What’s Wrong with the Policy of Releasing Patient Medical Information at Regional Public Hospital

Background : The release of medical information to third parties is the responsibility of the health facility to protect the health information contained in it from being damaged, lost, falsified data, and illegal access. Therefore, health facilities must have policies that regulate the system for releasing patient medical information to third parties. This study aims to analyze the policy of the patient's medical information release system in RSUD X. Method : This research is a descriptive study with a qualitative approach, through in-depth interviews and observation techniques. The informants in this study amounted to 12 people, namely the leadership of the hospital, the manager of medical services, the head of the medical record section, and the DPJP. Results : The results of this study indicate that RSUD X already has a policy regarding the system of releasing medical information to third parties but the release activities in the field it is not following the policy. This is because communication such as socialization from the leadership is still lacking so policy actors still do not know about the policy. The leadership has also never carried out monitoring and evaluation related to the release activity so the leadership does not know that other factors cause the policy not to work. Conclusion : The release of medical information to third parties already has a policy set out in the sop, but in its implementation, it is not following the existing sop due to the lack of socialization related to the sop to the discharge officers, the absence of monitoring


Introduction
In the law of the Republic of Indonesia number 29 concerning Medical Practice (2004) it is stated that the hospital is an organization that focuses on social and health care by providing comprehensive, curative, and preventive services [1]. Hospitals have various duties and responsibilities, one of which is protecting patient medical information from being lost, damaged, falsified, or illegal access and also releasing patient medical information following applicable laws and regulations to access media [2]. In other research it is said that medical information is confidential, containing the patient's identity, patient diagnosis, disease history, examination history, and treatment history which must be kept confidential [3,4].
Dimas Aulia Savitri 1* , Antono Suryoputro 1 , Farid Agushybana 1 , and Gunchmaa Nyam 2 10.12928/dpphj.v16i2.5759 At the regulation it is explained that the release of medical information to third parties (secondary release) is required to attach a power of attorney from the patient concerned or the patient's family representing the patient. This power of attorney is provided by the health service facility or hospital concerned so that its contents can be accounted for, then the holder of the power of attorney attaches his/her identity [5,6].
A research said that patient medical information contained in medical records is a source of data that is used for various purposes, considering that the data is confidential, the use of the data needs to refer to legal aspects, especially when releasing the information so that it can be legally accounted for. The release of medical information must have the patient's permission and be given a stamp that has given the power to ask for his medical information [7]. Another research stated that the information in the medical record is confidential but not absolute so that health workers have the right to explain the contents of the medical record with the permission of the patient concerned and there is an interest in court or law enforcement, but only the authorized hospital has the right to describe the contents of the medical record. So that in the activity of releasing medical information there must be compliance in accordance with the SOP set by the hospital [8].
Another research said, Implementation is a factor supporting the success of a policy, so to analyze a policy it is required to have standards that will be the basis of policy implementation. Implementing organizations also make resources both human resources and resources that facilitate implementing administration that is able to encourage effective implementation. Communication between organizations and enforcement activities, the characteristics of implementing agencies, and the environment consisting of economic, social, and political aspects of the jurisdiction or implementation. Attitudes among implementers also influence the implementation of the policy [9].
RSUD X has released medical information to third parties since the beginning of the hospital's establishment. However, in practice, the release of medical information at RSUD X still does not involve the director in the release process but only through officers on duty in each unit. The implementation that has not been suitable has had several impacts on RSUD X itself. This is not in line with regulation Permenkes/269/PER/III/2008 which explains that hospitals are responsible for protecting medical information from possible loss, damage, falsification, and unauthorized thirdparty access [2].
The activities of releasing patient medical information to third parties carried out at RSUD X so far have not been in accordance with Standard Operating Procedures. Where the release activity does not involve the director and the officer also does not ask for a power of attorney from the patient concerned and the applicant does not leave a photocopy of his identity as collateral. Based on this description, the author wants to analyze more deeply the implementation of the policy of releasing medical information to third parties in RSUD X.

Materials and Method
This research was conducted at RSUD X starting from April to October 2021. The data collection in this study is primary data and secondary data, the data collection is adjusted to the type of data to be collected. Primary data comes from observation and in-depth interviews. In-depth interviews were conducted with the research subjects, namely the main informants, totaling 10 people consisting of the Patient Responsible Doctor (DPJP) and 1 head of the medical record unit. There are 2 triangulation informants consisting of hospital leaders and medical service managers. The results of the interviews were confirmed by observation using a checklist sheet. Secondary data is obtained through documents related to the system for releasing patient information to third parties. This research has been approved by the ethics committee of the University of Jember with the number 1299/UN25.8/KEPK/DL/2021Interventionary studies involving animals or humans, and other studies require ethical approval must list the authority that provided approval, and the corresponding ethical approval code.

