Protocol for a mixed-methods exploratory investigation into the role of health information technology for the provision of cancer care in Indonesia [version 1; peer review: awaiting peer review]

Background: Cancer and its management can incur high costs, high risks and high demand. In Indonesia, there remains gap in the availability of national cancer data despite the establishment of a National Committee for Cancer Control. Multiple pilot projects have been developed by the Ministry of Health to improve the delivery of care, including interventions utilising digital health approaches and integrated referral information systems. However, it is not yet clear to what extent these approaches influence patient management or the experience of cancer patients themselves. This research aims to explore the current role of health information technology (HIT) in the provision of services and treatments for patients with cancer from primary to tertiary healthcare centres in Yogyakarta, Indonesia. Methods: The study will adopt an observational mixed-methods single case study design of health facilities involved in the delivery of cancer services in a sub-national health system. We will collect data through face-to-face interviews with a range of health professionals involved in the delivery of cancer care. Patients will be interviewed to share their views and experiences of the existing cancer referral system and communication with health facilities. Alongside interviews, we will undertake an analysis of routine data from participating health facilities to assess gaps in existing information systems. Data analysis will include framework analysis for qualitative data alongside descriptive analyses of quantitative data. Findings will be used to inform conceptual maps to be presented as part of Theory of Change workshops focused on understanding how the existing cancer referral Open Peer Review Reviewer Status AWAITING PEER REVIEW Any reports and responses or comments on the article can be found at the end of the article. Page 1 of 14 F1000Research 2020, 9:904 Last updated: 10 SEP 2020


