• Title/Summary/Keyword: 전자 의무 기록

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Selection of Clinical Records and Development of Data Management Program for Stroke Clinic Research (중풍 임상 연구를 위한 항목 선정 및 정보관리 프로그램 개발)

  • Moon, Jin-Seok;Choi, Sun-Mi;Cho, Ki-Ho;Yoon, Yoo-Sik
    • Korean Journal of Oriental Medicine
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    • v.11 no.1
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    • pp.109-118
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    • 2005
  • In a field of oriental medicine, it is necessary to collect systemically clinical data and integrate. Input data items was decided, then categorized by the modules through discussion of the institute and hospitals. Items are information of patient, history, aspects of occurrence, pattern identification, prescriptions of herbal medicine, the results of biochemical serum examination, blood cell count, urine analysis, CT, MRI, Chest PA, EKG etc. Factors in oriental medicine are Sasang constitution, Stroke-Pattern-Identification(china), differentiation of cold and heat syndrome. This tool was constructed by using Microsoft-Access 2000 and Microsoft Visual Basic 6.0. Furthermore this web-based system could be applied to multi-center clinical investigation.

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Implementation of Interface Solution between Medical Devices and EMR(Electronic Medical Record) (의료장비와 EMR(Electronic Medical Record)의 인터페이스 솔루션 구현)

  • Koh, Jong-Min
    • Proceedings of the Korea Information Processing Society Conference
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    • 2007.11a
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    • pp.489-492
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    • 2007
  • 전자의무기록(EMR)[1]을 도입한 이후 현재 의료장비의 EMR 연동상황이 극히 미비한 상태로 대두되고 있다. 종합병원 의료장비의 약 30%정도는 검사 결과물이 출력이 안되고 보여지기만 하는 구조로 되어 있어 직접 수기로 EMR 에 연동할 수 있는 소프트웨어에 입력하여 EMR 에 연동하고 있으며, 약 60%는 의료장비에서 프린터 혹은 시리얼통신으로 데이터를 출력할 수 있는 구조로 되어있다. 하지만 의료장비의 노후화 및 검사결과물의 인터페이스 특성이 다양하기 때문에 쉽게 연동하지 못하고 있으며, 대부분 종이 출력 결과물을 스캔을 통해 이미지를 저장하거나 받아서 EMR 에 연동하고 있다. 그 외 나머지 10%는 의료장비 자체의 저장장치 또는 네트워크를 통해 검사결과 데이터를 EMR 에 전송하는 구조로[2] 되어있다. 본 논문에서는 의료장비의 프린터를 통한 결과물을 EMR 에 연동하기 위한 인터페이스 솔루션을 구현하고, 검사결과의 출력 데이터를 이미지 복원 및 관리하는 방법을 통해 많은 수의 의료장비의 출력 데이터를 EMR 연동을 하여 인력 및 기타 사무용품의 소모를 줄이며, 검사결과를 실시간 진단할 수 있는 방법을 제시한다.

Performance of a Model to Predict Complication Occurance after Radical Gastrectomy according to Thresholds (임계값 설정을 통한 근치적 위절제술 후 합병증 발생 예측 모델의 성능 평가)

  • Su-Yeon Lim;Ja-Yun Choi
    • Proceedings of the Korea Information Processing Society Conference
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    • 2024.05a
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    • pp.687-689
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    • 2024
  • 위암은 전 세계적인 주요 건강문제이며, 근치적 위절제술은 위암의 표준치료이다. 근치적 위절제술 후 치료목표는 합병증 발생을 낮춰 병전 상태로 빠르게 회복하는 데 있다. 따라서, 근치적 위절제술 후 합병증 발생 여부를 선별하여 예측할 수 있는 성능이 좋은 모델을 개발하는 것은 위암환자의 회복에 매우 중요하다. 랜덤포레스트 모델은 여러 개의 결정트리를 활용한 배깅 방식의 대표적인 알고리즘으로 의료 데이터를 기반으로 한 예측에 있어 뛰어난 성능을 보여 주었다. 그러나 실제 데이터는 불균형이 빈번하게 발생하여 모델의 예측 성능에 영향을 미치므로, 최적의 분류 임계값을 설정하여 다수 클래스에 대한 편향을 줄이는 것이 중요하다. 따라서, 본 연구는 최근 10년 간 일개 대학병원의 전자의무기록 데이터를 활용하여 근치적 위절제술 후 합병증 발생을 예측하는 랜덤포레스트 모델을 개발하고, 임계값 설정을 통해 불균형 데이터에 대한 모델의 성능을 평가하고자 한다.

