IMPLEMENTATION OF TELERADIOLOGY SERVICES POLICY IN HEALTHCARE FACILITIES
Duta Kamesworo1, Edy
Susanto2, Gatot Murti
Wibowo3
Politeknik Kesehatan Kemenkes Semarang, Central Java, Indonesia
dutakame@gmail.com1, edysusanto@poltekkes-smg.ac.id2,
gatotmurtiwibowo@poltekkes-smg.ac.id3
|
KEYWORDS |
ABSTRACT |
|
Implementation;
Policies; Teleradiology; DICOM; PACS |
Teleradiology, according to Ministry of Health Regulation No. 20
of 2019, is a diagnostic radiology service that utilizes electronic
transmission of images from all radiology modalities, along with supporting
data, from Consultation Requesting Health Facilities to Consultation Provider
Health Facilities. The goal is to analyze the implementation of teleradiology service policies in healthcare facilities
and assess the supporting and inhibiting factors for the implementation of teleradiology service policies in healthcare facilities.
The research method used in this study is descriptive qualitative. A total of
12 informants were interviewed, including individuals from Batin Mangunang Hospital, PON
Hospital, and X Tambun Bekasi
Hospital. Purposive and snowball techniques were employed to identify informants
in this study, along with the use of data triangulation and ATLAS.ti software. The results of the implementation of teleradiology service policies at Batin
Mangunang Hospital currently involve the use of the
WhatsApp application for teleradiology
services. Previously, in 2016, the hospital had used applications from the
Ministry of Health, but this only lasted for a few months. The inhibiting
factor is that the implementers do not fully understand and implement teleradiology services, mainly because they did not
continue to provide funding sources and infrastructure facilities. The
implementation of teleradiology service policies at
PON Hospital for teleradiology services previously
used teleradiology from the Ministry of Health and
only ran for a few months. Currently, they use Picture Archiving And
Communication System (PACS) facilities. The supporting factor is that the implementors understand teleradiology
service policies related to DICOM usage standards. |
|
DOI: 10.58860/ijsh.v2i10.120 |
|
Corresponding Author: Duta Kamesworo
Email: dutakame@gmail.com
INTRODUCTION
To obtain
high-quality and safe radiology services, good technical management and control
are required, supported by appropriate infrastructure, personnel, and equipment
(Amir,
2018). In order to ensure
consistent quality in radiology services, a standard radiology service policy
that can serve as a guideline is necessary (Kuzairi
et al., 2017). Medical services that
provide diagnoses and/or treatments using image guidance, encompassing both
ionizing and non-ionizing radiation modalities, can be conducted by various
healthcare facilities, whether owned by the central government, local
government, or private healthcare facilities; this is the essence of clinical
radiology services (Nurdahniar,
2022). These healthcare
facilities can include Hospitals (RS), Public Health Centers (Puskesmas), as well as Clinics.
Common issues
often associated with the quality of radiology services in hospitals include
relatively long waiting times, particularly for services like chest X-rays,
which have the highest demand. Limited human resources, especially for
radiology specialists who have numerous other responsibilities such as
meetings, professional seminars, leave, and other commitments, can also pose
challenges. The absence of radiology specialists at the practice location
results in delayed services, causing temporary disruptions in radiology service
delivery. The interruption of radiology services is caused by a system that
depends on the presence of radiology specialists at the facility. If this
continues, it can significantly affect patient care, patient psychology, and
the quality of service (Heri,
2019). The best step to follow up on quality
radiology services is to innovate to address quality-related issues (Mas'uul
& Marwati, 2020). One approach is to implement teleradiology in radiology services, which can reduce
waiting times.
Through the
Directorate of Referral Health Services, the Ministry of Health introduces
telemedicine, a form of remote healthcare that utilizes telecommunications to
transmit medical data, images, videos, and medical knowledge from one location
to another. Teleradiology is one of the subsystems of
telemedicine. This is based on the Minister of Health of the Republic of
Indonesia's Decree No. 409/2016 on the Pilot Program of Telemedicine Services
Based on Video-Conference and Teleradiology (Decree
of the Minister of Health of the Republic of Indonesia Number 409 of 2016
concerning Trial Hospitals for Telemedicine Service Programs Based on
Video-Conference and Teleradiology, 2016). In this context, teleradiology
refers to diagnostic radiology services that electronically transmit images
from all radiology modalities and supporting information from requesting
healthcare facilities to consulting healthcare facilities, to gain expertise in
diagnosis. Teleradiology provides unlimited access to
radiology specialists in consulting healthcare facilities for healthcare
facilities that do not yet have a Radiology Specialist.
Healthcare
facilities that provide consultations and those that request consultations have
specific tasks as stipulated by Ministry of Health regulations, which must be
carried out during the implementation process, including the necessary
requirements such as the availability of human resources, facilities,
infrastructure, equipment, and applications. These services are carried out by
qualified healthcare professionals (medical and health personnel) who hold
practice licenses at the providing healthcare facilities and are in accordance
with the standards and regulations established by the legislation (Lestari,
2021). This explanation shows
that teleradiology services should be conducted
between the consulting healthcare facility and the requesting healthcare
facility and should meet several other requirements to provide teleradiology services.
Based on the
first preliminary study conducted at the Ministry of Health's office in Kuningan, Jakarta, it was found that since 2019, pilot testing
of telemedicine-based teleradiology services is no
longer being conducted. The Ministry of Health has established Regulation No.
20/2019 concerning the implementation of telemedicine services between
healthcare facilities (Regulation
of the Minister of Health of the Republic of Indonesia Number 20 of 2019
concerning the Implementation of Telemedicine Services Between Health Service
Facilities, 2019). The pilot program for teleradiology-based telemedicine services, selecting
several hospitals as consulting healthcare facilities and requesting healthcare
facilities, has been updated in its implementation process. The requirements
stated in this regulation require healthcare facilities to follow the rules
established by the Ministry of Health and be registered (Rosady
et al., 2022). These new provisions have
been included to assist and oversee the national rollout of telemedicine
services by the Ministry of Health, provincial health offices, district/city
health offices, and other relevant local regulations. The programs mentioned
above aim to improve patient safety, service quality, and public protection
against healthcare service threats.
In the second
preliminary study, it was found that there are hospitals and healthcare
facilities in the Bekasi area that electronically
transmit images from all radiology modalities and supporting data not to
consulting healthcare facilities, as stipulated by the Ministry of Health
regulations, but to individual medical and healthcare personnel using
electronic media such as email and social media, such as WhatsApp.
