream focuses on the establishment of
appropriate naNonal HIS governance structures and mechanisms.

IDHIS Strategy

Change and Adoption

Governance

IDHIS Solution

Information Service Delivery Information

Flow Tools Sources

Foundations

Figure 3-1. IDHIS Strategic Work Stream

ImplementaNon of the four strategic work streams needs to be undertaken in a Nghtly

coordinated and concurrent manner in order to effecNvely deliver the IDHIS work program.
Each work stream is highly dependent upon the success of the others.
Appropriate IDHIS foundaNons, in the form of compuNng infrastructure and consistent
informaNon standards, rules and protocols, are crucial to effecNvely sharing informaNon
across geographic and health sector boundaries. In this regard IDHIS foundaNons can be
viewed as analogous to an ‘informaNon highway’ – unless the system is connected up in some
uniform and rules based way, then informaNon cannot move across the network.
FoundaNons alone will not be of any value unless consumers, care providers and health care
managers have access to specific compuNng soluNons or tools to enable them to view and
share appropriate health informaNon. The implementaNon of naNonal IDHIS soluNons will

25
similarly be pointless unless consumers, care providers and health care managers are
moNvated to use these soluNons. This is a two way relaNonship as the quality of the
underlying IDHIS soluNons will also play a criNcal role in driving stakeholder take-up and
support of the IDHIS work program.
Finally it is unlikely that any of this can be achieved unless supported by a governance regime
which provides appropriate coordinaNon, visibility and oversight of IDHIS work program
acNviNes and outcomes.

3.3. STRATEGIC OBJECTIVES (SOs) AND INITIATIVES

The following are the IDHIS SOs, built around the four strategic work stream (noted above)
that are necessary to achieve the IDHIS vision and long-term health sector business goals.

3.3.1. IDHIS FoundaCons

The FoundaNons work stream focuses on implemenNng the basic infrastructural building
blocks required to enable the effecNve electronic sharing of informaNon across the
Indonesian health sector. These include the implementaNon of consumer and care provider
idenNfiers, establishment of standards, rules and protocols for informaNon exchange and
protecNon, and implementaNon of underlying physical compuNng and networking
infrastructure.
Establishing the naNonal foundaNons for IDHIS requires focused acNvity in five key areas:
✴ Iden;fica;on and authen;ca;on – There is a need to design and implement an
idenNficaNon and authenNcaNon regime for health informaNon as soon as possible as
this work will be absolutely fundamental to the naNon’s ability to securely and reliably
access and share health informaNon.
✴ Informa;on protec;on and privacy – The establishment of a robust privacy and
regulatory regime to authorise specific IDHIS iniNaNves, and ensure appropriate privacy
safeguards and consent processes for access to and use of health informaNon and
parNcipaNon in IDHIS iniNaNves.
✴ IDHIS informa;on standards – There is a need for a naNonal program of IDHIS
informaNon standards definiNon to underpin the consistent and accurate collecNon
and exchange of health informaNon.
✴ Investment in compu;ng infrastructure – A key barrier to IDHIS take-up is the relaNvely
poor quality of compuNng infrastructure (PCs, network connecNvity and core paNent,
clinical and pracNce management systems) across many parts of the Indonesian health
sector. There is a need to establish mechanisms to encourage care providers to invest
in the implementaNon and maintenance of an acceptable baseline of compuNng
infrastructure.
✴ Na;onal broadband services – A key foundaNon of the naNonal health informaNon
highway will be access to naNonal broadband services that provide connecNvity
between all Indonesian care providers. There is a need to engage and collaborate with

26
 relevant government and telecommunicaNons organisaNons to extend planned
broadband connecNvity infrastructure to all Indonesian health care providers as soon
as possible. As part of this process, there should be a focus on ensuring that naNonal
communicaNons infrastructure will be fit for IDHIS use and is priced in a manner that
does not discourage the sharing of health informaNon across geographic and health
sector boundaries.
The proposed standard objecNves for the IDHIS FoundaNon are:

Establish IDHIS standards, rules, and protocols for informa;on exchange and
SO.01
protec;on.

Although there are widely accepted internaNonal HIS standards, it is necessary to

localize and formally adopt them in the Indonesia environment. Therefore, in this
SO, the MoH intends to establish naNonally adopted standards, rules, and protocols
to enable the implementaNon of affordable, cost-effecNve, and accessible
technology that complies with these standards.
๏ Strategic Ini;a;ves:
✴ Establish IDHIS informaNon standards (e.g., Health Level Seven [HL7] standards,
InternaNonal ClassificaNon of Diseases [ICD], business coding).
✴ Establish a privacy and regulatory framework to ensure appropriate privacy
safeguards and consent processes for access to and use of health informaNon.

Establish comprehensive health facility, provider, and client registries with complete
SO.02
and current informa;on that meets stakeholders’ needs.
The MoH recognizes that developing and maintaining comprehensive master lists of
health faciliNes, providers, and clients is a necessary step toward monitoring health
infrastructure and services, and that these lists form a core component of the
naNonal HIS. InternaNonal best pracNce in IDHIS focuses on developing facility,
provider, and client registry systems that can be used to manage comprehensive
master lists of health faciliNes, providers, and clients respecNvely. Therefore, in this
SOs, the MoH intends to establish comprehensive master lists of faciliNes, providers,
and clients, and implement a standard facility registry system that is interoperable
with exisNng systems (i.e., District Health InformaNon System 2 [DHIS 2], hospital
referral informaNon system [HRIS], human resources for health informaNon system
[HRHIS], etc.).
๏ Strategic Ini;a;ves:
‣ Develop a harmonized data element specificaNon for the health facility, provider,
and client registries.
‣ Provide support to the revised registraNon process for public and private faciliNes
and providers.
‣ Implement the facility, provider, and client registry system.
‣ Develop management and maintenance guidelines for facility and provider
registries.

27
 Enhance ICT infrastructure and services to improve communica;on and informa;on
SO.03
sharing across the health systems and at all levels
ICT infrastructure forms the foundaNons for electronic communicaNon and
informaNon sharing across geographical and health-sector boundaries. This includes
the network connecNvity and core services that underpin an IDHIS environment. The
health sector is sNll characterized by limited and inadequate ICT infrastructure,
which presents significant obstacles to the deployment of Ina-Health services.
Therefore, in this SO the MoH intends to coordinate with MoCIT to establish a cost-
effecNve and affordable ICT infrastructure to support communicaNon and sharing of
informaNon across the conNnuum of the healthcare system.
๏ Strategic Initia;ve
‣ Facilitate health sector insNtuNons, including health faciliNes, to establish ICT
strategic plans that are aligned with their respecNve business funcNons and
prioriNes.
‣ Coordinate and support health sector insNtuNons, including health faciliNes, to
establish sustainable ICT infrastructure and services.
‣ Support health sector insNtuNons to be connected to the naNonal opNcal fiber
network as a priority in order to share a common connecNvity advantage.
‣ OperaNonalize an informaNon-sharing policy to facilitate open sharing of
informaNon, meeNng all privacy laws.

3.3.2. IDHIS SoluCons

The IDHIS SoluNons work stream focuses on the naNonal acNons that are required to
encourage the development and use of high priority IDHIS that improve the efficiency and
effecNveness of Indonesia health care delivery. These IDHIS soluNons represent the tangible
means by which consumers, care providers and health care managers will electronically
interact with the health system.
A great number of individual IDHIS soluNons have been implemented, or are in the process of
being implemented, across the Indonesian health sector with limited coordinaNon,
standardisaNon or integraNon. The focus of this work stream is to harness and align this
significant naNonal IDHIS acNvity to drive towards a desired set of naNonal outcomes.

Strengthen an electronic HR system to improve planning and management of health

SO.04
professionals at all levels
The Human resources for health (HRH) Portal has been senled, which conducted by
BDEHR. This portal connects the medical and dental informaNon system, which
managed by The Indonesian Medical Council (IMC), the pharmacist informaNon
system, which managed by the NaNonal Pharmacy Comminee (NPC), and the health
work force informaNon system (except medical, dental and pharmacist), which
managed by the Indonesian Health Workers Assemblies (IHWA). These three bodies
are data sources of registered health workers, who have received permission to
carry out health services to paNents.

28
 In this SO, the Ministry intends to integrate the BDEHR portal with the portal of
Ministry of EducaNon (MoEd), portal of Health-BPJS and portal of provincial as well
as district health office (PHO and DHO) to enable collecNng historical data of each
health workers, concerning the history of educaNon and training, as well as profiles
and performance in health care
๏ Strategic Ini;a;ves:
‣ IdenNfy and integrate exisNng HR systems into the BDEHR portal.
‣ Refine processes for managing and maintaining the health professional provider
registry.

Enable healthcare workers to have access to con;nuous professional development

SO.05
through e-learning and digital resources.
Included in the HRH strategies is the aim to increase producNon and improve quality
of training (pre-service, in-service, and conNnuous educaNon). A well-educated
workforce is vital to the discovery and applicaNon of healthcare pracNces to prevent
disease, promote well-being, and increase the quality life-years of the public.
Although there are several iniNaNves toward improving healthcare delivery through
the use of ICT, these iniNaNves usually overlook a criNcal need of using ICT to
improving quality by developing and maintaining a well-trained workforce of health
professionals. Therefore, in this objecNve, the Ministry plans to adopt the use of ICT
to develop and provide conNnuous educaNon to its health professionals. .
๏ Strategic Ini;a;ves:
‣ Develop and approve methodology for delivering blended learning, including
basic ICT training for health workers to enable them to use blended learning.
‣ Develop program and electronic content for various health professionals.
‣ Implement health sector e-learning plagorm.
‣ Develop digital resources to enable offline learning for areas with limited Internet
access along with online learning.

Strengthen disease preven;on, surveillance, and control by using a hybrid ICT

SO.06
solu;on to facilitate early detec;on and rapid repor;ng and response
Disease prevenNon and control strategies aim to improve disease surveillance and
enhance community parNcipaNon in health promoNon and disease prevenNon. The
use of Nmely informaNon is essenNal for effecNve detecNon of as well as rapid
reporNng and response to infecNous diseases. However, much of the current
informaNon is inaccessible, incomplete, or missing due to the lack of well-
coordinated and funcNonal disease surveillance systems. Therefore, in this SO, the
Ministry intends to use ICT to implement efficient, flexible, and comprehensive
systems to conduct infecNous disease surveillance and response as well as health
educaNon and promoNon.

29
 ๏ Strategic Ini;a;ves:
‣ Implement an electronic integrated diseases surveillance and response system
that is linked to the HMIS system.
‣ Implement an electronic informaNon system (including the use of television,
radio, etc.) to provide health educaNon
and promoNon.

Strengthen an electronic HMIS to support evidence-based health care and decision

SO.07
making.
M&E strategies aim to strengthen HMIS to improve evidence-based health care and
decision making for both clinical acNons and administraNon. The MoH has adopted
DHIS 2 as its core HMIS sofware, which includes M&E reporNng, data management,
and some HMIS data warehouse funcNons. The MoH has successfully completed its
pilot use of DHIS 2 and is currently scaling up its use for naNonal coverage. However,
much of the data, such as data from verNcal programs, community-based health
data, and data from specialized referral hospitals, are sNll lacking. Therefore, for this
objecNve, the Ministry intends to strengthen the HMIS system by integraNng exisNng
system, verNcal program, referral data, and community-based health data into DHIS
2, and developing a true data warehouse that can be used to support this strategic
area as well as others.
๏ Strategic Ini;a;ves:
‣ Integrate/link related informaNon systems and verNcal programs (HIV/TB/
malaria) HMIS informaNon into DHIS 2.
‣ Collect and integrate/link community-based health informaNon and services
‣ Collect and integrate/link health data from referral hospitals into DHIS 2.
‣ Implement a community-based HIS that is linked to the HMIS sofware.

Enable electronic delivery and interven;ons of health services to reduce child

SO.08 mortality; maternal mortality; and the burden of HIV/AIDS, TB, malaria, and non-
communicable diseases.
MoH is commined to the achievement of the Millennium Development Goals. The
plan includes strategies to improve access and quality of maternal, newborn, and
child health (MNCH) services delivery. In addiNon, HIV/AIDS, TB, and malaria are
among the most important infecNous diseases in Indonesia; therefore, the control,
or eradicaNon in the case of malaria, is among the Ministry’s strategies. Overall, the
assessment confirmed that the delivery of MNCH services as well as HIV and TB
intervenNons are difficult to monitor because of lack of informaNon and inadequate
data management across the service conNnuum. Therefore, in this SO, the Ministry
intends to use ICT to improve access to paNent data and improve health services in
health faciliNes. In addiNon, the objecNve includes using ICT to provide health
educaNon between clients and health workers as well as among health workers
themselves.
The prevalence of major non-communicable diseases (e.g., high blood pressure and

30
 diabetes) is rapidly increasing and presents a challenge to our health system and its
limited resources. These chronic diseases require records for clinical follow-up and
monitoring, and their prevenNon is possible through ICT-enabled community
intervenNons including health educaNon.
๏ Strategic Ini;a;ves:
‣ Implement and promote an electronic system (including mHealth services) to
enable paNent tracking, monitoring, idenNficaNon and referral of at-risk paNents,
provision of accurate informaNon to paNents, and improvement of
communicaNon with health faciliNes in emergency cases.
‣ Implement and promote an electronic medical records (EMR) system with clinical
decision support tools for reproducNve and child health services, HIV/AIDS, TB,
malaria, and non-communicable diseases (i.e., diabetes).
‣ Implement and promote health informaNon exchange and a shared health record
to allow sharing of informaNon among health providers.
Enable an electronic logis;cs and supplies system to ensure adequate quality and
SO.09 quan;;es of health commodi;es are always available at the point of service to meet
pa;ent demand
The medicine and supplies strategy aims to build the capability to provide managers
and facility administraNons with accurate and current medicine demand and use
data. The use of quality, Nmely logisNcs data is essenNal for effecNve supply chain
management and efficient procurement of needed supplies. However, much of the
current logisNcs data is inaccessible, incomplete, or missing, as is the availability of
true demand informaNon, making supply chain decision making challenging for the
MoH and its development partners. Therefore, in this SO, the Ministry intends to
develop a technology plagorm that will incorporate the exisNng system (enterprise
resource planning [ERP], warehouse management system [WMS], etc.) to assist in
data collecNon, disseminaNon, and processing.
๏ Strategic Ini;a;ves:
‣ Implement a naNonwide electronic LogisNc Management InformaNon System
(LMIS), leveraging exisNng systems.
‣ Integrate the system with exisNng ERP, WMS, IDHIS, and HMIS systems.

Enable electronic financial management to ensure effec;ve collec;on, alloca;on,

SO.10 and use of health financial resources at all levels in accordance with health plan
priori;es.
Hospital reforms and healthcare financing strategies aim to improve the quality,
equity, and availability of hospital services by enhancing the raNonality and the
efficiency in hospital resources management. With reference to current pracNces,
two main areas of improvement toward the introducNon of electronic financial
management pracNces are idenNfied: (1) comprehensive planning, budgeNng, and
reporNng between central level and recipients (district, region, and naNonal) and (2)
control of cost, revenue collecNon, capture of all financial transacNons, and
management of all resources in health faciliNes.

31
 ๏ Strategic Ini;a;ves:
‣ Implement a hospital management informaNon system (Hos-MIS) to manage
health financial and HR informaNon in the health faciliNes.
‣ Implement a data warehouse to foster and support more highly informed
decision making by ADEHR of MoH and other stakeholders on health sector
resources.
‣ Implement an integrated planning sofware system to support a comprehensive
PasdaNn health profile.
‣ Implement improved communicaNon and remote financial services for rural
workers.

Enable electronic communica;on and informa;on sharing mechanism for the

SO.11
referral system to improve quality of service.
Included in the referral hospital services strategies is the aim to improve quality of
service. Access to medical specialists is a challenge because the health sector
experiences limited health resources. The problem is aggravated by inefficient
processes; it is very common for paNents to be referred to a specialist without
adequate informaNon about their condiNons, a prior examinaNon, or clear quesNons
for the specialty consultant. Such poorly organized referrals result in wasted or
ineffecNve specialty visits that further worsen access to specialty care and impede
quality of care. To address these challenges, the Ministry intends to use ICT to
effecNvely communicate and share informaNon between primary care and specialty
care providers.
๏ Strategic Ini;a;ves:
‣ Develop health professional collaboraNve network using mobile device
technology following agreed-upon usage guidelines for clinical assistance.
‣ Implement an electronic referral system with mulNple data entry and reporNng
mechanisms (VoIP, mobile, Internet) for providers, management, and clients.

Enable electronic management of social welfare services, beneficiaries, and

SO.12
providers to improve access and quality of service delivery.

Social welfare and protecNon strategies aim to improve social services and
protecNon of vulnerable groups in the society. Although there are several iniNaNves
by the government of Indonesia, NGOs, and private insNtuNons that provide social
services, the actual needs in the country are not yet fully mapped. In addiNon, social
welfare is fragmented and mostly insNtuNon-based. Understanding and calculaNng
how and where to allocate the limited resources is difficult. To provide these
services, there is a need to store and organize informaNon related to social need,
providers, and target beneficiaries. Therefore, in this objecNve, the Ministry intends
to use ICT to enable monitoring of social service provision and demand across the
country.

32
 ๏ Strategic Ini;a;ves:
‣ Implement social welfare service informaNon system for managing and
monitoring of social services, beneficiaries, and providers.

Establish an electronic water, sanita;on and hygiene (WASH) management

SO.13 informa;on system to support evidence-based planning and investment in service
delivery
Improving access to water and sanitaNon is a target under Millennium Development
Goal 7. Access to safe water and basic sanitaNon, and adopNon of good hygiene
pracNces is vital to everyone’s life. Safe water sources, basic sanitaNon, and
improved hygiene pracNces can prevent water related diseases, other illnesses and
death. The use of quality and Nmely water, sanitaNon and hygiene (WASH)
informaNon by stakeholders is essenNal for effecNve planning and investment in
service delivery. However, much of the current informaNon about water, sanitaNon
and hygiene is inaccessible, incomplete, or missing. In this strategic objecNve, the
MoH intends to use ICT soluNons to address the informaNon gaps in the WASH
sector by transforming the way WASH data is generated, communicated, shared and
used.
๏ Strategic Ini;a;ves:
‣ Implement an electronic (mobile phone supported) informaNon system to
support the management and monitoring of WASH service delivery
‣ Integrate the WASH system with the HMIS sofware system

Establish telehealth services to enable electronic delivery of quality health care to

SO.14
individuals in remote areas lacking needed exper;se.

Referral hospital services strategies aim to increase access for paNents in need of
advanced medical care and improve quality of clinical services in hospitals.
Telehealth is the delivery of health-related services and informaNon through the use
of ICT in contexts where the providers and clients are in separate locaNons.
Telehealth is used to improve access to medical services that would ofen not be
consistently available in remote communiNes that lack needed experNse. In this SO,
the Ministry intends to use ICT to implement telehealth and tele-educaNon services
to enable provision of healthcare services at a distance.
๏ Strategic Ini;a;ves:
‣ Develop telehealth services and program.
‣ Implement required telehealth infrastructure.
‣ Implement telehealth services.

3.3.3. Change and AdopCon

The Change and AdopNon pillar’s SO focuses on what needs to be done to encourage and
enable parNcipants in the healthcare system to adopt IDHIS soluNons and change their work
pracNces to be able to use these soluNons effecNvely.