Introduction
In 2018, there was an estimated 348,809 cases and 207,210 deaths from cancer in Indonesia, projected to increase to 575,814 cases and 366,567 deaths annually by 2040 1 .After stroke, cancer has been reported as a leading cause of death in the country 2 .A cancer diagnosis can be potentially disastrous, with over 75% of patients with cancer in the Southeast Asia region experiencing death or financial catastrophe within one year 3 .The limited provision of cancer care in Indonesia was reflected in the Cancer Preparedness Index, an initiative in 2019 4 to highlight differences in cancer policy and systems between countries and how they relate to outcomes.Indonesia was rated 25 th of 28 countries evaluated 5 , largely influenced by limitations in its service availability, workforce, infrastructure, alongside a lack of cancer research.The consequences of a cancer diagnosis and the limited existing provision provide compelling evidence for the need to develop policies to improve access to and provision of cancer care in the country.
Cancer and its management can incur high costs, high risks and high demand 6 .According to WHO guidelines 7 , health systems should aim to provide a holistic approach to the management of cancers to prolong lives through early detection, timely diagnosis and adequate treatment, alongside providing palliative care for advanced cancer, carried out within the context of a comprehensive cancer control plan 8 .For Indonesia, where there is an increasing cancer burden, the Ministry of Health has yet to officially endorse the National Cancer Control Plan 9 .The current National Cancer Control Plan 9 contains 13 strategic goals, including the implementation of national cancer treatment guidelines, development of palliative care provision, and establishment of information and communication technology (ICT) systems to unpin developments in cancer provision 10 .The last of these is driven in part by the need to enhance data on cancer in the country.
A National Committee for Cancer Control was established in 1989, with one of its programs to develop a cancer registry and provide national cancer data.However, there remain gaps in the availability of national cancer data 11 .Attempts to develop a national population-based cancer registry have been conducted but stopped due to various reasons 12 , until it was re-established in 2016.Previously, cancer registries were more often conducted as pathology-based or hospital-based site-specific registries 11,12 .The more common sources for national cancer data are annual reports from the Ministry of Health, including the Indonesian Health Profile, Indonesian Basic Health Research, and secondary data from Indonesian Universal Health Coverage [13][14][15] .Ministry of Health publications provide tabular data from the health system, including cancer, but lack granularity with multiple cancer types grouped under one summary figure .A further driver for ICT development is to leverage its capabilities to overcome distance-time barriers and facilitate participation in global oncology care, education, and research, alongside opportunities to overcome gaps in patient care and clinical expertise 16 .Across the spectrum of cancer care, research literature from contexts with differing levels of resource report the role of digital technology is increasing, with their implementation supporting reductions in costs and increases in workflow efficiency, as well as improving overall health care value, patient outcomes, and quality of life 7,[17][18][19] .The implementation of digital technologies has been shown to enhance the management of cancer care in promoting patient-centeredness frameworks and improving patient care and safety 18,19 .A major subtype of technology use within cancer care is the health information technology (HIT), which supports the management of health information across computerised systems (e.g.electronic health records, e-prescribing systems) alongside the secure exchange of health information between consumers, providers, payers, and quality monitors 20 .HIT involves a range of stakeholders to support its coordination and use in providing quality care that can ultimately lead to patient satisfaction 21 .Its use in the context of cancer care can support improvements in coordination of care, shared care planning, person-centred coordination, and coordination between and within teams 22 .HIT may be advantageous in the context of health systems in low and middle-income countries (LMICs) due to the extensive coordination of care at and across various levels, including the community level, primary care centres, and secondary and tertiary care levels 23 .
In Indonesia, multiple pilot projects have been developed by the Ministry of Health to improve delivery of care, including a mobile phone app to gather data on the health of families and individuals 24 , integrated referral ICT systems 25 , integrated telemedicine approaches 26 and mobile-phone based data collection approaches for the national health insurance scheme 27 .Furthermore, various referral applications for use in health care facilities have been developed by the Ministry of Health of the Republic of Indonesia and Badan Penyelenggara Jaminan Sosial (BPJS) Kesehatan (which translates as Social Insurance Administration Organization), a national health insurance provider in Indonesia 28,29 .More recently, BPJS Kesehatan has required all primary healthcare centres (referred to as Puskesmas in Indonesia) to use P-Care, a cloud-based application aiming to record treatments and services of those covered by BPJS Kesehatan 30 .Through P-Care, Puskesmas can electronically refer patient information to higher levels of the health system to facilitate and manage bookings and appointments.The Ministry of Health has also developed an Integrated Referral Information System (SISRUTE) that can help health facilities to support similar vertical referrals across different levels of the health system, especially in the case of an emergency and urgent referrals 25,31 .However, it is not yet clear whether these various technologies improve efficiencies in patient management or improve the experience of patients with certain conditions, such as cancer, that require repeated and frequent visits to health facilities.
Despite being a strategic goal in national planning of cancer control, and its potential value in LMIC settings, such as Indonesia, there has been no research reported that details the existing ICT infrastructure in the delivery of care for patients with cancer.This research seeks to address this gap in knowledge and aims to explore the current role of HIT in the provision of services and treatments for patients with cancer from primary to tertiary healthcare centres.Identifying and mapping existing HIT for cancer care in Indonesia is intended to support critical thinking around the design, implementation, adaptation, and evaluation of existing systems.

Origin of research focus
In April 2019, a multi-stakeholder workshop was hosted by the study authors at Universitas Gadjah Mada (UGM), focusing on research priorities for cancer and digital technology research in Indonesia.The study team comprise applied health researchers with cancer and informatics expertise and experienced oncology clinical academics familiar with cancer provision in Yogyakarta.Attendees included representatives from the Ministry of Health (NCD Directorate), Ministry of Research, Technology and Higher Education, Ministry of Finance, Indonesian Cancer Foundation, independent commercial companies working in cancer care, academics from multiple departments in UGM including Internal Medicine, Surgery, Radiology, Public Health, and Nursing, and oncologists from hospitals in Yogyakarta, Indonesia.During discussions, it was highlighted that digital architecture on cancer care is not well understood in Indonesia.Research priorities highlighted during the workshop included determining available technologies used by cancer services, approaches to determining the quality of care delivery, patient-reported outcomes during and after cancer treatments, the development of palliative care approaches, and eliciting patient perspectives on the delivery of care.The proposed work is in response to the first priority, seeking to map the digital architecture of a defined region of Indonesia, to understand how it currently supports cancer care delivery and where there is scope for development.