The transmission is done using WhatsApp, and the
image format is sent as JPEG. This process has been in place for several years
and is considered effective for image expertise and speeding up radiology
services at the hospital. However, its implementation does not yet follow the
regulations issued by the Ministry of Health.
The aim of
this research is to analyze the implementation of teleradiology
service policies in healthcare facilities and to analyze the supporting and
inhibiting factors for the implementation of teleradiology
service policies in healthcare facilities using SWOT analysis as a
recommendation.
This research
is expected to provide benefits in the form of input for policymakers,
especially in the implementation of teleradiology
service policies in healthcare facilities, enhance the insights and knowledge
of the authors, particularly for readers who are generally concerned with the
implementation of teleradiology service policies in
healthcare facilities, and serve as a reference for future academic writing.
METHOD
This is a qualitative research study that explores empirical facts about
the implementation of teleradiology service policies
in healthcare facilities in accordance with the Republic of Indonesia Minister
of Health Regulation 20 of 2019 regarding Telemedicine Services Between Healthcare Facilities. The study involves observing
the implementation of teleradiology service policies
at various healthcare facilities, including Batin Mangunang Regional Hospital in the Tanggamus
district, PON Hospital in Jakarta, and RS X Tambun in
Bekasi. The selection of informants for this study is
based on purposive and snowball sampling techniques. The researcher conducts
observations of the implementation process of teleradiology
service policies at the following healthcare facilities: the healthcare
facility requesting consultations (Batin Mangunang Hospital in the Tanggamus
district), the healthcare facility providing consultations (PON Hospital in
Jakarta), and other healthcare facilities (RS X Tambun
in Bekasi).
RESULTS AND DISCUSSION
Implementation policy service teleradiology at
the facility service health contained in Minister of Health Regulation No. 20
of 2019 , namely about Maintenance Telemedicine Services Between Facilities
Health Services (Kamesworo Et Al., 2023). The
success of implementing teleradiology service
policies in healthcare facilities will vary depending on the characteristics,
the level of understanding of the people in power, and the conditions in these
health facilities. The implementation of teleradiology
service policies in healthcare facilities aims to analyze the factors that
support and inhibit their implementation.
Based on the data gathered from observations and interviews, the efforts
to implement these policies have been carried out at Batin
Mangunang Regional Hospital in the Tanggamus district and the National Brain Center Hospital,
following the teleradiology system established by the
Ministry of Health. However, at this moment, these efforts have not been fully
completed due to several barriers. In contrast, RS X Tambun
in Bekasi has not yet fully implemented the teleradiology service policy as prescribed by the Ministry
of Health. Hospital X Tambun Bekasi
continues to provide teleradiology services outside
the existing regulations set by the Ministry of Health.
Batin Mangunang
Regional Hospital (Health Facilities Requester Consultation)
Batin Mangunang Regional Hospital was previously known as RSUD Kotaagung. It officially changed its name to Batin Mangunang Regional Hospital
when Regional Regulation Number 51/2017, dated December 12, 2017, came into
effect. It is located in the Tanggamus district. The
name "Mangunang" commemorates a heroic
figure from the coastal Lampung area who opposed Dutch colonialists in the Gulf
region from 1820 to 1833. Naming the hospital after Batin
Mangunang serves to inspire the people of Tanggamus to emulate the heroic struggle of this historical
figure.
This hospital has the status of a Regional Public Service Agency (BLUD)
and is classified as a class C hospital. It is owned by the Tanggamus
Regency Government and occupies a significant area of land, covering 57,925
square meters, with a building area of 5,975 square meters. According to data
from the Ministry of Health, Batin Mangunang Regional Hospital offers 118 patient beds, catering
to various service classes, including class I, class II, class III, HCU,
isolation without negative pressure, and a special emergency room for Covid-19
cases. The hospital provides a wide range of medical services, including
general medicine, dentistry, MCH/KB, 24-hour emergency services, internal
medicine, pediatrics, surgery, obstetrics and gynecology, anesthesia, and
radiology.
List of Workers Radiation
Installation radiology own source
Power man For do service health as shown in table 1 below :
Table
1 List of Workers Radiation at Batin Mangunang Regional Hospital
district Tanggamus ( Health
Facilities Requester Consultation )
|
Power Type |
Qualification Have SIP/STR/SIB |
Amount |
|
Radiology |
|
|
|
Specialist
Doctor |
Specialist
Doctor Radiology |
1 |
|
Radiographer |
D-III
Radiological Engineering |
5 |
|
Physicist
Medical & PPR |
S-1
Physicist Medic |
1 |
|
General
Administration |
SENIOR
HIGH SCHOOL |
1 |
|
Technology
Information |
D-III
Radiological Engineering |
1 |
|
Total |
9 |
|
Source :
Document Report Installation Radiology at Batin Mangunang
Regional Hospital district Tanggamus Year 2023
Table 1
explains that at Batin Mangunang
Regional Hospital district Tanggamus has 9 radiation workers.
The Radiology department at Batin Mangunang
Regional Hospital in Kab. Tanggamus has a well-organized structure, enabling it
to effectively perform its service functions. The organizational structure of
the Radiology department is an integral part of the larger organizational
structure of Batin Mangunang Regional Hospital. Radiology services encompass
diagnostic procedures that utilize both ionizing and non-ionizing radiation,
which includes radiodiagnostic services. Radiodiagnostic services comprise
conventional services, while non-ionizing services encompass ultrasound
examinations (USG). Radiodiagnostic services are primarily conducted within the
radiology installation room, which includes a conventional radiology room, a
patient waiting area, and an operator room.