33
The majority of IDHIS adopNon and change acNviNes should be undertaken and managed at
local and regional levels across the Indonesian health system. There is a need, however, for
some naNonal strategies to accelerate the adopNon of IDHIS in Indonesia across the health
sector. This includes a coordinated program of awareness, training and educaNon, and
incenNve and compliance programs. The targets of these programs are consumers, care
providers, health care managers and vendors, with a parNcular focus on driving the adopNon
of IDHIS soluNons across Indonesian consumer and care provider communiNes.
Where IDHIS has been successfully implemented local or regional, it has typically been led by
pockets of the care provider community. In the majority of cases, however, there has been a
consistent and significant underesNmaNon of the effort required to engage and support care
providers in the adopNon of IDHIS soluNons. These IDHIS iniNaNves have demonstrated that
care providers will not adopt IDHIS without clearly understandable benefits to themselves
and to their paNents, or if any soluNon imposes inefficiencies within the care delivery process.
Based on this experience, there is an emerging realisaNon that winning the hearts and minds
of Indonesian health care parNcipants will be a criNcal factor in determining the ulNmate
success of the naNonal IDHIS agenda.

Establish a comprehensive change and adop;on strategy to promote and enforce

SO.15 the development and use of IDHIS solu;ons for both public and private ins;tu;ons
at all levels.
Although IDHIS has proved to bring about genuine potenNal benefits in many
countries, several pracNcal experiences indicate that the obtained benefits can vary
greatly depending on several factors, including the willingness of the actors to use
IDHIS soluNons to interact with the health system. Therefore, to ensure the
maximum benefit is obtained from the IDHIS investment, the Ministry intends to
establish a comprehensive change and adopNon strategy to promote and enforce
the use of these soluNons at all levels in the health system.
๏ Strategic Ini;a;ves:
‣ Establish naNonal awareness and educaNon campaigns on IDHIS programs.
‣ Review exisNng health facility and provider accreditaNon regulaNons to enforce
the use of IDHIS soluNons and required standards.
‣ Promote and empower local companies with the capacity and capability to
develop and maintain large-scale IDHIS soluNons.

3.3.4. IDHIS Governance

The IDHIS governance strategic objecNves focus on establishing the appropriate IDHIS
governance to provide leadership, coordinaNon and oversight to ensure successful delivery of
IDHIS.
The current naNonal IDHIS governance arrangements have supported improved coordinaNon
between PHO/DHO and the Government Referral Hospital in the oversight of their respecNve
health informaNon management responsibiliNes. However, the current arrangements are not
sufficient to provide effecNve governance of the naNonal IDHIS agenda. This is due to factors

34
such as a lack of organisaNonal capability or capacity to deliver the naNonal IDHIS strategy
and work program, a high reliance on collaboraNon between disparate comminee, sub-
comminee and working groups, and the relaNvely limited representaNon of key health
stakeholders in decision making processes.
There is a set of governance principles that should underpin the design of a naNonal IDHIS
governance structure.

Table 3-1. IDHIS Governance Principles

Governance Principle DescripCon
Clarity of accountability • Ensure clear decision making accountability and provide all stakeholders with
clarity regarding their roles and responsibiliNes
Transparency • Provide widespread visibility of the progress of IDHIS acNviNes
Appropriate stakeholder • Provide a forum for representaNon across all key stakeholder groups
representaCon • Ensure broad ownership and a balanced approach to the delivery of IDHIS
Sustainability • Implement a governance model that will not be unduly impacted by changes to
the poliNcal or stakeholder environment
Support for acCvity at • Recognise that IDHIS governance will need to support iniNaNves that deliver IDHIS
mulCple levels capability at differing levels of granularity
EffecCve leadership and • EffecNve leadership and coordinaNon of the range of acNviNes that need to occur
coordinaCon across all naNonal E-Health work streams
Balance local innovaCon • ConNnue to encourage local innovaNon while ensuring that the development of
and naConal outcomes E-Health soluNons supports naNonal E-Health outcomes

Establish and ins;tu;onalize an IDHIS governance structure to ensure effec;ve

SO.16
management and oversight of IDHIS Strategy implementa;on.
For successful implementaNon of the IDHIS Strategy, a well-defined governance
structure is required to provide improved visibility, coordinaNon, and control of
IDHIS acNviNes that are occurring across the country’s health sector. The governance
structure needs to incorporate the assembly of a management team and technical
team to combine the knowledge, skills, and stakeholder needs in a way that absorbs
and takes advantage of stakeholder contribuNons on a conNnuous basis. The main
components of the IDHIS governance structure are the PusdaNn and eHNCB. In this
SO, the Ministry intends to empowering as well as defines and insNtuNonalize these
components.
๏ Strategic Ini;a;ves:
‣ IDHIS governing board – Establish a naNonal governing board for IDHIS that
reports to the PusdaNn as the work unit MoH for ICT authority, has an
independent chair and a breadth of cross sectoral stakeholder representaNon.
The IDHIS governing board, namely eHealth NaNonal CoordinaNng Body (eHNCB),
should have accountability for sevng overall naNonal IDHIS direcNon and
prioriNes, for reviewing and approving IDHIS strategy and funding proposal and
for the monitoring of progress against IDHIS strategy deliverables and outcomes.
‣ IDHIS en;ty – Establish a IDHIS enNty to coordinate and oversee the IDHIS
strategy, investment and the execuNon of the naNonal components of the IDHIS
work program. The IDHIS enNty’s operaNng model should support discrete

35
 funcNons focused on strategy, investment management, work program
execuNon, standards development and IDHIS soluNons compliance. The IDHIS
enNty should be overseen and governed by the eHNCB. [ see appendix B]
‣ IDHIS regula;on func;on – Establish a IDHIS regulatory funcNon to implement
and enforce IDHIS regulatory frameworks. Regulatory frameworks should cover
areas such as the establishment and implementaNon of unique health care
idenNfiers for individuals, care providers and care provider organisaNons, the
integrity, privacy and security of personal health care informaNon, and the
licensing condiNons and compliance arrangements for electronic health record
operators.

lllll

36
4. IDHIS ENTERPRISE ARCHITECTURE

4.1. DEVELOPMENT METHODOLOGY

There are some policies and documents that will be used as guidelines by the MoH as the
legal framework for supporNng the IDHIS development as well as to set priority targets
✴ The IDHIS, which consists of seven informaNon building blocks [14 ]. The building blocks
of itself is not a system, but merely a grouping system of similar informaNon that will
be collated into a building [see Appendix C]
✴ InternaNonal and regional strategic priority agenda
• WHO Country CooperaNon Strategy (CCS) Agenda 2013-2017 [15], which consist five
strategic prioriNes agents. [see Appendix D]
• The Roadmap for Health Measurement and Accountability [16]. A Common Agenda
for the Post 2015 Era [see Appendix E]
• Asia eHealth InformaNon Network, Regional eHealth Strategic Plan: 2012-2017
ImplementaNon Plan. [see Appendix F]
✴ The Ministry of Health Strategic Plan Year 2015-2019 [17 ], which includes Improving
Health InformaNon Systems IntegraNon as one of the targets of achievement. This
strategy will be carried out through the following programs:
• Developing a "real Nme monitoring" for the enNre Program Performance Indicators
(PPI) and AcNvity Performance Indicator (API) of the Ministry of Health.
• Improving the ability of human resources informaNon management at the district /
city and province, so that the health profile will be issued T + 4 months, or it could
be published every April.
The next strategy is the strategic process of internal MoH , which should be managed
in excellent, namely increased synergy between Ministries/Agencies, Central and
Regional, Increased Partnership Home Affairs and Foreign Affairs, Increased IntegraNon
Planning, Technical Assistance and Monitoring EvaluaNon and Increasing EffecNveness
and Development.
✴ Other naNonal ICT related policies that has to be considered as guideline
• InformaNon and Electronic TransacNons [18]
• Public InformaNon [19]

14 Government Regulation No. 46 Year 2014 on Health Information Systems

15 Country Cooperation Strategy at a Glance, Indonesia. Global Health Observatory April 2014 http://apps.who.int/gho/data/node.cco
16 MA4Health: The Roadmap for Health Measurement and Accountability. Common Road Map Steering Committee http://
ma4health.hsaccess.org/partners
17 Five Years Strategic Plan of the Ministry of Health from 2015 to 2019
18 Act No. 11 of 2008 on Information and Electronic Transactions.
19 Act No. 14 of 2008 on Public Information

37
 • Data CommunicaNon in Integrated Health informaNon System [20]
✴ Reports, publicaNons and documents concerning the results of the assessment or
survey [21], [22], [23]
Methodology used to develop and/or update the IDHIS and Plan is as follows:
1. Review of the naNonal health prioriNes of the country; current IDHIS context;
assessments, findings and recommendaNons; planned strategies and acNviNes; and
environment to gain bener understanding and focus
2. Review of the exisNng IDHIS Framework - vision, mission, goals, and objecNves and
the IDHIS Toolkit.
3. Review of the exisNng priority focus areas and idenNficaNon of acNviNes required to
deliver the IDHIS vision.
4. Hold series of focus group discussions to comment and provide recommendaNons on
the exisNng IDHIS Strategic Framework and Plan.
5. Review of the outputs of the focus group discussions.
6. UpdaNng or refining of the exisNng IDHIS and Plan based on the review of outputs.
Facing many challenges that must be resolved by the eHNCB, both in solving the problem
which has been running as well as the complexity of the new challenges due to the
development needs of the environment, the preparaNon to form the eHNCB also needs to be
done comprehensive. Various aspects, which will be the scope of the eHNCB's work is
presented in the [see Appendix G].

4.2. GUIDING PRINCIPLE

In alignment with the NHNSF (WHO-ITU), the successful deployment of IT soluNons in public
organizaNons relies, among other factors, on the presence of clear IT strategic goals and on
the efficient integraNon of IT into government organizaNonal development. It clearly indicate
that the success or failure of such projects is caused by the role of top management rather
than technological issues. One of the major factors that contribute to the project failure is the
weakness in project management. Therefore MoH and each party involved in making
decisions or managing the development of IDHIS need to understand the factors that lead to
success or failure of an ICT project and working consistent with the principles that will reduce
the failure and enhance the success of naNonal ICT development.

20 Regulation of Health Ministry of Republic of Indonesia No. 92 Year 2014 on Management of Data Communication in Integrated Health
information System
21 Health Metrics Network, Indonesia Health Information System Review and Assessment. Ministry of Health. 2007
22 Statistics Indonesia, National Population and Family Planning Board, Ministry of Health, Jakarta, Indonesia and measure DHS, ICF
International, Calverton, Maryland, USA: Indonesia Demographic and Health Survey 2012. August 2013
23 The Landscape Analysis Indonesian Country Assessment Final Report 6 September 2010

38
4.2.1. Reducing Risk of Failure
Government’s InformaNon and CommunicaNon Technology (ICT) projects have become
notorious for running far behind schedule and failing to deliver the expected benefits. A
survey in 2005 discovered that 31% of InformaNon Systems (IS) projects failed to deliver on
Nme and another 31%, within budget, more than 50% of IS projects were not completed on
Nme or on budget, 5% of the projects were stopped before they were even completed. Most
large IS projects will exceed their original budgets and Nmelines by more than 50% and this
occurs much more ofen in the government than in the private industry. In addiNon to that,
there are evidence that “runaway” projects occur frequently, and new empirical evidence
that they occur more ofen in government organizaNons [24]
There are many ways to measure success or failure, but there is no clear dividing line
idenNfying the two. It is almost impossible to arrive to an agreement as to whether a project
succeeded or failed [25]. Anyhow, it may be useful to view them as being subjecNve judgments
when trying to make sense of the ambiguity of noNons of success and failure. For the purpose
of assuring consistency, the failure definiNon will adopt three resoluNon types as follow [26];
✴ Total Failure: An ICT project which has ended up as not being implemented, or a new
project that has been implemented, but eventually abandoned.
✴ Par;al Failure: Major goals of the ICT project have not been anained or significant
undesirable outcomes are experienced. A reasonably clear form of parNal failure is
sustainability failure where a project succeeds iniNally, but then fails afer a year or so.
✴ Success: An ICT project anains its major goals and does not experience significant
undesirable outcomes.
To avoid repeated failures that can be viewed from different dimension [see Appendix H], the
following table shows the grouping of the root causes of failure which can be used as general
idea for the Business Process Reengineering (BPR) in an ICT project that is being or will be
implemented [27]
Table 4-1. Classified Failure Factors
Failure Factors Classified Symptoms from the Field into Failure Types
Dimensions Project Failure Systems Failure User Failure
1 Lack of user involvement.
2 Mismanaging of project risk.
3 Inadequate esNmaNon of
work.
Project
4 Breaching of contract.
1 Management
Factors 5 Lack of project plan.
6 Lack of skills and knowledge in
project management

24 Nawi HSA., Rahman AA., Ibrahim O.: Government ICT Project Failure Factors: Project Stakeholders’ Views. Journal of Information Systems
Reserch and Innovation. ISSN: 2289-1358. http://seminar.utmspace.edu.my/jisri/
25 Lang RD., "Poject Leadership: Key Elements and Critical Success Factors for IT Project Managers," Journal of Healthcare Information
Management, vol. 21, 2007.
26 R. Heeks. (2002, October, 2011). Failure, Success and Improvisation of Information Systems Projects in Developing Countries. Available:
http://www.sed.manchester.ac.uk/idpm/publications/wp/di/di_wp11.pdf.
27 Al-Ahmad W., et al., "A Taxonomy of an IT Project Failure: Root Causes," International Management Review, vol. 5, pp. 93-106, 2009.

39
 Project
1 Management
Factors
Failure Factors Classified Symptoms from the Field into Failure Types
Dimensions Project Failure Systems Failure User Failure

7 Inadequate ICT background for

Project Managers.
Top
2 Management 1 Incompetent in making decision on selecNng ICT projects.
Factors
The design and technology
1 used not inline with the
current technology.

2 Low quality of the end

products.
3 Technology
Factors Low or no compaNbility
1 between new system and
the exisNng systems.

4 Insufficient required hardware

to interact with the systems.
1 Inadequate cost esNmaNon.
2 ReducNon of Project Cost.
3 Lack of ICT manpower in
several public agencies.
Organizational 4 Full of bureaucracy (especially
4 for decision making).
Factors
5 Process of project payment not
smooth.
Resistant to adapt to the new
systems (not enough Nme to
interact with the systems).
1 Project too big and complicated (ambiNous).
5 Complexity /
Size Factors 2 UnrealisNc expectaNons from
the project champion.

1 No feasibility study
conducted.
2 No project selecNon process carried out.
3 No BPR process
conducted.

4 No standard methodology in
place.
6 Process
Factors 5 End user does not involved in user acceptance process.
6 User requirement not met.
7 No systemaNc and appropriate project evaluaNon process.
IneffecNve communicaNon
among the vendor and
8 user during requirement
gathering
Note: • Project failure: the project does not meet the specification agreed upon, including the functional requirements,
budget, or completion deadline;
• System failure: the system does not work properly, including expected performance, not being used in the way
intended, or used as intended but does not deliver the expected benefits, or
• User failure: the system is not used in the face of user resistance because of such things as recalcitrance, lack of
training and ability of staff, and the complexity of the new system.

The above table shows that failure can be categoised as project failure, system failure and
user failure, where these failures can be found in different factors

40
4.2.1.1. Project Management Factors:
The issues of not meeNng the user requirement were common issues arising in most of
the projects. Controlling and managing risk in ICT projects is considered to be a major
contributor to project success. Not managing the project risk unNl it became a problem
is a major cause of project failure. A bener risk management, as a project and
organizaNonal capability, is criNcal for ICT project success in the public sector
environment. For this reason, a Project Manager must have project management skills
and good characterisNcs (have the ability to organize, could communicate and deal
with people, and could create and maintain good relaNonships). In addiNon to this,
another common scenario is the failure to involve the right people for the project
because of ‘office poliNcs’ during the project implementaNon. An example of this is
favoriNsm, where the selected person is the favorite person of the person in charge of
the department.

4.2.1.2. Top Management Factors:

Inappropriate ICT knowledge, lack of familiarity, and background among the top
management who were selected and decided on the project with the target
technologies will cause inaccurate decision and eventually contribute to the project’s
failure.

4.2.1.3. Technology Factors:

Many technology factors can appear as the cause of failure, among others
a. The developers fail to align the system design and technology used with the current
technology, which resulted into inappropriate systems with old design and obsolete
technology. This always occurred with the overextended schedule project.
b. The person responsible and accountable not possessing appropriate ICT
background.
c. ICT systems ofen have to be connected to other systems already in operaNon.
CompaNbility between ICT systems – already a major issue within a single agency –
becomes especially challenging where a number of agencies are involved.
d. The selecNon of vendor that could deliver good products in term of interoperability
and compaNbility is another factor that is important in ensuring the projects’
success.

4.2.1.4. OrganizaConal Factors:

There are cases where the average cost of a project has been reduced by the
government due to the economy downturn scenario. In other cases, there are agencies
or the project champions which did not accurately complete the project cost
esNmaNon which resulted in budget overruns.

4.2.1.5. Complexity / Size Factors:

Size and complexity of the projects also cause delay and frequent budget overruns. The
number of agencies involved is too high and it becomes complicated because their

41
 business processes are related and require exchange of informaNon. Central steering
of the project is difficult or someNmes even impossible in these cases. Probably 70% of
IT project failure is due to poliNcs, adding so much cost and complexity that the project
exceeds the cost or benefits.

4.2.1.6. Process Factors:

There are many process related factors that can contribute to the failure of project,
among others:
a. There is no business process reengineering (BPR) takes place before the project
starts although the project is big and complex.
b. There is no standard methodology used during the project execuNon. As a result,
monitoring of the projects become difficult. In terms of gevng user involvement in
the project, in most cases, the vendor or developer team failed to obtain full user
involvement especially during the user acceptance test. As a result, users do not
use the system afer it is implemented. This happens due to the systems not
meeNng their requirements and work process.
c. There is no project selecNon process, project is given without any prior feasibility
study.
d. The selecNon of the project is not based on government strategic plan
e. There is an absence of an appropriate ICT project evaluaNon process on the part of
the government.

4.2.2. Strengthening Success Factors

To strengthen the achieve the vision for the future interoperable health IT ecosystem, the
concept of the IDHIS enterprise architecture will be developed in alignment with a set of
guiding principles [28]:
✴ One size does not fit all,
To prevent the system implementaNon failure caused by the wide gap between design
and reality, innovator and technologists should have the chance to use the experience
(the feel and funcNon of tools) in order to best meet the user’s needs based on the
scenario at hand, technology available, workflow design, personal preferences, and
other ICT environment factors.
✴ Maintain modularity.
Complex systems are more resilient to change when they are divided into independent
components that can be connected together. Because medicine and technology will
change over Nme, we must preserve systems’ abiliNes to evolve and take advantage of
the best of technology and health care delivery. Modularity creates flexibility that
allows innovaNon and adopNon of new, more efficient approaches over Nme without
overhauling enNre systems.