Patient and public involvement
We consulted the Indonesian Cancer Foundation (ICF), Yogyakarta branch, on the design of the research study.The ICF is a non-governmental organization that aims to support the Government of Indonesia in its delivery of cancer care, by taking on promotional, preventive, as well as rehabilitative measures and supportive activities.The ICF also advocates on behalf of patients with cancer and their caregivers.We consulted the ICF about the questions for participants to make sure that the topic headings are exhaustive and capture the patient journey from the beginning of care and that the content of topic guides was acceptable to patients.The ICF supported engagement with patient groups and facilitated discussions on the types of study participants that were sought and the representativeness of the target population.We also conducted a preliminary discussion with healthcare professionals to inform the development of the topic guide for the study, ensuring the topic guide captures the flow of patients and the information processes undertaken by health facilities.During the dissemination of findings, we will consult with patient advocacy groups to i) guide key messages from findings of relevance to patients and members of the public; ii) support with developing plain language summaries of study findings for dissemination, and iii) identify which communication channels might be used to disseminate study findings for patient and public audiences.

Study design
The study will adopt an observational mixed-methods single case study design 32 of health facilities involved in the delivery of cancer services at the primary, secondary, and tertiary levels in a sub-national health system.For a country implementing decentralization, health politics at a sub-national level is highly influenced by the policy at the national level.An observational mixed-methods single case study design is well-placed to support the development of new theory 32 .We will use the approach to support the development of underpinning theory that reflects the current structure, content and use of IT infrastructure for referrals within cancer care in Yogyakarta, Indonesia.
Theoretical frameworks underpinning research Multiple theoretical frameworks have been developed that may have relevance to exploring and understanding HIT adoption and implementation in the health sector [33][34][35][36] .Within this study, we will draw on the socio-technical model 37 , one of the models used to review HIT comprehensively from various dimensions in the health system.The socio-technical model frames the focus of project activities to focus on multiple, interacting and key components to better understand HIT for cancer care in Yogyakarta.Eight interrelated dimensions of the socio-technical model will be explored: 1) hardware and software computing infrastructure, 2) clinical content, 3) human computer interface, 4) people, 5) workflow and communication, 6) internal organizational policies, procedures, and culture, 7) external rules, regulations, and pressures, and 8) system measurement and monitoring 37 .While these are presented as single components, the eight specific dimensions are multiple, interacting components with non-linear, emergent, dynamic behaviour (i.e., small changes in one aspect of the system lead to small changes in other parts of the system under some conditions, but large changes at other times).The relationships and dependencies across the dimensions of the HIT for cancer referrals in Yogyakarta will be explored during the intervention development phase of the project.We will develop conceptual maps to depict identified relationships and relay these to system users and policymakers to validate their content and guide discussions around prioritisation of intervention design to refine and develop existing HIT for cancer referrals.
A recent publication of the infrastructure supporting cancer referral systems in Indonesia has been published 38 .The framework used is based on enterprise architecture (EA) which refers to the Open Group Architecture Framework (TOGAF).This will be used to provide a detailed explanation regarding the structure and key components of the referral system as it relates to cancer, alongside providing insight into the first of the eight dimensions of the socio-technical model to be explored; hardware and software computing.In general, cancer referrals in Indonesia are conducted according to hospital classification type within the national health insurance framework.Although the study will be limited to Yogyakarta, the system observed in this study should also be able to represent the national cancer referral process with slight differences between region caused by availability of services and providers in each area.