Implementation of the Medical Information Release System to Third Parties
The release of medical information to third parties at RSUD X has been going on since the hospital was established and already has a special policy to serve as a reference for these activities in the form of SOP's. However, from the results of in-depth interviews, 9 of the 12 informants said they did not know for sure the flow of medical information released at RSUD X and also did not know the existence and contents of the SOP. All key informants also said that socialization from the leadership regarding the SOP and the flow had never been done. It is recommended that the socialization of the SOP be carried out to officers who directly handle activities.
"As long as I worked here, I never knew about the SOP, maybe if it's about the SOP, you can ask the medical record section", (informant 1)

Standards and Policy Objectives (SOP)
Based on the results of in-depth interviews with informants, 9 out of 12 informants said they were not aware of the existence of the SOP and also the contents of the SOP while they were working at RSUD X. In fact, the informant said that socialization from the leadership regarding the SOP had never been carried out. The preparation of the SOP also did not involve all officers who were directly involved in the release process.
"SOP drafters are hospital directors and teams; I was never involved in the preparation while working here" (Informant 3)

Resource
Based on the results of in-depth interviews with all informants, all informants said that for the adequacy of human resources to carry out the release of medical information, this was sufficient and competent in terms of educational background and length of service at RSUD X. Funding resources to support the release of medical information are sufficient and there have never been any problems. The budget is given in accordance with the needs that have been submitted by the officers to the leadership of RSUD X. The budget is given in the form of needs that are indeed proposed. The facilities and infrastructure resources to support the release of medical information have been provided adequately and are still very feasible to use. The facilities and infrastructure have also been used according to their needs and stored properly so that they are maintained.

Communication
The informants felt that leadership communication related to the release of medical information to third parties at RSUD X was lacking by the informants, where almost all of the informants said they did not know the flow of activities and the SOP. The informant also said that he had never heard of any socialization from the leadership regarding the release of this medical information while working at RSUD X.
"For socialization, it seems that there has never been" (informant 3) "Socialization has been done but it's been a long time, so it's natural that many don't know about the socialization or have forgotten about it" (informant 4)

Characteristics
The release of medical information to third parties at RSUD X as the implementing agency was not in accordance with the SOP that had been made, which did not involve the director giving approval but was replaced with a wet stamp. Regarding the division of tasks and obligations, it is clear and directly shared by the leadership, but in its implementation, most of the informants who are implementers do not know the distribution, so there is one informant who feels burdened by always explaining to other informants every time there is a request for the release of patient medical information at the RSUD X.

Environment
Environmental conditions are influenced by the economic, political, and social conditions of the community. The economic condition in RSUD X is quite good, where during the release of medical information there has never been a problem in terms of procurement of facilities and infrastructure. The influence of the environment comes from social factors from the community or the applicant's party where the applicant is considered impatient and easily provoked by emotions, it is also difficult to follow the regulations that have been made by the hospital so that the officer is forced to release medical information outside the provisions set by the hospital.
"As you know, the people around you are easily emotional. Difficult to comply with hospital regulations. If asked to wait or follow hospital rules which are often considered complicated, they will threaten with their sickle. To be honest, the officer here was scared and forced to provide medical information to them outside the hospital's policy" (informant 2)

Attitude
There has never been a reward and punishment system for implementing policies, all informants also said they felt the need for a reward and punishment system for officers who released medical information in accordance with established SOPs so that all officers knew the policies and contents of the policy and also know each other's duties