Records Management and Archives in Korea : Its Development and Prospects (한국 기록관리행정의 변천과 전망)

  • Nam, Hyo-Chai
    • Journal of Korean Society of Archives and Records Management
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    • v.1 no.1
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    • pp.19-35
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    • 2001
  • After almost one century of discontinuity in the archival tradition of Chosun dynasty, Korea entered the new age of records and archival management by legislating and executing the basic laws (The Records and Archives Management of Public Agencies Ad of 1999). Annals of Chosun dynasty recorded major historical facts of the five hundred years of national affairs. The Annals are major accomplishment in human history and rare in the world. It was possible because the Annals were composed of collected, selected and complied records of primary sources written and compiled by generations of historians, As important public records are needed to be preserved in original forms in modern archives, we had to develop and establish a modern archival system to appraise and select important national records for archival preservation. However, the colonialization of Korea deprived us of the opportunity to do the task, and our fine archival tradition was not succeeded. A centralized archival system began to develop since the establishment of GARS under the Ministry of Government Administration in 1969. GARS built a modem repository in Pusan in 1984 succeeding to the tradition of History Archives of Chosun dynasty. In 1998, GARS moved its headquarter to Taejon Government Complex and acquired state-of-the-art audio visual archives preservation facilities. From 1996, GARS introduced an automated archival management system to remedy the manual registration and management system complementing the preservation microfilming. Digitization of the holdings was the key project to provided the digital images of archives to users. To do this, the GARS purchased new computer/server systems and developed application softwares. Parallel to this direction, GARS drastically renovated its manpower composition toward a high level of professionalization by recruiting more archivists with historical and library science backgrounds. Conservators and computer system operators were also recruited. The new archival laws has been in effect from January 1, 2000. The new laws made following new changes in the field of records and archival administration in Korea. First, the laws regulate the records and archives of all public agencies including the Legislature, the Judiciary, the Administration, the constitutional institutions, Army, Navy, Air Force, and National Intelligence Service. A nation-wide unified records and archives management system became available. Second, public archives and records centers are to be established according to the level of the agency; a central archives at national level, special archives for the National Assembly and the Judiciary, local government archives for metropolitan cities and provinces, records center or special records center for administrative agencies. A records manager will be responsible for the records management of each administrative divisions. Third, the records in the public agencies are registered in the computer system as they are produced. Therefore, the records are traceable and will be searched or retrieved easily through internet or computer network. Fourth, qualified records managers and archivists who are professionally trained in the field of records management and archival science will be assigned mandatorily to guarantee the professional management of records and archives. Fifth, the illegal treatment of public records and archives constitutes a punishable crime. In the future, the public records find archival management will develop along with Korean government's 'Electronic Government Project.' Following changes are in prospect. First, public agencies will digitize paper records, audio-visual records, and publications as well as electronic documents, thus promoting administrative efficiency and productivity. Second, the National Assembly already established its Special Archives. The judiciary and the National Intelligence Service will follow it. More archives will be established at city and provincial levels. Third, the more our society develop into a knowledge-based information society, the more the records management function will become one of the important national government functions. As more universities, academic associations, and civil societies participate in promoting archival awareness and in establishing archival science, and more people realize the importance of the records and archives management up to the level of national public campaign, the records and archival management in Korea will develop significantly distinguishable from present practice.