Health system context
The cancer control program in Indonesia predominantly focuses on promotion and preventative efforts (e.g.increasing knowledge for the public about approaches to cancer prevention and known risk factors) and early detection program at the primary care 39 .Delivery of care is across general and specialty hospitals which the Indonesian government classifies into several classes (A, B, C, D) based on facilities and the services provided by the hospitals (Table 1) 40 .Class A hospital is the highest level.This category was established for referral purposes 41 .For cancer service delivery, management is divided across primary, secondary, and tertiary referral facilities.Cancer services in Indonesia are classified based on the level of service, namely primary care (examination and or basic medical action in the health sector of care/clinic/health centre in the primary health care), secondary care (access to specialist doctors in D type/C type/B type hospitals), tertiary care (medical examination and or treatment performed by oncology subspecialist in A type hospitals) 42 .
The provision of services as part of cancer care varies across different levels 43 .Services at the primary health care level involve education and counselling related to cancer, screening of cancer, providing first aid in cancer emergencies, case finding and passing referrals, and registering cancer data 44 .Services at the secondary level involves further handling of patient referrals from primary health facilities, managing cancer emergencies, conducting special cancer medical examinations and actions, establishing cancer diagnoses, multidisciplinary teams, providing health lifestyle advice, and conducting cancer data regimens.Services at tertiary level services include conducting primary and secondary checks related to cancer, following up on patient referrals from secondary health facilities and emergency cancer cases, advanced diagnostic investigations, follow-up examinations, integrated management, special medical actions, referrals, and registration of cancer data 45 .
Using data from 2015, there were a total of 2,488 hospitals in Indonesia, comprising both general (n = 1,949) and specialty (n = 539) hospitals.As a first step to explore the role of HIT in cancer care, this study focuses on the Special Region of Yogyakarta, a region of Indonesia located on the island of Java.Reflective of population maldistribution in Indonesia, 70% of its inhabitants are condensed on the island of Java, which equals 11.5% of the land area of Indonesia, while the remainder are sparsely distributed across a further 17,000 islands 46 .The current population of the Special Region of Yogyakarta was 3,656,108 in the most recent 2019 census 47 .

Setting
The study will be conducted in the Special Region of Yogyakarta, Indonesia, across ten facilities supporting delivery of cancer care.The facilities will be selected through stratified purposeful sampling intended to reflect variation among different levels of the health system (i.e.primary care, D type hospital, C type hospital, B type hospital, and A type hospital).The selected sample will be based on the maturity of the referral system within the healthcare center and whether the health facility is active in the national cancer registry network.A sampling frame will ensure representation of health facilities of each level of care.This includes Primary Health Care Facilities (FKTP) and Advanced Referral Healthcare Facilities (FKRTL).All participating facilities will be based in the Yogyakarta special province, with an overview of facility groupings by health ministerial decree outlined in Table 2 48 .

Participants
The study will recruit staff in healthcare facilities, both those involved in the management of cancer referral systems and those who are providing care to cancer patients (Figure 1).In this study, patients will also be recruited to provide insights into their experience engaging with the referral service system and maintaining communication with the service provider/health facilities.

Sample selection
Following the selection of health facilities, interviews with staff and patients will be conducted within each of the participating health center sites.Participants will be purposively sampled to ensure representation of perspectives to inform existing referral processes.This will include both health facility staff who have a direct role in cancer referral management and patients with cancer.Purposive sampling will ensure selection of participants likely to provide richly-textured information relating to referral processes.Inclusion criteria for health facility participants includes working in cancer care at any of the health facilities being recruited from, and having worked in their role for 1 or more years.This will ensure representation of participants across health facilities involved in the referral and management of patients with cancer, alongside the range of staff types working within facilities (i.e.service directors, clinicians, information system managers and cancer program managers).A sampling frame will be developed for selecting patients at each facility, including characteristics of age (adults and children), sex (males and females), cancer type and service currently accessing (including inpatient, outpatient, one day care, and radiotherapy).This will capture variation in the flow and processes of patients across clinical settings.For interviews with child participants, caregivers will be present and accompany them during the interview.Only participants that are able to consent or assent to participation and have no communication impairment will be approached to participate.The criteria and sampling size of the patients are detailed in Table 3.
The sample size for health facility and patient participants to be recruited across sites was determined by the exploratory nature of the study and pragmatic considerations (i.e.resource constraints in terms of research budget and research team size).The selection of sites to ensure information-rich data collection was guided through consultation with the District Health Office.The adequacy of data quality and richness being gathered during interviews will be monitored through regular team meetings.A sampling frame for health facility staff is outlined in Table 4 and for patient participants in Table 3.We will consult with the clinical teams in each cancer unit in participation sites to support with patient recruitment.

