• Quality Improvement in Health Care
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• v.4 no.2
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• pp.174-183
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• 1997

Background : Medical records thought to be reflecting the quality of medicine. By this ground, examination of medical records can be served to evaluate, and to improve the quality of medical care. To examine the medical records, we need some standards or checklists which can be used to sort out the problems. Methods: We developed checklists for medical records evaluation. We studied 1,677 medical records about its completeness using this checklists in one educational hospital. Survey was completed by 5 well trained staffs of medical record department. Results are analyzed. SPSS/PC+ program was used for statistics. Results : 13.8% of discharge summary was incomplete. Recording of the demographic information was also poor in incomplete medical records compared to complete ones. Progress note was recorded average 4.16 times during 11.9 hospital days. After 4th hospital day, recording rate of progress note dropped sharply. Rate of professor's signature on operation records was poor(27%). He or she who described the discharge summary well also wrote progress note well. Conclusions: Fill-up of demographic date should be stressed during medical record education program. Strategy to create the environment emphasizing the responsibility of professor on quality medical record should be made. We suggest new index (number of records/hospital stay) for the evaluation of completeness of progress note.

• 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.

• The Korean Society of Law and Medicine
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• v.13 no.1
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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.

• Quality Improvement in Health Care
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• v.9 no.2
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• pp.176-197
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• 2002

Backgound : This study is to suggest the standardized format of the clinical sheets and the standardized items of every clinical sheet. The standardization of the medical records will increase the faithfullnes of the contents in them and it will contribute to construct the good health information system. Method : From Jan. 1st. 2001 to March 31st 2001, we gathered as many paper clinical sheets as possible by every class of institutions to review the faithfulness of the clinical contents in them. Clinical sheets of 9 tertiary care hospitals, 6 general hospitals and 56 clinics were gathered. Two experienced medical record administrators reviewed them. The review focus was to check whether the items recommend by the hospital standardization review criteria and hospital service evaluation organization were appeared in the clinical sheets and whether the contents of every item were written. Results : Tertiary care hospitals; In case of administrative data, the contents were filled well if the items were fixed. The clinical data like C.C, history,physical examiniation were filled well, but if the items were not fixed, some items were omitted. The result is that more items are to be filled if they are fixed. General hospitals Administrative data were filled more than 50%. Final diagnosis was filled about 66.7%.But other clinical data were not filled well and not many clinical related items were appeared in the sheets.In the legal point of view, the reason for visiting hosptals or the right diagnosis, patient condition at discharge could not be confirmed well.In surgery cases, surgical procedures could not be confirmed well as many surgical related information(surgery time, fluids and blood, number of sponges, biopsy, etc) were omitted. Clinics More than 70% administrative data were filled and fixed as items. Among the clinical related data, laboratory result was the most credible data. But without the right diagnosis, drug orders were given and doctors' written signatures were not appeared over 96.4%. So the clinical sheets cannot be used as a legal document. Conculusion : There was a tendency that the contents were filled well if the items were fixed in the documents, We also suggest a clinical check list to review the completeness and faithfulness of the clinical sheets. If many hospitals use the suggested clincal check list and if they make the necessary items fixed in the clinical sheets, the quality of the medical record will increase dramatically.

• Journal of information and communication convergence engineering
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• v.18 no.4
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• pp.260-266
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• 2020

This study presents the categorical structure for ther epresentation of a 3D human body position system in the WD stage after NP approval by the International Organization for Standardization (ISO), analyzes the needs of electronic medical record users and establishes future implementation plans for expanding its use in Korea. Research was conducted on the needs of doctors, nurses, health and medical information managers, and radiology departments, which are the main stakeholders of electronic medical records. The overall requirements for electronic medical records were derived from the results, and the requirements for each stage of use of electronic medical records were analyzed. Based on the results of the study, the study proposes plans to expand the use of the categorical structure for the representation of the 3D human body position system, and also aims to establish a standard system for health and medical terminology in Korea and contribute to the development of health and medical information standards through international standardization.

