• Title/Summary/Keyword: Electronic Health Record

Search Result 148, Processing Time 0.024 seconds

Design and Implementation of a Nursing Records for the Nursing Process for Use Within the Health Level 7 Clinical Document Architecture (HL7 임상문서구조의 기반 한 간호과정을 위한 간호기록지의 설계 및 구현)

  • Kim, Hwa-Sun;Tran, Tung;Kim, Hyung-Hoi;Lee, Eun-Joo;Cho, Hune
    • Journal of Korea Multimedia Society
    • /
    • v.9 no.8
    • /
    • pp.1054-1066
    • /
    • 2006
  • This study proposes a new paradigm hospital information system through the nursing classification system and design of the HL7 clinical document architecture (Health Level Seven CDA) for information-sharing among various healthcare institutions. Nursing information CDA are included coding systems of nursing diagnosis, nursing intervention, nursing activity and outcomes. And, we have developed CDA generator for active generation of XML document. This study aims to facilitate the optimum care by providing health information required for individuals to nursing specialists in real-time, to help improvements in health, to improve the quality of productive life. This study has the following significance. First, an expansion and redefining process conducted, founded on the HL7 clinical document architecture and reference information model, to apply international standards to Korean contexts. Second, we propose a next-generation web based hospital information system that is based on the clinical document architecture. In conclusion, the study of the clinical document architecture will include an electronic health record (EHR) and a clinical data repository (CDR), and also make possible healthcare information-sharing among various healthcare institutions.

  • PDF

Statues and Improvement of Electronic Medical Record System in Traditional Korean Medicine

  • Jung, Bo-Young;Kim, Kyeong Han;Kim, Song-Yi;Sung, Hyun-Kyung;Park, Jeong-Su;Go, Ho-Yeon;Park, Jang-Kyung
    • Journal of Pharmacopuncture
    • /
    • v.21 no.3
    • /
    • pp.195-202
    • /
    • 2018
  • Objectives: The study was to survey use of electronic medical records in subjects of Korean medicine doctors working for Korean medicine organizations and to contemplate ways to develop utilization of electronic medical records. Methods: On August 2017, it conducted online self-reported survey on subjects of Korean medicine doctors at Korean hospitals and clinics who agreed to participate in the study. A total 40 doctors in hospital and 279 doctors in clinic were included. The surveyed contents include kinds of electronic chart, reason for not using electronic medical records and problems with creation of medical records. Results: It finds that 100% of those working at Korean medicine hospitals and 86.4% of those at Korean medicine clinics have used electronic medical records. Subjects answered the biggest reason for not using electronic medical records was inconvenience. The most serious problems with creation of electronic medical records at Korean medicine organizations found in the study include there was no method of creation of medical records and no standardized terminology for use in electronic medical records. Conclusion: For utilization of electronic medical records at Korean medicine organizations, standardization of terminology, development of EMR in favour of its users and development of strategy that motivates use of EMR are required.

A study on standardization & completion of transfer consultation record for patients transferred to emergency medical center (응급의료센터로 전원된 환자의 진료의뢰서 표준화 및 충실도에 관한 연구)