Development of an Electronic Document for DNR Informed Consent based on the Electronic Medical Record System (전자의무기록 기반의 심폐소생술금지 동의서의 전자서식 개발)

  • Park, Ji-Kyeong
    • The Korean Journal of Health Service Management
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    • v.10 no.3
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    • pp.99-111
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    • 2016
  • Objectives : This study developed an iPad-based animation for an electronic informed consent to directly help patients prepare an informed consent. The goal was to raise patients' understanding about the contents contained in a DNR informed consent in the current medical situation in which DNR informed consents are mostly written by a guardian. Methods : The development of a DNR electronic informed consent was done in 3 stages: analysis, design and development. The analysis stage was done with a survey on the real status of preparing a DNR informed consent in a medical institution. The design stage was done with the contents in the DNR electronic informed consent through a primary and secondary Delphi survey. The development stage created a DNR electronic informed consent and evaluated it through a tertiary Delphi survey. Results : After evaluating the appropriateness of the composition of the contents, the understanding of the contents, the convenience of use, the reflection of an expert opinion, and the suitability of the application, all had scores higher than 4 points. Conclusions : The results of this study show that our proposed DNR electronic informed consent can help patients better understanding the contents of a DNR informed consent.

Frailty assessed by the electronic frailty index and its impact on health outcomes in older adults with chronic diseases: a systematic review (전자허약지수(electronic frailty index)를 활용한 만성질환 노인의 허약평가와 건강결과 간의 관계: 체계적 고찰)

  • Jung-Wook Shin;Min-Young Yu;Youn-Jung Son
    • Journal of Korean Biological Nursing Science
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    • v.25 no.4
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    • pp.229-242
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    • 2023
  • Purpose: The electronic frailty index (eFI), which is derived from electronic health records, has been recommended as screening tool for frailty due to its accessibility and ease of use. The objective of this systematic review was to identify the prevalence of frailty assessed by the eFI and its influence on health outcomes in older adults with chronic diseases. Methods: We searched PubMed, Embase, Web of Science, CINAHL, SCOPUS, Cochrane, Google search, and nursing journals in Korean from January 2016 to December 2022. Results: Twelve studies were analyzed. The eFI score, based on routine clinical data, was associated with adverse health outcomes. The most frequent outcome studied was mortality, and the eFI was associated with increased mortality in nine studies. Other outcomes studied included hospitalization, length of stay, readmission, and institutionalization in relation to hospital care usage, and cardiovascular events, stroke, GI bleeding, falls, and instrumental activities of daily life as health conditions. Conclusion: Early identification of frailty in older adults with chronic diseases can decrease the burden of disease and adverse health outcomes. The eFI has a good discriminative capacity to identify frail older adults with chronic diseases.

A Development of Reference Terminology Subset Editor for effective adaption of Clinical Vocabulary (임상용어의 효율적 적용을 위한 참조용어 Subset 에디터의 개발)

  • Cho, Hune;Kim, Hyung-Hoi;Choi, Byung-Guan;Choi, Young-Yeon;Kim, Hwa-Sun;Hong, Hae-Sook
    • Journal of Korea Multimedia Society
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    • v.11 no.3
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    • pp.364-372
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    • 2008
  • It is highly useful in an actual clinical setting to apply appropriate medical terms to every area of electronic medical record (EMR) and link them effectively, as a single medical terminology system cannot cover all medical concepts. In order to use standardized terms conveniently and efficiently, it is required to categorize them depending on the purpose of individual departments or physicians and thereby develop organized subsets of extracted terms highly likely to be used. In addition, it is important to such a subset to make it possible to change or correct standardized terminology system and continue to develop and upgrade to meet renewed demands of users. In this paper, data including chief compliant, symptoms, diagnosis, operation, and history of previous treatments were collected from discharge summary of patients with Department of Neurosurgery at Busan National University Hospital for analysis. In addition, subset database was created, and for terms needed to be added, the physician directly performed mapping through connection with reference terminology server and developed subset editor for the purpose of creating new subset database. Therefore, it is expected that this can serve as a practical and effective management method to reduce problems and inefficiency caused by existing vast terminology system.