28 Connecting Health and Care for the Nation: A Shared Nationwide Interoperability Roadmap. https://www.healthit.gov/sites/default/files/
ONC10yearInteroperabilityConceptPaper.pdf

42
✴ Leverage the market.
Demand for interoperability from health-IT users are a powerful driver to advance our
vision. As payment and care delivery reform increase demand for interoperability and
bridging among health informaNon systems, the government will support to the
implementable interoperable and bridge applicaNons and tools as part of the health
informaNon exchange program.
✴ Build upon the exisEng health IT infrastructure.
Interoperability requires technical and policy conformance among networks, technical
systems and their components. It also requires behavior and culture change on the
part of users. In the era of Universal Health Coverage (UHC), the interoperability
between health care system and payment system are requires to be align, online and
in line. Significant investments for these systems development have been made in
health IT across the care delivery system and in other relevant sectors that need to
exchange informaNon with individuals and care providers. To the extent possible,
project iniNaNng should be encouraged to build from exisNng health IT infrastructure,
increasing interoperability and funcNonality as needed.
✴ Simplify.
Where possible, simpler soluNons should be implemented first, with allowance for
more complex methods in the future.
✴ Focus on value.
Striving to make sure that our interoperability efforts yield the greatest value to
individuals and care providers; improved health, health care, and lower costs should be
measurable over Nme and at a minimum, offset the resource investment.
✴ Consider the current environment and support mulEple levels of advancement.
Not every clinical pracNce will incorporate health informaNon technology into their
work in the next 3-10 years, and not every pracNce will adopt health IT at the same
level of sophisNcaNon. We must therefore account for a range of capabiliNes among
informaNon sources and informaNon users, including EHR and non-EHR users, as we
advance interoperability. Individuals and caregivers have an ongoing need to find,
send, receive, and use their own health informaNon both within and outside the care
delivery system and interoperable infrastructure should enable this.
✴ Empower individuals.
Members of the public are rapidly adopNng technology to manage numerous aspects
of their lives, including health and wellness. However, many of these tools do not yet
integrate informaNon from the health care delivery system. Health informaNon from
the care delivery system should be easily accessible to individuals and empower them
to become more acNve partners in their health just as other kinds of data are
empowering them in other aspects of their lives.
✴ Protect privacy and security in all aspects of interoperability.
It is essenNal to maintain public trust that health informaNon is safe and secure. To
bener establish and maintain that trust, appropriate, strong, and effecNve safeguards
for health informaNon should be ensured in place to increase the interoperability

43
 across the industry. Greater transparency for individuals regarding the business
pracNces of enNNes that use their data should also be supported

4.3. ENTERPRISE ARCHITECTURE

4.3.1. Framework Viewpoint

To drive the transformaNons of the Indonesian strategies in healthcare system by leveraging
ICT to improve health and social welfare for all ciNzens, the health sector needs to
understand completely what it is that is being transformed and what effect those changes will
have. In addiNon, stakeholders need to have a roadmap that supports this transformaNon. To
understand more completely and plan a way forward, the Ministry will adopt enterprise
architecture (EA) as the framework to guide the development of an integrated naNonal HIS
for the accomplishment of:
✴ Strategically aligned - Alignment with the MoH Enterprise Architecture Policy will
ensure that current and future ICT soluNons and services:
✴ Support the ministry’s vision and strategic plans - Performance objecNves are designed,
implemented and managed according to the requirements of the MoH EA, the
Indonesian eGovernment as well as the regional IDHIS strategy
✴ Pa;ent centric – PaNent-focused informaNon and data models underpinning ICT
soluNons and services will support the paNent centric view of service delivery including
rights of access, safety, respect, parNcipaNon and privacy.
✴ Accessible services – Interoperability and integraNon between ICT soluNons and
services will enable secure exchange and access to accurate, Nmely and trustworthy
sources of informaNon across the conNnuum of care.
✴ Sustainable and effec;ve solu;ons – Quality ICT soluNons and services will be
developed to ensure efficient and effecNve use of informaNon and to meet the growing
demands and future needs of the MoH.
✴ Standards based – An adaptable, scalable and evolvable architecture that includes
recognized informaNon, messaging and infrastructure standards specific to healthcare
will lead to innovaNve and responsive ICT soluNons and services, value for money and
clearly arNculated benefits.
Enterprise architecture (EA) can be described as a comprehensive framework used to manage
and align an organisaNon's technology assets (in this case IT), people, operaNons, and projects
with its operaNonal characterisNcs. In other words, the EA would define how informaNon and
technology should support the business (healthcare in this case) operaNons and provide
benefit for the business.
An overall enterprise architecture for healthcare can be described using six viewpoints:
1. The execu;ve perspec;ve: Focuses on the purpose, scope and policies for the
‘healthcare system’. This view describes the business purpose and strategy, which
defines the playing field.

44
 2. The business perspec;ve: Describes the business requirements and how to meet them
(i.e. the business models). This is a descripNon of the organisaNon within which the
healthcare informaNon system must funcNon. Analysing this view reveals which parts
of the enterprise can be supported by technology.
3. The architect perspec;ve: Describes the puzzle pieces that deliver the system’s
funcNonality and the way those pieces interact with each other, and also outlines how
the system will saNsfy the organisaNon's informaNon needs (someNmes referred to as
the computaNonal and informaNon viewpoints). The representaNon is free from
soluNon-specific aspects or producNon-specific constraints.
4. The engineering perspec;ve: Describes the technology specificaNon models and is
concerned with the infrastructure required to support system implementaNon and
distribuNon. This is a representaNon of how the system will be implemented. It makes
specific soluNons and technologies apparent and addresses producNon constraints.
5. The technical perspec;ve: Describes the tool configuraNon models. These
representaNons illustrate the implementaNon-specific details of certain system
elements: parts that need further clarificaNon before producNon can begin. This view is
less architecturally significant than the others are because it is more concerned with an
individual part of the system than with the whole.
6. The opera;onal/implementa;on perspec;ve: Refers to operaNonal systems.
The NHNSF, which will be designed in this document, mainly only refers to the first three of
these viewpoints: execuNve, business and architect perspecNves, and does not refer to a
parNcular instanNaNon (i.e. a parNcular healthcare system). Systems built using different
topologies, or different technologies, can achieve interoperability as long as their execuNve,
business and architect perspecNves are consistent with each other, or can be made to align.
The NHNSF provides the ‘standards’ for developing interoperable IDHIS systems and is not
prescripNve regarding the specific infrastructure or technology stack that a parNcular IDHIS
system employs, although a suggesNon for such an infrastructure is made. The goal of the
NHNSF is to enable interoperability between IDHIS soluNons that are based on the
Framework.
The model for transformaNonal health informaNon management depicts the component
funcNons of informaNon management across a healthcare organizaNon. InformaNon
governance is seen as the accountability framework for these funcNons [29]. Also
encompassing data governance, it is the formalized oversight structure through which leaders
advance policies, processes and standards for the component funcNons. Guiding principles
are useful, because while technology and best pracNces evolve, the principles serve as a
foundaNon for arNculaNng values and standards.

29 Kloss L, MA, RHIA, and Precyse: Health Information Management In 2016. Guiding Principles and a Governance Framework For A Digital
Age. HIM Innovation Community

45
 Information Governance
Information Content & Information
Design & Records Analysis &
Capture Management Use

Information Integrity & Quality

+
Information Access, Security & Confidentiality

Figure 4-1. Model For Transformational Health information Management

InformaCon Governance
✴ To ensure a formalized oversight framework and leadership for the advancement of
policies, processes and standards for the adopNon, implementaNon, maintenance,
interoperability and appropriate use of data and informaNon.
✴ To enhance the value of informaNon assets and their strategic uses to improve clinical

InformaCon Integrity And Quality

✴ To conNnuously improve the value and trustworthiness of the informaNon asset by
ensuring that data and content are valid, accurate, reliable, current and
comprehensive and reflect the conNnuum of care.

Access, Security And ConfidenCality

✴ To ensure that personally idenNfiable and other confidenNal health and business
informaNon are available only to authorized persons and used only for authorized
purposes.
✴ To ensure that security risks and vulnerabiliNes are proacNvely managed.

InformaCon Design And Capture

✴ To improve the efficiency and quality of data collecNon, capture, downstream
informaNon use, interoperability and reuse through effecNve informaNon architecture,
content definiNons and standards.
✴ To enhance the saNsfacNon of those responsible for capture and reduce costly
redundancy through standardizaNon.

Content And Records Management

✴ To maintain designated records sets, including legal health records, and other types of
records in accordance with the clinical and business needs of the organizaNon and all
applicable legal and regulatory requirements.
✴ To deploy explicit policies and best pracNces for management, retenNon and
disposiNon that account for all records in all media.

46
 InformaCon Analysis And Use
✴ To ensure that the requisite clinical and non-clinical data and informaNon are available,
trusted and usable by those who rely on them to make decisions to improve health
and healthcare.

4.3.2. The execuCve perspecCve

The development of the execuNve perspecNve for the NHNSF will be based closely to the
Indonesian Health Strategy. In 2015 the Minister of Health as shown in figure 2-1, has set a
five Health Strategies for Strengthening Health Care to achieve the Health Development
Towards Healthy Indonesia. [30 ]
In the effort of prioriNsing the focus of IDHIS in supporNng the naNonwide health strategy, the
development of NHNSF will also be selected and developed in alignment with the main target
priority of the health system development

Health Service and Health Sector

Because of the explicit focus on interoperability, the scope of this document will be limited to
the pervasive IDHIS services needed to support the sharing of longitudinal, person-centric
health informaNon on a system-wide (naNonal) basis. This system-wide focus excludes the
various IT standards associated with technologies and devices located within the four walls of
specific physician offices, labs, pharmacies or hospitals. Rather, it focuses on informaNon
sharing between these and other health delivery partners. However, in order to be
interoperable with external systems, there is an implicit inference that the same approach
and standards should be used for the systems within the four walls of a facility.
Exploring the target of achievement in each strategy in strengthening health services, the
process should be started with a set of Health Business Sector Strategies as proposed bellow:
✴ Primary Health Service
✴ Advanced Health Service
✴ Central-Level Support
✴ Human Resources for Health
✴ Health Care Financing
✴ Public-Private Partnerships
✴ Maternal, Newborn, and Child Health
✴ PrevenNon and Control of Communicable and Non-Communicable Diseases
✴ Emergency Preparedness and Response
✴ Social Welfare and Social ProtecNon
✴ Monitoring, EvaluaNon, and Research
✴ Medicine and Supplies
✴ ICT in Health

30 Nila F. Moeloek: Health Development Towards Healthy Indonesia. Regional Meeting of National Health Central, Denpasar, February 15, 2015

47
The matrix table of cross relaNon between the Health Care Strategy and the Health Business
Sector Strategies will be like follows

Table 4-1. Linking IDHIS Strategic Objectives to Health Sector Strategies

Strategic Work Stream, HIS Building Blocks and The MoH OrganisaCon
In 2014 the Indonesian government published the government regulaNon on health
informaNon systems with the aim [31]:
1. Ensuring the availability, quality, and access to valuable health informaNon and
knowledge can be jusNfied;
2. Empowering community parNcipaNon, including professional organizaNons in the
implementaNon of Health InformaNon Systems; and
3. Realizing the implementaNon of the Health InformaNon System within the scope of the
naNonal health system in an efficient and effecNve manner, especially by strengthening
cooperaNon, coordinaNon, integraNon, and synchronizaNon in support of sustainable
health development.
This IDHIS consist of seven (7) building blocks, which is not a collecNng of sub-system building
enNNes, but merely as a grouping of informaNon to facilitate the achievement of the above
objecNves, namely
1. InformaNon health efforts
2. Research and development of health informaNon

31 Government Regulation No. 46 Year 2014 on Health Information Systems

48
 3. InformaNon on health financing
4. Health human resources informaNon
5. InformaNon pharmaceuNcal, medical device, and food,:
6. InformaNon management and health regulaNons:
7. InformaNon empowerment

Strategic Work Stream

IIHIS Foundations
IDHIS Solutions
Change and Adoption
IDHIS Governance

Organisation 0f MoH
DG, Public Health
DG, Disease Prevention and IDHIS Building Blocks
Control
Health Care Information
DG, Health Care
Research and Development
DG, Pharmacy and Health of Health information
Equipment Health Financing Information
National Institute for Health HRH Information
Research and Development Pharmaceutical, Medical device, and
Board for Development and Food Information
Empowerment of HR Management and Health Regulations
Information
Secretary General. MoH Community Empowerment Information
* DG: Directorate General

Figure 4-2. IDHIS Contextual Relationship Framework

The primary objecNve for the strategic iniNaNve described in the previous chapter is to create
a single point of accountability represenNng Knowledge & InformaNon and technology service
delivery in the health service, and to drive technology enablement, adopNon and innovaNon
to achieve bener paNent outcomes. To achieve this effecNvely, the contextual relaNonship
between the substances within every strategic iniNaNve with the MoH organizaNonal
structure as well as IDHIS building blocks should be mapped clearly.
The IDHIS SoluNon (blue color) will be the most crucial subject which should be distributed
proporNonally to the IDHIS building blocks, while the other three aspects of strategic work
stream can be managed as general naNonal plan to ensure the conNnued alignment of the
technology architecture and capabiliNes across the whole service and across all sevngs with
the strategic direcNon. Each single business delivery of Healthy Indonesia Program should be
developed through this relaNonship by all MoH working units, which accountable responsible
for the verNcal domain specific acNon plan, to ensure the horisontal integraNon of all acNon
plans of the MoH. This concept will work to promote cross-capability integraNon, re-usability,
and standardisaNon to ensure that new demand is always considered in the broader context.
ResponsibiliNes for the funcNon include defining robust and clear standards and policies for
technology implementaNon and service delivery; owning the design of all architectural layers
including business process, informaNon, applicaNon and technical; defining and quality

49
assuring compliance with policies relaNng to informaNon security and risk; and owning the
overall sourcing strategy.
To support the needs of the MoH’s working unit, each group of informaNon in IDHIS building
blocks must contain specific informaNons that can be used as the target of the work plan by
each MoH’s working unit. Every strategic iniNaNve in each strategic objecNve should be
grouped clearly in the IDHIS building blocks. By this approach, the horizontal integraNon could
be achieved through the synergism of the acNon plan of each MoH’s working units that have
had the same goal.
Based on this matrix structure, the verNcal dimension facilitates focus on quality, consistency
and standardizaNon of methods and pracNces, and realizaNon of cross-organisaNonal
synergies. The horizontal dimension creates focus on alignment with, and delivery to health
service requirements, and providing end-to-end delivery accountability with paNent care.

Table 4-2. Matrix Cross Relation Between Strategic Initiative and IDHIS Building Block

IDHIS SoluCon IDHIS Building Blocks

Research and Development of

device, and Food Information

Health Financing Information

Community Empowerment
Management and Health
Pharmaceutical, Medical
Health Care Information

Regulations Information
Health information
Strategic IniCaCve

HRH Information

Information
SO.04 Implement a health professional provider registry l l
IdenNfy and integrate exisNng HR systems (HRHIS, PMO-RALG, l
etc.) into the professional provider registry
Refine processes for managing and maintaining the health l l
HRH Related

professional provider registry

SO.05 Develop and approve methodology for delivering blended l l
learning
Develop program and electronic content for various health l l l
professionals
Implement health sector e-learning plagorm l l l
Develop digital resources to enable offline learning program l l
SO.06 Implement an electronic integrated diseases surveillance and l l l l
response system that is linked to the HMIS system
Implement an electronic informaNon system to provide health l l l
educaNon and promoNon
Surveillance Related

SO.07 Integrate related informaNon systems and verNcal programs l l

(HIV/TB/malaria) informaNon into DHIS 2.
Integrate data from referral hospitals into DHIS 2 l l
Implement a community-based HIS that is linked to the HMIS l l
sofware
SO.08 Implement an electronic medical records (EMR) system with l l
clinical decision support tools
Implement a shared health record and health informaNon l l
mediator that support mobile services

50
 IDHIS SoluCon IDHIS Building Blocks

Research and Development of

device, and Food Information

Health Financing Information

Community Empowerment
Management and Health
Pharmaceutical, Medical
Health Care Information

Regulations Information
Health information
Strategic IniCaCve

HRH Information

Information
SO.09 Implement a naNonwide eLMIS, leveraging exisNng systems l l l
Resources & Financial Related

Integrate the system with exisNng ERP, WMS, IDHIS, and HMIS l l l l
systems
SO.10 Implement a hospital management informaNon system l l l l l l l
(HoMIS) in the health faciliNes
Implement a data warehouse for health resources (finance, l l l l l l
medicine, HR, etc.)
Implement an integrated planning sofware system to support l l
a IDHIS profile
Implement improved communicaNon and remote financial l l l
services for rural workers
SO.11 Develop health professional collaboraNve network using l l
mobile device technology
Implement an electronic referral system l l l
SO.12 Implement social welfare service informaNon system for l l
Referal Related

managing and monitoring of social services, beneficiaries, and

providers
SO.13 Implement the WASH system l l
Integrate the WASH with the HMIS system l l
SO.14 Develop IDHIS integraNon with telehealth services l l
Implement required telehealth infrastructure l
Implement telehealth services l

4.3.3. MoH and Stakeholder Network RelaCon

Intended for planners, policy makers and decision makers, the IDHIS Architectures is deigned
to integrate data from various stakeholders (see figure 4-3.X below), including human
resources, surveillance, medicines and medical equipment, health care faciliNes, financial as
well as other health environmental data. The MoH also needs partnership (see figure 4-3.Y
below) to assist in managing of IDHIS as well as understanding and solving technological
challenges for building the IDHIS.
The design of IDHIS basically is to support the achievement of two main goals
1. Individual Health Service (IHS) and Community Health Service (CHS).
To support the improvement of Indonesian Health data quality, which collected from
the Individual Health Service (IHS) and Community Health Service (CHS), all subsystems
of each IDHIS domain associated with this goal should be prioriNzed. Design and
implementaNon of various subsystems need to be implemented gradually by

51
 considering the integraNon between each other and with regard to the availability of
resources and infrastructure readiness
2. Electronic Health Record (EHR)
The healthcare industry is making significant progress in the quest for electronic health
records (EHRs), which will improve the quality and safety of paNent care and achieve
real efficiencies in the healthcare delivery system. EHR management (EHRM) is the
process by which electronic (e.g., digital) health records are created or received and
preserved for evidenNary (e.g., legal or business) purposes. The MoH needs to be
involved in various regulaNon and supervision, therefore it is necessary to build
interoperability between IDHIS with EHR systems held by businesses in the healthcare
industry

INDONESIAN TELEHEALTH ARCHITECTURE

INDONESIAN HEALTH INFORMATION ARCHITECTURE

X
DATA SHARING
Organizational Structure Ministry of Health HIS
A
Business Intelligence Ministry of Health
Executive Information Ministries / Gov
Minister of Health System Institutions
Inspectorat Gen. Secretariat Gen. Advisor of Min. (Decision Support System)

Provincy &
District/City Gov

Business Intelligence DG & Agencies

Community B Indonesian Nat.
for Health Research

Domain
Board for Develop-

Health Service Army and Police

Prevention & Cntrl

ment & Empower-

DG Public Health

National Institute

HRH
DG Pharmacy &
Hlth Equipment

Directorate
DG Health Care

& Development

Domain General Professional

DG Disease

ment HRH

Surveillance Information Organization

Individual
System
Health Service Domain
Supply Chain Academic Inst.
1 2 3 4 5 6 Association

Business intelligence Secretariat General Health Facilities

Planning & Budgeting Bureau International Cooperation Br
C Association
Financial & St.Property Bureau Comm & Human Srv Bureau Secretary General
Legal & Organization Bureau
Personal Bureau General Bureau Information System
Other
Stakeholders

Electronic
Health
Record Y
BPJS / Other Health MIS Support eHealth/mHealth Infrastructure PARTNERSHIP
Insurance Application Support ICT Support

Figure 4-3. Indonesian HIS Architecture

Architecture of Internal informaNon system of MoH consist of ExecuNve InformaNon System

(A), Integrated Directorate General InformaNon System (B), and InformaNon Systems of the
Secretary General (C)
1. ExecuNve InformaNon System (EIS)
a. An EIS (A) is a specialized informaNon system used to support senior-level decision
making. Learn how senior management uses an execuNve dash board to keep a
close eye on how well their organizaNon of health program is doing.
b. EIS is designed to support the Strategic Decision Makers Group, which consist of
Minister of Health, the Inspectorate General, the Secretariat General and Advisor to
the Minister.