  • Yoou, Soonkyu;Kim, Kwang Hwan;Cho, Hae Kyung
    • The Korean Journal of Emergency Medical Services
    • /
    • v.5 no.1
    • /
    • pp.177-198
    • /
    • 2001
  • The purpose of this research which was conducted by surveying the transfer consultation records from 360 medical institutions such as general hospitals, hospitals, clinics to the Emergency Medical Center at E University Hospital for six months(Jan. 1, 2000 - Jun. 30, 2000) are to standardize & complete transfer consultation record of hospitals at the 1st & 2nd referral level and to give patients transferred emergency medical center medical information services on a better quality. The conclusions and suggestions from this study were summarized as follows; (1) Examing the distribution of the referral medical consultation(transfer) sheet type, surgery part local clinic sheet types were 34.4%, medical part local clinic sheet types were 26.7%, undifferentiated local clinic sheet types were 23.9% and hospital level sheet types were 15.0%. (2) The items of the transfer consultation records had been standardized more than 75% in the order of patient's name, date, doctor's name, diagnosis, patient's status, impressions. (3) That the degree of recording completion on these items is in the order of patient's name, date, diagnosis, impressions was revealed. (4) Because the standardization and the degree of recording completion are very low in the patient's gender, age, address, electronic recording system was needed for more perfect input of initial patient informations. (5) This standardizing & complete recording on examination and medication will prevent re-examination and abuse of medication for patients transferred emergency medical center. (6) EMT Transfer System should be fixed in all medical institute for the standardizing & complete recording on care period and departure time will give many emergency patients the proper treatments at the proper time. (7) It was revealed that developing new standardized transfer consultation record & using electronic recording system are needed. (8) The complete recording & Fast Track System were needed for higher rate of bed operation at emergency medical center and more hospital profit.

  • PDF

A Study on Legal Protection, Inspection and Delivery of the Copies of Health & Medical Data (보건의료정보의 법적 보호와 열람.교부)

  • Jeong, Yong-Yeub
    • The Korean Society of Law and Medicine
    • /
    • v.13 no.1
    • /
    • pp.359-395
    • /
    • 2012
  • In a broad term, health and medical data means all patient information that has been generated or circulated in government health and medical policies, such as medical research and public health, and all sorts of health and medical fields as well as patients' personal data, referred as medical data (filled out as medical record forms) by medical institutions. The kinds of health and medical data in medical records are prescribed by Articles on required medical data and the terms of recordkeeping in the Enforcement Decree of the Medical Service Act. As EMR, OCS, LIS, telemedicine and u-health emerges, sharing and protecting digital health and medical data is at issue in these days. At medical institutions, health and medical data, such as medical records, is classified as "sensitive information" and thus is protected strictly. However, due to the circulative property of information, health and medical data can be public as well as being private. The legal grounds of health and medical data as such are based on the right to informational self-determination, which is one of the fundamental rights derived from the Constitution. In there, patients' rights to refuse the collection of information, to control recordkeeping (to demand access, correction or deletion) and to control using and sharing of information are rooted. In any processing of health and medical data, such as generating, recording, storing, using or disposing, privacy can be violated in many ways, including the leakage, forgery, falsification or abuse of information. That is why laws, such as the Medical Service Act and the Personal Data Protection Law, and the Guideline for Protection of Personal Data at Medical Institutions (by the Ministry of Health and Welfare) provide for technical, physical, administrative and legal safeguards on those who handle personal data (health and medical information-processing personnel and medical institutions). The Personal Data Protection Law provides for the collection, use and sharing of personal data, and the regulation thereon, the disposal of information, the means of receiving consent, and the regulation of processing of personal data. On the contrary, health and medical data can be inspected or delivered of the copies, based on the principle of restriction on fundamental rights prescribed by the Constitution. For instance, Article 21(Access to Record) of the Medical Service Act, and the Personal Data Protection Law prescribe self-disclosure, the release of information by family members or by laws, the exchange of medical data due to patient transfer, the secondary use of medical data, such as medical research, and the release of information and the release of information required by the Personal Data Protection Law.