Field observations
We will carry out participant observation in the field prior to interviews with health professionals to collect information on the routine method and variety of patient data collected in the health facilities.We will explore a range of forms used in the healthcare centers (i.e.patient registration form, referral form, consent form, medical resume).We will also gather data on the availability of radiotherapy and chemotherapy services, including details on the average daily visits, available beds, duration and frequency of the treatments, number of human resources, and the equipment used.The output from the observation will form the basis of interviews with the health personnel.

Health personnel interviews
Semi-structured face-to-face interviews will be conducted with staff involved in providing care for cancer patients.This includes hospital managers or directors of the patient service, clinicians, and health information system managers.Access to respondents will be through a written letter directed to the management of healthcare facilities.This interview will be conducted with staff from various areas because of the interrelation between units in conducting cancer care, including referral services.Data will be collected from 48 in-depth interviews.Where face-to-face interviews are not possible, interviews will be offered via telephone or video calls in place of meeting face-to-face.
Prior to the interview, written consent will be obtained to record and transcribe the interview.The one-hour semi-structured interviews will be conducted face-to-face by an interviewer; a note-taker will be present for the duration of the interview.Interviewers will record observations about the circumstances of the interview, summarise key opinions and factors that arise, and note considerations for modifying the topic guide for subsequent interviews.
A topic guide and questions have been developed to guide the interview (Table 5).Interviews will focus on the implementation of the existing HITs and cancer registry, the workflow and interoperability, current policies related to HIT, barriers in architecture, digital literacy of the personnel, and human resources constraints.

Patient interviews
For adult patient participants, in-depth interviews will focus on an exploration of participants' experiences of using a referral service system and how they maintain communication with the service provider, current use of digital technologies (such as smartphones), and gaps in provision that participants feel would improve or enhance existing service provision for patients with cancer.For child participants, the interview will be conducted with the caregiver to explore their experiences of using the referral systems.The interviews will be conducted following the topic guide detailed in Table 6.
We will conduct face-to-face interviews with cancer patients.Caregivers, typically family members, often accompany patients to clinical appointments and are involved in the decision making process in Indonesia 49 .As such we will be flexible about whether interviews are conducted with individual patients or in dyads with their caregivers.All participants will be required to sign an consent form to participate in the study.
Prior to the interview, where participant literacy levels are high, written consent will be obtained to record and transcribe the interview.Where literacy is low, verbal consent to record and transcribe the interview will be obtained from the participant.For those providing verbal consent, participants will be asked whether they would like to have a trusted relative or friend as their witness.The 30-minute-interviews will be conducted by an interviewer; As with health professional interviews, interviews will be held by telephone or video calls where face-to-face meetings are not possible.
Audio recording and electronic copies of consent forms will be stored in password-protected files using the Microsoft OneDrive platform.An electronic copy of consent materials will be made as soon as possible following an interview and once an electronic version has been created, paper copies will be destroyed.Only research team members will have access to the OneDrive platform folder set up for the study.On completion of this study, all electronic data on the OneDrive folder, (i.e.electronic copies of consent forms and audio recordings of interviews), will be moved to an electronic archive for 5 years prior to being permanently destroyed.Following completion of the study we will assess the suitability of wider sharing of research data, once deidentified, via a research data repository.All study participants will be assigned an identification code, which will be delinked from their identity across all study documentation.

Quantitative data collection
We will collect the summary of the distribution and demographic data of cancer patients from hospitals and Puskesmas routine reports, along with data from the district health office; Data will be drawn from the report of the 24-month period prior to the study taking place in May 2020.We will collect the number of admitted and referred cancer patients in the last two years.Variables included will be the type of admission (emergency room, inpatient, outpatient), referral status (referred Table 6.Topic guide for patient interview.

Topic Heading Questions
Patients' experience in the admission process and communication with health facilities Please can you tell me about when you first visited this health facility.

