• 대한예방한의학회지
• /
• 제18권3호
• /
• pp.11-21
• /
• 2014

The rapid development and distribution of information communication industry facilitates the changes of hospital administration, introducing EMR(Electronic Medical Record) instead of paper-based medical record in the medical field. The developed countries such as U.S. have established EMR system after in the middle of 1970s because the primary advantages of EMR is to store and handle vast amounts of records efficiently and increase the quality of health care. Most of health organizations in Korea also apply medical record system to their administration. As the result, they have accomplished a scientific administration system through the use of medical record to handle a variety of patient's information including patient's confidentiality and privacy such as family history, social status, income level, and so on. However, access to and the misuse of EMR causes illegal infringement of patient's information and finally it becomes a very serious medical issue. Potential leakage and misuse of records may seriously infringe patient's privacy rights. In this respect, the related agencies in the public and private sector have been making efforts to prevent patient's records leakages. Especially, the revision bill of Medical Law in 2002 establishes the ways on the security and standards of electronic records. However, it does not provide the proper guidelines which is applied to the rapid changes of the medical environment. One of the most priorities in the hospital administration is the production and maintenance of an accurate medical records fulfilled by medical recorders. Therefore, it is very important for health care providers to hire ethical-based medical recorders. But, unfortunately most of hospitals overlook the importance of their roles. All parts including government, physician and patient must have more concerns on the problems related to EMR. Therefore, this study aims to propose the proper ways to resolve the problems coming from EMR.

• 한국화재소방학회논문지
• /
• 제24권1호
• /
• pp.64-71
• /
• 2010

이 연구를 위해 2009년 1월1일부터 2009년 2월 8일 까지 일개 종합병원에 119구급대로 내원한 모든 환자의 구급활동일지 255부를 조사하였다. 구급활동일지의 전체 기재율 62.1%, 가장 높은 항목은 환자 인수자에 대한 기록으로 100.0%, 가장 낮은 항목은 의사지도에 관한 항목으로 0.4%로 나타나 기대치에 미치지 못한 것으로 조사되었다. 효율적인 응급의료 정보전달매체로서의 119구급활동일지의 기재율을 높이기 위해서는 전문 인력의 확충과 의료진의 적극적인 관심 및 피드백, 구급활동일지의 항목 배열의 규칙성, 기록의 중요성에 대한 지속적인 교육이 필요할 것으로 사료된다.

• 정보처리학회논문지D
• /
• 제9D권6호
• /
• pp.1127-1136
• /
• 2002

의료계에서는 보다 나은 의료 서비스를 환자들에게 제공하기 위하여 발달된 컴퓨터 기술을 이용한 병원 정보 시스템을 요구하고 있다. 이에 따라 의료 및 건강 정보를 공유하고 교환하기 위하여 전자 의무 기록 시스템이 출현하게 되었다. 이 논문에서는 우리가 XML을 이용하여 개발한 전자의무기록 시스템을 소개한다. 이 전자의무기록 시스템은 자료저장소, 문서 구조 관리기, 문서 작성기. XML 자동생성기 등의 주요한 4개의 모듈로 구성되어있다. 또한 우리가 개발한 전자의무기록 시스템의 가용성을 평가하기 위하여 정형외과의 외래환자 의무기록에 적용하여 보았다.

• 한국의료질향상학회지
• /
• 제9권2호
• /
• pp.176-197
• /
• 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.

• 디지털융복합연구
• /
• 제10권2호
• /
• pp.193-200
• /
• 2012

기존의 EMR 방식은 병원 내에 서버를 두고 있어 환자의 개인정보들이 병원관계자나 악의적인 목적을 가진 사람들에게 쉽게 노출되었다. 그리고 이외에도 환자의 의료기록들이 병원 내에 저장되어 있어 의료사고가 발생하더라도 병원관계자들이 수정할 여지가 있다. 이러한 정보 노출 문제점을 해결하기 위해 안전한 전자의무기록을 제안한다. 제안한 전자의무기록은 의료과실이 일어났을 때 중요한 정보를 제공함으로서 신뢰할 수 있는 정보로 이용될 수 있다. 그리고 제안한 시스템은 안전하고 효율적으로 환자를 인증하고 환자 개인의 의료정보를 보호할 수 있으므로 보다 높은 보안성을 제공할 수 있다.

• 한국정보전자통신기술학회논문지
• /
• 제13권3호
• /
• pp.250-261
• /
• 2020

개인정보를 포함한 다양한 데이터를 활용하기 위해서는 정보주체의 권리를 보장하며 데이터 활용을 할 수 있는 모델이 필요하다. 정보주체를 고려하는 개인정보 활용 패러다임의 변화는 마이데이터를 기반으로 하는 다양한 데이터 활용 모델을 만들어내고 있으며, 다양한 개인정보가 생겨나고 다뤄지는 의료분야에서도 이러한 움직임이 진행되고 있다. 이번 논문에서는 마이데이터 기반 개인 건강/의료 데이터 활용 생태계가 확산되었을 때, 생겨날 수 있는 이해관계자들 간의 데이터 거래모델을 제안하였고 다양한 실험 결과를 기반으로 한 수학적 모델링을 통해 정보주체와 데이터 활용자 모두의 요구사항을 만족할 수 있는 개인 건강/의료 데이터 거래모델이 성립할 수 있음을 보였다.

