• Journal of Korea Society of Digital Industry and Information Management
• /
• v.5 no.3
• /
• pp.127-133
• /
• 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.

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

• Journal of Yeungnam Medical Science
• /
• v.36 no.3
• /
• pp.225-230
• /
• 2019

Background: It is not possible to measure how much activity is required to understand and code a medical data. We introduce an assessment method in clinical coding, and applied this method to neurosurgical terms. Methods: Coding activity consists of two stages. At first, the coders need to understand a presented medical term (informational activity). The second coding stage is about a navigating terminology browser to find a code that matches the concept (code-matching activity). Systematized Nomenclature of Medicine - Clinical Terms (SNOMED CT) was used for the coding system. A new computer application to record the trajectory of the computer mouse and record the usage time was programmed. Using this application, we measured the time that was spent. A senior neurosurgeon who has studied SNOMED CT has analyzed the accuracy of the input coding. This method was tested by five neurosurgical residents (NSRs) and five medical record administrators (MRAs), and 20 neurosurgical terms were used. Results: The mean accuracy of the NSR group was 89.33%, and the mean accuracy of the MRA group was 80% (p=0.024). The mean duration for total coding of the NSR group was 158.47 seconds, and the mean duration for total coding of the MRA group was 271.75 seconds (p=0.003). Conclusion: We proposed a method to analyze the clinical coding process. Through this method, it was possible to accurately calculate the time required for the coding. In neurosurgical terms, NSRs had shorter time to complete the coding and higher accuracy than MRAs.

• Korea Journal of Hospital Management
• /
• v.13 no.1
• /
• pp.42-64
• /
• 2008

This study was conducted to evaluate the quality in medical records by analyzing its completeness through setting up the level of record on the patient's past history and through examining the actual medial records. Targeting the information on the patient's past history in interns' records, residents' records and nurses' records toward 403 inpatients who were admitted first in 2004 at an university hospital due to stomach cancer. We analyzed whether the charts were recorded or not, recording level, the satisfaction with the expectant level of the records in the hospital targeted for a research and the level of agreement. The results were as follows; first, as for the rate of recording those each items, they were high in the chief complaint & present illness and the past illness history. Depending on the group of recorders, the recording rate showed big difference by items. Second, as a result of measuring the level after dividing the recording level of items for the patient's past history from Level 1 to Level 4 by each item, the admission history, the past illness history, and the family history were about Level 3, and the smoking history, the medication history, the chief complaint & present illness, the drinking history and allergy were about Level 2. In the admission department, it was excellent in the interns' records for the medical department. Third, as a result of its satisfactory level by comparing the expect level of a record and the actual record by item in information on the patient's past history, which was expected by the medical-record committee members of the hospital targeted for a study. And forth, we analyzed the level of agreement with Kappa score in the level of 'Yes' or 'None' related to the corresponding matter in Level 1, in terms of information on the past history in the intern's record, the resident's record, and the nurse's record. The level of agreement in the resident's record & the nurse's record, and in the intern's record & the resident's record was from "excellent" to "a little good". There were differences in the level of completeness and in reliability for the information on the past history by the recorder group or by the admission department. The encounter process that was performed by the admission department or the recorder group, indicated the result that was directly reflected on the quality of medical records, thus it was required further study about the medical record documentation process and quality of care. The items that showed the high recording rate quantitatively were rather low, consequently we'd should develop the tool for the qualitative inspection and evaluate the medical records further. And the items were needed to be detailed in the record level were rather low, and hence there needed to be a documentation guideline and education by the clinical departments.

• 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.

• Journal of Korean Medical classics
• /
• v.24 no.1
• /
• pp.1-14
• /
• 2011

Background : Much Opinions of inefficiency to put the standard term of oriental medicine in and around literature into medical records. Purpose : Suggest an alternative according to analysis of differences between 'Term System' from in and around literature and term of medical records. Method : Research on the difference according to analysis of difference between producing term from in and around literature using DB Program and term from medical records. Result : The best System is that reflecting 'Korean Expression' of term of oriental medicine and part of term of western medicine and general.

• 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.

• The Journal of Korean Medical History
• /
• v.25 no.1
• /
• pp.23-41
• /
• 2012

'The Daily Records of Royal Secretariat of Chosun Dynasty' is a record created in Seung-jeong-won, a secretariat for kings of Chosun, and is a government record which holds conversations between kings and their vassals as it is. General affairs in terms of the royal family and national administration are recorded, but what is more important is the records on diseases of kings and how they were treated. This study is to look into diseases from which King Injo(1959-1649) had suffered based on the records written during the time of his reign, which was from 1623 to 1649. Also, the "curse incident" and the death of prince Sohyeon, son of King Injo, both of which had significant influence on the health of the king, were reviewed in relation to the disease records.

• Journal of Korean Medical classics
• /
• v.32 no.2
• /
• pp.49-70
• /
• 2019

Objectives : Medical records of Xueji in the "Xiaozhufurenliangfang" were examined in this study which aimed to look at the medical situation in gynecology of China's Ming Dynasty period, in hopes for it to yield implications and treatment directions to gynecology in $21^{st}$ century Korea. Methods : The medical records were systematically organized with a medical anthropological approach along with overall analysis of the entire records, which lent meaningful statistical information in numeric form. A bibliographical review of the text as historical artifact was undertaken as well. Results : In managing gynecological conditions, Xueji frequently attributed them to depletion of Qi and Blood of the Spleen and Liver. In terms of pathogenic factors, he frequently mentioned Fire and Heat, and as etiological factors, emotional distress. For treatment, he frequently used 'Bu Zhong Yi Qi Tang(補中益氣湯)', 'Xiao Yao San(逍遙散)' and 'Gui Pi Tang(歸脾湯)'. Conclusions : Through studying the medical records of Xueji in "Xiaozhufurenliangfang" a close look into a master's insight on gynecological disorders in terms of diagnosis and treatment was achieved. The formulas he used are widely applied even today, and this study shows that the formulas's clinical application could be expanded even wider.

• Korea Journal of Hospital Management
• /
• v.28 no.3
• /
• pp.1-14
• /
• 2023

Purposes: It is very important to establish a clinical data warehouse based on a common data model to offset the different data characteristics of each medical institution and for drug surveillance. This study attempted to establish a clinical data warehouse for Dankook university hospital for drug surveillance, and to derive the main items necessary for development. Methodology/Approach: This study extracted the electronic medical record data of Dankook university hospital tracked for 9 years from 2013 (2013.01.01. to 2021.12.31) to build a clinical data warehouse. The extracted data was converted into the Observational Medical Outcomes Partnership Common Data Model (Version 5.4). Data term mapping was performed using the electronic medical record data of Dankook university hospital and the standard term mapping guide. To verify the clinical data warehouse, the use of angiotensin receptor blockers and the incidence of liver toxicity were analyzed, and the results were compared with the analysis of hospital raw data. Findings: This study used a total of 670,933 data from electronic medical records for the Dankook university clinical data warehouse. Excluding the number of overlapping cases among the total number of cases, the target data was mapped into standard terms. Diagnosis (100% of total cases), drug (92.1%), and measurement (94.5%) were standardized. For treatment and surgery, the insurance EDI (electronic data interchange) code was used as it is. Extraction, conversion and loading were completed. R language-based conversion and loading software for the process was developed, and clinical data warehouse construction was completed through data verification. Practical Implications: In this study, a clinical data warehouse for Dankook university hospitals based on a common data model supporting drug surveillance research was established and verified. The results of this study provide guidelines for institutions that want to build a clinical data warehouse in the future by deriving key points necessary for building a clinical data warehouse.