52
2. Directorate General InformaNon System (DGIS)
a. DGIS is unified informaNon system of each directorate-general consist of: (1). the
Directorate General of Public Health (DGPH), (2). Directorate General of Disease
PrevenNon and Control (DGDPC), (3). Directorate General of Health Services
(DGHS), (4). Directorate General of Pharmacy and Health Equipment (DGPHE), (5).
the NaNonal InsNtute for Health Research and Development (NIHRD), and (6). the
Board of Development and Empowerment on Human Resources for Health
(BDEHRH).
b. DGIS (B) consists of three main domains, namely the domain of human resources,
surveillance and supply chain. Each domain will contain various subsystems that will
support the interests of each party in an integrated health care organizaNon.
c. The data generated from this group is the major source of EIS.
3. Secretary General InformaNon System (SGIS)
a. SGIS (C) is unified informaNon system from each bureau, which is under the
authority of the secretariat general, consist of Planning and BudgeNng Bureau,
Finance and State Property Bureau, Legal and OrganizaNon Bureau, Personnel
Bureau, InternaNonal CooperaNon Bureau, CommunicaNon and Human Services
Bureau, and the General Bureau
b. Secretary General responsible for the coordinaNon of tasks implementaNon,
supervising, and providing administraNve support to all organisaNonal units in the
Ministry of Health. SGIS is a management informaNon system to support the MoH
in administraNve aspects, beyond the operaNonal management of health services.
Therefore SGIS is an informaNon system that must be integrated with informaNon
systems in each directorate-general
4. Included in the group of stakeholders for the Health InformaNon Exchange (HIE),
among others ministries and state agencies, provincial governments and district / city
government, the Indonesian NaNonal Army and Police, health professional
organizaNons, associaNons of health educaNon insNtuNons, associaNons of health care
faciliNes and other partners, are all stakeholders in the HIS architecture of the MoH.
5. Included in the group of stakeholders to support insurance management and
informaNon technology:
a. BPJS and Other Health Insurance, are partners in the insurance sector which has a
system of health financing informaNon. The diagram of HIS architecture show the
relaNonship posiNon between the ongoing developments of BPJS as well as private
insurance with the Indonesian HIS. With the fourth-largest populaNon in the world
and a growing economy, along with rising incomes, Indonesia presents many
opportuniNes to healthcare providers and suppliers looking for markets to expand
in.
b. SupporNng Partners in Management InformaNon Systems, are partners that has the
ability in the development, monitoring and evaluaNon, as well as governance in the
field of informaNon and communicaNon technologies related to educaNon /
training, health care and health research. Interoperability cooperaNon with these

53
 partners in various regions, can be a solid foundaNon for improving the quality of
data and informaNon in the field of educaNon / training, health care and health
research. One example is a partnership with nine State UniversiNes in Indonesia to
be a Center of Excellence
c. SupporNng Partner in IDHIS ApplicaNon and m-Health, are partners that develop
Puskesmas applicaNons in all aspects or in part, guide and train in the use of
applicaNons and help resolve problems if there is trouble. They are potenNal
partners in the region and needs to be directed at data standards set by the MoH.
Partnership with them as a part in building the naNonal health data base will be
able to reduce the problem of change management, accelerate the deployment of
HIS and reduce the cost of training and supervision by the MoH.
d. SupporNng Partner in Network Infrastructure, are partners with competence in the
field of network infrastructure. Network infrastructure refers to hardware and
sofware resources of the enNre network that enables network connecNvity,
communicaNon, operaNon and management of the enterprise network. Network
infrastructure provides the communicaNon path and services between users,
processes, applicaNons, services and external networks/the Internet. These fields
are beyond the capacity of the health ministry, therefore it needs to be cooperaNon
with these parNes, like BPPT, Telkom

4.4. STANDARDS AND INTEROPERABILITY

4.4.1. DefiniCon
Many definiNons are available to describe interoperability. However, a frequently used
definiNon is:
Interoperability is the ability of two or more systems or components to exchange
informa;on and to use the informa;on that has been exchanged.
There are many different types of interoperability perNnent to health. Interoperability
standards can be considered from three different viewpoints to maximise business benefit [32]
[33 ][34 ] ; (i) Technical interoperability, (ii) SemanNc interoperability, (iii) Process

interoperability.
These concepts are interdependent, and all three are needed to deliver significant business
benefits.
1. Technical interoperability is the exchange of data between computer system A and
computer system B. It does not know or care about the meaning of what is exchanged.
For example, emails transmined from one computer to another generally contain
content informaNon that is not understood by the sending or receiving computer.

32 Healthcare Information and Management Systems Society. HIMSS Dictionary of Healthcare Information Technology Terms, Acronyms and
Organisations . 2010 [Online]. Available from: http://www.himss.org. Accessed on: 29 June 2012.
33 Benson T. Training Material on Principles of Healthcare Interoperability HL7 and SNOMED. 2009. Available online from: http://
www.abies.co.uk/. Accessed on 13 February 2013
34 Benson T.: Principles of Health Interoperability HL7 and SNOMED. © Springer-Verlag London Limited 2010

54
 2. Seman;c interoperability guarantees that computer system A and computer system B
understand the meaning of data in the same way and use and interpret the data that is
exchanged. This is specific to domain and context and usually involves the use of codes
and idenNfiers. SemanCc interoperability is central to healthcare interoperability. For
example, a laboratory informaNon system transmits results to a pracNce management
system at a GP pracNce. The pracNce management system recognises the structure,
format, units and meaning of the result sent by the laboratory system. In order to
achieve this, both systems use a common terminology or language to communicate.
3. Process interoperability incorporates business processes. It is important that business
processes also interoperate and the people involved share a common understanding to
enable computer system A and computer system B to work together. Process
interoperability is achieved when human beings share a common understanding, so
that business systems interoperate and work processes are coordinated. They obtain
benefits only when they use the new system in their day-to-day work; if it is not used
as intended, for whatever reason, it is a failure. For example, healthcare professionals
must standardise business rules to ensure that health informaNon is recorded in a
uniform and Nmely manner such that the transfer of informaNon between systems is
consistent and complete.
Alongside the types of interoperability, interoperability can also be categorised into various
levels, each indicaNng a level of complexity of health informaNon exchange. In order to
facilitate complex levels of interoperability, a number of adoptable standards for the various
types or categories of interoperability has been developed, many of which can operate in
tandem to allow funcNonal and semanNc interoperability. The following types or categories of
standards are used in healthcare [35 ][36]:
1. Messaging standards – messaging standards outline the structure, content and data
requirements of electronic messages to enable the effecNve and accurate sharing of
informaNon. The term ‘message’ refers to a unit of informaNon that is sent from one
system to another, such as between a laboratory informaNon system and a GP’s clinical
informaNon system. Examples of messaging standards include HL7 v2.x for
administraNve data and Digital Imaging and CommunicaNons in Medicine (DICOM) for
radiology images.
2. Terminology standards – terminology standards provide specific codes for
terminologies and classificaNons for clinical concepts such as diseases and medicaNons.
Terminology systems assign a unique code or value to a specific disease or enNty, for
example, the ICPC-2 code for ‘asthma’ is R96. (18) Terminologies are used primarily to
capture clinical informaNon at the point of care. As such, they are highly detailed, have
predefined relaNonships and are fine grained. ClassificaNon systems – such as ICD-10-
AM – group related concepts together to saNsfy a specified use case, for example,
causes of disease. ClassificaNons are more suited to the recording and analysis of
secondary use data such as research or epidemiology purposes. It is necessary to select
different classificaNons and terminologies in combinaNon to enable complete coverage

35 E-health Standards and Interoperability. ITU-T Technology Watch Report, April 2012
36 IHE IT Infrastructure (ITI) Technical Framework. Volume 1. (ITI TF-1) Integration Profiles Revision 6.0 – Final Text August 10, 2009. Copyright
© 2009: IHE Internationa

55
 across all of healthcare. Examples of terminology standards include ICPC-2, ICD-10-AM,
SNOMED CT for clinical terms and LOINC for laboratory results. The Authority is due to
publish guidance on terminology standards for Ireland in the third quarter of 2013.
3. Document standards – document standards indicate the type of informaNon included
in a document and also the locaNon of the informaNon. Examples of document
standards include the paper-based SubjecNve, ObjecNve, Assessment, Plan (SOAP)
standard and also HL7 Clinical Document Architecture (CDA) for electronic sharing of
clinical documents. HL7 have developed document-standard specificaNons for a
conNnuity of care document (HL7 CCD) and a discharge summary (HL7 DS).
4. Conceptual standards – conceptual standards allow the transmission of informaNon
between systems without any loss of the meaning or context of that informaNon. For
example, the HL7 Reference InformaNon Model (RIM) provides a framework for
describing health informaNon and the context around it, i.e. who, what, when, where
and how.
5. Applica;on standards – applicaNon standards determine the implementaNon of
business rules for sofware systems to interact with each other. For example,
applicaNon standards can allow a single user to log in to mulNple informaNon systems
in one environment allowing efficient access to the required health informaNon. This
can facilitate the simultaneous viewing of health informaNon across mulNple databases
that are not electronically integrated.
6. Architecture standards – architecture standards define a generic model for health
informaNon systems. They allow the integraNon of health informaNon systems by
providing guidance to aid the planning and design of new systems and also the
integraNon of exisNng systems. This is achieved by defining common data elements
and business logic between systems. For example, the CEN standard ENV12967
(Healthcare InformaNon Systems Architecture or HISA) provides an open architecture
that is independent of technical specificaNons and applicaNons. This standard enables
integraNon of common data and business logic between systems, which is achieved via
a middleware§ layer allowing informaNon exchange between different systems.
To narrow down these stacks of standards, the iniNal effort for the development of IDHIS
should be focusing primarily on such cohesive ‘stacks’ of standards that have been
internaNonally balloted. This approach Ned in with the interoperability focus and miNgated
implementaNon risk. The three stacks of standards idenNfied are:
1. The family of standards based on the HL7 V3 Reference InformaNon Model (RIM)
[Health Level Seven InternaNonal].
2. The standards based on the ISO 13606 Parts 1-5 / Open EHR Reference Model (RM)
[The EN 13606 AssociaNon].
3. The interoperability standards-based profiles developed by the global organisaNon,
integraNng the Health Enterprise (IHE) [IHE InternaNonal, 2012].
The results of the evaluaNon to these standards stacks against the criteria using a risk
assessment are shown in table above.

56
 Table 4-4. Standards ‘stacks’ evaluation matrix

4.4.2. Levels of Requirements

To support interoperability between systems and meaningful sharing of data, health
informaNon standards must cover both the syntax (structure) and semanNcs (meaning) of the
data exchanged. Interoperability standards are not sofware or hardware, but are the
blueprints that technology developers can use to develop health informaNon systems that
will be inherently compaNble with other systems adhering to these same standards [37].
Process interoperability is achieved when human beings share a common understanding, so
that business systems interoperate and work processes are coordinated. They obtain benefits
only when they use the new system in their day-to-day work; if it is not used as intended, for
whatever reason, it is a failure. To bridge the gap caused by the different angle of
requirement, the definiNon of interoperability requirements can be done at different levels of
granularity to fit the target audience. To clarify where the NHNSF adopNon process operates,
four levels of requirements can be defined, as followed [38][39][40 ][41]
1. Business case level: This represents the business view of IT systems, for example a
‘chronic disease management system’. It has some fuzziness and flexibility due to the
many ways in which one can idenNfy and structure a use case. Business use cases are
the most successful when they cover a small and achievable scope for implemenNng
requirements, each providing value whilst remaining achievable.
2. Interoperability service level: An interoperability service defines a number of related
means and constraints to exchange specific types of health informaNon for
communicaNng this informaNon from one or more systems to another. They should
define the core interoperability services that are most likely required to support a
broad range of business level use cases. Examples are ‘electronic drug prescribing’,
‘sharing of paNent medical summaries’, etc.
3. Integra;on and Content Profile level: This is more granular than the interoperability
service level in order to provide maximum flexibility in terms of implementaNon
architectures. To achieve this architecture independence actors from mulNple

37 Overview of Healthcare Interoperability Standards. © Health Information and Quality Authority 2013
38 ISO/IEC 10746 series:1996/1998, Information Technology - Open Distributed Processing
39 ISO 12967 series :2009, Health Informatics - Sevice Architecture
40 Witting K., Moehrke J.: IHE IT Infrastructure White Paper Health Information Exchange: Enabling Document Sharing Using IHE Profiles.
Copyright © 2012: IHE International, Inc.
41 National Health Normative Standards Framework for Interoperability in eHealth in South Africa . © CSIR and NDoH 2013

57
 integraNon profiles are combined. IntegraNon profiles are common interoperability
building blocks, easily implemented in various sofware architectures that can be
effecNvely factored in order to achieve maximum re-use of specificaNon and
implementaNon methods. It also allows for evoluNonary growth. Standards generally
operate at a domain-focused level in that mulNple standards are required to define an
IntegraNon Profile. The IntegraNon and Content Profile level is the most pracNcal level
at which to perform interoperability conformance tesNng.
4. Base standard level: Base standards are in some cases healthcare specific, or can be
applicable across a wide range of industries to achieve fundamental IT communicaNon
or security management. Base standards are foundaNons to enable the creaNon of
elementary services, messages and documents to support any possible use case
domain. They are also use case driven, but address the significant challenge of
anNcipaNng a greater variety of needs and market evoluNon. Since base standards are
not necessarily healthcare specific, their use requires a number of constraints provided
at Profile level (e.g. the selecNon of base standards among a set of compeNng
standards to idenNfy healthcare suitable opNons).
The business case levels combined with the interoperability services would consNtute the
interoperability specificaNons. Figure below illustrates how these four levels support each
other, by adding technical depth as one moves from business level use cases, to the middle
where it is possible to accomplish effecNve, testable and robust interoperability (at the IHE
level), and all the way to the most granular details provided by the base standards. Business
level use cases are many, varied and naturally overlapping. Base standards are also varied and
have complex foundaNonal specificaNons delicate to combine. The middle two layers are
where a criNcal raNonalisaNon and definiNon of common ‘soluNon building blocks’ are best
conducted.

Business Use Interoperability Integration and

Base Standard
Case Level Service Content Profile

Figure 4-5. Level of requirement (adapted from IHE International [2007]:p.11)

4.4.3. Challenges to healthcare interoperability

One of the key challenges to the implementaNon of interoperability standards for health is
the heterogeneity of health informaNon systems in Indonesia, as in other countries. Most
large hospitals will use many different ICT systems from different suppliers, each supporNng
different funcNons. There is no single health informaNon system that could facilitate all
administraNve, clinical, technical and laboratory ICT requirements of a large healthcare
organisaNon. In such a fragmented environment, the requirement to achieve interoperability
is criNcal and the need for interoperability standards becomes evident.

58
Cultural change within the health sector is required to ensure independent healthcare
organisaNons are willing to share health informaNon beyond the confines of their own
systems. StandardisaNon removes an element of local autonomy for providers and the
percepNon may exist that independent control of health informaNon systems by providers is
compromised.
The changes required in business processes and operaNons at local level also act as a barrier
to implementaNon as providers and local ICT professionals must be educated about new
processes and methods of recording health informaNon with the introducNon of standardised
terminologies. Although the benefits of interoperability in healthcare are considerable, they
may be difficult to realise as the benefits are dispersed across a large number of stakeholders
such as vendors, providers, policy makers and the individual. Some vendors use a lack of
interoperability to their advantage as a customer retenNon strategy by building systems that
can only interoperate with their own products.
Investment is required in terms of standards-compliant systems development and
implementaNon, and considerable effort is required in terms of change management in order
to achieve interoperability. The investment required by early standards adopters at the
leading edge of new iniNaNves is typically significantly higher and the benefits slower to
accrue, than that required by implemenNng standards-based systems that are already widely
in use. The late adopter benefits from the investment and effort of the early adopter in terms
of Nme and money needed to ensure any failures and barriers to success are dealt with. This
means that vendors and providers in parNcular may be hesitant to bear the cost of
progressing the implementaNon of interoperability standards unNl many other organisaNons
have already achieved interoperability.

4.4.4. Levels of interoperability

There are four levels of interoperability, each demonstraNng a level of sophisNcaNon and
standardisaNon of health informaNon interoperability:
1. Non-electronic informa;on – there is minimal use of technology to share data and
most health informaNon is recorded and shared on paper. For example, referral from
primary care to secondary care by paper-based referral lener sent via standard postal
service.
2. Machine transportable informa;on – transmission of non-standardised data using
basic informaNon technology. This data cannot be electronically manipulated. For
example, sharing of paper-based health informaNon via fax or email anachment.
3. Machine organisable informa;on – transmission of structured electronic messages
containing non-standardised data. This means that informaNon can be shared
electronically. However, an interface is required between one or more systems to
translate the data from the structure used by the sending system to the structure used
by the receiving system. For example, the exchange of electronic health informaNon
between a hospital system and a General PracNce Management System at a GP
pracNce via the naNonal Healthlink project.

59
 4. Machine interpretable informa;on – transmission of structured messages containing
standardised and coded data. This means that systems exchange health informaNon
electronically using a format and vocabulary that is readable and interpretable by the
receiver without the requirement for an interface to decode the informaNon. For
example, a discharge summary is transmined electronically from the hospital
informaNon system to the primary care electronic record of the paNent in a structured
and coded format that is used by both systems, such as HL7 Clinical Document
Architecture (CDA) and SNOMED CT.

4.4.5. Dimensions of interoperability

In order to bener understand the type and level of interoperability that are needed when
planning to share health informaNon, it is useful to document the requirements necessary to
facilitate the desired outcome of integraNng any systems. The Healthcare InformaNon and
Management Systems Society (HIMSS) IntegraNon and Interoperability Steering Comminee
(I&I) defined six dimensions of interoperability in order to provide a framework for
considering the types of interoperability concerns to be addressed when developing
integrated healthcare soluNons. These dimensions can aid providers in planning and selec;ng
the type and level of interoperability required to achieve the successful exchange of health
informaNon:
1. Uniform movement of healthcare data is achieved between systems such that the
clinical purpose and meaning of the data is preserved. For example, the units of
measurement denoted in a laboratory result are preserved during and following
transmission of the result.
2. Uniform presentaNon of data is achieved enabling various providers using different
systems to view informaNon in the same visual format when this is required. For
example, the visual indicaNon of an abnormal laboratory result is consistent across all
systems ensuring providers are alerted consistently to any detected abnormaliNes.
3. Uniform user interface controls are established enabling consistent context and
navigaNonal control across various underlying systems. For example, the controls used
to log out of various systems are consistent across these systems ensuring the
likelihood that providers successfully exit systems without compromising the privacy
and confidenNality of individuals.
4. Uniform safeguarding of data security and integrity is achieved by ensuring that data in
transmission between systems is only accessible to authorised users and programs. For
example, when an electronic prescripNon is transmined from a primary care system to
a pharmacy system, only the users authorised to prescribe, dispense or administer the
prescripNon can access the informaNon. Any intercepNon of the informaNon in transit
should be detectable by the receiving system.
5. Uniform protecNon of confidenNality is achieved by ensuring strong informaNon
governance controls are in place across organisaNons involved in the sharing of health
informaNon. For example, a healthcare organisaNon in receipt of personal health
informaNon from another organisaNon will not release any of that informaNon without
the prior consent of the individual to whom the informaNon pertains.