Scope service observed radiology in accordance
with table 2 below :
Table 2 Coverage Service Radiology at Batin Mangunang Regional Hospital
district Tanggamus (Fasyankes
Requester Consultation)
|
No |
Scope
Service Radiology |
Observed Aspects |
|
1 |
Modality
|
Amount
The modalities owned by Batin Mangunang
Regional Hospital are 2 (two) units. Which consists of 1 (one)
conventional radiology tool and an ultrasound (USG) tool |
|
2 |
Worker
Radiation |
Amount
worker radiation 9 (Nine) people. |
|
3 |
Implemented
teleradiology |
Teleradiology done 2016 through appointment
health facilities requester consultation . Right now
, that's it replaced with utilization application WhatsApp
For send picture radiology |
|
4 |
Regulations
|
Regulations
used is Minister of Health Regulation No. 20 of 2019 for regulation teleradiology and Minister of Health Decree No. 409 of
2016 for appointment health facilities requester consultation |
|
5 |
Person
in charge of service teleradiology |
Parties
involved in service teleradiology is appointed
hospital management Ka.Inst.Radiology |
Based on
results grouping document obtained some data as in table 3 below
:
Table 3 Checklist Documents On Service Radiology at Batin Mangunang Regional Hospital district Tanggamus
(Fasyankes Requester Consultation)
|
No |
Element Study |
Checklist |
|
|
There is |
There isn't any |
||
|
1 |
Regulation legislation (
regulation general ) |
√ |
|
|
2 |
Source SK Power man |
√ |
|
|
3 |
Structure organization teleradiology |
√ |
|
|
4 |
Policies in Hospitals |
|
√ |
|
5 |
Standard Operational Procedure (
Ministry of Health ) |
√ |
|
|
6 |
Proof of implementation in the
field |
√ |
|
|
5 |
Standard Operational Procedure
(by whatsapp ) |
|
√ |
A. Jakarta National Brain Center
Hospital (Fasyankes Giver Consultation)
The National Brain Center Hospital is expected to become a
comprehensive healthcare facility specializing in brain and nerve care, setting
an example for handling neurological cases in Indonesia. This general class A hospital, which falls under the Ministry of Health, is
located on Jalan MT Haryono
in Jakarta. The hospital boasts an 11,000-square-meter rectangular area and an
11-story building, commencing its operations on July 1, 2013.
With a focus on enhancing the quality of service for the
community, the National Brain Center Hospital is committed to prioritizing
patient safety, improving access, and ensuring customer satisfaction. It also continuously
adapts and upgrades its services in accordance with technological advancements
and customer needs. The success of these plans will be evaluated through
indicators, including certification and accreditation from JCI (Joint
Commission International).
Among its various specialties, stroke is given particular
attention, requiring a dedicated and comprehensive management team to provide
fast, precise, and accurate care. Based on its commitment to quality, the
National Brain Center Hospital has been established as a Center of Excellence
in Advanced Clinical Care, Restoration and Rehabilitation, Education and
Training, Basic Clinical and Comprehensive Research, Product Development, and
Community Policy Development.
List of Workers Radiation
Installation radiology own source Power man For do service health as
shown in table 4 below ;
Table 4 List of Workers Radiation at the National Brain Center Hospital
(Fasyankes Giver Consultation)
|
Power
Type |
Qualification
Have SIP/STR/SIB |
Amount |
|
Radiology |
|
|
|
Specialist
Doctor |
Specialist
Doctor Radiology |
3 |
|
Radiographer |
D-III & DIV
Radiological Engineering |
30 |
|
Physicist Medic |
S-1 Physicist
Medic |
1 |
|
PPR |
Physicist Medic |
1 |
|
General
Administration |
S1 |
1 |
|
Worker |
SENIOR HIGH
SCHOOL |
1 |
|
Nurse Radiology |
Bachelor of
Nursing , Nurse |
4 |
|
Technology
Information |
DIV Radiology
Engineering & S1 Computer |
2 |
|
Total |
43 |
|
Source : Document Report Installation
Radiology at the National Brain Center Hospital in 2023
Table 4 explains that at the National Brain Center Hospital there are 43
workers radiation with various profession and discipline mutual knowledge
synergize For produce quality the best service.
Service Radiology
The National Brain Center Hospital offers a range of diagnostic imaging
services, including Digital Radiography (DR), ultrasonography, a 256-slice
Computed Tomography (CT Scan), and a 3 Tesla Magnetic Resonance Imaging (MRI)
to enhance the accuracy of medical diagnoses. Digital Radiography involves the
use of X-rays to evaluate various organs within the body, including the chest
(heart and lungs), stomach, and bones throughout the body. At the National
Brain Center Hospital, this examination is performed using a digital system,
resulting in sharper and more precise images.
CT Scan, a modality that uses X-ray radiation
and computer technology, allows for detailed examination of internal organs in
the head, neck, chest, abdomen, and limbs. The hospital's CT scan equipment,
featuring 256 slices, enables faster and more accurate imaging. This CT scan is
particularly effective for specialized examinations of blood vessels, such as
those in the head, heart, and limbs. Additionally, it can be used to assess
heart blood vessels without the need for heart-rate-lowering medications and to
evaluate brain perfusion (blood flow).
These examinations play a crucial role in the early treatment of acute
stroke by distinguishing between bleeding and non-bleeding stroke types,
assessing blood vessel conditions, and evaluating brain perfusion. This
information is invaluable for making decisions about stroke management,
enabling faster interventions and potentially minimizing disability. The
National Brain Center Hospital's ultrasound capabilities allow for the
assessment of internal organs, such as those within the abdomen, as well as
surface organs like muscles, nerves, thyroid, and breasts. Using Doppler
techniques, the examination of blood vessels can also be conducted. MRI
examinations utilize magnetic fields to provide a comprehensive view of the
body's internal organs. This thorough examination is highly beneficial for
medical diagnostics and evaluation (Caldwell et al., 2022). In cases
of stroke due to blockage vessels blood acute (very early), MRI can detect very
early disorders, which are not can assessed with method other. MRI 3 Tesla has
the most up-to-date technology possible evaluation to abnormalities in the
brain like a tumor with mark very high diagnostic and precision,
so can differentiate types of benign and malignant tumors. At the National
Brain Center Hospital it is also available package inspection For evaluate
function parts brain in a way Specific as part from handling tumor patients so
effect side surgery minimum maybe. There are also C-Arm tools and tools Cathlab as tool addition interventional diagnostic, as well
Panoramic tool for diagnostics in clinic National
Brain Center Hospital teeth.
