• Title/Summary/Keyword: Electronic Medical Record (EMR)

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Analyzing Health Information Technology and Electronic Medical Record System-Related Patient Safety Incidents Using Data from the Korea Patient Safety Reporting and Learning System (환자안전보고학습시스템 자료를 활용한 의료정보기술 및 전자의무기록시스템 관련 환자안전사건 분석)

  • Cho, Dan Bi;Lee, Yu-Ra;Lee, Won;Lee, Eu Sun;Lee, Jae-Ho
    • Quality Improvement in Health Care
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    • v.27 no.2
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    • pp.57-72
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    • 2021
  • Purpose: At present, there are a variety of serious patient safety incidents related to problems in health information technology (HIT), specifically involving electronic medical records (EMRs). This emphasizes the need for an enhanced electronic medical record system (EMRS). As such, this study analyzed both the nature of and potential to prevent incidents associated with HIT/EMRS based on data from the Korea Patient Safety Reporting and Learning System (KOPS). Methods: This study analyzed patient safety incidents submitted to KOPS between August 2016 and December 2019. HIT keywords were used to extract HIT/EMRS incidents. Each case was reviewed to confirm whether the contributing factors were related to HIT/EMRS (HIT/EMRS-related incidents) and if the incident could have been prevented (HIT/EMRS-preventable incidents). The selected reports were summarized for general clarity (e.g., incident type, and degree of harm). Results: Of the 25,515 obtained reports, 2,664 incidents (10.4%) were HIT-related, while 2,525 (9.9%) were EMRS-related. HIT/EMRS-related incidents were the third largest type of incident followed by 'fall' and 'medication incidents.' More than 80% of HIT/EMRS-related incidents were medication-related, accounting for approximately one-third of the total number of medication incidents. Approximately 10% of HIT/EMRS-related incidents resulted in patient harm, with more than 94% of these deemed as preventable; further, sentinel events were wholly preventable. Conclusion: This study provides basic data for improving EMR use/safety standards based on real-world patient safety incidents. Such improvements entail the establishment of long-term plans, research, and incident analysis, thus ensuring a safe healthcare environment for patients and healthcare providers.

Considerations for the Migration of Electronic Medical Records to Cloud Based Storage (전자의무기록의 클라우드 기반 저장소 이동시 고려사항)

  • Yi, Myongho
    • Journal of Korean Library and Information Science Society
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    • v.47 no.1
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    • pp.149-173
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    • 2016
  • As cloud computing becomes more and more popular and ubiquitous, many organizations are deciding to move their whole information infrastructure to the cloud. The healthcare industry is one of those that is beginning to utilize cloud-based solutions en masse. Cloud based computing and storage offers numerous benefits including scalability, cost efficiency, and accessibility, which in turn have the potential to streamline hospital operations. Despite the potential benefits of acquiring this system, considerations must still be given to the migration of the massive amounts of personal and highly protected data to a cloud-based solution. Health care organizations must consider all matters of security, reliability, and availability, to ensure that patients' data remains compliant to the Health Insurance Portability and Accountability Act (HIPAA) compliant. This paper will examine the benefits and challenges of such operation to determine the best practices for the utilization of Electronic Medical Record (EMR) cloud based networking and storage for small to mid-sized hospitals.

The effects of Technological and Business Expertise of IT Service Provider on Relationship Quality: The case of EMR system (IT 서비스 제공자의 기술/업무 전문성이 관계품질에 미치는 영향: 전자의무기록 시스템의 사례)

  • Park, Jun-Gi;Lee, Sangwoo;Shin, Hyunkyung;Lee, Jungwoo
    • Korea Journal of Hospital Management
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    • v.20 no.1
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    • pp.39-52
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    • 2015
  • This study provides empirical evidence for the role of IT professional's expertise in hospital IT service encounters. It is posited here that IT professional's technological expertise and business expertise are associated with relationship quality(trust, satisfaction, commitment). Partial least square analyses are conducted, using data collected from 216 hospital workers. The results confirm that technological expertise strongly impacts on commitment and business expertise maintain a strong impact on satisfaction and trust. This study uses a cross-sectional survey as a research method. Longitudinal study seems necessary to further explore how expertise perception is actually formed between IT professionals and users in hospital service environments. The analysis also reveals that it takes time to grow relationship quality. Implications are discussed, and further studies are suggested.