60
 6. Uniform assurance of a common degree of system service quality is achieved by
ensuring that interoperable systems are reliable and that robust emergency plans are
in place in the event of a breakdown of communicaNon between systems. For
example, access to an individual’s healthcare record is usually available electronically
in an emergency department, but there are manual procedures for retrieval in place in
the event that there is a breakdown of communicaNon between systems.

4.5. NATIONAL HEALTH NORMATIVE STANDARD FRAMEWORK (NHNSF)

4.5.1. Reasoning
To date, guidance and investments in IDHIS made by MoH have yielded local benefits but
have not created the desired ’network effect’ because of a lack of interoperability between
heterogeneous IT systems. The role of the standards-based strategy outlined in this
document is to arNculate an interoperability framework that may be used to achieve the
desired network effect. It represents a first step towards a complete IDHIS enterprise
architecture specificaNon for Indonesia. When fully developed, this IDHIS enterprise
architecture would be a robust basis for strengthening the IDHIS soluNons across all levels of
healthcare in both the public and private health systems, which will interoperate with each
other to support person-centric conNnuity of healthcare. To arNculate the IDHIS framework
into a set of foundaNonal basis for interoperability, the MoH purpose a Na;onal Health
Norma;ve Standard Framework (NHNSF) for IDHIS.
The general philosophy followed for developing the NHNSF is that of adopt, adapt and
develop (in that order). The approach adopted is to first consider exisNng standards that
could meet the requirements, only adapt these when essenNal and only develop a new
standard when there is no other alternaNve. Adherence to these principles would ensure that
the eHNCB could leverage internaNonal best pracNce and avoid duplicaNon of effort, as well
as ensuring that only tried and tested standards, which are already used in the development
of sofware products, are selected for use.
According to the WHO and ITU NaNonal eHealth Strategy Toolkit [WHO and ITU, 2012], a
naNonal eHealth environment is made up of a number of enabling environment and ICT
environment components, as illustrated in table below
✴ Enabling environment: leadership, governance and mulN-sector engagement; strategy
and investment; legislaNon, policy and compliance; workforce; and standards and
interoperability.
✴ ICT environment: infrastructure; and services and applicaNons.

Table 4-5. Role of eHealth components (adapted from [WHO and ITU, 2012
Components Description
Enabling Governance • Directs and coordinates eHealth acNviNes at all levels like hospitals and
environment health care providers. CriNcal areas of governance are management of
the eHealth agenda, stakeholders’ engagement, strategic architecture,
clinical safety, management and operaNon, monitoring and evaluaNon,
and policy oversight

61
 Enabling
environment

Components Description
Strategy and •
Develops, operates and sustains the naNonal eHealth vision.
Investment •
These components support the development of a strategy and plans to
serve as guide in the implementaNon of the eHealth agenda. Investment
refers to the funding or amount needed for execuNng the strategies and
plans.
LegislaCon, • FormulaNon of the required legislaNons, policies and compliance to
Policy and support the anainment of the eHealth vision.
Compliance • Examples of these are the naNonal legislaNons, policies, and regulaNons
on how health informaNon are stored, accessed and shared across
geographical and health sector boundaries; implementaNon of unique
health idenNfier; implementaNon of naNonal health data standards; and
sofware cerNficaNon or accreditaNon.
Human • Workforce or manpower to develop, operate or implement the naNonal
Resource eHealth environment such as the health workers who will be using
eHealth in their line of works, health care providers, informaNon and
communicaNon technology workers, and others.
Standards and • Promotes and enables exchange of health informaNon across
Interoperability geographical and health sector boundaries through use of common
standards on data structure, terminologies, and messaging. One strategy
to ensure compliance to health data
• standards for interoperability is the implementaNon of sofware
cerNficaNon or accreditaNon where eHealth soluNons must comply in
order to be cerNfied as able to exchange health informaNon.
ICT Infrastructure • Establishes and supports health informaNon exchange, i.e. the sharing of
environment health informaNon across geographical and health sector boundaries, and
implementaNon of innovaNve ways to deliver health services and
informaNon. Infrastructure includes physical technology and sofware
plagorms, services and applicaNons to support health informaNon
exchange.
• Examples of these are high-speed data connecNvity and compuNng
infrastructure, like computers and mobile devices for the collecNon,
recording and exchange of electronic informaNon, among others.
Services and May be supplied by government or commercially. Provide :
applicaCon
• Tangible means for enabling services and systems.
• Access to, and exchange and management of, informaNon and content.
• Users include the general public, paNents, providers, medical aids (NHI),
and others.

Leveraging the IDHIS experiences by the MoH, the needs of NHNSF is mandatory and should
be designed as a crucial foundaNon upon which IDHIS infrastructure and services will rest. The
NHNSF addresses the standards and interoperability component (highlighted in yellow in
Figure below). The introducNon of standards that enable consistent and accurate collecNon
and exchange of health informaNon across health systems and services, as addressed in the
NHNSF, are therefore part of the enabling environment.

Leadership and Governance

Strategy Legislation, Workforce

Service and Applications
and Policy and
Investment Compliance
Standard & Interoperability

Infrastructure

Figure 4-6. eHealth components (WHO-ITU)

62
Lack of interoperability between heterogeneous systems is a key obstacle to realizing the
potenNal benefits of IDHIS. Interoperability refers to the ability of two or more informaNon
and communicaNon technology (ICT) systems or components and of the business processes
they support to exchange informaNon/data and to enable the sharing of informaNon and
knowledge exchanged. Four types of interoperability exist :
✴ Technical interoperability: Covers the technical maners of connecNng systems and
services through interfaces, protocols etc. applying appropriate sofware engineering
techniques and methodologies. It is usually associated with the hardware/sofware
components, systems and plagorms enabling machine-to-machine communicaNon. In
IDHIS, its focus is ofen on communicaNon protocols and the infrastructure needed for
those protocols to operate.
✴ Syntac;cal interoperability: Is concerned with data formats and message formats.
Messages transferred by the communicaNon protocols must have a well-defined
syntax and encoding, but also carry data or content at the same Nme. This is a core
issue in IDHIS.
✴ Seman;c interoperability: Is associated with the meaning of content, focused on the
human rather than machine interpretaNon of the content. It refers to a common
understanding between people of the meaning of the content (informaNon) being
exchanged. In IDHIS, its focus is ofen on coding standards.
✴ Organiza;onal interoperability: Is concerned with the definiNon of business goals,
modeling business processes and organisaNonal collaboraNon issues. It refers to the
ability of organisaNons to effecNvely communicate and transfer meaningful data/
informaNon, whilst using a variety of different informaNon systems over different
infrastructures, across different geographic regions and cultures. OrganisaNonal
interoperability depends on the success of technical, syntacNcal and semanNc
interoperability.
Within IDHIS, the focus of the NHNSF project is primarily on semanNc, syntacNc and
organisaNonal interoperability (limited to the data flows in certain work processes) within the
context of paNent-centric healthcare management informaNon systems. Technical
interoperability is referred to only as far as messaging is concerned.
Furthermore the NHNSF does not focus on systems that aggregate data at district/provincial,
etc. level, or clinical care IT systems itself (for example, cardio-vascular care systems,
radiology or pathology systems, etc.). The NHNSF may include systems that allow for requests
for informaNon produced by such systems or to produce data that can be used by such
systems. The NHNSF does not address other systems found in healthcare faciliNes, which
focus on non-paNent centric funcNons, such as accounNng systems or human resource or
payroll systems.

4.5.2. AssumpCons of the NHNSF and the general philosophy

The development of both the NHNSF and its associated implementaNon guidelines and
governance model is based on the following assumpNons:

63
 1. Effort for sharing infrastructure and electronic health record for IDHIS have been
iniNated naNonally
2. Interoperability is required for the exchange of paNent-based transacNonal data
between the point of care and/or the local EMR system and the shared naNonal
infrastructure and the naNonal EHR, in order to support conNnuity of care, service
remuneraNon and the aggregaNon of data health metrics.
3. The NHNSF and its associated assessment instrument directly affects any exchange of
paNent-based transacNonal data, from a regional or healthcare facility-based EMR
system, to the shared naNonal infrastructure and the naNonal electronic health record.
4. Interoperability between the various modules of a regional or local healthcare facility-
based EMR system is not directly affected by the HNSF. However, the interacNons with
the shared EHR will be simplified if the same principles and standards were used for
the local healthcare facility-based EMR system, i.e. if the healthcare facility-based EMR
is based on the same standards as required for the shared EHR and interacNng with the
shared EHR.
5. The data held in the shared naNonal EHR will primarily be used for:
5.1. Provision of conNnuity of care for paNents across different service providers and
healthcare faciliNes.
5.2. GeneraNon of naNonal healthcare metrics, which are defined in the NaNonal
Indicator Dataset (outlined in Puskesmas / Primary Healthcare InformaNon
System [PHIS]).
6. The NHNSF iniNally only focuses on interoperability with a naNonal shared electronic
health record (EHR) system, and specifically only on paNent-centric funcNons. It only
focuses on systems that use and update data in such a shared EHR. Peripheral systems,
such as financial (payment) and accounNng systems, human resource systems, etc. will
be limited in general interfacing with the Health-BPJS’s informaNon system
7. Interoperability standards are also required for the sharing of paNent-based data, held
in the shared naNonal EHR, with accredited healthcare service providers.
8. As per the MoH’s work plan, an eHealth NaNonal CoordinaNng Body (eHNCB) should be
established, to maintain and govern the implementaNon of the HNSF, as well as the
standards referred to in the HNSF. The eHNCB should work closely with healthcare
providers and other relevant stakeholders to govern the implementaNon of the
NHNSF, and develop, adopt and maintain IDHIS standards-based profiles and
standards.

4.5.3. NHNSF Governance and Processes

In order to implement the NHNSF, a governance structure must be established. This calls for
the establishment of the eHealth NaNonal CoordinaNng Body (eHNCB) for Indonesia, as per
the IDHIS Strategy .
The role of the eHNCB should include:

64
 1. IdenNficaNon of care guidelines, workflows, acNviNes and informaNon sharing
requirements for each strategic objecNve.
2. Ongoing review of standards-based profiles and base standards to ensure that these
support the business use cases and business processes.
3. CreaNon and maintenance of a data model for a shared Puskesmas data repository.
The data model must define the exact data structure for the shared electronic health
record and the informaNon that must be exchanged with the shared infrastructure.
This will be determined by the minimum essenNal informaNon required for conNnuity
of care, reimbursement and generaNon of the naNonal health metrics,. This data
structure will be accompanied by a naNonal data dicNonary, defining all data elements
to be used in IDHIS, PCare and other health informaNon systems in Indonesia. The
eHNCB should work closely with key officials in MoH in order to ensure that the data
model and the related naNonal data dicNonary are aligned with the eHNCB at all Nmes,
and that any changes in workflows, care protocols and funcNons are reflected in the
mandatory standards-based profiles and base standards where necessary.
4. AdopNon, adapNon, localisaNon and development of standards-based profiles and
base standards, whenever gaps emerge. This would include a set of content standards
(coding and terminologies and informaNon display) and guidelines for their
implementaNon.
5. Establishing a naNonal compliance funcNon within the eHNCB to test and cerNfy that
IDHIS soluNons comply with IDHIS standards, rules and protocols.
6. Provision of guidelines to developers and suppliers of health informaNon systems with
respect to the use of standards-based profiles and standards.
7. Establishing a set of evaluaNon criteria against which to test whether a candidate
sofware applicaNon complies with the adopted, localised and mandated standards-
based profiles and their related base standards.
8. Provision of a plagorm for developers and suppliers to test their sofware applicaNons
against the mandatory requirements of the eHNCB.
9. With the guidance of IHE [42 ], organising a Indonesian naNonal or regional
‘connectathon’ to test the interoperability capability of systems that are currently
implemented or candidates for implementaNon.
10.The eHNCB should also have the role to represent Indonesia on internaNonal standards
development organisaNons and other enNNes related to eHealth standardisaNon
Detail informaNon concerning the requirement for building a robust organisaNon of eHNCB is
outlined in appendix G

lllll

42 IHE Technical Frameworks General Introduction. Appendix :Integration Statements. Revision 0.1 - Draft for Public Comment September 24,
2012. Copyright © 2012: IHE International, Inc.

65
66
5. ROADMAP

5.1. EXSISTING CONDITION

5.1.1. Health InformaCon Exchange

The Indonesian Ministry of CommunicaNon Technology (MoCT) has set up the Roadmap of
the Indonesian e-Government ImplementaNon as shown in the figure below

The establishment of a civil government. (Where all G2B, G2C,

2019
G2G and G2E served)
Physical
Integration
Virtual integration of all government activities (Data warehouse
2018
and Data Mining is working properly)

Colaboration among government agencies in the activities: G2B,

2017 G2C, G2G, G2E. Various activities involving more than one
Logical agency implemented via single portal
Integration Intergovernmental transactions with employees, the public,
2016 businesses and other agencies. Various transactional activities
can be served automatically.

Interaction between the government and its employees, the

2015 public, government and business as well as others. If employees,
the public, businesses, other agencies ask, some answer.
Consolidation
All information / data is available in digital form, consolidated,
2014 accessible and updated for the service, employees, the public,
business and fellow government

Figure 5-1. Roadmap of the Indonesian e-Government Implementation [43 ]

The government of Indonesia has recognized the ICT funcNon to facilitate the government
flow of informaNon, one of the main focus areas is the flow of informaNon between health
care services and Ministry of Health. It is essenNal to work toward improved access to ICT,
especially broadband network services, bridge the digital device and interoperability among
electronic applicaNons and recognizing the contribuNon of health-IT developers. The
availability of health-IT infrastructure will be the main responsibility of the government.
Significant investment strategy for the development of health informaNon systems is an
important need to be regulated by the government to prevent further fragmentaNon and
stand-alone informaNon system, in addiNon to reduce cost in purchase, the adaptaNon to the
local exisNng established systems is recommended. Capacity building of the personnel skills
who’s handling the systems is also required. Meanwhile, the government has also mandated

43 Ibenk Dwi Anggono: eGovernment Indonesia Update 2015 - 2019. Ministry of Communication Technology, the Republic of Indonesia

67
to provide health informaNon applicaNon to the provinces which have not built their health
informaNon systems. Standard and regulaNons possibly developed by adopNng the strong-
local health informaNon system. Nevertheless, law and regulaNon, standard, protocol and
guideline to the ICT implementaNon for health need to be available.
To date the Health InformaNon Exchange is applicable interoperability model to exchange
informaNon and data communicaNon among systems with web based service using enterprise
service bus (ESB).
MoHA
(population data)

Health BPJS
(membership data)
MoR
(pilgrim data)

Log
Appli Book
cation Primary Care
(service data)
Comm
Data unication
Appli
cation

SIKD
A G en
eric

SISK
OHA
T.KE
S

Existing Hospit
a l
In Progress

Figure 5-2. Progress of Health Information Exchange in Indonesia

The Health InformaNon Exchange is applicable interoperability model to exchange

informaNon and data communicaNon among systems with the support of service-oriented
architecture (SOA) paradigm and web based service using enterprise service bus (ESB).
Ministry of Health use the Open-HIE to able communicate with Ministry of Home Affair to
extract and use the single idenNty number for health care service delivery. KOMDAT and
SIKDA GENERIK are available applicaNons developed by the government to be ready to bridge
and interoperable with other systems. Other opportunity and challenge is bridging and data
exchange with the BPJS Kesehatan. The exisNng health-IT infrastructure to support the health
insurance implementaNon is sNll under development.
Harmonize data communicaNon provided by the health data dicNonary, further improve
development of the dicNonary will be needed as well as development of data exchange
protocol and regulaNons, minimum data set for data communicaNon to all health care levels.
Data bank infrastructure planned to be available at district and province level to collect and
compile all data from health faciliNes, as well as its management and maintenance. These
data banks will have communicaNon channel to the naNonal data warehouse at naNonal level.
Each province will have real Nme dashboard of informaNon which will be connected and
aligned with the dashboard at naNonal level using DHIS2 to support decision making process.

68
5.1.2. Referral System Networking
The Referral System is a part of Indonesia Health System that manages the delegaNon of tasks
and responsibiliNes of healthcare providers on a reciprocal basis either verNcally or
horizontally. There are two type of referral system
✴ Medical referral (diagnosNc and treatment): paNent consultaNon, sending specimens
and inviNng special health personnel
✴ Health referral (promoNon and prevenNon): epidemiological survey and eradicaNon of
outbreaks, food aids, invesNgaNon of food poisoning, special aids during disaster and
displaced populaNon/refugee, clean water technology and laboratory

Ministry of
cross-sectoral & Health Health BPJS
community

provincial health
offices

government &
district health
offices private hospital

primary care
centers
‘PUSKESMAS’
health community health care facilities
networking networking
Provincial Government Authority
Indonesian Government
Regional Cooperation Relations
International Cooperation Relations

Figure 5-3. Indonesian Referral System Networking

Renewal in health referral system had been implemented in early 2014 since the enactment
of the new health ministerial regulaNon [44] and to date is sNll in the early phase where
healthcare organizaNon and paNent need to adapt to it. With this implementaNon, one must
iniNally get healthcare service from the primary care center (Puskesmas) as the 1st Ner; if the
primary care center is incapable in providing the service, the paNent will be referred to the
secondary care (hospitals) as the 2nd Ner and so on. This scheme is known as the verNcal
referral between different Ners. The other scheme is the horizontal referral where healthcare
provider could refer a paNent to another healthcare provider in the same Ner [45]. PaNent
transfer to another referred healthcare provider should also be complemented by paNent
profile, history and medical record. This informaNon can be used to prevent redundant
medical checking and facilitate medical personnel to treat the paNent. Thus, integraNon of

44 Regulation of the Minister of Health of Republic Indonesia Number 75/2014 regarding Community Health Center (Puskesmas)
45 a practical guide: System Reference Tiered. BPJS 2014. http://bpjs-kesehatan.go.id/bpjs/index.php/arsip/view/37

69
data and process among healthcare providers could ensure the availability of this
informaNon. The informaNon needed would not have to be recorded mulNple Nmes and
resulted on redundant and superfluous informaNon.
The above figure shows that Puskesmas is the main core for the health data source.
Puskesmas has three main funcNons : First, as an organizer of Public Health Efforts at primary
level in its working area; Second, as a centre for providing health data and informaNon in its
working area and as a trigger of health-oriented development in the region, and; Third, as an
organizer of Individual Health Service (UKP) at primary level which are good quality and user-
oriented services.
Health services in Puskesmas are divided into two categories: Firstly, as a centre for primary
public health care. This means that Puskesmas provides promoNve and prevenNve health
services by targeNng groups and the community to maintain and improve health and prevent
diseases. Secondly, Puskesmas as a centre for primary individual health care. Under this
funcNon, Puskesmas serves as a gate keeper or the first point of contact of the formal health
services and as a referral filter in accordance with the standard of medical care required.
It is clear that any iniNal effort for the development of IDHIS should consider the benefit for
the robust development of Puskesmas-IS. The capacity of Puskesmas and other stakeholders
in health insNtuNons need to be clearly idenNfied. The detailing of the capacity and the role
related to the beneficiaries in the using of informaNon system can be iniNated from the main
concern of each party as follows:
✴ Interna;onal level: InternaNonal agencies (WHO, UNAIDS), donor agencies,
internaNonal non-governmental organizaNons (NGOs).
✴ Regional level: regional bodies ─ AEC, regional NGOs.
✴ Na;onal and provincial level: government ministries, health-BPJS, naNonal NGOs,
naNonal and provincial governments, provincial hospitals and health departments.
✴ Local level: Puskesmas (primary health care centers), personnel at health clinics, health
workers, doctors, tradiNonal healers, community leaders, paNents and ciNzens.
Currently the Puskesmas-IS has been linked with a Health InformaNon Exchange (HIE) MoH
and connect with applicaNons BPJS to Puskesmas (P-Care) and has integrated well with
demographic data from the Interior Ministry. Electronic Puskesmas-IS applicaNon
development will be finalized in December 2016.
To expand the potenNal beneficiaries of Puskesmas-IS, which include various stakeholders in
key health insNtuNons, and in society as a whole in the developing world, is important to
examine individuals and groups within the key insNtuNons in the health system as target
beneficiaries of ICTs, and in doing so, to examine their capaciNes and needs, as well as the
potenNal for ICTs to assist in efficiency and effecNveness at each level in the system.