• KSII Transactions on Internet and Information Systems (TIIS)
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• v.16 no.3
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• pp.947-971
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• 2022

The Electronic Medical Record (EMR) is a valuable source of medical data intelligence in e-health systems. The watermarking techniques have been used to authenticate the owner and protect the EMR from illegal copying. The existing distributive strategies, successfully operated to secure the EMR, are found to be inadequate. Blockchain technology, mainly, is employed by a sharing database that allows the digital crypto-currency. It rapidly leads to the magnified expectations acme. In this excitement, the use of consortium adopting the technology based on Blockchain, in the EMR structure, is found improving. This type of consortium adds an immutable share with a translucent record of the entire business and it is accomplished with responsibility, along with faith and transparency. The combination of watermarking and Blockchain technology provides a singular chance to promote a secured, trustworthy electronic documents administration to share with the e-records system. The authors, in this article, present their views on consortium Blockchain technology which is incorporated in the EMR system. The ledger, used for the distribution of the block structure, has team healthcare models based on dissimilar multiple image watermarking techniques.

• Journal of the Korea Institute of Information and Communication Engineering
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• v.14 no.3
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• pp.595-602
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• 2010

EMR(Electronic Medical Record) is being broadly used in general medical institution, but it could be more efficient and convenient if patients could use it themselves. Because present EMR is the formula written by medical experts with professional words, the patient can not identify his detailed symptoms and even the name of disease. Otherwise, the patient should have many efforts for obtaining his medical records. To solve this problem, this study developed Patient-Accessible EMR system, which was founded as one of patient-centric medical services, and it shows that the patient can take his medical information without medical experts.

• Proceedings of the IEEK Conference
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• 2009.05a
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• pp.402-404
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• 2009

The development of health information technology enables people to access, view and acquire personal health record. But still, there have been a number of obstacles such as the absence of the standard to realize the ideal Personal Health Record(PHR) system. In this study, we proposed the service model that serves periodic Health Record Summary which is made by a medical specialist to people who are in the busy lives. Healthcare data from EMR in a hospital including people generate themselves at home is sent to a physician to make a medical opinion, and then it is changed into Health Level 7 Continuity of Care Document(CCD) format for interoperability. After a physician writes his opinion about patient's health condition, it will send to people by email. People who receive the health record summary data by email can save them into a USB device to view own PHR and medical comments of a physician through a computer. It will help people managing their own health condition with an opinion of a medical specialist.

• The Journal of Korea Institute of Information, Electronics, and Communication Technology
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• v.13 no.3
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• pp.250-261
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• 2020

Today, data subjects should be considered to utilize various personal data. To support this paradigm, the concept of "My Data" has proposed and has realized in various industrial sectors, including medial sectors. Based on the concept of the medical My Data, this paper proposes a personal health record (PHR) and an electronic medical record (EMR) data trading model. Particularly, this paper proposes a system model to support the medical My Data environment and relevant procedure among stakeholders for PHR/EMR data trading that ensures the rights of data subjects. Based on the proposed system model, this paper also proposes various mathematical models to analyze the behavior of stakeholders and shows the feasibility of the proposed data trading model that satisfies the requirements of both data subjects and data consumers.

• Proceedings of the Korea Information Processing Society Conference
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• 2010.04a
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• pp.352-352
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• 2010

It is difficult to settle the well-designed local terminology for imaging report in the hospital information system (HIS). One of the major reasons is the local terminology with poor contents have been used in the hospital. Thus, we mapped the locally used terms in nuclear medicine imaging report to the SNOMED-CT, which had been widely used in the electronic medical record system, for implementation of hospital information system. Preliminary construction of terminology dictionary was done by mapping of local terms to SNOMED-CT and LexCare Suite. Further study may be warranted.