  • PDF

Analysis of Nursing Records for Elderly Patients with Abdominal Pain in the Emergency Medical Center (응급의료센터에 내원한 복부통증 노인 환자에 대한 간호기록 분석)

  • Lee, Hyeo Ki;Kim, Jong Im
    • Journal of muscle and joint health
    • /
    • v.26 no.1
    • /
    • pp.27-34
    • /
    • 2019
  • Purpose: This study was done to analyze nursing assessment and nursing care for pain in the electronic nursing records for the elderly patients with abdominal pain visiting the Emergency Medical Center. Methods: This study is a descriptive study based on nursing records from January to December 2015. A total of 1155 records for elderly patients with abdominal pain were gathered. Results: The mean age of elderly patients whose records were analyzed was 75.2 years. Analysis of nursing records regarding pain management showed that semi-urgent severity (93.7%), direct emergency room visits (58%), and 6.01 hours of emergency room stay (6.01 hours)were the most frequently documented characteristics of the elderly patients with pain complaints. Recording time of nursing assessment for abdominal patients was 1.01 hour; the average pain intensity was 3.97. The mostly used nursing intervention for abdominal pain was medication (65.1%). There was no record of non-pharmacological pain nursing interventions. Conclusion: The results of this study showed that improving knowledge and nursing practice for pain management is much of necessity. In particular, development of the non-pharmacological nursing interventions for pain is needed. Further research is also imperative to develop and evaluate record systems for pain management that can be used in the emergency room.

The Acceptance Factors for Electronic Medical Record System (전자의무기록시스템의 수용요인)

  • Chun, Je-Ran
    • Journal of Digital Convergence
    • /
    • v.13 no.12
    • /
    • pp.47-53
    • /
    • 2015
  • In this paper the factors are analyzed, which influenced on the acceptance of Electronic Medical System (EMR) of healthcare organization in Korea. The measured variables and factors were defined on the base of former research works. The questionnaires with Likert's 5 scale were administrated in the 102 general hospitals in Korea. This data was analyzed with SPSS v. 20. According to the result of factor analysis, the 4 influencing factors were grouped. They are, "ICT-infrastructure of healthcare organization", "Management strategy of healthcare organization", "EMR acceptance" and "EMR-performance". 5 hypotheses about the correlations between factors were formulated and analyzed with structural equation model(SEM). The result of this paper could be the good reference to the healthcare organizations on how they should implement and operate the EMR system.

A Study on Advanced RBAC Model for Personal Information Security Based on EHR(Electronic Health Record) (EHR System에서 개인정보보호를 위한 개선된 RBAC 모델에 관한 연구)

  • Ahn, Eun-Kyoung;Kim, Byung-Hoon;Lee, Dong-Hwi;Kim, Kui-Nam
    • Convergence Security Journal
    • /
    • v.9 no.2
    • /
    • pp.49-58
    • /
    • 2009
  • In medical Institution, Electronic Health Record (EHR) is "must access information" to medical staff considering it as medical information. However, this unnecessary exploration of personal information must be treated confidentially because the information is highly related to other's private concerns. It is necessary that medical workers should be also restricted to their access to EHR depending on their roles and duties. As the result, this article explains that "EHR access control will be executed by differentiating authorized medical staff from non medical-related staff as well as EHR access will be only permitted to authorized medical staff depending on their work status conditions. By using Advanced RBAC model on medical situation, we expect to minimize unnecessary leak of EHR information; especially, emergency medical care is needed, access control is highly required depending on a person in charge of the cases or not, and restricted medical information defined by the patient one-self is only allowed to be accessed.

  • PDF

Development and Evaluation of Electronic Health Record Data-Driven Predictive Models for Pressure Ulcers (전자건강기록 데이터 기반 욕창 발생 예측모델의 개발 및 평가)