Table 5-1. Stakeholders Role and Concern

ParCcipant Role Main RelaConships Concerning

Ministry of Stewardship of the Health AuthoriNes Finance, overall performance measures
Health NaNonal Health System
All parNcipants Best pracNce and guideline
AdministraNon of Health CiNzens, Care Providers, Benefits and Eligibility, Claims and Payments
Benefits Health AuthoriNes (HA)

70
Ministry of
Health

ParCcipant Role Main RelaConships Concerning

Stewardship of Provincial Most other parNcipants Client IdenNty Management, Provider data
IDHIS services in the system management, LocaNon data management,
Electronic Health Record management,
Pharmacy business processes
Health Delivery of IDHIS services Care Providers IDHIS data and services, parNcularly including
AuthoriCes to care providers EHR, scheduling of resources and referral
(HA)
Ministry of Heath Provincial IDHIS services, such as RegistraNon
Service and Drug Profiles
Health BPJS Stewardship of naNonal CiNzen Overall performance measures of naNonal
health insurance health insurance implementaNon
Care Delivery of IDHIS services Other HAs IDHIS data and services, parNcularly including
Providers to other HA EHR, scheduling of resources and referral
Provision of care CiNzens Health care informaNon
Laboratories DiagnosNc orders and results
Pharmacies MedicaNon orders
Care Provision of care CiNzens Health care informaNon
Provision

The process and governance aspect should both be managed by a relevant IDHIS standards
authority, specifically set up to address health informaNon system issues. This authority
should not only consists of standards experts, it should include representaNves who have the
necessary experNse to advise on all of the IDHIS components.

5.1.3. Puskesmas InformaCon System

Electronic informaNon system has been implemented in most Puskesmas since years, which
developed partly by the government and the rest by the private developer. In the iniNal phase
some exisNng applicaNons, such as Siha, Sin and nutriNonal applicaNons, has been integrated
and gradually sustained to be able to connect with other system within HIE. In line with the
changing demands of the environment and government policy, currently the Ministry of
Health has been improving the exisNng electronic applicaNon modules (Generic SIKDA &
SP2TP) to align with the standard data sets of Puskesmas as sNpulate in the latest RegulaNon
of Health Ministry 2014 on Puskesmas [46]. The goal of improvement is to built comprehensive
data center based from integrated individual electronic database by name by address, not
only record data that is aggregated and supplied from the PoH data center (partly sNll
processed manually).
Improvements were made to the reporNng system as well as the type of data reported, and
will be published as regulaNons of health minister.
In general, the type of data that is being refined include data of family members, Puskesmas
idenNty, outpaNent general services, outpaNent dental care, stock of drug, idenNty of
toddlers and mother, TB treatment, case of leprosy, acNvity of sanitaNon clinic, acNvity of
environmental health inspecNon, health status of school children and nursing care of
individuals, families and groups.
The reporNng system consists of (i) basic data, which include idenNty, characterisNcs of the
working area, resource, organizing, and (ii) program data, which include acNviNes of essenNal

46 Regulation of Health Ministry of Republic of Indonesia No. 75 Year 2014 on Community Health Center (Puskesmas)

71
public health efforts, acNviNes of community health development efforts, acNviNes of
individual health efforts, senNnel events, extraordinary events and outbreaks.
In addiNon, the ministerial regulaNon will also regulate the data management, which consist
of collecNon, processing, analysis, and presentaNon acNviNes, storage, uNlizaNon, as well as
security and confidenNality.
With the commencement of the NaNonal Health Insurance Programme (JKN) in the same
year, there are two major naNonwide informaNon systems that are in progress for
integraNon, the Puskesmas-IS, developed by the MoH, and the NaNonal Health Insurance
InformaNon System (P-Care), developed by Social Security Management Agency for the
Health Sector (Health-BPJS).
A lot of meeNngs and discussions have been conducted to carry out the integraNon between
the two systems and to date there is sNll no common base standard has been adopted as a
robust integraNon tool between both systems. Although both groups are deeply interested in
using standards (i.e., code sets, communicaNon formats) to drive interoperability, they ofen
struggle with how to get started. The environmental condiNons between both parNes are
obviously different and need to be bridged through a coordinaNng body to capture the needs
of each party in ditel. Environmental differences between the two systems can be described
as follows
✴ In an effort to integrate the various informaNon systems developed by various IT
companies and used by Puskesmas in various regions, MoH has ever been trying to
create a health sevice applicaNon program to be used naNonwide in all Puskesmas, but
the results beyond what was expected. Based on this experience, the MoH now is
trying for focuse only on its funcNon as a regulator and coordinator, while the
development of applicaNon programs submined to the respecNve policies of regional
governments along with the private developer. Shifing in this policy is in line with the
strategy to prevent failure as described in secNon 4.2.1.
✴ P-Care on the other side was designed and developed under condiNons of Indonesia
does not have a payment systems for health insurance. They starNng from nothing to
something and focuse on one single data collecNon tool. There were no naNonwide
payment systems for health insurance that has been developed.
Referring to the success and failure of system development, the naNonwide integraNon
process of these two systems will not be generalized through an approach of "one fits all",
but the characterisNcs of the environment, local capacity, culture, funding capacity and
health authority in each province will be carefully considered. IntegraNon efforts should be
iniNated by sevng the standards required for the integraNon process, but the
implementaNon of system integraNon needs to be adjusted to the condiNons in each region.
These challenges must be addressed through cooperaNon between the relevant parNes in the
naNonal organizaNon

5.2. SUBJECT PRIORITY

Based on the technocraNc thinking and current environment, a set of priority is proposed as
follows:

72
1. It is recommended that the IDHIS infrastructure investments should focus on
supporNng person-centric healthcare.
2. It is recommended that an eHNCB be established to oversee the implementaNon of the
IDHIS. To adopt and maintain IDHIS standards-based profiles and base standards,
healthcare providers and other relevant stakeholders should be involved closely
3. It is recommended that a health data dicNonary of MoH for IDHIS in Indonesia can be
combined with a standard that is widely used by the private sector to produce a single
standard that applies naNonally as a uniform naNonal data set that promotes data
uniformity, availability, validity, completeness, reliability, and consistency. Further, the
use of the dicNonary will ensure uniform collecNon, presentaNon and sharing of data
throughout the health sector. Further, the use and enrichment of the dicNonary will
ensure uniform collecNon, presentaNon and sharing of data throughout the health
sector.
4. It is recommended that the development and publicaNon of a naNonal HIS enterprise
architecture for Indonesia be undertaken immediately. The analyses and findings of
this report provide a significant input towards the development of such an artefact.
5. In order to implement the IDHIS Standard Framework it is recommended that, the
MoH must publish applicable policies and legislaNon in support of the sharing of health
informaNon for purposes of person-centric healthcare delivery.
6. It is recommended that the development of IDHIS under the supervision by the
PusdaNn / eHNCB follows a defined, coordinated process for standards adopNon in an
annually recurring four-step process together with users and developers of healthcare
informaNon technology, promoNng steady improvements in integraNon:
6.1. Development process:
The development process is executed at the naNonal level in order to produce
naNonally agreed upon IntegraNon and Content Profiles:
6.2. IdenNfy interoperability problems:
Clinical and technical experts work to define criNcal use cases for informaNon
sharing, focusing on, for example, common interoperability problems with
informaNon access, clinical workflow, administraNon and the underlying
infrastructure.
6.3. Specify integraNon profiles:
Technical experts create detailed specificaNons for communicaNon among
systems to address these use cases, selecNng and opNmizing established base
standards. They idenNfy relevant base standards and define how to apply them
to address the problems, documenNng them in the form of IHE IntegraNon
Profiles.
6.4. Deployment process:
The deployment-validaNon process is carried out at the level of specific countries
or regions. There are some extensions or adaptaNons to the globally agreed upon
Profiles and these are specified in this process:
6.5. Test systems at the connectathon:
Industry implements these specificaNons in HIT and tests their systems for

73
 interoperability at the carefully planned and supervised events called
connectathons. This allows them to assess the maturity of their implementaNon
and resolve issues of interoperability in a supervised tesNng environment.
6.6. Publish IntegraNon Statements :
Vendors publish IHE integraNon statements to document the IHE IntegraNon
Profiles their products support. Users can reference the IHE IntegraNon Profiles in
RFPs, greatly simplifying the systems acquisiNon process.

Note: The concept of a Connectathon

The tesNng process employed by the IHE is called a ‘connectathon’. It provides coordinaNon, tools and
opportuniNes for face-to-face interoperability tesNng for vendors and developers of healthcare IT systems
implemenNng IHE profiles and integraNon capabiliNes. Connectathons are held regularly in Europe and North
America, with events in other countries becoming more frequent.
A Connectathon allows parNcipaNng sofware vendors or developers to test their implementaNon of IHE
profiles and to benchmark their products against their peers. During a connectathon the parNcipaNng systems
exchange informaNon with each other, performing all of the transacNons required for the parNcular use cases
and roles they have opted to be tested in. The results of tesNng are recorded and made available for review.

5.3. PROPOSED ROADMAP

5.3.1. Strategical Approach

This IDHIS Roadmap proposes criNcal acNons that the public and private sector need to take
to advance the country towards an interoperable health IT ecosystem towards 2025.
Achieving such an interoperable system is an essenNal element towards IDHIS vision of bener
care through smarter spending, leading to healthier people. Achieving that bener care system
and bener health for all will, through health IT interoperability, require work in 3 criNcal
pathways: 1) Requiring standards; 2) MoNvaNng the use of those standards through
appropriate incenNves; and 3) CreaNng a trusted environment for the collecNng, sharing and
using of electronic health informaNon.
It will require to agree to a set of rules of engagement that will bring trust to the system for
consumers and others, it will allow to see that the privacy expectaNons of consumers are
respected, that states are aligned in policy, that stakeholders are aligning payment and other
levers to advance and sustain a durable interoperable ecosystem, to make data more
portable and liquid with tools like APIs, and to have a set of standards that allow more
seamless, yet appropriate, sharing of electronic health informaNon for “small” (individual
paNent), “big” (populaNon level and beyond) and “long” data (wrapping around the individual
and telling their health story over Nme).
The IDHIA iniNaNve is an opportunity to engage the systemaNc approach for computerizaNon
and transformaNon of the core business processes in the health sector. The ambiNon is to
cover all priority areas as arNculated in the IDHIS Strategy. Therefore the implementaNon of
the IDHIS Strategy is organized into phases, each phase covering a set of HIS components that
address specific priority areas.

74
The IDHIS strategic phases indicate the main areas of emphasis at a parNcular period, based
on the exisNng condiNon and available resources. It can be predicted that the development of
IDHIS bit behind with what should have been achieved for the naNonal integraNon plan in the
e-government roadmap. Therefore, the proposed phase does not exclude iniNaNon of parallel
acNviNes where appropriate opportuniNes arise.

Phase 0: Establishing IDHIS FoundaCons and Governance

Phase 0 focuses on establishing the basic building blocks to ensure successful
implementaNon of IDHIS soluNons. The purpose of this phase is as follows:
✴ Define, establish, and insNtuNonalize the governance structure to support
implementaNon of the IDHIS Strategy.
✴ Develop a IDHIS architecture and standards for health informaNon exchange
✴ Establish a privacy and regulatory framework to ensure appropriate privacy safeguards
and consent processes for access to and use of health informaNon.
✴ Implement the physical compuNng and network infrastructure in hospitals/insNtuNons
and connecNvity to the naNonal backbone (hospitals, MDAs, etc.).
✴ Implement the facility, provider, and client registry system.
✴ Promote broad-based and coordinated stakeholder dialogue and engagement toward
operaNonalizaNon of the IDHIS strategy.

Phase 1: Implement an EA to support effecCve use and management of health resources

Phase 1 focuses on implemenNng an EA to support effecNve use and management of
health resources (financial, medicine, HR, etc.). This phase includes implementaNon of the
Puskesmas MIS and other health faciliNes to manage finance, medicine, and HR at health
faciliNes. In addiNon, this phase includes implementaNon of a centralized health resources
performance management system (i.e., data warehouse for health resources).
Included in this phase is the implementaNon of the LogisNc Management InformaNon
System (Log-MIS). More specifically, the purpose of Phase 1 is the following:
✴ Implement the Puskesmas MIS with focused to Primary Health Care.
✴ Implement a health resources performance management system (i.e., data warehouse
for health resources).
✴ Implement the Log-MIS.
✴ Implement a health informaNon mediator and integrate exisNng informaNon systems.
✴ Implement an integrated planning sofware system to support a comprehensive
council health profile.

Phase 2: Implement the EA to support reproducCve and child health (RCH) services, HIV/
AIDS, TB and non- communicable diseases intervenCons
Phase 2 focuses on implemenNng an EA to support ReproducNve and Child Health (RCH)
services and HIV and TB intervenNon services. This phase includes implementaNon of an
Electronic Medical Records (EMR) system to support maternal health and newborn
services delivery and HIV and TB intervenNons. The EMR implementaNon will be built as a
component of Puskesmas MIS from Phase 2. Included in this phase is the implementaNon

75
 of a shared health record and health informaNon exchange, enabling informaNon sharing
among health authoriNes and creaNng seamless informaNon transfer among care
providers across the health faciliNes.
✴ Implement NaNonal Health IdenNfier Infrastructure.
✴ Implement NaNonal PaNent Portal.
✴ Implement EMR for Maternal, Neonatal and Child Health (MNCH) services and HIV and
TB intervenNons.
✴ Implement the health informaNon exchange that supports mobile services.
✴ Implement an electronic referral system.
✴ Implement ePrescribing Systems.
✴ Implement PaNent Summary Records.

Phase 3: Other IDHIS soluCon implementaCon

Phase 3 will focus on implemenNng a community-based health informaNon system. More
specifically, the purpose of Phase 3 includes the following:
✴ Implement online Referrals and Scheduling.
✴ Implement PaNent Summary Records.
✴ Implement online Access to Health InformaNon.
✴ Implement electronic learning soluNon for health professionals.
✴ Implement a community-based health informaNon system.
✴ Implement an electronic social welfare informaNon system.
✴ Implement an electronic Water, SanitaNon, and Hygiene (WASH) management
informaNon system
While the Ministry is working to develop its IDHIS strategy, it currently implements several
IDHIS soluNons, including Health Management InformaNon System (HMIS) sofware
strengthening, Human Resources Health InformaNon System (HRHIS), and implementaNon of
the electronic integrated disease surveillance and response (eIDSR) system. More specifically,
the Ministry is working to achieve the following:
✴ Strengthen and roll out HMIS sofware (DHIS2).
✴ Strengthen HRHIS.
✴ Implement eIDSR.

5.3.1. Milestone and Target

Indicator/ Phase
Strategic IniCaCve Target
Milestone 0 1 2 3
IDHIS Foundation
SO. Establish IDHIS standards Number of Hospitals Approved IDHIS standards within one l
01 (e.g., HL7, ICD, business
coding)
using the IDHIS
Standards
year afer the eHNCB established

76
 SO. Indicator/ Phase
01Strategic IniCaCve Target
Milestone 0 1 2 3
Establish a privacy and Presence of funcNonal At least each hospital will have a l
regulatory framework (PRF) privacy and regulaNon copy of privacy and regulatory
to ensure appropriate privacy framework framework within one year afer PRF
safeguards and consent published
processes for access to and
use of health informaNon

SO. Develop a harmonized data Availability of agreed Annually as per review of several l
02 element specificaNon for the
health facility, provider, and
data element
specificaNon sets for
indicators and data elements

client registries facility and provider

master list
Provide support to the Facility and provider Facility and provider registraNon l
revised registraNon process registraNon business process insNtuNonalized within one
for public and private process map year afer the eHNCB established
faciliNes and providers established
Implement the facility, Presence of funcNonal Facility registry and provider registry l
provider, and client registry facility and provider complete implemented within two
system. registries year afer the eHNCB established
Develop management and Management and Facility registry and provider registry l
maintenance guidelines for maintenance management and maintenance
facility and provider registries guidelines developed guidelines developed and used
and used within two year afer the eHNCB
established

SO. Establish ICT strategic plans Number of hospitals/ Have ICT strategic plans for all l
03 for hospitals and other
insNtuNons
insNtuNons with
implemented ICT
regional, zonal, and naNonal referral
hospitals and other insNtuNons
Strategic Plan
Establish sustainable ICT Number of hospitals/ All regional, zonal, and naNonal l
infrastructure and services. insNtuNons installed referral hospitals installed with LAN
with LAN and other
infrastructure
Connect health faciliNes and Number of hospitals/ All regional, zonal, and naNonal l
insNtuNon to the naNonal insNtuNons connected referral hospitals/insNtuNons
opNcal fiber network to the naNonal connected to the naNonal backbone
backbone network
OperaNonalize an Availability of InformaNon sharing policy crafed l
informaNon-sharing policy funcNonal informaNon within one year afer the eHNCB
sharing policy established

IDHIS Solution
SO. Implement a health ProporNon of health All health professionals registered in l
04 professional provider registry professionals
registered
the health professional registry that
is integrated with all HR systems
IdenNfy and integrate exisNng Number of funcNonal All HR systems integrated into the l
HR systems (HRHIS, PMO, integrated HR systems professional provider registry
etc.) into the professional in place
provider registry
Refine processes for ProporNon of All professionals registered l
managing and maintaining the registered health
HRH Related

health professional provider professionals managed

registry and maintained
SO. Develop and approve Availability of blended Blending learning methodology l
05 methodology for delivering
blended learning
learning methodology