Scope service observed radiology in accordance
with table 5 below :
Table 5 Coverage Service
Radiology at PON Hospital (Fasyankes Giver
Consultation)
|
No |
Scope
Service Radiology |
Observed
Aspects |
|
1 |
Modality |
Amount The
modalities owned by PON Hospital are 12 (twelve) units consisting of from
CT-Scan 256 slices 1 (one) unit, CT-Scan 128 slices 1 (one) unit, MRI 1 (one)
unit, digital radiography (DR) 1 (one) unit, Panoramic 1 (one) unit, Mirra -Ray Mobile 2 (two) units, ultrasonography (USG) 1
(one) unit, C-Arm 2 (two) units and tools cathlab 2
(two) units.. |
|
2 |
Worker Radiation |
The number of
radiation workers is 43 (forty three) people |
|
3 |
Implemented teleradiology |
Teleradiology done 2016
through appointment health facilities giver consultation. Currently
implemented is service use system picture
archiving communications system (PACS) |
|
4 |
Regulations |
Regulations used is
Minister of Health Regulation No. 20 of 2019 for regulation teleradiology and Minister of Health Decree No. 409 of
2016 for appointment health facilities giver consultation |
|
5 |
Person in charge of
service teleradiology |
Parties involved in
service teleradiology is Hospital management
appointed Inst. Radiology |
Checklist Document
Based on results grouping document obtained
some data as in table 6 below :
Table 6 Checklist Documents
On Service PON Hospital Radiology
(Health Facilities Giver
Consultation)
|
No |
Element Study |
Checklist |
|
|
There is |
There isn't any |
||
|
1 |
Regulation legislation ( regulation general ) |
√ |
|
|
2 |
Source SK Power man |
√ |
|
|
3 |
Structure organization teleradiology |
√ |
|
|
4 |
Policies in Hospitals |
√ |
|
|
5 |
Standard Operational Procedure ( Ministry of Health ) |
√ |
|
|
6 |
Proof of implementation in the field |
√ |
|
B. Hospital X Tambun
Bekasi (Other Health Facilities)
Hospital X Tambun Bekasi
adopted its official name from a healthcare facility previously known as a
clinic in the Tambun Bekasi
area. The hospital was granted its official name in 2012, following the
approval of its operational status by the Head of the Bekasi
District Health Service. Prior to becoming a hospital, Hospital X Tambun Bekasi operated as a general
practitioner's clinic, established by Dr. Typical Jonny BS, famously referred
to as "Dr. J." This clinic, known as Dr. J Clinic, was established in
1995 with a mission to provide proper healthcare services to the economically
disadvantaged in the community. In its early days, Dr. J. not only managed the
clinic but also frequently attended to critically ill patients on-site and made
house calls to provide medical care. Over time, the clinic expanded its service
coverage and continually grew to meet the increasing healthcare needs of the
community.
Since end in 2012, Clinic Dr. J has obtain
permission Hospital operations from Head of the Bekasi
District Health Service above the name of Hospital X Tambun
Bekasi as Name disguise. Clinic Dr. J has official
become a hospital and can operate as a Class D Primary Hospital based on
Minister of Health Regulation no. 24 of 2014 concerning Class D Pratama Hospitals with capacity take care stay as many as
45 places sleep . Currently Hospital X Tambun Bekasi is working do project development land and
development facilities and infrastructure new To use increase class Hospital
services up to reach class C with specialization in the field transplant
kidney. RS X Tambun Bekasi
Has vision Become a coveted hospital Bekasi
community. A number of poly services provided including, general, teeth &
mouth, disease in, obstetrics and gynecology, pediatrics, and surgery general.
Apart from that There is service support medical which
includes, laboratory, radiology, pharmacy, etc.
List of Workers Radiation
Installation radiology own source Power man
For do service health as shown in table 7 below ;
Table 7 List of Workers Radiation
at Hospital
X Tambun
Bekasi (Other Health Facilities)
|
Power
Type |
Qualification
Have SIP/STR/SIB |
Amount |
|
Radiology |
|
|
|
Specialist
Doctor |
Specialist
Doctor Radiology |
1 |
|
Radiographer
(includes PPR) |
D-III
Radiological Engineering |
4 |
|
Technology
Information |
D-III
Radiological Engineering |
1 |
|
Total |
6 |
|
(Source : Document Report
Installation Radiology Hospital X Tambun Bekasi 2023)
Table 7 explains that at Hospital X Tambun Bekasi there are 6 workers
radiation .
Service Radiology
The radiology unit at X Tambun Bekasi Hospital offers diagnostic services that utilize
both ionizing and non-ionizing radiation, including radiodiagnostic
services. Radiodiagnostic services encompass
conventional services, while non-ionizing services include ultrasound (USG)
examinations. The radiodiagnostic services are
primarily conducted within the radiology unit, which includes a conventional
radiology room, a patient waiting area, and an operating room. The radiology
unit's services extend to emergency unit patients, outpatient care, and
inpatient care. The outpatient care services comprise general medical care,
internal medicine, maternal and child health (family planning services -
KIA/KB), and pediatric healthcare services.
Scope service observed radiology in accordance with table 8 below :
Table 8 Coverage Service
Radiology Hospital X Tambun Bekasi
( Other Health Facilities )
|
No |
Scope
Service Radiology |
Aspects
Observed |
|
1 |
Modality |
Amount The
modalities owned by RS X Tambun Bekasi
are 3 (three) units consisting of from 1 (one) unit of conventional x-ray equipment,
1 (one) unit of mobile x-ray equipment and 1 (one) unit of ultrasonography
(USG) |
|
2 |
Worker Radiation |
Amount worker
radiation 6 (six) people |
|
3 |
Implemented teleradiology |
Teleradiology
performed is with utilise application WhatsApp For
send picture radiology. Already walk from year |
|
4 |
Regulations |
Haven't used yet
regulations Minister of Health Regulation No. 20 of 2019 for regulation teleradiology |
|
5 |
Person
in charge of service teleradiology |
Parties
involved _ in service teleradiology is the hospital
management that handed over policy to part radiology |
Checklist Document
Based on results grouping document obtained some data as in table 9 below :
Table 9 Checklist
Documents On Service Radiology Hospital X
Tambun Bekasi (Other Health
Facilities)
|
No |
Element Study |
Checklist |
|
|
There is |
There isn't any |
||
|
1 |
Regulation legislation ( regulation general ) |
|
√ |
|
2 |
Source SK Power man |
√ |
|
|
3 |
Structure organization teleradiology |
√ |
|
|
4 |
Policies in Hospitals |
√ |
|
|
5 |
Standard Operational Procedure |
|
√ |
|
6 |
Proof of implementation in the field |
√ |
|
The data that the researchers obtained is related
to the implementation of the teleradiology service
policy in various healthcare facilities. This includes Bakti
Mangunang Regional Hospital in the Tanggamus district, which serves as the healthcare facility
requesting consultation, National Brain Center Hospital (PON Hospital) as the
healthcare facility providing consultation, and Hospital X Tambun
Bekasi as another healthcare facility. This
implementation is in accordance with Minister of Health Regulation No. 20 of
2019 regarding the maintenance of intermediary telemedicine services in
healthcare facilities.