  • Park, Seul Ki;Park, Hyeoun-Ae;Hwang, Hee
    • Journal of Korean Academy of Nursing
    • /
    • v.49 no.5
    • /
    • pp.575-585
    • /
    • 2019
  • Purpose: The purpose of this study was to develop predictive models for pressure ulcer incidence using electronic health record (EHR) data and to compare their predictive validity performance indicators with that of the Braden Scale used in the study hospital. Methods: A retrospective case-control study was conducted in a tertiary teaching hospital in Korea. Data of 202 pressure ulcer patients and 14,705 non-pressure ulcer patients admitted between January 2015 and May 2016 were extracted from the EHRs. Three predictive models for pressure ulcer incidence were developed using logistic regression, Cox proportional hazards regression, and decision tree modeling. The predictive validity performance indicators of the three models were compared with those of the Braden Scale. Results: The logistic regression model was most efficient with a high area under the receiver operating characteristics curve (AUC) estimate of 0.97, followed by the decision tree model (AUC 0.95), Cox proportional hazards regression model (AUC 0.95), and the Braden Scale (AUC 0.82). Decreased mobility was the most significant factor in the logistic regression and Cox proportional hazards models, and the endotracheal tube was the most important factor in the decision tree model. Conclusion: Predictive validity performance indicators of the Braden Scale were lower than those of the logistic regression, Cox proportional hazards regression, and decision tree models. The models developed in this study can be used to develop a clinical decision support system that automatically assesses risk for pressure ulcers to aid nurses.

An Authentication Model based Fingerprint Recognition for Electronic Medical Records System (지문인식 기반의 전자의무기록 시스템 인증 모델)

  • Lee, Yong-Joon
    • The KIPS Transactions:PartC
    • /
    • v.18C no.6
    • /
    • pp.379-388
    • /
    • 2011
  • Ensuring the security of medical records is becoming an increasingly important problem as modern technology is integrated into existing medical services. As a consequence of the adoption of EMR(Electronic Medical Records) in the health care sector, it is becoming more and more common for a health professional to edit and view a patient's record. In order to protect the patient's privacy, a secure authentication model to access the electronic medical records system must be used. A traditional identity based digital certificate for the authenticity of EMR has private key management and key escrow of a user's private key. In order to protect the EMR, The traditional authentication system is based on the digital certificate. The identity based digital certificate has many disadvantages, for example, the private key can be forgotten or stolen, and can be easily escrow of the private key. Nowadays, authentication model using fingerprint recognition technology for EMR has become more prevalent because of the advantages over digital certificate -based authentication model. Because identity-based fingerprint recognition can eliminate disadvantages of identity-based digital certificate, the proposed authentication model provide high security for access control in EMR.

The Case and Implications of Terminology Mapping for Development of Dankook University Hospital EHR-Based MOA CDM (단국대학교병원 EHR 기반 MOA CDM 구축을 위한 용어 매핑 사례와 시사점)

  • Yookyung Boo;Sihyun Song;Jihwan Park;Mi Jung Rho
    • Korea Journal of Hospital Management
    • /
    • v.29 no.1
    • /
    • pp.1-18
    • /
    • 2024
  • Purposes: The Common Data Model(CDM) is very important for multi-institutional research. There are various domestic and international CDM construction cases to actively utilize it. In order to construct a CDM, different terms from each institution must be mapped to standard terms. Therefore, we intend to derive the importance and major issues of terminology mapping and propose a solution in CDM construction. Methodology/Approach: This study conducted terminology mapping between Electronic Health Record(EHR) and MOA CDM for constructing Medical Record Observation & Assessment for Drug Safety(MOA) CDM at Dankook University Hospital in 2022. In the process of terminology mapping, a CDM standard terminology process and method were developed and terminology mapping was performed by applying this. The constructions of CDM mapping terms proceeded in the order of diagnosis, drug, measurement, and treatment_procedure. Findings: We developed mapping guideline for CDM construction and used this for mapping. A total of 670,993 EHR data from Dankook University Hospital(January 1, 2013 to December 31, 2021) were mapped. In the case of diagnosis terminology, 19,413 were completely mapped. Drug terminology mapped 92.1% of 2,795. Measurement terminology mapped 94.5% of 7,254 cases. Treatment and procedure were mapped to 2,181 cases, which are the number of mapping targets. Practical Implications: This study found the importance of constructing MOA CDM for drug side effect monitoring and developed terminology mapping guideline. Our results would be useful for all future researchers who are conducting terminology mapping when constructing CDM.

  • PDF