Develop program and ProporNon of Electronic content developed in one l

electronic content for various electronic learning year afer the eHNCB established
health professionals content developed
Implement health sector e- Number of health All health professionals using the l
learning plagorm professionals using the system within one year afer the
system eHNCB established
Develop digital resources to Number of digital To have digital resources for all l
enable offline learning resources for health programs within two year afer the
program professionals eHNCB established

77
 Indicator/ Phase
Strategic IniCaCve Target
Milestone 0 1 2 3
SO. Implement an electronic FuncNonal Indonesia To have IDSRS full funcNonal within l
06 integrated diseases
surveillance and response
Surveillance and
Response System
two year afer the eHNCB established

system that is linked to the (IDSRS)

HMIS system
Implement an electronic Number of health Health educaNon and promoNon
informaNon system to provide educaNon and programs implanted
health educaNon and promoNon programs
promoNon supported by
electronic system
Surveillance Related

SO. Integrate related informaNon Number of systems All target systems and verNcal l
07 systems and verNcal programs and verNcal program
(HIV/TB/malaria) informaNon integrated to DHIS 2
program integrated into DHIS 2

into DHIS 2.
Integrate data from referral Number of referral Health informaNon collected from all l
hospitals into DHIS 2 hospitals with available referral hospitals
data in the DHIS 2
Implement a community- ProporNon of required All appropriate informaNon captured
based HIS that is linked to the health informaNon into the Community Based HIS
HMIS sofware entered in the system (CBHIS)
SO. Implement an electronic ProporNon of hospitals EMR implemented in regional, zonal l
08 medical records (EMR) system
with clinical decision support
using EMR system and naNonal referral hospitals

tools
Implement a shared health ProporNon of hospitals All hospitals and clinics integrated l
record and health informaNon and clinics integrated into the Health InformaNon Exchange
mediator that support mobile into the health (HIE) and paNent informaNon is
services informaNon mediator available from any connected facility
SO. Implement a naNonwide ProporNon of health eLMIS implemented and used within l
09 eLMIS, leveraging exisNng
systems
faciliNes using eLMIS two year afer the eHNCB established

Integrate the system with Number of systems All candidate systems integrated into l
Resources & Financial Related

exisNng ERP, WMS, IDHIS, and integrated with eLMIS eLMIS

HMIS systems
SO. Implement a hospital Number of hospitals HoMIS implemented in all regional, l
10 management informaNon
system (HoMIS) in the health
implemented with
HoMIS
provincial and naNonal referral
hospitals within three years afer the
faciliNes eHNCB established
Implement a data warehouse Number of hospitals/ Data collected from regional , zonal l
for health resources (finance, insNtuNons that and naNonal, referral hospitals and
medicine, HR, etc.) provide data to the other insNtuNons
data warehouse
Implement an integrated Number of POH using To have the DHIS2 sofware l
planning sofware system to DHIS2 sofware implemented in all PHO
support IDHIS profile
Implement improved Percent of health l
communicaNon and remote workers with improved
financial services for rural communicaNon and
workers financial services
SO. Develop health professional Number of doctors All medical doctors in regional, zonal, l
11 collaboraNve network using
mobile device technology
connected in the
network
and naNonal referral health faciliNes
in the network
Implement an electronic ProporNon of paNents Electronic referral system is l
referral system treated in health funcNonal both horizontally and
faciliNes referred from verNcally from district to regional and
other faciliNes from regional to zonal level
(horizontal or verNcal
referral) supported by
the electronic system
SO. Implement Prokesga Number of services All social welfare services and l
12 informaNon system (PIS) for
managing and monitoring of
registered and
managed by the PIS
recipients supported by the PIS
Referral Related

family services and

beneficiaries

78
 Referral Related
Indicator/ Phase
Strategic IniCaCve Target
Milestone 0 1 2 3
SO. Implement the WASH system WASH management The WASH system is rolled out in all l
system is deployed and urban and rural areas
13 used
Integrate the WASH with the WASH and HMIS The WASH informaNon is available in l
HMIS system systems integrated the HMIS system
SO. Develop IDHIS integraNon Developed integraNon All appropriate telemedicine services l l
14 stanadrd with telehealth
services
to telemedicine
services
developed

Implement required Number of health Required infrastructure implemented l

telehealth infrastructure faciliNes with in all regional, zonal, and naNonal
funcNonal referral hospitals
telemedicine
infrastructure
Implement telehealth services Number of health Telemedicine/telehealth services l
faciliNes using implemented in all regional, zonal,
telehealth services and naNonal referral hospitals

Change and Adoption

SO. Establish a naNonal Number of IDHIS At least 4 campaign programs held l l l l
15 awareness campaigns on
IDHIS programs
awareness campaign
programs held
annually (quarterly)

Review exisNng health Reviewed facility and Reviewed facility and provider l l
facility and provider provider accreditaNon accreditaNon regulaNon within two
accreditaNon regulaNon to regulaNon years afer the eHNCB established
enforce the use of IDHIS
soluNons and required
standards to support the
operaNon, management,
and decision making

Promote and empower local Number of local l

companies with the capacity companies
and capability to develop empowered for IDHIS
and maintain large-scale soluNons development
IDHIS soluNons and use

IDHIS Governance
SO. Establish IDHIS governing Number of IDHIS To have two eHNCB naNonal meeNng l l
16 board meeNngs held within one month afer the eHNCB
established
Establish IDHIS enNty Number of IDHIS To have IDHIS operaNng model l
meeNngs held within one year afer the eHNCB
established

Establish IDHIS regulaNon Percentage of IDHIS To have two ICT regulaNon by l l l l

soluNons requests December 1017
funcNon reviewed by eHNCB

The proposed milestone and target as well as the achievement indicators should be adjusted
afer IDHIS requirement assessment has been clearly defined by the eHNCB. The duraNon of
each phase should be decided by the MoH in alignment with the budgeNng availability

lllll

79
80
6. MONITORING AND EVALUATION (M&E)

Monitoring and evaluaNon is a leadership and governance strategy to track and assess the
results of implemenNng the IDHIS roadmap or plan. It measures the performance of the
desired IDHIS outcomes and addresses the weaknesses or gaps encountered in actual
implementaNon of the IDHIS plan. The desired IDHIS outcomes serve as indicators to assess
the adopNon and use of IDHIS in the country. There are two components of monitoring and
evaluaNon, i.e. monitoring the execuNon of the plan (inputs, acNviNes, and outputs as defined
in the plan) to keep track of the status of implementaNon, and monitoring results if the plan
delivers the desired outcomes, impact and level of change.
The deliverables from each acNon lines and acNviNes are the output indicators and the
desired IDHIS outcomes are the outcome indicators. The output indicators shall be used to
measure the adopNon of IDHIS and outcome indicators for the results of adopNon. Issues,
concerns, problems and/or challenges shall be idenNfied and evaluated during monitoring
and evaluaNon for appropriate acNons. Regular status reporNng and communicaNon shall be
provided to ensure delivery of required outputs and anainment of expected outcomes.
For the iniNal baseline measures for output and outcome indicators, a working group shall be
formulated to determine the numbers or figures based on historical data or zero for none.
The governance model and processes for naNonal monitoring and evaluaNon shall be
included in the establishment of the IDHIS governance structure to direct, implement,
enforce, monitor, and evaluate the naNonal adopNon of IDHIS in the country.

lllll

81
82
7. RECOMMENDATION

The acNons recommended following the delivery of this NHNSF for Interoperability in IDHIS
are closely linked to the issue of the most expected by the user and the service provider to be
discussed intensively
1. Strategy and leadership:
✴ Adopt an incremental approach to the development of shared, naNonal health data
integraNon
✴ Accelerate the delivery of high priority IDHIS soluNons in a naNonally aligned manner.
2. Stakeholder engagement:
✴ Workshop the NHNSF with relevant stakeholder groups in order to gain acceptance of
the proposed framework and refine it where necessary.
✴ Establish IDHIS stakeholder forums and working groups with cross-sectorial
representaNon and clearly defined objecNves and goals.
3. Standards and interoperability:
✴ Establish a properly mandated enNty, for the purposes of this document referred to as
IDHIS, to work closely with healthcare providers and other relevant stakeholders to
develop, adopt and maintain NHNSF profiles and base standards.
✴ Provide sufficient resources to the eHNCB so that it can develop, adopt and maintain
NHNSF profiles and informaNon standards for data and message structures, coding and
terminologies and informaNon display.
✴ Establish a naNonal compliance funcNon within the eHNCB to test and cerNfy that
IDHIS soluNons comply with NHNSF standards, rules and protocols.
✴ With the guidance of IHE, organise a naNonal or regional connectathon to test the
interoperability capability of systems that are currently implemented or candidates for
implementaNon.
4. Governance and regulaNon:
✴ Design and implement a consistent naNonal legislaNve framework for informaNon
protecNon, privacy and consent.
✴ Establish an independent IDHIS regulaNon funcNon to implement and enforce IDHIS
regulatory frameworks.
✴ Develop a eHNCB, which allows strong coordinaNon, visibility and oversight of IDHIS
work program acNviNes.
5. Investment, affordability and sustainability applicaNons and tools to support healthcare
delivery:
✴ Encourage investment in the development and deployment of high priority, standards
compliant and scalable IDHIS soluNons.

83
 ✴ Establish mechanisms to encourage care providers to invest in the implementaNon and
maintenance of an acceptable baseline of compuNng infrastructure.
6. Benefits realisaNon:
✴ Establish programs to encourage the adopNon and use of high priority IDHIS soluNons.
✴ Implement naNonal awareness campaigns that focus on communicaNng the scope and
benefits of high priority soluNons to consumers and care providers.
✴ Encourage healthcare parNcipants to adopt and use high priority ISHIS soluNons and
modify their work pracNces to support these soluNons.
7. Capacity and workforce:
✴ Implement changes to vocaNonal and terNary training programs to increase the
number of skilled, naNonally available IDHIS pracNNoners.
8. IDHIS foundaNons:
✴ Coordinate the rollout of appropriate naNonal broadband services to all care providers.
✴ Implement a set of IDHIS foundaNons that will provide a plagorm for health
informaNon exchange across geographic and health sector boundaries.
✴ Design and implement a naNonal soluNon to enable the unique idenNficaNon and
authenNcaNon of Indonesian paNents/consumers and care providers.
8. Monitoring and evaluaNon of the IDHIS Strategy 2015-2019:
✴ Establish capacity within the eHNCB for monitoring and evaluaNon of the IDHIS
Strategy 2015-2019 .

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APPENDICES

Appendix A:
NaConal context for eHealth development: summary

Context Characteristics
I. ExperimentaCon • eHealth is project-based with iniNaNves usually small, few in number and
and early disconnected
adopCon • Projects are proof-of-concept pilots where ICT is introduced in a limited context
• Projects are rarely sustainable due to the lack of infrastructure, skills and integraNon
• The commercial ICT market is fragmented with linle local experNse available
• Funding and technical support is ofen provided by aid agencies, donors and external
actors
• InternaNonal obligaNons for public health reporNng cannot be met
II. Developing and • eHealth is sNll project-based, but larger in scale with greater awareness of its potenNal
building up • eHealth systems (e.g. health informaNon systems, supply-chain management systems,
electronic medical records systems) emerge, but remain verNcal, fragmented and
unable to scale up
• Growth occurs in the commercial ICT market, with significant effort to anract
internaNonal ICT vendors. Local vendors emerge and government interest grows
• IniNaNves such as e-government, e-banking and other commercial ICT services begin
to take hold; but the health sector lags behind
• There is a lot of acNvity, learning by doing, and significant project risk
• Aid agencies and donors are sNll acNve funders; there is more private sector and
government investment in development and adopNon of cost-effecNve technologies
• Public-private partnerships increase in number
• eHealth is viewed as part of a broader effort to expand ICT and economic
development
• Early successes are promising, but scale-up is not possible and health impact remains
limited
• InternaNonal obligaNons for public health reporNng can someNmes be met through
verNcal systems
• Examples of eHealth include more extensive telemedicine networks, adopNon of EMR
systems on a limited basis, procurement and stock tracking systems, and mHealth
trials
III. Scale up and • Investment and adopNon scales up with a more comprehensive policy basis
mainstreaming • The commercial ICT market is well established with larger vendors, both internaNonal
and local
• The health sector takes a leading role in planning and using eHealth to deliver on
health objecNves
• The health ICT industry is acNve; with new business models and compeNNon, paid
services commonplace, and insurance reimbursement increasing
• New businesses and economic opportuniNes arise; there are new plagorms for
innovaNon and services, including for other markets
• InternaNonal obligaNons for public health reporNng can be met
• Health informaNon systems are increasingly linked, but sNll face problems due to
legacy systems
• Examples of eHealth include hospital and care networks, home health monitoring,
chronic disease management applicaNons, and tailored online services for self-
management of health records

85
Appendix B:
IDHIS EnCty

The IDHIS EnNty should have the following set of responsibiliNes.

✴ Strategy – the review and monitoring of IDHIS strategy outcomes and the development
of strategic recommendaNons and prioriNes for consideraNon by the eHNCB.
✴ Investment – the development of IDHIS investment submissions and business cases for
consideraNon by the eHNCB, and verified by PusdaNn for the budgeNng and tracking of
IDHIS investment, which funded by the government.
✴ Execu;on – the coordinaNon of specific project iniNaNves across the foundaNons,
adopNon and change and IDHIS soluNons work streams, focusing on the delivery of on
Nme and on budget projects, the reporNng of project progress, and the management
of project dependencies, risks and issues.
✴ Standards Development – the definiNon, maintenance and enhancement of IDHIS
standards and the implementaNon of a consistent process for undertaking this work.
✴ Solu;ons Compliance – the tesNng of whether IDHIS sofware products and soluNons
saNsfy naNonally agreed cerNficaNon criteria and standards.
These funcNons should iniNally reside within the one IDHIS enNty to allow them to be
established in a coordinated manner. Once the funcNons have matured, consideraNon can be
given to separaNng those funcNons that may best operate as disNnct enNNes in the long term.

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Appendix C:
Building Blocks of The Indonesian Health InformaCon System

The Indonesian Health InformaNon System consists of seven informaNon building blocks [6].
The building blocks of itself is not a system, but merely a grouping system of similar
informaNon that will be collated into a building that has the funcNon as seen in the picture:
1. Informa;on health efforts, contains informaNon about:
1.1. implementaNon of prevenNon, improvement, treatment, and rehabilitaNon of health
1.2. Health Care FaciliNes.
2. Research and development of health informa;on, contains informaNon about:
2.1. results of research and development of health care
2.2. intellectual property rights in health.
3. Informa;on on health financing, contains informaNon about:
3.1. source of funds
3.2. allocaNon of funds
3.3. expenditure.
4. Health human resources informa;on, contains informaNon about:
4.1. the type, number, competence, authority, and equitable distribuNon of health
human resources
4.2. resources for the development and empowerment of human resources health
4.3. implementaNon of the development and empowerment of health human resources.
5. Informa;on pharmaceu;cal, medical device, and food, contains informaNon about:
5.1. type, shape, material, quanNty and efficacy of pharmaceuNcal preparaNons
5.2. the type, form, number, and the benefits of medical devices
5.3. the type and content of foods.
6. Informa;on management and health regula;ons, contains informaNon about:
6.1. health planning
6.2. guidance and supervision of health efforts, research and development of health,
health financing, health human resources, pharmaceuNcal, medical devices, and
food, community empowerment
6.3. health policy
6.4. product of law
7. Informa;on empowerment, contains informaNon about:
7.1. types of community organizaNons concerned with health
7.2. the results of community empowerment
7.3. health, including community mobilizaNon

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Appendix D:
WHO Country CooperaCon Strategy Agenda 2013-2017

In line with the naNonal development plan, Indonesia has developed its longer-term Health
Strategy document 2005-2025. The second medium-term health strategy 2009-2014 is
expiring in 2014 and the process of preparaNon for 3rd medium-term health strategy 2015-
2019 is on-going. NaNonal strategic planning document 2011-2025 on HRH is in place. An ICT
master plan for MoH exists which needs revising. [7]

Strategic PrioriCes Main Focus Areas for WHO CooperaCon

STRATEGIC PRIORITY 1: • Expand coverage and impact of HIV intervenNons for prevenNon,
control and care
Provide technical and
management support to help • Provide conNnued technical support to address MDR and XDR TB and
sustain and strengthen key TB-HIV co-infecNons through intervenNons such as TB infecNon control
programmes to prevent and and treatment, drug resistance monitoring, operaNonal research and
control communicable diseases. TB-HIV collaboraNon
• Promote implementaNon of combinaNon therapy for malaria
treatment, as well as wider coverage of impregnated bednets for
malaria prevenNon and control
• Technical support in Neglected Tropical Diseases of public health
importance, especially LymphaNc Filariasis, Leprosy, Yaws,
Schistosomiasis and soil transmined helminthes
• Support achieving universal childhood immunizaNon in every village

STRATEGIC PRIORITY 2: • Support monitoring of the prevalence of noncommunicable diseases

and related risk factors
Promote public health approaches
to prevenNon and control of • Support implementaNon of best pracNces in tobacco control; and
noncommunicable diseases adherence to, and implementaNon of, the WHO Framework ConvenNon
for Tobacco Control
• Support prevenNon and health promoNon to control and prevent NCD

STRATEGIC PRIORITY 3: • Support improvement of access to quality maternal, neonatal, child,

and adolescent health services
Promote policies and strengthen
programmes to improve child, • Promote diversificaNon of reproducNve and sexual health services,
adolescent and reproducNve health including adolescent health, reproducNve tract infecNons and cancers,
and healthy ageing
• Advocate strengthening of naNonal capacity to integrate gender equity
and a human rights approach into policies and programmes
• Promote Gender Equity and Equality and acNons against violence
against women

STRATEGIC PRIORITY 4: • Strengthen management and innovaNons in the health system by

supporNng implementaNon of regulaNons for public and private
Support naNonal efforts to provision of health services in line with universal health coverage.
promote policies and strengthen
the health system to improve • Strengthen HRH insNtuNonal capacity by supporNng for appropriate
access to quality health services in standards, protocols, pre-service trainings and conNnued professional
support of Universal Health development along with support implementaNon of global and naNonal
Coverage (UHC) strategies on human resources for health
• Support revising as needed and implemenNng naNonal medicine
policies including medicine procurement and supply chain management
along with quality assurance of essenNal drugs, equipment and
tradiNonal medicines
• Strengthen and insNtuNonalize integrated health informaNon systems
with UHC informaNon systems along with capacity strengthened for
uNlizaNon of HIS data for planning and decision making.