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Comparison of Health Behaviors and Health Indices According to Percutaneous Coronary Intervention in Patients with Chest Pain -Analysis of Nursing Information Chart and Electronic Medical Record- (흉통환자의 관상동맥중재술 시행 여부에 따른 건강행위 및 건강지표 비교 - 간호정보조사지와 전자의무기록 분석-)

  • Kweon, Mi-Soo;Lee, Sook-Jeong
    • The Journal of the Korea Contents Association
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    • v.19 no.12
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    • pp.279-288
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    • 2019
  • The purpose of this study was to compare the health behaviors and health indices according to whether a percutaneous coronary intervention(PCI) was performed due to chest pain. This is a secondary data analysis study of nursing information questionnaires and electronic medical records of 247 chest pain patients in a hospital from January 2010 to December 2017. The participants were divided into non-PCI and PCI groups, and the health behaviors, blood pressure, and blood lipid levels were collected at the first hospital admission and re-admission. Collected data were analyzed using SPSS 24.0. As a result of the study, smoking and lipid levels were significantly healthier than the participants in PCI group during re-hospitalization. Non-PCI group had a high risk of smoking despite the high risk of coronary artery stenosis. It was found that continuous integrated management to promote health behavior is needed. The significance of this study was to identify the importance of health behavior in patients with the risk of cardiovascular disease.

The Autonomy, Nursing Performance based on the Awareness and satisfaction of EMR System for Nurses (간호사의 전자의무기록(EMR) 인식도와 만족도에 따른 자율성 및 간호업무성과)

  • Kang, Jisook;Kim, Sunja;Kim, Wonjeong
    • Journal of the Korea Academia-Industrial cooperation Society
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    • v.16 no.9
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    • pp.6061-6070
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    • 2015
  • The purpose of this study was to examine relations on the autonomy, nursing performance based on the awareness and satisfaction of electronic medical record system for nurses. This Study was a descriptive survey design using convenience sampling. There were 194 general hospital nurses, who agreed to participate in this study, taken a structured questionnaire during august 2013. SPSS 20.0 version was used for descriptive analysis, frequency, percentage, mean, standard deviation, independent t-test, one-way ANOVA and Pearson correlation coefficiency. The major findings of this study were as follows. The mean score on the awareness of EMR was 3.68, the mean score on the satisfaction was 3.47 and nursing autonomy mean score was 3.25, nursing performance mean score was 3.55. There were significant differences in the awareness according to working field and computer certificate. There were significant differences in satisfaction depending on whether they held computer certificates Head nurses and the above scored significantly higher in nursing performance compared to nurses at the lower position. Also, higher awareness was significantly related to higher satisfaction. Higher satisfaction was significantly related to higher nursing autonomy and performance. The findings of this study imply that nurses need to raise their EMR awareness and satisfaction and make best used of their qualification with their computer certificate.

Factor affecting Unplanned Readmissions after Cardiac Valve Surgery: Analysis of Electric Medical Record (심장판막수술 환자의 비계획적 재입원 영향요인: 전자의무기록분석)

  • Lee, Jung Sun;Shin, Yong Soon
    • The Journal of the Korea Contents Association
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    • v.22 no.2
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    • pp.794-802
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    • 2022
  • This retrospective study was to investigate the characteristics of unplanned readmission and factors affecting readmission within 30 days of discharge in patients who underwent heart valve surgery through electronic medical records. The participants were 423 unplanned re-hospitalization within 30 days after heart valve surgery at a tertiary hospital in Seoul from January 2018 to August 2019. A total of 48 patients (11.3%) were unplanned readmissions, and the most common causes were atrial fibrillation in 13 cases (27.1%) and pain at the surgical site in 13 cases (27.1%). Other causes were: 10 cases (20.8%) of warfarin inappropriate treatment concentration, 7 cases of general weakness (14.6%), 5 cases of hypotension (10.4%), 4 cases of pericardial effusion (8.3%), 3 cases of surgical wound infection (6.3%), 3 cases of hemorrhage (6.3%), 3 cases of high fever (6.3%), and 1 case of cerebral infarction (2.1%). Variables influencing readmission were history of cancer (OR = 2.60, 95% CI 1.13-6.03, p = .025) and the patients who went to a home rather than a hospital after discharge (OR = 2.91, 95% CI 1.33-6.36, p = .008), as a type of valve surgery, mitral valve valvuloplasty had a higher readmission rate than aortic valve replacement (OR = 1.21, 95% CI 1.21-4.98, p = .012). In order to reduce unplanned readmissions, an tailored education program is needed to enable patients and caregivers to manage their comorbid chronic diseases before discharge and assess risk factors for readmission in advance.