How often do you visit the facility?
What was your experience of the registration procedure for your treatment in this health facility?
Were you admitted to different health facilities prior to this?If so, what was your experience of being referred to this facility?
How do you usually communicate with the health facility?Do you use any technology devices for your cancer care (e.g.look for information or health services)?
Is there any special application or call centers that you use to support how you manage your condition?If so, how often do you use it/them?How has your experience been of communicating with the health facility?
Challenges in the treatment process and recommendation to support cancer care When were you first diagnosed?When did you start your first treatment?
Did you experience any difficulties with regards to care between the time you were first diagnosed and when you started to receive treatment?
Did you experience any difficulties in the admission process and/or referral process?
Did you experience any difficulties in collecting information related to your treatment?
Were there any aspects of your experience of cancer care that you feel could be improved to better support your needs?
or not), and the outcome (discharged, died, referred).The data will be used to determine patterns of referral as reflected through routine data and explore whether these data can inform where gaps exist in the existing referral system.

Data analysis
Qualitative data.Interviews will be transcribed verbatim before being imported into NVivo 12 software for deductive framework analysis.An initial exploration and charting of pseudonymised transcripts will be undertaken (AE) through a process of line-by-line coding.Initial coding will be conducted using a random set of transcripts (n=3) for each of the three key stakeholder groups (i.e.patients, health professionals involved in the care of patients with cancer, health professionals and administrators involved in the management of cancer referral systems).A final framework will be agreed through discussion with the wider team.Once inconsistencies are resolved, all remaining interview transcripts will be coded within the joint coding frame.In order to explore common themes and divergences across the stakeholder groups, comparative analysis in the framework will be undertaken.A model of the coding frame will be developed, and each theme and subtheme given a definition to ensure internal consistency of each code.Illustrative codes will be reported for each theme, with the study ID code to demonstrate reporting from across the sample breadth.Safeguards for rigour and quality of data analysis will be embedded into the analysis process, including: regular team meetings to discuss transcripts, codes, and development of themes, alongside verification of accuracy of data through listening to audio recordings of interviews and assessing transcripts by team members (AF, MJA).Where possible, respondent validation will be incorporated into the analysis, sharing summaries of preliminary findings with research participants to provide an opportunity for them to engage with, and add to, interview and interpreted data.The final output from the analysis will be used to inform the development of conceptual maps, ensuring representation of data from all participant groups.
Quantitative data.Descriptive statistics will be generated to inform specific themes of interest (as outlined in Table 7).
Exploration of routine datasets will provide insights into the current distribution and demographic data of patients accessing cancer services in participating sites.This will also be explored at a regional level, with descriptive analysis of regional data providing insights into the distribution and patterns of cancer prevalence in the Yogyakarta region.Secondary data from routine reports will be analysed using Stata/MP 14.1 (StataCorp LLC, College Station, USA).We will also apply network representation analysis to visualise the data.Pairwise relationships between health facilities across the levels of the health system will be derived from descriptive analysis and will be described as a collection of nodes and edges to depict relationships between the facilities.This is intended to provide visually informative data alongside guiding conceptual model development as part of subsequent Theory of Change workshops.

