• Title/Summary/Keyword: Medical Records Systems

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A Preliminary Study on Clinical Decision Support System based on Classification Learning of Electronic Medical Records

  • Shin, Yang-Kyu
    • Journal of the Korean Data and Information Science Society
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    • v.14 no.4
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    • pp.817-824
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    • 2003
  • We employed a hierarchical document classification method to classify a massive collection of electronic medical records(EMR) written in both Korean and English. Our experimental system has been learned from 5,000 records of EMR text data and predicted a newly given set of EMR text data over 68% correctly. We expect the accuracy rate can be improved greatly provided a dictionary of medical terms or a suitable medical thesaurus. The classification system might play a key role in some clinical decision support systems and various interpretation systems for clinical data.

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A Study on the Current Status and Tasks of Medical Records Management: Focused on Applying the KS X ISO 15489 to the Y Hospital (의무기록관리의 현황과 개선방안: KS X ISO 15489표준의 Y병원 적용 중심으로)

  • Lee, Eun-Mi;Kim, Myeong;Hee, Jin
    • Journal of the Korean Society for information Management
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    • v.29 no.3
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    • pp.257-285
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    • 2012
  • As the electronic medical records systems (EMRs) are introduced into the hospitals in Korea and the needs of chief stakehoders of medical records are changed, the environments related to creating and managing medical records has been changed dynamically. At this moment it might be meaningful to examine medical records based on records management principles rather than information management principles. The purpose of this paper is to apply the KS X ISO 1549 standards, which covers the principles of records management, to hospital medical records management and assess the current quality of medical records management, and define a few tasks of improvement for hospitals. To achieve this goal, this study has performed following activities: Firstly, principles that could be applied to medical records management were prepared for each record management steps described in the standards, such as capture, registration, classification, storage, access, trace and disposition, and 22 principles were selected from those 7 steps of the record management. Secondly, the Y hospital, which is affiliated with a medical school in Seoul, was chosen to evaluate the current situation regarding medical records management. The department head of the medical records management team in Y hospital was interviewed and the present status was evaluated according to each principle. Thirdly, tasks for improvement were suggested, in such stages as access, trace and disposition. With this study as a cornerstone, useful implications are expected to be gathered from future studies that apply standards for metadata of records, management systems for records, and record management systems to medical record management in hospitals.

A Study on the Analysis and Methods to Improve the Medical Records Management in a Large University Hospital (대형 대학병원의 의무기록관리 현황분석 및 개선방안에 관한 연구)

  • Lee, Ju-Yeon;Kim, Yong;Kim, Geon
    • Journal of Korean Society of Archives and Records Management
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    • v.13 no.1
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    • pp.107-134
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    • 2013
  • Many hospitals introduce the electronic medical record systems (EMRS) to implement a digital type of hospital. However, there are various problems in managing and preserving medical records. Systems, such as OCS, PACS, and EMR, are independently operated without formal standards related to medical records management. To manage medical records effectively, distributed medical records including paperand electronic-type should be managed in an integrated manner. With its analysis of the current status in the management of medical records of J University Hospital, this study proposes methods to solve the problems extracted from the results of the analysis, and a management model for an integrated medical records management based on the process of records management of ISO 15489.

Agreement of Iranian Breast Cancer Data and Relationships with Measuring Quality of Care in a 5-year Period (2006-2011)

  • Keshtkaran, Ali;Sharifian, Roxana;Barzegari, Saeed;Talei, Abdolrasoul;Tahmasebi, Seddigheh
    • Asian Pacific Journal of Cancer Prevention
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    • v.14 no.3
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    • pp.2107-2111
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    • 2013
  • Objectives: To investigate data agreement of cancer registries and medical records as well as the quality of care and assess their relationship in a 5-year period from 2006 to 2011. Methods: The present cross-sectional, descriptive-analytical study was conducted on 443 cases summarized through census and using a checklist. Data agreement of Nemazi hospital-based cancer registry and the breast cancer prevention center was analyzed according to their corresponding medical records through adjusted and unadjusted Kappa. The process of care quality was also computed and the relationship with data agreement was investigated through chi-square test. Results: Agreement of surgery, radiotherapy, and chemotherapy data between Nemazi hospital-based cancer registry and medical records was 62.9%, 78.5%, and 81%, respectively, while the figures were 93.2%, 87.9%, and 90.8%, respectively, between breast cancer prevention center and medical records. Moreover, quality of mastectomy, lumpectomy, radiotherapy, and chemotherapy services assessed in Nemazi hospital-based cancer registry was 12.6%, 21.2%, 35.2%, and 15.1% different from the corresponding medical records. On the other hand, 7.4%, 1.4%, 22.5%, and 9.6% differences were observed between the quality of the above-mentioned services assessed in the breast cancer prevention center and the corresponding medical records. A significant relationship was found between data agreement and quality assessment. Conclusion: Although the results showed good data agreement, more agreement regarding the cancer stage data elements and the type of the received treatment is required to better assess cancer care quality. Therefore, more structured medical records and stronger cancer registry systems are recommended.

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.