A. Bakti Mangunang
Regional Hospital district Tanggamus (Fasyankes Requester Consultation)
The implementation of the teleradiology service policy at Batin Mangunang Regional Hospital
in the Tanggamus district primarily aims to enhance
the quality of radiology services, especially by reducing the waiting time for
the interpretation of radiology films or results. An old and classic problem,
which has historically hindered the prompt reading of radiology films, has now
been significantly mitigated, resulting in increased efficiency from a time
perspective. Based on the data gathered from observations and interviews, it is
evident that efforts to implement the teleradiology
service policy have been incorporated into the healthcare facility's standard
operational procedures (SPO). However, it is important to note that not all
aspects of the teleradiology service have been fully
integrated into the SPO, particularly for the ongoing teleradiology
services.
The
initial implementation of teleradiology services
adhered to the instructions and guidance provided by the Ministry of Health and
was supported by the necessary equipment during the initial months of
implementation. However, various conditions and circumstances have prevented
further progress since then. Presently, teleradiology
services have become simpler in terms of the equipment required and are
cost-effective. This simplification is largely attributed to the utilization of
features on social media platforms, such as the use of the WhatsApp
application for sending images in JPEG format, which has significantly
streamlined the process.
Initially, the standard format for radiology film results was in the
original DICOM format. However, it was later changed to the JPEG format, and
the images were sent to specialized radiology doctors via WhatsApp.
This shift in format has significantly reduced the time it takes for the images
to reach the doctors.
Batin Mangunang Regional Hospital's response to the
implementation of teleradiology services was
initially aligned with the system provided by the Ministry of Health. The
implementation started as planned but encountered several challenges that
hindered its progress. One key challenge was the availability of specialist
radiology doctors, and another was related to the financial burden of meeting
the requirements for radiology film distribution, which was borne by Batin Mangunang Regional Hospital
itself.
To date, the use of teleradiology, as
specified in Minister of Health Regulation No. 20 of 2019, has not been fully
executed due to various technical and non-technical constraints. As an
alternative, the hospital has continued to provide radiology services using
information and communication technology, choosing to use the WhatsApp application as the most effective solution. This
choice was based on the convenience of WhatsApp for
both staff and specialist radiology doctors.
In terms of human resources and infrastructure, the health facilities
requesting consultation have met the necessary requirements as per regulations.
Their tasks have been executed in accordance with established guidelines and
standards. The availability of infrastructure, equipment, applications, and
timing aligns with the standards set by the Ministry of Health. However, the sustainability
of teleradiology services is hindered by challenges
related to internet network issues, procurement from suppliers, and a lack of
financial certainty between supporting and supported hospitals. Consequently,
the hospital has opted to use WhatsApp as the medium
for delivering radiology films to specialists.
Another reason for using the teleradiology
system based on the WhatsApp application, after the
discontinuation of teleradiology by the Ministry of
Health, is to enable the radiology department to continue meeting quality
indicators for radiology examinations. These indicators include ensuring that
chest X-ray examinations are completed within 3 hours and that critical
radiology reads are done within 1 hour.
Based on the observational data collected by researchers, the continued
use of the teleradiology system as per the Ministry
of Health's guidelines has revealed the need for evaluation and improvements.
The necessary improvements pertain not only to the application system itself
but also to the establishment of clear rates and policies for interpreting the
results by the supporting hospital, with a focus on expediting the process. It
is important to remember that one of the primary goals of implementing teleradiology services is to enhance the speed of radiology
services, particularly in reducing waiting times.
Information provided by the informants highlights the fact that the
Ministry of Health's teleradiology implementation at Batin Mangunang Regional Hospital
was closely related to several essential factors, which were discussed
extensively with policy makers from the Ministry of Health and the management
of both the supporting and the managed hospitals. Additionally, information
shared by specialist radiologists emphasizes the significant hope that
potential obstacles, particularly in areas with a high volume of patients, can
be addressed through the teleradiology system. The
key to overcoming these challenges lies in maintaining the quality of the
images produced by radiology equipment and ensuring that the radiologist
receives high-quality images for interpretation. Thus, finding a suitable
modality or delivery medium that can accommodate these needs is crucial.
Following channel service teleradiology based
application whatsapp the researcher get :
Chart
1 Teleradiology flow based application whatsapp at Batin Mangunang Hospital as health
facilities requester consultation (Processed
research data 2023)
Chart 1 above describes the process in which a radiographer conducts an examination
of a patient and obtains the results in DICOM format. These results are then
converted using computer radiography (CR) tools into JPEG format. Subsequently,
the images are sent through the WhatsApp application
to a specialist radiologist for interpretation. Afterward, the radiologist
sends the expert results back to the radiographer, who then provides them to
the patient and stores them in an archive.
B. National Brain Center Hospital (Fasyankes giver consultation)
The response of PON Hospital's management to the implementation of teleradiology services initially involved aligning with the
existing system provided by the Ministry of Health. However, at the outset, the
implementation did not progress as expected, primarily due to a lack of full
understanding of the policy regarding teleradiology
services. As of the present moment, the use of teleradiology
services, as specified in Minister of Health Regulation No. 20 of 2019, has not
been fully executed due to several technical and non-technical constraints. The
most significant obstacle is related to internet network limitations, which
impede the smooth operation of teleradiology
services.
These challenges are also linked to issues with equipment compatibility,
which hinders the Ministry of Health's teleradiology
services from functioning effectively. Up to the current time, radiology
services at PON Hospital are conducted using a Picture Archiving &
Communication System (PACS) that utilizes the hospital's intranet and internet
facilities.
PON Hospital has been utilizing a PACS system since its inception in
2014, providing excellent service. In cases where the Requesting Hospital for
consultation (Batin Mangunang
Regional Hospital) utilizes teleradiology based on
the WhatsApp application to facilitate the reading of
radiology results, PON Hospital employs the latest PACS technology known as
Fujifilm PACS Synapse. The use of this device significantly shortens the
process of delivering results, eliminating the need to convert images from
DICOM to JPEG for radiology specialists located outside of PON Hospital. The
availability of human resources meets the necessary requirements and is in
compliance with regulations, with each individual occupying a position based on
their profession.
Hospital X
Tambun Bekasi (Other
Health Facilities)
The implementation of the teleradiology policy
at RS X Tambun Bekasi has
the general goal of enhancing the quality of radiology services, particularly
by reducing the waiting time for radiology film results to be read by experts.
