• 대한약침학회지
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• 제21권3호
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• pp.195-202
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• 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.

• 한국응급구조학회지
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• 제5권1호
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• pp.177-198
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• 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.

• 의료법학
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• 제13권1호
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• pp.359-395
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• 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.

• 근관절건강학회지
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• 제26권1호
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• pp.27-34
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• 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.

• 융합보안논문지
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• 제9권2호
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• pp.49-58
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• 2009

의료기관에서 환자의 개인건강정보는 진료를 위해 의료진의 정보열람이 반드시 필요한 사항이다. 그러나 이러한 정보의 불필요한 노출은 개인정보보호와 관련이 있어 민감하게 취급되어야 하며, 의료기관에 종사하는 사용자들이라 할지라도 접근에 있어 역할에 따른 제한이 필요하다. 따라서 본 논문에서는 의료진과 그 이외의 직원들 간의 사용자 식별을 통한 개인건강정보의 접근 통제뿐만 아니라 업무에 따른 조건을 추가하여 사용자 직종 내에서도 상황에 따른 접근 통제에 대해 연구하였다. 응급상황, 담당과 여부에 따른 접근 통제, 그리고 환자가 정하는 본인의 개인정보에 대한 접근통제를 포함하여 확장된 개념의 역할기반 접근제어를 합으로써 의료기관내에서 환자의 개인건강정보의 불필요한 접근이나 유출을 최소화 할 수 있다.

• 대한간호학회지
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• 제49권5호
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• pp.575-585
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• 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.

• 디지털융복합연구
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• 제13권12호
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• pp.47-53
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• 2015

본 연구에서는 의료기관에서 진료의 질 향상을 위해 도입하고 있는 전자의무기록 (Electronic Medical Record : EMR)시스템의 수용 및 활용을 결정짓는 요인들을 분석하였다. 전자의무기록에 대한 기존 연구를 바탕으로 하여 측정변수와 요인들을 정의하였고, 현재 EMR시스템을 구축하여 운용하고 있는 종합병원으로 부터 수집된 데이터로 실증분석을 하였다. 요인들 사이의 상관관계를 분석하기 위하여 연구모델을 구축하였고, 이를 바탕으로 요인들 사이의 관계를 규정하는 가설을 설정하였고, 이 가설들을 구조방정식 (Structural Equation Model : SEM)을 통해서 분석하였다. 분석 결과에 의하면 EMR시스템의 수용 결정에 영향을 미치는 요인은 의료기관의 경영전략 이고, EMR시스템의 수용은 EMR시스템의 경영성과에 영향을 미치는 것으로 판명되었다. 본 연구의 결과는 한국의 의료기관들이 EMR시스템을 구축하거나 운용하는데 있어서 중요한 참고자료가 될 수 있을 것으로 기대한다.

• 정보처리학회논문지C
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• 제18C권6호
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• pp.379-388
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• 2011

의료정보는 환자에게 중요한 개인정보로써 반드시 보호돼야 한다. 특히 전자의무기록에 접근할때, 의료인의 강화된 신원확인에 대한 인증방식이 필요하다. 기존의 공인인증서 기반 인증모델은 개인키 관리, 권한위임 등 문제점으로 전자의무기록의 특성을 반영하지 못했다. 본 논문에서는 전자의무기록 시스템에 의료인이 접근하는 경우 지문인식 기반 인증 모델을 적용하여 강화된 인증방식을 제안한다. 전자의무기록의 지문인증 모델은 의료업무의 특성을 반영하여 개인키 관리, 권한위임 문제를 원천적으로 해결하였다.

• 한국병원경영학회지
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• 제29권1호
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• pp.1-18
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• 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.

• 한국산학기술학회논문지
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• 제12권4호
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• pp.1703-1710
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• 2011

목적 : 성인병관리 및 개인건강관리를 위해 개인건강기록(PHR)은 매우 중요하다. 현재 노인 또는 장년층과 미래 노인, 장년층과의 차이를 비교해 보기 위해 젊은층(대학생)과 성인을 대상으로 조사하였다. 방법: 두 연령집단의 면대면 설문조사를 성인(131명)과 대학생(398명)을 2009년 5월 11일부터 22일까지 실시하였다. 설문지는 18개 문항으로 구성되었다. 결과 및 결론: 젊은층보다는 성인층에서 PHR을 사용하겠다는 의지(대학생그룹3.3, 성인그룹3.7)와 지인들에게 PHR을 추천하겠다는 의지(대학생그룹3.1, 성인그룹3.8)가 비교적 높게 나타났다. 반면, 성인그룹은 종이형 PHR(63.2%)을 선호하였으며 대학생그룹은 ePHR(71.1%)을 더 선호하였고, PHR에 담겨져 있는 정보유출에 대한 우려가 성인그룹(3.7)보다 대학생그룹(4.5)이 높은 것으로 나타났다. PHR에 대한 교육 시기는 고등학교와 대학교로 응답하였다. 따라서 젊은층의 PHR활성화를 위해서는 ePHR에 대한 조기교육과 사용이 편리한 PHR개발이 이루어져야 할 것으로 사료된다.