Discussion
Another regulation is stated the process of implementing service standards needs to be internalized and socialized. Internalization is carried out to provide understanding to all levels of service delivery organizations. Meanwhile, socialization is done to build understanding and common perception [10]. In another research policy implementation in which there are goals or objectives to be achieved through an activity to produce certain outputs and outcomes. If a policy is not prepared properly then the goals or objectives of the policy cannot be realized [11]. Many research it is said that if the implementation of the policy is expected to be effective, the individual or organization responsible for implementing the decision must know each other as well as implement and understand clearly the intent and purpose of the policy. If policy implementers do not clearly understand the intent and purpose of the policy, the implementers will be confused about what they are doing, and if forced, the results will not be optimal. Policy implementation is widely seen as an administrative tool in which all implementers and policy makers jointly carry out the policy to achieve the desired goals. Policy implementation begins with the goals and objectives set by policy makers [12,13].
A research said in the release of medical information, some obstacles are often faced by hospitals, namely the lack of socialization of SOPs to discharge officers. Socialization needs to be carried out to unite understanding and common perceptions in the policy implementation environment. The socialization explained in detail the flow of policy implementation In addition to implementing SOPs, hospitals also need to socialize efforts to overcome problems that will occur and have occurred to improve the quality of further policy implementation [14,15]. Another research said that SOP is an instruction that contains the steps of a certain activity process that is compiled based on a mutual agreement and made by the relevant health service facility. Hospitals should have or make SOPs regarding the release of medical information to third parties so that discharge officers can provide optimal services regarding the release of medical information [16]. Meanwhile, other researchers said that SOPs have a very important role in the release of medical information, considering that medical information is very confidential and should not be misused by either the patient, the hospital, or third parties including insurance. Apart from being the basis for the release of medical information, SOPs also act as a communication process between the patient, the Vol. 16 hospital, and the insurance company so that the release process is carried out in accordance with applicable regulations. This is to reduce the level of leakage of patient medical information [17].
A research said, resources have an important role in policy implementation, because if the personnel who carry out have a sense of responsibility then the implementation of the policy will run effectively. Implementing policies must be supported by human resources, infrastructure, and financial resources. If there are not enough implementers to implement the policy, then the implementation of the policy will be ineffective. The success of a policy is supported by adequate resources in terms of quality and quantity. Another research said, competent human resources are able to encourage a policy to run optimally, competent human resources are people who have attended education and training. Medical record officers have received education in their field so that their ability to work is not in doubt. The release of medical information to third parties should be carried out by medical record officers who are more familiar with medical information and information release. Thus minimizing the release of information to irresponsible parties [19,20].
A research says that communication is important in an organization because communication can increase mutual understanding between employees and superiors and can also improve the coordination of every activity in the organization. Communication can also affect the performance of officers in releasing medical information [21]. Other research says that a leader must determine effective communication with all parties involved in the policy implementation process, and also a leader must be a motivator if the policy implementation process experiences difficulties. Policy implementation will also be effective if the policy is communicated effectively to policy implementers and with communication, the goals and objectives of a policy will be fulfilled [22,23].
Many researchers say that the characteristics of the implementing agency are the formal structure of the organization and the informal attributes of its members. The elements that influence it are the competence of the staff, the level of supervision and decision-making to the process, political resources, vitality, the level of open communication, and the relationship both formal and informal between the agency and decision-making. The success of a policy is influenced by the characteristics of the bureaucracy that match the policy being implemented. the characteristics of implementers who comply with the policy can facilitate equality of perception so that they can respond to each other to achieve implementation goals [24,25]. Other research said that the weak support between implementing agencies and the involvement of outside groups in implementation results in weak coordination and cooperation. Coordination and cooperation that have not been optimal are the cause of the implementation of policies that have not been carried out according to the aims and objectives of the policy [26,27].
A research says that in a policy implementation there will be a number of factors that interact with others, these factors are the content of the policy, the environment, politics, and the target group. The implementation of a policy cannot be separated from the juridical, sociological, and philosophical aspects. Then the policy must also consider threats, effectiveness, resource support, operational technical, political, economic, social, cultural, security and defense. A policy implementation becomes a very important sequence in the entire policy process, because only with implementation can the goals and objectives of the policy be realized. In addition, several studies have stated that understanding a policy well from the policy process to its implementation, including identifying the factors that influence policy implementation, is a must to ensure the effectiveness of the policy implementation itself. To ensure a truly effective policy implementation, policymakers must carry out continuous monitoring and evaluation [28,29].
A research says that punishment and rewards given by the leadership are useful for increasing the high productivity of employees or increasing employee performance. With the implementation of clear rewards and punishments, employees will be more responsible for the tasks assigned to them, although reward and punishment are contradictory words, they can motivate and influence employee performance. The application of rewards that are much more emphasized than punishment will have a very good impact on improving employee performance in carrying out their work. Other research says that the reward system has a significant effect on work productivity, so companies must further improve the reward system for employees to be motivated

Conclusion
The leadership of RSUD X is considered lacking in socializing the SOP to the implementers so almost all implementers say they are not aware of the SOP and have never participated in the socialization from the leadership regarding the release of medical information while they are working at RSUD X. The communication between the leadership of RSUD X and the implementers is considered lacking so the leadership does not know that there are social factors that greatly affect the implementation of the release of medical information to third parties in RSUD X which is not following the policies that have been set.
The leadership of RSUD X should improve communication with implementing officers so that they can find out what factors cause officers not to comply with applicable policies and what makes officers not aware of the existence of SOPs in RSUD X.