• 디지털융복합연구
• /
• 제11권6호
• /
• pp.213-219
• /
• 2013

본 연구에서는 의료정보의 효율적 생성과 관리를 주 업무로 하는 의무기록사가 IT기반 의료 환경에서 보건정보관리자로 성공적으로 변화하기 위한 방안을 제언하고자 하는데 그 목적이 있다. 이러한 연구 목적에 따라, 의무기록사로서의 업무 현황 분석(As-Is)과 보건정보관리자로 탈바꿈하기 위한 미래모형(To-be)에 대한 분석을 실시하였다. 현황 분석 대상 자료는 1)의무기록사 국가고시 과목 2)보건정보관리자 자격시험과목 3)국내 의무기록사들의 현재 직무 분석자료 4)최근 3년간 대한의무기록협회 학술대회 및 교육 주제였다. 미래모형(To-be)자료는 미국보건정보관리자협회(AHIMA)에서 제시한 'HIM Professional Roles in E-HIM(R)'이었다. 이러한 자료들의 비교 분석을 통해 현재 의무기록사의 신규 진입이 필요한 역할은 Business change manager(업무 변화 관리자), IT training specialist(IT 교육전문가), Consumer advocate(의료소비자 중재자), Clinical alerts and reminders manager(임상 경고 및 신호 관리자), Enterprise application specialist(전사적 응용 시스템 전문가)로 분석되었다.

• 한국의료질향상학회지
• /
• 제9권1호
• /
• pp.52-64
• /
• 2002

Background : Coding of principal diagnosis is essential component for producing reliable health statistics. We performed this study to evaluate the current practice of principal diagnoses determination and coding, and to give some basic data to improve coding of principal diagnosis. Method : Nineteen medical record administrators (MRAs) of 3 university hospitals participated in coding principal Dx. from August 1, 2001 to August 31, 2001. From each hospital, 10 medical records of patients with high frequency disease were selected randomly. Each 10 medical records were grouped into three (A. B, C). Then, these 30 medical records were given to each MRAs for coding. At the same time questionnaire was given to each of them. Questions were to prove how they decide and code the principal diagnosis among many current diagnoses; how they decide and code the principal diagnosis when they see irrelevant diagnosis recorded as the principal diagnosis in medical record, when only tentative diagnoses were recorded without final diagnosis, and when different diagnoses were recorded in different sheets of same record. Agreement of coding among 3 hospitals were compared and survey results were analysed with SAS 6.12. Results : Agreement of coding was found in medical records 5-6 of each 10 medical records. Causes of disagreement were as follows. Difference of clinician's opinion from each hospital; mixed use of guideline from KCD-3 and guideline from DRG; difference in 4th digit classification according to the absence of pathology report in the medical record; difference of abbreviations among hospitals. 57.9% of MRAs selected the principal diagnosis recorded by physician, 42.1% of MRAs decided principal diagnosis after consulting to KCD-3 guideline. When there were difficulties in determining the principal diagnosis, 42.1% of MRAs decided principal diagnosis after discussion with the physician, 26.3% after discussion with fellow MRAs. Conclusion : There were differences in codings among hospitals. To minimize the difference, we suggest the development of disease-specific guidelines for coding in addition to the current general guideline such as KCD-3. To do this, Coding Clinic which can produce guidelines is needed.

• Journal of Information Technology Applications and Management
• /
• 제12권2호
• /
• pp.129-143
• /
• 2005

In recent years, two major streams in medical information systems are：1) system integration among OCS(Order Communication System), EMR(Electronic Medical Record), PACS(Picture Archiving and Communication System), and ERP(Enterprise Resource Planning) and 2) system integration through medical collaboration between East and West medical service providers. One of the characteristics which differentiate the Korean medical industry from the western medical industry is the East-West medical collaboration. In many respects there are many differences between East and West medical treatment. Although East and West medical treatment have developed from different medical philosophies and standards, we assume that the better medical care can be provided by integrating their medical procedures effectively. The two possible approaches to the integration of East and West medical information systems are suggested in this paper：One is loosely coupled model and the other is tightly coupled model. EMR improves the quality of medical record which reflects the quality of clinical practice. It provides more efficient and convenient way of input, retrieval, storage, communication and management of medical data. We abstracted the standard medical procedures from the two medical procedures performed in Daejeon Oriental Hospital and Hehwa Clinic at Daejeon University and also abstracted database schema by analyzing the characteristics of information needed in East-West medical collaboration. Our EMR is composed of two types of data：one is structured data and the other is unstructured data, which are formalized by SOAP(Subjective, Objective, Assessment, Plan) format. Currently the integrated system is implemented and operated successfully for six months.

• Journal of Preventive Medicine and Public Health
• /
• 제48권5호
• /
• pp.239-248
• /
• 2015

Objectives: The purpose of this study was to assess the inter-rater reliability and intra-rater reliability of medical record review for the detection of hospital adverse events. Methods: We conducted two stages retrospective medical records review of a random sample of 96 patients from one acute-care general hospital. The first stage was an explicit patient record review by two nurses to detect the presence of 41 screening criteria (SC). The second stage was an implicit structured review by two physicians to identify the occurrence of adverse events from the positive cases on the SC. The inter-rater reliability of two nurses and that of two physicians were assessed. The intra-rater reliability was also evaluated by using test-retest method at approximately two weeks later. Results: In 84.2% of the patient medical records, the nurses agreed as to the necessity for the second stage review (kappa, 0.68; 95% confidence interval [CI], 0.54 to 0.83). In 93.0% of the patient medical records screened by nurses, the physicians agreed about the absence or presence of adverse events (kappa, 0.71; 95% CI, 0.44 to 0.97). When assessing intra-rater reliability, the kappa indices of two nurses were 0.54 (95% CI, 0.31 to 0.77) and 0.67 (95% CI, 0.47 to 0.87), whereas those of two physicians were 0.87 (95% CI, 0.62 to 1.00) and 0.37 (95% CI, -0.16 to 0.89). Conclusions: In this study, the medical record review for detecting adverse events showed intermediate to good level of inter-rater and intra-rater reliability. Well organized training program for reviewers and clearly defining SC are required to get more reliable results in the hospital adverse event study.