However, the challenge lies in the fact that a radiology specialist cannot be
on standby 24 hours a day, posing a unique challenge for the hospital to
maintain efficient wait times while ensuring quality service. Based on
observational data and interviews, it is observed that the implementation of
the teleradiology policy at RS X Tambun
Bekasi is conducted using the WhatsApp
application as a medium, as teleradiology services
from the Ministry of Health have not yet been put into practice.
Furthermore, the standard operational procedures for teleradiology
using the WhatsApp application are not yet available,
primarily due to the radiology unit at RS X Tambun Bekasi undergoing a transition from automatic processing to
a digital radiography (DR) device. Data indicates that teleradiology
services using the WhatsApp application have only
been implemented since 2022, after the hospital switched from using digital
radiography (DR) for radiology films. This implementation involves sending
radiology images in JPEG format via WhatsApp to
radiology specialists.
The JPEG images are obtained after being formatted in the digital
radiography system by radiographers. The quality of the resulting images aligns
with the assessments made by radiology specialists and provides ease in
obtaining expert results for radiology images.
Following channel service teleradiology based
application whatsapp the researcher get :
Chart 2 Teleradiology flow based application whatsapp
at RS X Tambun Bekasi
as health facilities others ( Processed research data 2023)
Chart 2 above describe that radiographer after do
examination of the patient and obtaining results description format dicom, then do conversion in digital radiography tools to
jpeg format. After That picture then burn it to a compact disc (CD). moved to a personal computer (PC) for sent through
application whatsapp to doctor specialist radiology
For be read results radiology patient. After That doctor send results expertise
to radiographer return For Then given to patient and stored as archive.
Supporting Factors and Inhibiting
Factors Implementation Policy Service Teleradiology In Facilities Health Services
There are several models that serve as guidelines for implementing
public policies, and their implementation should align with the formulated
policies. In this thesis research, the implementation model used is George C.
Edwards III's policy implementation model. Efforts to achieve the objectives of
a policy involve establishing structures, programs, and regulations in the
implementation process. However, policy implementation has its own dynamics.
In the implementation of policies, numerous factors come into play,
including contributing factors that support policy implementation and
inhibiting factors that hinder it. In the context of the implementation of the teleradiology service policy, as outlined in Minister of
Health Regulation No. 20 of 2019, at various health facilities such as Batin Mangunang Regional Hospital
(a health facilities requester for consultation), National Brain Center
Hospital (a health facilities giver for consultation), and RS X Tambun Bekasi (a health
facilities others), several supporting and inhibiting factors have been
identified. To uncover these factors affecting the implementation of the teleradiology service policy in health facilities, whether
they are requester consultation facilities, giver consultation facilities, or
others, the researchers have employed the implementation model proposed by
George C. Edwards III. This model examines factors related to communication,
sources of power, disposition, and bureaucratic structure to understand the
dynamics of policy implementation.
Batin Mangunang
Regional Hospital district Tanggamus (Fasyankes Requester Consultation)
factor supports and
factors inhibitor implementation policy service teleradiology
at Batin Mangunang Regional
Hospital (health facility requester consultation) is revealed with George C.
Edward III's implementation model approach, namely seen through aspect
communications, sources power, disposition and structure bureaucracy. Linkages
aspects the in implementation service teleradiology
health facilities requester consultation explained as following
:
Communication
Communication is one of the influencing aspects for the success of any
implementation. Effective communication is crucial for achieving the objectives
of policy implementation. Implementing a policy effectively will only happen if
the policy makers already know what needs to be done. This knowledge can be
conveyed effectively through communication, ensuring that every decision and
regulation regarding policy implementation is communicated to the right target.
In this research on the implementation of the teleradiology
service policy, there are three key aspects to consider in terms of
communication: the implementor's understanding and knowledge of policy execution, any
resistance encountered during policy implementation, and the achievement of the
policy's objectives.
Understanding and Knowledge of
Health Facility Management in Implementing the Teleradiology
Service Policy
The understanding and knowledge within the health facility management
regarding the implementation of the teleradiology
service policy is significant. While hospital management comprehends the
policy, they don't fully grasp all aspects of the teleradiology
service policy. Hospital management had initiated the teleradiology
service policy from the Ministry of Health in 2016, but the system experienced
disruptions, leading to the decision to implement teleradiology
based on WhatsApp. The current state of the radiology
service at Batin Mangunang
Regional Hospital utilizes WhatsApp, and there is no
concrete plan for the implementation of the teleradiology
service policy from the Ministry of Health.
In the implementation of the teleradiology
service policy at Batin Mangunang Regional Hospital, there was no resistance
from the target group. The facts in the field reveal that no resistance has
arisen. In the event of any problems, hospital management, radiology, and the
target group will collaboratively address them.
Achievement
of Teleradiology Service Policy Goals
To achieve the policy objectives, the offered
policies need to align with the needs of the target group. The objective of the
policy is to obtain remote expertise results using information technology
facilities to ensure the smooth running of radiology service quality
indicators. The management's incomplete understanding of the teleradiology
service policy is due to the issuance of the WhatsApp application-based
teleradiology service policy.
Resource
Resources for a policy encompass various
elements, including human resources, financial resources, infrastructure, and
the competence of human resources. Human resources are a significant supporting
factor for the success of a program. There are three key aspects of resource
power in this research: the availability of human resources, funding sources,
infrastructure, and the competence of human resources.
Availability Human Resources
The availability of human resources is crucial in the implementation of
the teleradiology service. The group of individuals
involved includes radiology specialists, radiographers, and information
technology personnel. According to the interview results, it is evident that
the availability of human resources for the implementation of the teleradiology service at Batin Mangunang Regional Hospital is sufficient and aligned with
the hospital management's plans.
Availability Sources of Funds and
Infrastructure
Through interviews with several informants, it was observed that funding
sources and infrastructure for the implementation of the teleradiology
service at Batin Mangunang
Regional Hospital were available during the initial months of implementation by
the Ministry of Health, but then they ceased to be available.
Availability Human Resources
In the dedicated effort to implement policies, having competent
personnel is vital. The competence of individuals functioning as implementers
in fulfilling policies is crucial. Limitations in the competence of these
individuals can lead to program failures, especially if their skills or
qualifications do not align with the required standards. Interviews conducted
revealed that the human resources in the radiology department at Batin Mangunang Regional Hospital
are already aligned with the core responsibilities of each worker.