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 Strategic PrioriCes Main Focus Areas for WHO CooperaCon
STRATEGIC PRIORITY 5: • Improve the capacity of the health care system to manage cases of
epidemic-prone diseases and to prevent hospital-acquired infecNons
Strengthen the preparedness,
surveillance and effecNve response • Strengthen surveillance, response to and preparedness for, disease
to disease outbreaks, acute public outbreaks and pandemics, especially in the context of the InternaNonal
health emergencies and the Health RegulaNons (IHR 2005)
effecNve management of health- • Emphasize emergency miNgaNon and preparedness, including bener
related aspects of humanitarian hazard and vulnerability assessments
disasters

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Appendix E:
The Roadmap for Health Measurement and Accountability

The Roadmap signals a major change in the way the internaNonal community works with
countries to deliver more accurate and sustainable measurement and accountability for the
health-related SDGs. This process will evolve in three phases over the next fifeen years [47]:

PHASE 1, 2015–2017: Endorsement and consensus

✴ ParNcipaNng low- and middle-income countries to complete assessments and idenNfy
prioriNes for strengthening their health in- formaNon systems, leveraging internaNonal
norms and guidance
✴ NaNonally-set Nmetables to be created for stakeholders and investors to define
country-specific commitments to naNonal plans and accountability mechanisms.
✴ Health related SDGs, targets, indicators, and measures to be agreed upon and
endorsed by all member states through the governance mechanisms of WHO and the
United NaNons General Assembly (UNGA).
✴ CompleNon of a global five year Roadmap implementaNon plan, with milestones, prior-
ity naNonal and internaNonal investments, accountability mechanisms, and imple-
mentaNon arrangements.
✴ The UN, World Bank, USG and other partners to establish communiNes of pracNces and
technical working groups, building on exist- ing MDG monitoring mechanisms.
✴ Launch of collaboraNve global program of public goods to support country health
informaNon and accountability plagorms.
✴ Launch of Global Financing Facility for reproducNve, maternal, newborn, and child
health (RMNCH), including window on CRVS investments

PHASE 2, 2018–2024: Investments in plans for country health informaCon and

accountability planorms
✴ Major donors lead efforts to transiNon from program-specific investments in informa-
Non and reporNng to country reporNng using a naNonal health informaNon system.
✴ Based on individual country assessments, CRVS systems will be aligned with
internaNonal standards; regular census schedules will be established; household
surveys will be conducted according to a regular program; naNonal health faciliNes will
build informaNon capaciNes to include surveillance and response; data and
interoperability standards for eHealth systems will be established and disseminated;
and relevant government insNtuNons and internaNonal partners will have access to
basic health system data, such as annual naNonal health accounts, and a minimum
dataset for the workforce.

47 MA4Health: The Roadmap for Health Measurement and Accountability. Common Road Map Steering Committee http://
ma4health.hsaccess.org/partners

90
PHASE 3, 2025–2030: Sustainable measurement and accountability
✴ Countries to transiNon away from internaNonal development assistance, with sufficient
support for strengthening and sustaining robust health informaNon systems.

Country Roadmap Global/Regional

5 countries completed HIS investment plan 2015 Glion consensus M4H Summit
Agree health related SDGs 12 countries 2016 Launch of Global Financing Facility
completed HIS investment plan Joint health UNGA fInalize SDGs Establish UN health
sector review monitoring sub-group Expert and social
accountability review WHA endorse
roadmap Final MDG report
25 countries completed HIS investment plan 2017 SDG progress report
Baseline “Countdown” progress report
Joint health sector review
WHA health-related SDG review
35 countries completed HIS investment plan 2018 SDG progress report
Joint health sector review
45 countries completed HIS investment plan 2019 SDG progress report
Expert and social accountability review
Joint health sector review
55 countries completed HIS investment plan 2020 SDG progress report
Joint health sector review 1st “Countdown” progress report
WHA health-related SDG review
62 countries completed HIS investment plan 2021 SDG progress report
Joint health sector review
68 countries completed HIS investment plan 2022 SDG progress report
Expert and social accountability review
Joint health sector review
75 countries completed HIS investment plan 2023 SDG progress report
Joint health sector review 2nd “Countdown” progress report
WHA health-related SDG review
81 countries completed HIS investment plan 2024 SDG progress report
WHA health-related SDG review
Joint health sector review
Joint health sector review 2025 SDG progress report

Joint health sector review 2026 SDG progress report

3rd “Countdown” progress report
Joint health sector review 2027 Expert and social accountability review
Joint health sector review 2028 SDG progress report
4th “Countdown” progress report
WHA health-related SDG review
Joint health sector review 2029 Final SDG progress report
Expert and social accountability review
Joint health sector review 2030 UNGA review progress of SDGs
Final “Countdown” progress report
WHA health-related SDG review

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Appendix F:
Asia eHealth InformaCon Network Strategic Plan: 2012 – 2017

In the effort to build IDHIS that can also be used for the benefit of the informaNon exchange
in the ASEAN region, some of the acNviNes in the four strategy of AeHIN and has been able to
be implemented will be adopted as one of the guides in preparing the acNon plan of IDHIS.
DescripNon of acNons within the AeHin strategic plan are as follows:
STRATEGY ACTIONS
1. Build 1.
1.1. Implement naNonal eHealth, HIS, CRVS strategies and plans.
capacity for ✴ Establish mulC-stakeholder governance mechanism to advocate, coordinate, and
eHealth, manage changes and risks
Health ✴ Apply best pracNces for assessment, strategic planning, cosCng, implementaCon
InformaCon plans, and monitoring and evaluaCon
Systems • eHealth – WHO-ITU "NaNonal eHealth Strategy Toolkit"
(HIS), and
Civil • HIS – HMN "Framework and Standards for Country HIS"
RegistraCon • CRVS – WHO-UQ "Improving the quality and use of birth, death and cause-of-
and Vital death informaNon: guidance for a standards-based review of country pracNces"
StaCsCcs 1.2. Advocate for eHealth, HIS, and CRVS career paths to be addressed in annual sector
(CRVS) in the budgets, training and work plans.
countries and ✴ Define ehealth/HIS/health informaCcs competencies for public health
in the region. professionals in low and middle income countries
✴ Promote development of naConal associaCons and conferences for health
informaNcs
✴ Convene naNonal workshops, conduct pre- and in-service training, and support
internaNonal exchanges and fellowships for eHealth, HIS, CRVS professionals and
members of AeHIN
✴ Support inter-universiNes collaboraNon on curriculum development on e-health/
HIS/health informaNcs for undergraduate and graduate program
✴ Promote joint research/publicaNon on ehealth, HIS, health informaNcs, and CRVS
issues
1.3. Promote eHealth, HIS, and CRVS among key non-health stakeholders (e.g., Bureau of
StaNsNcs; Ministries of ICT, Finance, Planning, JusNce or Civil Registry; and private
health providers)
✴ Express call to acCon on eHealth, HIS, and CRVS to relevant mulN- sector ministers
in naNonal and internaNonal forums (e.g., World Health Assembly, high-level
meeNngs, Regional Comminee MeeNngs)
2. Increase peer 2.
2.1. Convene regular mulC-country conference and workshops consisting of policy makers
assistance and implementers.
and ✴ Promote eHealth, HIS, CRVS systems sharing, learning, peer-to- peer assistance
knowledge ✴ Explore innovaNve techniques and tools to resolve eHealth, HIS, CRVS technical
exchange and issues
sharing ✴ Promote standard frameworks, data sets, and planorms of standardisaNon and
through interoperability
effecCve
networking. 2.2. Develop open eLearning plagorm and repository for AeHIN.
✴ Establish AeHIN Website (www.aehin.org)
✴ UNlize the Health Ingenuity Exchange (HingX) (www.hingx.org) to access and share
artefacts (such as open standards/open source infrastructure and soluNon stacks)
✴ Develop eHealth, HIS, CRVS map of acCviCes across AeHIN
✴ IniNate AeHIN open ehealth academy
✴ Support the development of Centres of Excellences in ehealth, HIS, and CRVS in
each country

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 STRATEGY ACTIONS
3. Promote 3.
3.1. Implement eHealth, HIS, CRVS best pracNces for systems and soluNons planning,
standards design, development, implementaCon, operaCons, and maintenance.
and ✴ Promote standardisaCon and interoperability of health systems (organizaNonal and
interoperabili technological interoperability)
ty within and ✴ Apply enterprise architectural approaches, such as the CollaboraNve Requirements
across Development Methodology (CRDM), to assess user needs, gather requirements, and
countries. design specificaNons
✴ Demonstrate country and regional interoperability of eHealth systems and soluNons
✴ Implement programme management techniques for planning, cosNng, technical
documentaNon, changes, risks, tesNng, quality assurance, operaNons, and
maintenance.
3.2. IdenNfy, develop, implement appropriate health data standards.
✴ Conduct country health data standards and interoperability workshops
✴ Conduct training on specific priority standards
4. Enhance 4.
4.1. Establish and maintain an official interagency coordinaCng mechanism for eHealth,
leadership, HIS, and CRVS management and oversight
sustainable
governance, 4.2. Enhance leadership skills, organisaConal development, change and risk management
and of eHealth, HIS, and CRVS.
monitoring 4.3. Expand linkages between public and private sectors.
and ✴ Develop partnerships, technical advisory, and consultaNve groups
evaluaCon. ✴ Extend coordinaCon at the sub-naConal level
✴ Promote corporate social responsibility pilots, such as within the
telecommunicaNons industry
4.4. Provide or strengthen the legal basis and polices for improving eHealth, HIS, and CRVS
systems and soluNons.
4.5. Conduct monitoring and evaluaCon to ensure that eHealth, HIS, and CRVS systems
strengthening delivers according to health prioriNes.

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Appendix G:
Proposal for the eHealth NaConal CoordinaCng Body (eHNCB)

1. Background
In an effort to make improvements systemaNcally on IDHIS that have been implemented,
following the changes to the current MoH organizaNon and health environment as well as
aligning with the guidelines recommended by WHO-ITU and various internaNonal bodies, the
existence of an independent body to coordinate and bridge the needs of the government,
private sector and the environment had to be taken more seriously. The eHNCB is an
important component in ensuring the overall success of the IDHIS Strategy in Indonesia, one
of which is IDHIS. The eHNCB will provide a system-level perspecNve to the Ministry and
stakeholders on ICT and IDHIS needs, prioriNes, and iniNaNves within the country.
The role of the eHNCB is to provide advice to the Ministry and stakeholders on the
implementaNon of the IDHIS Strategy.

2. Set of ResponsibiliCes
The eHNCB should have the following set of responsibiliNes.
✴ Strategy – the review and monitoring of IDHIS strategy outcomes and the development
of strategic recommendaNons and prioriNes for consideraNon by the IDHIS Steering
Comminee
✴ Investment – the development of IDHIS investment submissions and business cases for
consideraNon by the IDHIS Steering Comminee, and the budgeNng and tracking of
IDHIS investment funds
✴ ExecuNon – the coordinaNon of specific project iniNaNves across the foundaNons,
adopNon and change, and IDHIS soluNons work streams, focusing on the delivery of
on-Nme and on-budget projects; the reporNng of project progress; and the
management of project dependencies, risks, and issues
✴ Standards Development – the definiNon, maintenance, and enhancement of IDHIS
standards and the implementaNon of a consistent process for undertaking this work

3. Subject of AcCvity

✴ Provide leadership and strategic guidance in moving forward with IDHIS as aligned with
ongoing priority projects, the IDHIS Strategy, and the HSSP III.
✴ Provide IDHIS and eGov (electronic government) experNse and knowledge to the
broader health system.
✴ Oversee the implementaNon of the IDHIS Strategy.
✴ Champion IDHIS iniNaNves at naNonal, regional, and district levels.
✴ Set and prioriNze IDHIS-related policies and projects, including regulaNng and
approving IDHIS projects from the subcomminees and partners, and assessing and
idenNfying start-up and subsequent IDHIS projects.
✴ Coordinate the formulaNon and review of the IDHIS Strategy.

94
 ✴ Oversee IDHIS plans, standards, and harmonious execuNon of all projects.
✴ Establish criteria for idenNficaNon and selecNon of IDHIS soluNons.
✴ IdenNfy opportuniNes for collaboraNon with key naNonal and internaNonal IDHIS
partners.
✴ Pursue funding opportuniNes and leverage exisNng investments to support the IDHIS
Strategy.
✴ Provide advice to the Ministry and stakeholders on the allocaNon or reallocaNon of
resources as appropriate to achieve the IDHIS Strategy.

4. Scope of Member Competence

The eHNCB will be composed of one representaNve from Ministries, Departments, and
Agencies, Hospitals, other government insNtuNons, associaNons, partners and experts, which
have competence in the health system or the health infrastructure. The involvement of
agencies and sectors beyond those that consNtute the comminee membership will occur
through processes that are employed to undertake the comminee’s work. The competence of
eHNCB member should be established in a balanced manner, in order to overcome the
challenges related to the substance within the scope of the comminee, include:

4.1. Networked care:

This theme includes policy categories and issues that can enhance the ability of providers,
departments, organizaNons, and jurisdicNons to work in a coordinated environment to
improve care of the populaNon.
1. CreaNng an enabling environment: This category includes policy issues related to
creaNng enabling environment for smooth adopNon of IDHIS soluNons.
2. Sharing of informaNon, knowledge and pracNce. This category includes policy issues
related to the process of sharing informaNon, knowledge, and pracNces between
organizaNons.
3. Making transfer of informaNon easier. This category includes policy issues that enable
smooth transfer of informaNon from one provider to the other or from one insNtuNon
to the other.
4. Making the transfer of informaNon safer. This category includes policy issues related to
transfer of informaNon in a secure and integrated form.
5. Challenges for networked care. This category includes various challenges that can be
faced during the provision of networked care.

4.2. Inter-jurisdicConal PracCce.

This theme includes policy categories and issues that deal with the transfer of informaNon
and provision of care between different jurisdicNons.
1. Professional portability. This category deals with the issues related to the ability of
health care providers to provide care to paNents or give advice to physicians in
jurisdicNons other than where they are currently licensed.

95
 2. Challenges in inter-jurisdicNonal pracNce. This category includes policy issues that can
pose challenge to the implementaNon of inter-jurisdicNonal IDHIS.

4.3. Diffusion of IDHIS addressing digital divide.

This theme includes policy categories and issues that enhance the use of IDHIS among the
neediest populaNons to improve health services.
1. Increasing penetraNon of services. This category consists of policy issues that can
increase the ability of technologies to reach poor, remote and most vulnerable
populaNon groups.
2. Developing “Open” policies. This category includes policy issues that can make IDHIS
available for poor and remote groups of populaNons.

4.4. IntegraCon into exisCng systems.

This theme includes policy categories and issues that enable integraNon of IDHIS projects and
programs with the regular services. The issues covered under this theme are grouped under
the following four categories:
1. Achieving broader goals through IntegraNon. This category includes policy issues that
should be included as part of the government’s or insNtuNon’s vision to benefit most
from IDHIS technologies.
2. FacilitaNng integraNon. This category includes policy issues that may facilitate
integraNon of IDHIS services in the rouNne services provided by individuals or health
care insNtuNons.
3. IdenNfying and involving the stakeholders. This category includes policy issues that
deal with idenNficaNon and inclusion of different groups of stakeholders into the
planning and implementaNon of IDHIS.
4. Challenges with integraNon. This category includes policy issues that may pose
challenges for the integraNon of IDHIS services.

4.5. Handling innovaCon at different levels.

This theme includes policy categories and issues that can enhance the capability of
insNtuNons to implement IDHIS successfully. The issues covered under this theme are
grouped under the following three categories:
1. Assigning definite roles. This category includes policy issues that define the roles of
different players in introducing new and innovaNve technologies in health care.
2. Managing change brought by new technologies and ideas. This category includes policy
issues related to the smooth transiNon of insNtuNons with the introducNon of
technology.
3. Assessing technologies. This category includes policy issues to ensure that the
technology that is acquired for IDHIS programs is appropriate and acceptable to the
users.

96
4.6. Policy goal seqng.
This theme includes policy categories and issues that can guide the insNtuNons in defining
policies for IDHIS. The issues covered under this theme are grouped under the following four
categories:
1. Making IDHIS possible/feasible. This category includes areas of policy development
that could enhance the profile of IDHIS, and enable insNtuNons to get bener benefits
from these innovaNons.
2. Making policies flexible. This category includes certain characterisNcs of policy that
would give it the flexibility to manage change and bring sustainable change.
3. Providing effecNve governance. This category includes areas of policy development
that provision of good governance for the IDHIS programs.
4. Guidelines for different stakeholders. This category includes policy issues that prepare
different stakeholders for successful IDHIS adopNon.

4.7. EvaluaCon and research:

This theme includes policy categories and issues that can guide the process of evaluaNon and
research to generate evidence for adopNon of IDHIS. The issues covered under this theme are
grouped under the following two categories:
1. EvaluaNng the impact IDHIS. This category includes policies regarding measurement of
various impacts of IDHIS in different environments:
2. Assessing new technologies. This category includes areas of technology assessment
that may require support from policies.

4.8. Investment.
This theme includes policy issues that can suggest business models for IDHIS adopNon.

4.9. Ethical issues.

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Appendix H
Government’s project success and failure

The government’s ICT project implementaNon process is complex, usually requiring

simultaneous anenNon to a wide variety of factors. A number of studies have dealt with the
concept of success/failure factors in ICT projects, and some different types of models have
been established. The ITPOSMO factor model proposed by Heeks in 1999, consists of seven
key dimensions [48][49]. Each of these dimensions has, in turn, a set of CriNcal Success/Failure
Factors that were drawn for analyzing e-government projects in different countries. These
dimensions are:
✴ InformaNon (factors related to quality and prerequisites of system inputs and outputs);
✴ Technology (factors such as the availability and compaNbility of hardware and
sofware);
✴ Processes (alignment and integraNon between the system and exisNng/new processes
to achieve stated objecNves);
✴ ObjecNves, Values, and MoNvaNon (e.g. organizaNon culture, guiding values);
✴ Staffing and Skills (factors such as the availability of skilled personnel and adequacy of
training provided for using the system);
✴ Management Systems and Structures (factors such as managerial pracNce and
flexibility of organizaNonal structures); and
✴ Other Resources (money and Nme required).
Yeo’s [50] survey, conducted in 2000, of close to 100 respondents associated with a major
project failure in Singapore, grouped failure factors into three organizaNonal categories as
below;
✴ Context-driven: factors dealing with culture, leadership, and organizaNonal issues.
✴ Content-driven: factors related to technology and business process, the “what” and
the “how”.
✴ Process driven: factors related to strategic formulaNon and change management or
under the influence of the project manager.
A different approach has been categorized the framework as consisNng of four quadrants:
customer; scope and requirements; execuNon; and environment as below [51:
✴ Customer: focuses on risk factors relaNng to customers and users. These factors are
ofen beyond the project manager’s control.
✴ Scope and requirements: focuses on risk factors associated with a project manager’s
inability to judge a system’s scope.

48 Heeks R. and Bhatnagar SC., "Understanding Success and Failure in Information Age Reform," in International Practice in IT-Enabled Public
Sector Reform, Routledge, London, UK, 1999, pp. 49-74.
49 Heeks, RB. (2001) Building e-Government Development. i-Government paper no 12. IDPM,
University of Manchester http://www.man.ac.uk/idpm/idpm_dp.htm
50 K. Yeo, "Critical Failure Factors in Information System Projects," International Journal of Project Management, vol. 20, pp. 241-246, 2002
51 Wallace L. and Keil M., "Software Project Risks and Their Effect on Outcomes," Communications of the ACM, vol. 47, pp. 68-73, 2004.

98
 ✴ ExecuNon: focuses on such risk factors as inadequate project staffing, inappropriate
development methodology, failure to define roles and responsibiliNes, and poor
project planning and control.
✴ Environment: focuses on risk factors in both internal and external environments,
including changes in organizaNonal management.
The Dutch government’s ICT projects categorize factors that could affect the project in
threefold [52];
✴ PoliNcal complexity
✴ OrganizaNonal complexity
✴ Technical complexity

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52 Leydesdorff E. and Wijsman T., "Why government ICT projects run into problems?," N. C. o. Audit, Ed., ed. Netherlands, 2007.

99
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lllll

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