Patient Management System (SPP) Pioneer Of Electronic Medical Record System In MOH Hospital

Introduction And Development System

SPP which stands for Sistem Pengurusan Pesakit (SPP) has started to become a household name among the staff of Ministry of Health.

Did You Know What is SPP?

Sistem Pengurusan Pesakit (SPP) is a backbone for the development of Hospital Information System (HIS) for Public Health Ministry hospitals. SPP is a local product and Intellectual Property owned entirely by Ministry of Health (Owner of Intellectual Property Right (IPR)). It was developed by a vendor who was appointed in 2007 and involved up to today.

The first version was performed at Hospital Tuanku Ja’afar Hospital Seremban and Hospital Port Dickson. Version 2 was conducted at Hospital Raja Permaisuri Bainun, Hospital Seremban and Port Dickson. Hospital Kuala Lumpur, Hospital Kajang Hospital and Hospital Tengku Ampuan Rahimah use Outpatient Module version 2.6 under eKL project until today.

In 2012, SPP has been upgraded to version 3.0 and conducted at Hospital Raja Permaisuri Bainun, Ipoh. With a variety of improvements required by the user, SPPV3 been upgraded to version 3.1.

In 2014, SPPV3.1 was launched to 3 more hospitals which are Hospital Tuanku Ja’afar Seremban, Hospital Raja Perempuan Zainab II, Kota Bahru and Hospital Bentong. The project was initiated in February 2014.

The Development Concept Of SPP

The concept is in line with the policies, processes and procedures for KKM with the aspirations adapted to the hospital environment. Development and implementation of the system comes in stages, began in 2007 under the RMK-9. Hospital Tuanku Ja’afar, Seremban and Hospital Port Dickson is a leading implementer of this system and were fully deployed in September 2008.

Mesyuarat Jawatankuasa Pemandu IT dan Internet Kerajaan Bil.3/2009 chaired by the Chief Secretary of Government has decided “KKM will develop an Hospital Information System (HIS) application to be implemented in hospitals that have not had a system“.

The Implementation Of SPP At 8 Hospitals In KKM

Modules Contained In Sistem Pengurusan Pesakit

8 modules have been prepared in SPPV3.0. This module is linked in the Sistem Pengurusan Pesakit (SPP) at the hospital. The cycle of Sistem Pengurusan Pesakit (SPP) starting from registration of patient at counter, the procedure for admitted patient, “Order” Management to the Department of Pathology, Radiology, Pharmacy, Diet and Catering, which makes it accessible to the Bill and Payment Management Module and subsequent access to the Medical Record Management Module. An appointment can also be applied through the Patient Management System. Information Management staff as Rosters, Shift and annual leave can be arrange in the system.

SPP As A Pioneer For Medical Record Electronic Systems

Where is the role of Sistem Pengurusan Pesakit (SPP) as pioneer for Medical Record Electronic Systems at KKM Hospital?

Modules are developed according to the guidelines and policy that already set. Work processes must be followed and systematically, this indirectly guide user more discipline. SPPV3.1 for Medical Record Module has prepared 5 important function such as;

1. Physical Medical Record Management (BHT)
2. Medical Report / Refunds Management
3. Medical Institutions Management
4. Disposal of Medical Record
5. Statistic Report

Physical Medical Record Management (BHT)

Differentiate Physical Medical Record Management

Work Process	Manual System	Implementation of SPP
Application System	No Medical Record Management application system	Application Physical Medical Report Management Module at Department Medical Record Ward/Clinic/Daycare
Admission of patient at Ward	Patient Registration in Registration Book Copy process takes time and security risk	Register in SPP System Biography data will used for each information.
Patient Discharge : Dispatch Physical Medical Record to Department of Record	Book used for list record as deliver proof from ward and signature revealed as acceptance at Department Medical Record. Repeated copying information process and the risk of error and a waste of time.	Delivery process through system (send) and proof of acceptance at Department Medical Record (received): Will save times
Medical Record tracing processes and receiving patient folders	Uses of Tracer for borrowing and sent with dispatch book. Repeated copying information process	Borrowing, Approval, Notification and Monitoring through online. Documented information more organized and systematic. Easy for review.
Report for Physical Medical Record Management	Must prepared daily basis, monthly and yearly Delay the process and sometimes inaccurate	Automatic generate from system More confident and fast Data will stored more systematic in a long period.
Monitoring	Location for Patient Record difficult to identify because in a manual process.	Easy, fast and efficient.