Disposition
Disposition, as the third factor influencing policy implementation, is
critical. It encompasses the character and attitudes of the implementers,
including qualities such as honesty and democratic nature. Implementers with
positive dispositions are more likely to execute policies effectively, aligning
with the intended message of the policy. Conversely, if the attitudes and
perspectives of implementers differ from the policy maker's intentions, the
policy implementation process may be ineffective. In this study, the
disposition factor was evaluated, focusing on implementer characteristics such
as honesty and the ability to find democratic solutions to problems. The
research findings demonstrated that implementers exhibited sufficient honesty
and a democratic nature, with a commitment to openness in problem-solving. This
observation was substantiated by the minutes and results of routine radiology
activity meetings.
Structure Bureaucracy
Even with available resources and knowledgeable implementers, weaknesses
in bureaucratic structure can impede policy implementation. The presence of
standard operational procedures (SOP) and the complexity of organizational
structure are crucial elements. SOP serves as a reference and guideline for
internal implementers, ensuring that policy execution aligns with the goals and
objectives. Based on interview results, SOP for teleradiology
are available and have been prepared by the Ministry of Health. However, SOP
for teleradiology based on WhatsApp
are yet to be established. This gap implies that the
management might not have a complete understanding of how to implement the teleradiology service policy at Batin
Mangunang Regional Hospital.
National Brain Center Hospital (Fasyankes Giver Consultation)
The factors supporting and inhibiting the implementation of the teleradiology service policy at the National Brain Center
Hospital, a health facility providing consultation, are evaluated using George
C. Edward III's implementation model approach. This evaluation considers
aspects such as communication, resource power, disposition, and structural
bureaucracy. The interconnectedness of these aspects in the implementation of teleradiology services at health facilities providing
consultation is explained as follows:
Communication
In this research on the implementation of the teleradiology
service policy, three aspects of communication are scrutinized: the
implementer's understanding and knowledge of policy execution, resistance
encountered during policy implementation, and the achievement of the policy's
objectives. Effective communication plays a crucial role in the success of
policy implementation. Policies are executed effectively when policy makers
clearly convey their intentions, and implementers comprehend these intentions.
The knowledge of what needs to be done can be effectively communicated through
well-established communication channels.
Understanding and Knowledge
(Health Facility Management) in Implementing Teleradiology
Service Policy
The understanding and knowledge of the policy's implementation lie with
the hospital management, which is the policy holder. Although the hospital
management has some understanding of the implementation of the teleradiology service policy, they have not fully
comprehended it. In 2016, the hospital management initially began implementing
the teleradiology service policy from the Ministry of
Health, but the system didn't last long. This discontinuation was attributed to
issues related to the strength of the internet signal at the requesting
hospital consultation and problems with the sophistication of personal
computers (PC).
Based on observational documents, the National Brain Center Hospital
currently maintains its radiology installation services using a Picture
Archiving & Communication System (PACS), which has been in use since 2014.
Resistance in Implementation Implementation Service Teleradiology
by Medical Personnel and Health Personnel as Group Target
During the implementation of the teleradiology
service policy at the National Brain Center Hospital, there was no resistance
observed from the target group. It was found that there was no resistance
emerging. If any problems did arise, hospital management, radiology, and the
target group would discuss and address them together.
Achievement of Policy Goals
Service Teleradiology
Achieve the objectives of the policy, it is important that the policies
offered align with the needs of the target group (Torres & Clegg, 2014). The
policy objectives aimed to obtain expert results remotely using information
technology facilities, thereby ensuring that quality service indicators in
radiology run smoothly. However, the hospital management does not fully
understand some aspects related to the teleradiology
service policy. This resulted in discontinuing the teleradiology
service offered by the Ministry of Health, which was intended to support the
policy's objectives. As a consequence, the policy objectives for the
implementation of teleradiology services were not
fully realized and were focused on internal services at PON Hospitals using
PACS.
Resources
In this research, there are three important aspects of resources to
consider: the availability of human resources, financial resources, facilities
and infrastructure, and the competence of human resources themselves.
Availability Human Resources
Concerning the implementation of teleradiology
services, the relevant resources consist of the target group, which includes
radiology specialists, radiographers, and information technology personnel.
According to the interview results, it was evident that the availability of
human resources for implementing teleradiology
services at the National Brain Center Hospital was sufficient and aligned with
the pre-established plans made by the hospital management.
Availability Sources of Funds and
Infrastructure
Based on interviews with several informants, the researcher discovered
that the availability of funding sources and infrastructure for implementing teleradiology services at the National Brain Center
Hospital was initially fulfilled during the early stages of the teleradiology service implementation by the Ministry of
Health, but after a few months, these resources were no longer available. This
indicates that the availability of funding sources and infrastructure was only
temporarily fulfilled at the beginning of the teleradiology
service implementation and subsequently ceased.
Competence Human Resources
Based on interviews with several informants, it was found that the
competence of human resources in the radiology installation at the National
Brain Center Hospital is in line with the main duties of each worker's job (Bamieh & Ziegler, 2023).
Disposition
Disposition factors were assessed in this study, covering implementer
characteristics, such as honesty and openness in problem-solving between
implementers and the target group in the implementation of the teleradiology service policy at the National Brain Center
Hospital. The results of the interviews revealed that the implementer
characteristics are sufficiently honest and democratic, and there is always
openness in problem-solving. This information is supported by observation
documents, including meeting minutes and results of routine radiology
activities.
Bureaucratic Structure
While the
necessary resources for policy implementation are available, and the
implementers are aware of what needs to be done and are willing to carry out
the policy, the potential for policy failure still exists due to weaknesses in
the bureaucratic structure (Balaguer-Martínez et al., 2023).
The first
aspect to consider is the presence or absence of standard operational
procedures (SOP) and the complexity of the organizational structure. SOP serves
as a reference and a set of guidelines that internal implementers must follow
to ensure that the actions taken in policy implementation align with the goals
and objectives of the policy. Internal implementers are required to adhere to
the existing SOP.
It is
worth noting that SOP for teleradiology services have
been developed and provided by the Ministry of Health, and there are also SOP available for using PACS. This suggests that
the management of the National Brain Center Hospital is aware of and
knowledgeable about the teleradiology service policy
implementation. However, the full accomplishment of this policy has not been
realized, as the Ministry of Health's radiology policy has not been fully
implemented since a few months after its initiation.