Database for Hospice Nursing in Electronic Medical Record (호스피스 전자기록을 위한 데이터베이스 개발)

  • Kim, Young-Soon;Lee, Chang-Geol;Lee, Kyoung-Ok;Kim, Ok-Kyum;Kim, In-Hye;Kim, Mi-Jeong;Hwang, Ae-Ran;Lee, Won-Hee
    • Journal of Hospice and Palliative Care
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    • v.7 no.2
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    • pp.200-213
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    • 2004
  • Purpose: The purpose of this study was to create an electronic nursing record form to build a hospice nursing process database to be used in the u-hospital EMR system. Specific aims of the study were: 1. To generate a complete, accurate, and simple electronic nursing record form. 2. To verify its appropriateness following documentation with the standardized hospice protocol. 3. To verify its validity and finalize the hospice nursing process database through discussion among hospice professionals. Methods: Nursing records from three independent hospice organizations were collected and analyzed by five expert hospice nurses with more than 10 years of experience, and a nursing record database was developed. This database was applied to 81 hospice patients at three hospice organizations to verify its completeness. Results: 1. An electronic nursing record form with completeness, accuracy, and simplicity was developed. 2. The completeness of the standardized home hospice service protocol was 95.86 percent. 3. The hospice nursing process database contains 18 items on health problems, 79 items on related causes and major symptoms, and 229 items on nursing interventions. Conclusion: The new nursing record form and database will reduce documentation time and articulate and streamline the working process among team members. They can also improve the quality of hospice services, and ultimately enable us to estimate hospice service costs.

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Monitoring on Dose Index Analyzed in the Mammography (유방촬영검사에서 선량지표분석에 대한 모니터링)

  • Cho, Ji-Hwan;Lee, Hyo-Yeong;Im, In-Chul
    • Journal of the Korean Society of Radiology
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    • v.10 no.7
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    • pp.477-482
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    • 2016
  • This study is tried to determine whether the management of medical radiation is well handled by comparison the guidelines of KFDA(korea food & drug administration) with analysis of dose indicator in mammography. As a method, it is analysed that kVp, exposure time, mAs, compressed breast thickness, average glandular dose and body mass index that were classified in the examination of both breasts by CC(cranio-caudal) and MLO(medio-lateral oblique) with EMR(electronic medical record) and dose report that were sent to the PACS(picture archiving communication system). As a result, in the site inspection according to the age, Compressed breast thickness in CC and MLO were the thickest of 45.6 mm and 49.6 mm in the 50-59 year old respectively. In the overall average compressed breast thickness, CC were 44.2 mm and MLO were 48.9 mm. MLO has more thick by 4.7 mm. In average glandular dose, CC were 1.05 mGy and MLO were 1.14 mGy. MLO has higher by 0.09 mGy than CC. As the compressed breast thickness increases 10mm, CC and MLO increases 0.15 mGy and 0.17 mGy respectively. When it was compared with the average glandular dose of 1.16 mGy per 1 film presented by KFDA, CC was showed 1.05 mGy. However, the 60 mm or more was found to exceed a 1.30 mGy. Also, As the compressed breast thickness was higher, body mass index showed high score. And in the case of 25 or more in the obese body index according to body mass index, it was showed obesity in case of the compressed breast thickness was more than 50mm.

Characteristics of patients who visit the dental emergency room in a dental college hospital

  • Kim, Chihun;Choi, Eunhye;Park, Kyeong-Mee;Kwak, Eun-Jung;Huh, Jisun;Park, Wonse
    • Journal of Dental Anesthesia and Pain Medicine
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    • v.19 no.1
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    • pp.21-27
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    • 2019
  • Background: Emergencies in dentistry can be classified as medical and dental. Medical emergencies occur mainly during dental treatment in patients with a systemic disease. Dental emergency departments are largely divided into dental emergency rooms located in dental college hospitals and medical emergency rooms located in medical institutions. This study aimed to analyze the characteristics of and provide help to dental emergency patients in a dental hospital. Methods: Overall, 1806 patients admitted to a dental emergency room at Yonsei University Dental Hospital for 1 year were included. The data collection period was from October 1, 2014 to September 30, 2015. An investigator reviewed medical records from the electronic medical record (EMR) system and radiographs. Results: The patients were 1,070 men and 736 women. The sex ratio was 1.45:1. The commonest age group was of 0-9 years, including 451 (25.0%) patients, followed by 20-29 years, including 353 (19.5%) patients, and 30-39 years, including 277 (15.3%) patients. Of the 108 patients transferred to the Severance emergency department, 81 had trauma, 19 were in pain, 4 were bleeding, and 4 had other complaints. Among chief complaints, 1,079 patients (60.3%) had trauma, 564 (31.5%) had pain, and 75 (4.2%) had bleeding. Twenty-three cases (1.3%) were caused by temporomandibular disorder (TMD). Conclusion: Dentists should be able to adequately assess patients in a dental emergency room and treat trauma, pain, and bleeding.

