• Title/Summary/Keyword: Electronic Medical Record

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A Study of Comparing the Paper-Based Medical Record with the Electronic Medical Record on the Level of Medical Record Completeness and the Accordance (종이의무기록과 전자의무기록의 기재 충실도 및 일치도 비교 연구 : 의사의 입원.퇴원기록지와 간호사의 입원.퇴원간호정보기록지를 중심으로)

  • Shin, A-Mi;Jung, Sun-Ju;Lee, In-Hee;Son, Chang-Sic;Park, Hee-Joon;Kim, Yoon-Nyun;Youn, Kyung-Il
    • Korea Journal of Hospital Management
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    • v.15 no.1
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    • pp.1-12
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    • 2010
  • This study was tried to evaluate the level of completeness and the accordance in electronic medical records by comparing paper-based medical record in doctor's admission records, discharge summary, and nursing information records. Medical records of inpatients of neurology department that the 100 paper-based medical records in 2004 and 100 electronic medical records in 2006 were targeted. Existence of record items and doctor-nurse record accordance were evaluated in doctor's admission record, discharge summary, admission nursing information record, and discharge nursing information record. There were not any differences between electronic medical records and paper-based medical records in doctor's admission record and discharge summary. Electronic medical records had less missing records than paper-based medical records in admission and discharge nursing information records. Electronic medical records showed higher accordance than the paper-based medical record in doctor-nurse record generally, but there were statistically differences in only medication, allergy, smoking, and drinking (p<0.05). In this study, it was verified that the quality of electronic medical records are better than paper-based records in nursing information record and doctor-nurse record agreement.

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Study for Improvement of the Doctor's Satisfaction and Completeness of the Medical Record in the EMR System (전자의무기록(EMR) 시스템하에서 의사의 만족도와 의무기록정보의 기재 충실도 향상 방안)

  • Park, Un-Je
    • Korea Journal of Hospital Management
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    • v.16 no.2
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    • pp.19-30
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    • 2011
  • This study aims to present ways to enhance the stabilization of electronic medical records, ensure the commitment to filling in information of the medical record and improve the overall quality Electronic Medical Record(EMR) information. For that purpose, the present state of the incomplete record rate and the doctor's satisfaction in Electronic Medical Record(EMR) have been surveyed by comparing and analyzing Paper-based Medical Record(PMR) and Electronic Medical Record(EMR). The survey was conducted on 31 doctors in charge of EMR system and each PMR and EMR inpatients were collected for a period of 5 months and analyzed. The results showed that the doctor's satisfaction level was higher for EMR, and the rate of incomplete record appeared to be lower in EMR in departments of both internal and external medicine. In this context, it can be said that the higher efficiency of EMR helped accomplish the increase in commitment to completing medical record information and improve the quality of the data.

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The Study of Metadata Model to Identify Electronic Medical Record (전자의무기록 식별을 위한 메타데이터의 연구)

  • Hong, Sung Ho;Kim, Young Seop
    • Journal of the Semiconductor & Display Technology
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    • v.13 no.2
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    • pp.63-66
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    • 2014
  • Managing electronic medical record is very difficult, because the currently electronic medical system is not designed standard that is uniform and proper. In this paper, in order to overcome this situation, we propose meta-data for the management of the electronic medical record as a single system. To this end, we first analyzed the research on electronic medical records and related standards. Second, we, on the basis of the analysis result, abstracted electronic medical record and entities related on electronic medical, and we designed an entity-relationship model. And finally, we have to complete the meta-data through the setting attributes in this entity-relationship model. Through this study, it was possible that we can complete metadata highly expressive medical records, and suggest an alternative for problem of current medical records systems.

Designing and Implementing a PKI-based Safety Protocol for Electronic Medical Record Systems (공개키 기반의 안전한 전자의무기록에 관한 프로토콜 설계 및 구현)

  • Jin, Gang-Yoon;Jeong, Yoon-Su;Shin, Seung-Soo
    • Journal of Digital Convergence
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    • v.10 no.4
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    • pp.243-250
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    • 2012
  • This study proposes new protocol protecting patients' personal record more safely as well as solving medical dispute smoothly by storing the record not into a computer server in hospitals but into the National Health Insurance Corporation computer server. The new protocol for electronic medical record is designed using RSA public key algorithm and DSA digital signature. In addition, electronic medical record systems are built up with more safety and reliability through certificate authority. The proposed medical information systems can strengthen trust between doctors and patients. If medical malpractice occurs, the systems can also provide evidence. Furthermore, the systems can be helpful to reduce medical accidents. The systems could be also utilized efficiently in various applied areas.

Development of Electronic Medical Record System Using XML (XML을 이용한 전자의무기록시스템 개발)

  • Kang, Byeong-Do;Jung, Suk-Ho
    • The KIPS Transactions:PartD
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    • v.9D no.6
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    • pp.1127-1136
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    • 2002
  • In the medical field. the desire of the hospital information system based on the advanced computer technology has been increased because hospital staffs wanted to provide better medical services to their patients by using it. So, the electronic medical records have emerged to share and exchange medical and healthcare information stored in database. In this paper. we developed an electronic medical record system using XML. This system includes four modules : data repository. document structure manager, document writter and XML automatic generator. For the purpose of evaluating the usability of the electronic medical records of our system, we also applied it to out-patient medical records in the department of orthopedic surgery.