Medical Report Management / Refund

Application of Medical Report for insurance purpose, legal and others is an issued by Medical Record Department

Via SPPV3.1;

• Medical Record Officer or staff at Medical Record Department can handle the application, payment, update the application status through system easily and faster.
• The mailing will generate automatically based on the assigned format by system.
• Monitoring the Preparation of Medical Report easily and faster.
• Specialist and Medical Officer can;

1. Key in Report (Medical report typing process) through system based on the assigned format, easy and faster to complete it.
2. Specialist or Medical Officer can Inquiry for Statement Refunds.

• Achievement of Medical Report preparation automatically from system.

Management of Medical Report by electronic in SPPV3.1 will ensure each work process must be followed, as example payment must be settled before the next process. Improper work process that not align with the guidelines are not allowed in SPPv3.1.

Medical Board Management

Via SPPV3:

•  Medical Record Officer can register an application through system.
• All the work process will update by the system.
• Mailing in assigned format can directly generate by system.
• Medical Board Report can Key in into the system.
• Monthly/Yearly report can directly generate from system and it is more accurate and fast.

Medical Records Disposal

• General Disposal (Medical Records disposal) is a process to generate a list of records disposal on the assign date.
• Through this function medical record have enough period of storage and comply with the disposal will be listed for the purpose.
• However this module still not been used because medical record data that already register in the system not reached the period of the disposal.

Statistics Report Management

Medical Record Department known as Data Bank. History of collecting statistics;

1. Era Before 1990an

All patient information documented manually.

2. Era from 1991 until 2011

Unit IDS (PIK) introduced:

• 1991-1994 Medical Care System (MC)
• 1994-1998 Hospital Management Information System 2 (HMIS 2)
• 1999-2011 Sistem Maklumat Rawatan Pesakit (SMRP)

For hospital that been provide with Sistem Pengurusan Pesakit Dalam (SPPD), demography information will upload and download to ward and Medical Record Unit. Diagnoses will code and key in into computer at Medical Record Department.

Hospital without SPPD still make the patient registration manually in Patient Registration Book. Demographic information will key in into System Application after the patient discharge with the diagnosis that has been encoded.

Daily performance data will collected in Daily Ward Cencus PD 103 and the information will key in into the System MC/HMIS 2/ SMRP/ SMRP Web Base. The report will generate for retention monthly/yearly based on the format provided.

3. Era after SPP has been introduced

2008 until present:

• Computer has been supplied in each location involved with 8 modules of SPP.
• Information from Patient Registration directly connected to related modules.
• Standardize information and Introduction Sticker at Medical Record Folder.
• Statistic Information based on work process of patient admissions.
• Information PER PD 103 no need to key in at Medical Record Unit. No duplication task and save the manpower.
• Diagnosis will Key In from ward by Medical Officer while patient treatment directly and report generate from SPP will prevent the unreadable writing.

When Sistem Pengurusan Pesakit (SPP) is introducing, Patient Registration is fully done by online. Information in Register Book PER PD 101transfered into database and connected with patient management at ward and clinic along the treatment to the patient. Information from Register Book already transfer and stored in the system.

Comparison Implementation Manual System With SPP

Benefit Of SPP

Acceptance Of SPP Among Hospital Staff

In early implementation of SPP, not all the hospital staff can accept it easily. Efforts were made in order to ensure all the staff be ready for “Change Management”. After the implementation reach until 7 years, and staffs have realized the importance and benefit of this system, they give the highest commitment to ensure the implementation of this system more effective.

Medical Division Development, Ministry of Health Malaysia look forward to implement Sistem Pengurusan Pesakit at the hospital which hospitals that not been provided that system.

Medical Record Officer Or Assistant Medical Record Officer Roles In Implementation Of SPP

Medical Record Officer or Assistant Medical Record Officer should had an important roles in the implementation of SPP. Medical Record Department that synonym with Bank Data must plays the important roles at any hospital to ensure the information that already collected more quality and accurate. For those who had expertise in handling the system must cooperate to realize the excellent of this Sistem Pengurusan Pesakit.

Impact Implementation Of SPP For User

Assistant Medical Record Officer position already introduced since 1986 and already reach to 30 years. After the implementation Patient Management System in 2008 which after 22 years of its services, SPP will acts as PIONER FOR MEDICAL RECORD ELECTRONIC SYSTEM AT KKM HOSPITAL. Hopefully the Sistem Pengurusan Pesakit (SPP) will increase on a par as Hospital Information System (HIS) that using the high technology in this country. An electronic information is more systematic and quality.

 

Last Reviewed	:	11 August 2017
Writer	:	Pn. Zarimah Binti Jaafar
Translator	:	Pn. Zarimah Binti Jaafar
Accreditor	:	Pn. Siti Ajar Binti Baharim