Development of customized patient data analysis process for quality of care improvement : focused on foreign patients (진료 품질 향상을 위한 환자 데이터 맞춤형 분석 프로세스 개발: 외국인 환자를 중심으로)

  • Roh, Eul Hee;Kim, Yoo Jung;Park, Sang Chan
    • Journal of Korean Society for Quality Management
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    • v.46 no.3
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    • pp.539-550
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    • 2018
  • Purpose: The purpose of this study was to find meaningful patient groups of disease using foreign patients data and analyze implemented test of the patient groups. Methods: The data was collected by foreign patients' EMR data of K university hospital. The author proposed tree-form patients' characteristic diagram through statistical methods that association rule, proportion test, clustering using prescription information and questionnaire information. Results: This study's analysis process was applied high blood data and diabetes data. Analysis showed other characteristic of meaningful patient groups in high blood and diabetes. In high blood, test implementation rate of patient group showed the differences. And in diabetes, test implementation rate of patient group and implemented test list showed differences. Conclusion: The result of this study can play a role as basic data that can be clinical testing standard in preventive aspect. Eventually, 5 dimensions of SERVQUAL will be improved by this study's process.

Factors Associated with Discontinuation of Postoperative Intravenous Patient Controlled Analgesia (수술 후 자가통증조절요법 중단 관련요인)

  • Lee, Kyungran;Kim, Yunmi
    • Journal of Korean Biological Nursing Science
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    • v.20 no.4
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    • pp.236-243
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    • 2018
  • Purpose: The purpose of this study was to identify the factors associated with the discontinuation of patient controlled analgesia (PCA) after surgery. Methods: The data of 1,092 adult patients that were over 20 years of age and underwent PCA after surgery in the Gachon University Hospital from May 1 to June 30, 2017, were collected through the patients' Electronic Medical Record (EMR). The collected data was analyzed via the use of the Chi-test, t-test and multivariate logistic regression analysis using SPSS 18.0 program. Results: The postoperative PCA discontinuation rate was 26.1%. It was associated with various symptoms, such as those of nausea, dizziness, and headache. The PCA discontinuation was also related with female (odds ratio, OR= 1.75; confidence interval, CI= 1.09-2.82), nausea (OR= 105.27; CI= 61.03-181.58), total intravenous anesthesia (TIVA) of the thyroidectomy (OR= 10.43; CI= 5.01-21.70). Conclusion: It is necessary to provide additional medication and nursing interventions to reduce nausea, which is the symptom associated with PCA discontinuation, especially in the operation of female subjects and thyroidectomy under TIVA. That is, those who are at a high risk for PCA discontinuation should be able to administer additional antiemetics or reduce non medication nursing interventions.

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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A Retrospective Study of Facial Paralysis Sequelae for Korean Medical Treatment (말초성 안면마비 후유증에 대한 한방 치료를 위한 후향적 차트리뷰 연구)

  • Bae, Hyo-Bin;Yoon, Hwa-Jung;Ko, Woo-Shin
    • The Journal of Korean Medicine Ophthalmology and Otolaryngology and Dermatology
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    • v.32 no.1
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    • pp.59-73
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    • 2019
  • Objectives : The purpose of this study is to confirm and to suggest the Korean medical treatment is effective treatments to patients with facial paralysis sequelae. Methods : We conducted a survey on patients with facial paralysis sequelae who visited the facial paralysis center from August 2017 to November 2018. We then evaluated House-Brackmann Grading System(HBGS), Sunnybrook Scale(S-Scale), Visual analog scale(VAS) against those who agreed and analyzed the information through Electronic Medical Record(EMR) and Order Communication System(OCS). Results : Clinically, Korean medical treatment such as embedding therapy are effective for the facial paralysis sequelae. For the purpose of raising the level of evidence against this, research will be needed to confirm the treatment effects by comparing accurate assessment indicators that are conducted before and after the treatment. Conclusions : In order to confirm the progress of treatment of facial paralysis sequelae, evaluation indicators such as House-Brackmann Grading System and Sunnybrook Scale should be performed by experts. And after 3-4 weeks, if patients have any sequelae symptoms, it may be helpful to take treatments such as pharmacopuncture treatment and embedding therapy at intervals of 1-2 weeks depending on the symptoms or areas.