Electronic Medical Record Modification Prevention Protocol (전자의무기록 변경 방지 프로토콜)

  • Joo, Han-Kyu
    • Journal of Digital Contents Society
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    • v.11 no.2
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    • pp.135-144
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    • 2010
  • Medical records are very important records and should not be modified after creation. The current medical records are liable to improper modification. With the development of information technology, electronic medical records (EMR) are used widely. For the EMR, cryptographic primitives may be used to develop techniques to prevent medical record modofication. In this research, a technique to prevent improper medical record prevention is proposed. It uses crytographic primitives such as linked hash, digital signature, and electronic notarization. A prototype system is also developed for performance analysis. The proposed method makes the medical record modification impossible with a small amount of additional cost.

Legal Status of Medical Personnel on Medical Records (환자의 의무기록 관련 의료인의 법적 지위)

  • Lee, Baek-Hyu
    • The Korean Society of Law and Medicine
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    • v.11 no.2
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    • pp.309-335
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    • 2010
  • This study is a paper reviewed legal status of medical personnel and issues of law on recently discovered medical records. As the increase of medical personnel who have gone through the administrative disposal in regards to the medical records, it is needed to examine the legal issue or dispute on the medical records under the current law. Medical records are the statement on patient's medical conditions made by the medical personnel. This records are used as important source for patient's further treatment. This becomes the communication route between the patients and the other medical personnel, and it provides the patients a right to find out their medical information. According to the Medical Service Act (Article 21), a medical personnel shall prepare respectively a record book of medical examination and treatment. And medical personnel shall make a signature. Furthermore, the medical personnel or the opener of the medical institutions must preserve the record book (including an electronic medical record). Meanwhile, the issues of a ban on false entry, additional record, revision or manipulation on the medical record have been recently on the rise. This paper briefly examined the major issues in regards to the medical records. It especially clarified the legal duty on medical records and its major-contentious-issues. At the same time, it pointed out the problems of the unreasonable over interpretation of the law. Furthermore, this suggested the guidelines for the further discussion and review.

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A study of access control using fingerprint recognition for Electronic Medical Record System (지문인식 기반을 이용한 전자의무기록 시스템 접근제어에 관한 연구)

  • Baek, Jong Hyun;Lee, Yong Joon;Youm, Heung Youl;Oh, Hae Seok
    • Journal of Korea Society of Digital Industry and Information Management
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    • v.5 no.3
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    • pp.127-133
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    • 2009
  • The pre-existing medical treatment was done in person between doctors and patients. EMR (Electronic Medical Record) System computerizing medical history of patients has been proceed and has raised concerns in terms of violation of human right for private information. Which integrates "Identification information" containing patients' personal details as well as "Medical records" such as the medical history of patients and computerizes all the records processed in hospital. Therefore, all medical information should be protected from misuse and abuse since it is very important for every patient. Particularly the right to privacy of medical record for each patient should be surely secured. Medical record means what doctors put down during the medical examination of patients. In this paper, we applies fingerprint identification to EMR system login to raise the quality of personal identification when user access to EMR System. The system implemented in this paper consists of embedded module to carry out fingerprint identification, web server and web site. Existing carries out it in client. And the confidence of hospital service is improved because login is forbidden without fingerprint identification success.

Design and Implementation of Electronic Medical Record System Based on HL7-CDA for the Exchange of Clinical Information (임상 정보교환을 위한 HL7-CDA 기반의 전자의무기록 시스템의 설계 및 구현)

  • Cho, Ik-Sung;Kwon, Hyeog-Soong
    • The Journal of Korean Institute of Communications and Information Sciences
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    • v.33 no.5B
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    • pp.379-385
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    • 2008
  • For the sharing and exchange of information between medical clinics, the clinical document has to be built on a standardized protocol such as a HL7-CDA. But it is difficult to exchange information between medical clinics because clinical document such as electronic medical record that include text and image, have different structure of document and type of expression. In this paper, we propose the electronic medical record system based on HL7-CDA that can share and exchange clinical information between medical institute. For this purpose, we have to design the schema of the clinical document architecture after we select the essential items of medical record and define templates. The proposed system can minimize integrating process and save parsing time when clinical information exchange and refer, by converting electronic medical record to base64 encoding scheme and integrate it in a XML document.

A study on the recognition of medical institution workers and the development of the certification system after electronic medical record certification (전자의무기록 인증 후 의료기관 종사자 인식과 인증제 발전을 위한 연구)

  • Cho-Yeal Park
    • Journal of the Health Care and Life Science
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    • v.11 no.2
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    • pp.173-180
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    • 2023
  • In this study, senior general hospital, general hospital medical institutions certified by the Electronic Medical Record System Management Portal in 2021 were surveyed on the recognition of changes in medical information management and EMR system functionality. Through verification, it was implemented to promote future development of the certification system and long-term development of the electronic mandatory record certification system. A total of 1,189 respondents were used for final analysis using structured questionnaires, and in particular, differences in recognition of certification systems and system functionality after EMR certification were verified by conducting average analysis and ANOVA. As a result of analysis, the electronic mandatory record certification system was confirmed to affect positive work changes and perceptions on medical institution workers, and after certification of the electronic mandatory record system, it showed operational effects in many ways. Based on the results of this study in the future, communication follow-up research is needed.