Intervention development and modelling
This study intends to understand and map existing referral processes as part of cancer service provision in Yogyakarta.However, findings are also intended to be used to guide prioritization of future intervention development to refine existing referral processes.The findings from the quantitative and qualitative components of the study will be fed back to key stakeholders in cancer service delivery within Yogyakarta and national representatives.This will be used to elicit feedback on study findings and derive priorities for future research and intervention development.
A narrative synthesis approach will be used as a framework to guide the describing, comparing and combining of heterogeneous qualitative findings and quantitative results from across the study.The synthesis of findings will be used to generate conceptual maps.We will use elements of Popay et al.'s methodology of narrative synthesis 50 which guides the bringing together of disparate literature from multiple sources.We will follow the steps outlined by Popay et al. 50, which will include: i) developing a theory of how the referral system currently works, why and for whom; ii) developing a preliminary synthesis of findings from across the study activities; iii) exploring relationships in the data, including exploration of alignment of findings against the TOGAF approach (e.g.The use of a conceptual map (also referred to in the literature as logic models, analytical frameworks, concept maps, or influence diagrams) will provide a means of visualising the underlying theory of change beneath the existing referral system as determined through the study.The conceptual map presents a useful framework for describing how the referral system is believed to achieve its effects.By presenting this information graphically, rather than in narrative form, we hope to gain a clearer view of the relationship between constituent parts and how they interact.We will produce different types of conceptual map for engagement with key stakeholders, including both activity maps (focusing on the implementation process and aiming to describe the intention of the referral system and the specific steps needed to achieve this intention) and outcomes maps (focusing on the connections between the resources, activities and the outcomes, which may be subdivided into short-term outcomes, long-term outcomes and impact).Discussions will also incorporate prioritisation of future efforts including around digital health technologies specifically for cancer, regulations that ensure the effectiveness and efficiency of cancer referrals (including financing, infrastructure, human resources, technology regulation, interoperability, and data standards), and potential partnerships between government and private sector (public-private mix).
Conceptual maps will be presented, reviewed, discussed and refined during stakeholder meetings and workshops.Two workshops will be conducted.The first will focus on Yogyakarta stakeholders (District Health Office, Provincial Health Office, National Insurance Agencies, Indonesian Cancer Foundation, and health facilities) to determine pathways to impact at the provincial level.The second meeting will focus on the national perspective (with representatives from The Ministry of Health, Yogyakarta Provincial Health Office, National Insurance Agency, and Hospital Organizations) to discuss the recommendations derived from the research and their relevance for national policy.Alongside enhancing and validating findings from the study, conceptual maps will be used formatively as a mechanism for engaging with stakeholders and stimulating debate about future development of the cancer referral system in Yogyakarta.The data collected will be the basis for interventions related to improvement and innovation for cancer referral services in Yogyakarta and may have national relevance.

Ethics
The study involves participation of human subjects requiring consideration of ethics issues relating to informed consent of participants, beneficence, ensuring participant confidentiality and protection of study data, and a respect for privacy.This research has received ethical approval from the joint Medical and Health Research Ethics Committee (MHREC) of Universitas Gadjah Mada and Dr. Sardjito Hospital (No. KE/FK/1075/EC/209).The MHREC has the rights to monitor the research activities at any time.

Dissemination of information
A number of activities will be undertaking to support dissemination of project findings.These will include: (1) developing newsletters and press releases to communicate key project findings to the general public, (2) delivering presentations at local and national conferences in Indonesia, alongside presentation at international conferences, (3) publishing articles in peer-reviewed journals and (4) social media through research team member and institutional accounts.Participants will be anonymised in any dissemination activities.Only pseudonymised, non-identifiable characteristics and quotes will be used in dissemination.

Study status
The study is currently recruiting participants.

Research registration
This study has been registered with Research Registry (researchregistry5807) 15/07/2020.

Conclusion
This research seeks to determine the current role of HIT in the provision of services and treatments for patients with cancer.Our findings will inform critical thinking around the design, implementation, adaptation, and evaluation of existing systems.Through early engagement and participation of key stakeholders and project partners we intend that findings to have immediate utility.We will disseminate our findings to the Ministry of Health and other key stakeholders, alongside presenting findings at conferences and in peer-reviewed journals.
Findings from the study will also be communicated to the government at regional and national levels, hospitals, and primary care centers alongside as part of intervention development and modelling meetings.We will also develop a policy briefing report and an intervention guide related to improving cancer services in Indonesia based on the findings of this study.The benefits of publishing with F1000Research:

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Family caregivers' involvement in caring for a hospitalized patient with cancer and their quality of life in a country with strong family bonds
Underlying data No data are associated with this article Reporting guidelines Figshare: SRQR checklist for 'Protocol for a mixed-methods exploratory investigation of the role of health information technology in the provision of cancer care in Indonesia' https:// doi.org/10.6084/m9.figshare.12656381.v1 5149.Effendy C, Vernooij-Dassen M, Setiyarini S, et al.: .Psychooncology.2015; 24(5): 585-591.PubMed Abstract | Publisher Full Text 50.Popay J, Roberts H, Sowden A, et al.: Guidance on the conduct of narrative synthesis in systematic reviews.The ESRC methods programme.2006; 15:

checklist for 'Protocol for a mixed-methods exploratory investigation of the role of health information technology in the provision of cancer care in Indonesia
'. figshare.Online resource.2020. http://www.