Hospital
X Tambun Bekasi (Other
Health Facilities)
The factors that support and inhibit the
implementation of the teleradiology service policy at
RS X Tambun Bekasi (a
health facility serving other roles) are examined using the implementation
model developed by George C. Edwards III. This analysis is based on various
aspects, including communication, sources of power, disposition, and the
bureaucratic structure. The relationships between these aspects in the
implementation of teleradiology services for health
facilities providing consultations are explained as follows:
Communication
In research This implementation policy service teleradiology
there are 3 (three) things to look at from aspect communication that is Implementor's understanding and knowledge within carry out
policy , resistance in implementation policies and their achievements objective
policy .
Understanding and Knowledge
(Management Health Facilities) In Implementing Policy Service Teleradiology
The understanding and knowledge of the implementors
regarding the policy in question are primarily related to the hospital
management, who are the policy holders. It has been observed that the hospital
management does not have a full understanding of the implementation of the teleradiology service policy. In addition to the lack of
full understanding of the implementation policy, RS X Tambun
Bekasi is also in the process of upgrading to SIRS (Sistem Informasi Radiologi Seri) and Electronic Medical Record (ERM) systems
to enhance the quality of service (Półchłopek et al., 2020).
Based on observations and documents, the radiology unit services at RS X
Tambun Bekasi continue to
use the application-based WhatsApp for teleradiology. This approach is favored because it not only
simplifies the process but is also deemed sufficient for the radiologists to
conduct their image evaluations.
Resistance in
the Implementation of Teleradiology Services by Medical Personnel and Health
Personnel as Target Groups
In implementing the teleradiology service policy
at Hospital X Tambun Bekasi, there was no resistance from the target group, and
if any issues arise, they are discussed and resolved collectively by the
hospital management, radiology staff, and the target group.
Achievement
of Teleradiology Service Policy Goals
The goal of the teleradiology service policy is
to obtain remote expertise results using information technology facilities to
ensure the smooth operation of radiology service quality indicators. However,
it was observed that the hospital management does not fully understand the
teleradiology service policy, as they have not provided teleradiology services
in accordance with the regulations issued by the Ministry of Health to support
the policy objectives. Thus, the policy objectives for implementing
teleradiology services cannot be considered achieved because the indicators
used do not meet the Ministry of Health's regulations.
Resource
There are three important aspects of resources
in this research: the availability of human resources, funding sources and
infrastructure, and the competency of human resources.
Availability
of Human Resources
In implementing teleradiology services, the
relevant resources include the target group, which consists of radiology
specialists, radiographers, and information technology personnel. Based on
interview results, it is evident that the availability of human resources for
implementing teleradiology services at RS X Tambun Bekasi is sufficient and
aligns with the hospital's prepared plans.
Availability
of Funding Sources and Infrastructure
Interview results revealed that there are
funding sources and infrastructure available for implementing teleradiology
services at RS X Tambun Bekasi (Barasa & Tsisiga, 2014). However, the procurement of SIRS (Sistem
Informasi Radiologi Seri) and ERM (Electronic Radiology Management) is still in
the planning stage. Therefore, the availability of funding sources and
infrastructure has not yet been fully realized. RS X Tambun Bekasi will need to
prepare for the next stages, including the acquisition of SIRS and PACS
(Picture Archiving and Communication System) facilities.
Competence Human Resources
Based
on the results of interviews, it was found that the competence of the human
resources in the radiology unit of Hospital X Tambun Bekasi is aligned with the requirements of each worker's
job.
Disposition
The evaluation of the disposition factor in this study encompasses the
characteristics of the implementors, including their
honesty and openness in resolving issues between the implementers and the
target audience during the implementation of the teleradiology
policy at Hospital X Tambun Bekasi.
Based on the results of interviews, it was found that the implementors
displayed sufficient honesty, a democratic nature, and a commitment to openness
in problem-solving (Polk, 2015). The fact
that these implementor characteristics, such as
honesty, a democratic approach, and a commitment to open problem-solving, are
already in place is supported by documented evidence, including meeting minutes
and the results of routine activities in the radiology department.
Structure Bureaucracy
Even if the necessary resources are available, the implementers are
knowledgeable about what needs to be done, and they have the desire to execute
a particular policy, there is still a possibility that the policy may not be
successfully implemented due to structural weaknesses.
One key aspect of this structural weakness is the presence or absence of
standard operational procedures (SOP) and the complexity of the organizational
structure (Dameri et al., 2023). SOP
serve as references and guidelines for internal implementers to ensure that the
actions taken during policy implementation align with the goals and objectives
of the policy. Internal implementers are expected to follow the established SOP.
In the case of teleradiology service, it was
found that SOP were not yet available (Lödel et al., 2020). This is
because teleradiology was being carried out using the
WhatsApp application as a medium, and the transition
from automatic processing to digital radiography (DR) was in progress. The lack
of established SOP may hinder the smooth implementation of the policy.
CONCLUSION
Based on the
analysis of the results displayed, it can be concluded that the implementation
of the teleradiology service policy in health
facilities is facing challenges. In both requesting and providing health
facilities, there seems to be a lack of full understanding and implementation
of the teleradiology service policy. This may be
attributed to the fact that the Ministry of Health has only recently introduced
the teleradiology service, while the management still
wishes to maintain the traditional radiology services. Furthermore, in some
health facilities, the policy has not been fully implemented due to a lack of
understanding of the regulations. In these facilities, issues related to
funding and infrastructure have also hindered the full
adoption of teleradiology, even after several months
of its introduction by the Ministry of Health. Additionally, other health
facilities are facing challenges in procuring the necessary equipment and
infrastructure for teleradiology due to a lack of
available funds.
To better
understand the factors influencing the implementation of the teleradiology service policy, a SWOT analysis was
conducted. Supporting factors include effective communication between
requesting and providing health facilities, as well as a lack of resistance to
the policy. This suggests that the target groups in these facilities perceive
the benefits of teleradiology. Additionally, health
facilities that request teleradiology have good
availability of qualified staff and the necessary competencies. They also
exhibit an honest and democratic approach in implementing the policy, remaining
open to the concerns of their target groups. Furthermore, these facilities have
established standard operating procedures and maintain a simple bureaucratic
structure. In contrast, other health facilities face inhibiting factors. In
terms of communication, the management of requesting health facilities doesn't
seem to fully comprehend and implement the teleradiology
policy. After initially implementing the service, they decided to continue
using teleradiology via WhatsApp,
and later, they switched to using the Picture Archiving & Communication
System (PACS) for intranet and deep internet services for reading radiology
results. These decisions have contributed to the challenges in policy
implementation.
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