The use of Electronic Medical Records for Clinical Decision-Making at RSUD Dr. Hasri Ainun Habibie, Gorontalo Regency

Abstract

Electronic Medical Records (EMR) have become an important component of hospital information systems because they provide faster and more integrated access to patient information and may support clinical decision-making. This study aimed to describe the use of EMR in supporting clinical decision-making at RSUD Dr. Hasri Ainun Habibie, Gorontalo Regency, including the level of use, ease of access to patient information, healthcare workers’ perceptions, and barriers to implementation. This study employed a descriptive qualitative design conducted in March–April 2026. Five informants were selected purposively, consisting of one information technology staff member as the key informant, one head of medical records as the main informant, two reporting staff members, and one medical support staff member. Data were collected through in-depth interviews, observation, and documentation, and analyzed through data reduction, data presentation, and conclusion drawing. The findings indicate that EMR has been implemented through the Hospital Management Information System (SIMGOS) and is routinely used in patient services. Healthcare workers directly involved in patient care are required to use EMR. Patient data completeness was reported at approximately 75%, categorized as fairly complete, although some system features were not yet fully utilized. EMR facilitated faster access to patient information and supported diagnosis, intervention, and therapy decisions. The main barriers were occasional network or system disruptions and user adaptation. Overall, EMR was perceived as useful for improving work efficiency, service quality, and the timeliness and accuracy of clinical decision-making. Continuous training, infrastructure improvement, system integration, data security, and development of clinical decision-support features are recommended.