Clinical Information Interchange System using HL7-CDA

  • Jung, Yong Gyu;Lee, Young Ho
    • International journal of advanced smart convergence
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    • v.1 no.2
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    • pp.47-51
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    • 2012
  • In highly developed society, information and communication technologies are widely used for better medical services. These information and communication technologies should be more and more acceptable in all hospitals for exchange medical records. EMR becomes more convenient than the previously used paper charts. It will be able to record medical institutions every time and dual treatment. Each is different specifications for each medical institution to use the program or document to exchange it. The personal clinic records still does not exchange well. To solve this gap between medical alienation, this paper describes the concepts of HL7-CDA and proposes types of telemedicine system. To resolve time and space constraints, new form of treatment methods presents in future directions after described about related systems. CDA enables electronic medical records to the each medical center and gradually expanded by exchanging the patient's medical records. This paper is using XML-based CDA documents as a hierarchical for medical information exchange standards compliant HL7-CDA documents. It could be possible currently used structural variety of multimedia data. Thus It is able to send and receive HL7-CDA-based medical information and clinical information to identify the medical institutions of medical information with interchange system design and building standards, and through mutual exchange of clinical information.

Analysis of Nursing Records for Elderly Patients with Abdominal Pain in the Emergency Medical Center (응급의료센터에 내원한 복부통증 노인 환자에 대한 간호기록 분석)

  • Lee, Hyeo Ki;Kim, Jong Im
    • Journal of muscle and joint health
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    • v.26 no.1
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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.

Medical Data Base Controlled By Medical Knowledge Base

  • Chernyakhovskaya, Mery Y.;Gribova, Valeriya V.;Kleshchev, Alexander S.
    • Proceedings of the Korea Inteligent Information System Society Conference
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    • 2001.01a
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    • pp.343-351
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    • 2001
  • World practice is evidence of that computer systems of an intellectual support of medical activities bound up with examination of patients, their diagnosis, therapy and so on are the most effective means for attainment of a high level of physician\`s qualification. Such systems must contain large knowledge bases consistent with the modern level of science and practice. To from large knowledge bases for such systems it is necessary to have a medical ontology model reflecting contemporary notions of medicine. This paper presents a description of an observation ontology, knowledge base for the physician of general tipe, architecture, functions and implementation of problem independent shell of the system for intellectual supporting patient examination and mathematical model of the dialog. The system can be used by the following specialist: therapeutist, surgeon, gynecologist, urologist, otolaryngologist, ophthalmologist, endocrinologist, neuropathologist and immunologist. The system supports a high level of examination of patients, delivers doctors from routine work upon filling in case records and also automatically forms a computer archives of case records. The archives can be used for any statistical data processing, for producing accounts and also for debugging of knowledge bases of expert systems. Besides that, the system can be used for rise of medical education level of students, doctors in internship, staff physicians and postgraduate students.

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Risk Factors for Surgical Site Infections According to Electronic Medical Records Data (전자의무기록(EMR) 자료를 활용한 수술부위감염 관련요인)

  • Kim, Young Hee;Yom, Young-Hee
    • Journal of Korean Academy of Fundamentals of Nursing
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    • v.21 no.2
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    • pp.151-161
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    • 2014
  • Purpose: The purpose of this study was to identify the risk factors that influence surgical site infections after surgery. Methods: This study was a retrospective research utilizing Electronic Medical Records. Data collection targeted 4,510 adult patients who had 8 different kinds of surgery (gastric surgery, colon surgery, laparoscopic cholecystectomy, hip & knee replacement, hysterectomy, cesarean section, cardiac surgery) in 4 medical care departments, at one general hospital between January 2006 and December 2011. Multivariate logistic regression analyses were used to identify the risk factors affecting surgical site infections after surgery. Results: Risk factors for increased surgical site infection following surgery were confirmed to be age (OR=1.59, p<.001), BMI (Body Mass Index)(OR=1.25, p=.034), year of operation (OR=2.45, p<.001), length of operation (OR=3.06, p<.001), ASA (American Society of Anesthesiology) score (OR=1.36, p=.025), classification of antibiotic used (OR=2.77, p<.001), duration of the prophylactic antibiotics use (OR=1.85, p<.001), and interaction between classification of antibiotic used and duration of the prophylactic antibiotics use (OR=1.90, p=.016). Conclusions: Results suggest that risk factors affecting surgical site infections should be monitored before surgery. The results of this study should contribute to establishing effective infection management measures and implementing surveillance systems for patients who have actual risk factors.

A Blockchain Application for Personal health information: Focusing on Private Block Scheme (개인 의료정보 보호를 위한 블록체인 적용 방안: 프라이빗 블록 스킴을 중심으로)

  • Kwon, HyukJun;Kim, Hyeob;Choi, Jaewon
    • Knowledge Management Research
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    • v.19 no.4
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    • pp.119-131
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    • 2018
  • In this paper, I research the issue of information security for medical information system of each parties. The outflow of the Personal medical information can lead to problems of medical systems and disadvantage to an individual. In this paper, we research the information security based on a blockchain. In addition, I have analyzed blockchain. I suggest a medical information system framework that can help to keep the privacy of patients by using a blockchain network. Also, In this paper try to explain using private blockchain for medical system. Blockchain can keep the integrity and transparency of the medical records. This research, shows how can build the private blockchain for medical records and how to get the integrity of Data from Private Blockchain and Distuributed Ledger Technology.