• Korea Journal of Hospital Management
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• v.15 no.1
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• pp.1-12
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• 2010

This study was tried to evaluate the level of completeness and the accordance in electronic medical records by comparing paper-based medical record in doctor's admission records, discharge summary, and nursing information records. Medical records of inpatients of neurology department that the 100 paper-based medical records in 2004 and 100 electronic medical records in 2006 were targeted. Existence of record items and doctor-nurse record accordance were evaluated in doctor's admission record, discharge summary, admission nursing information record, and discharge nursing information record. There were not any differences between electronic medical records and paper-based medical records in doctor's admission record and discharge summary. Electronic medical records had less missing records than paper-based medical records in admission and discharge nursing information records. Electronic medical records showed higher accordance than the paper-based medical record in doctor-nurse record generally, but there were statistically differences in only medication, allergy, smoking, and drinking (p<0.05). In this study, it was verified that the quality of electronic medical records are better than paper-based records in nursing information record and doctor-nurse record agreement.

• Korea Journal of Hospital Management
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• v.16 no.2
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• pp.19-30
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• 2011

This study aims to present ways to enhance the stabilization of electronic medical records, ensure the commitment to filling in information of the medical record and improve the overall quality Electronic Medical Record(EMR) information. For that purpose, the present state of the incomplete record rate and the doctor's satisfaction in Electronic Medical Record(EMR) have been surveyed by comparing and analyzing Paper-based Medical Record(PMR) and Electronic Medical Record(EMR). The survey was conducted on 31 doctors in charge of EMR system and each PMR and EMR inpatients were collected for a period of 5 months and analyzed. The results showed that the doctor's satisfaction level was higher for EMR, and the rate of incomplete record appeared to be lower in EMR in departments of both internal and external medicine. In this context, it can be said that the higher efficiency of EMR helped accomplish the increase in commitment to completing medical record information and improve the quality of the data.

• The Korean Society of Law and Medicine
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• v.11 no.2
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• pp.309-335
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• 2010

This study is a paper reviewed legal status of medical personnel and issues of law on recently discovered medical records. As the increase of medical personnel who have gone through the administrative disposal in regards to the medical records, it is needed to examine the legal issue or dispute on the medical records under the current law. Medical records are the statement on patient's medical conditions made by the medical personnel. This records are used as important source for patient's further treatment. This becomes the communication route between the patients and the other medical personnel, and it provides the patients a right to find out their medical information. According to the Medical Service Act (Article 21), a medical personnel shall prepare respectively a record book of medical examination and treatment. And medical personnel shall make a signature. Furthermore, the medical personnel or the opener of the medical institutions must preserve the record book (including an electronic medical record). Meanwhile, the issues of a ban on false entry, additional record, revision or manipulation on the medical record have been recently on the rise. This paper briefly examined the major issues in regards to the medical records. It especially clarified the legal duty on medical records and its major-contentious-issues. At the same time, it pointed out the problems of the unreasonable over interpretation of the law. Furthermore, this suggested the guidelines for the further discussion and review.

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

• The Korean Journal of Health Service Management
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• v.6 no.4
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• pp.61-72
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• 2012

The purpose of this study was to propose how to improve and develop the college curriculum of medical record administration, satisfying requirements from hospitals having medical record administrators. For the purpose, this researcher surveyed medical record administrators serving at hospitals located in Busan, Changwon, Masan and Jinju. Finally analyzed were responses from 100 medical recorders. The frequency of searching medical records to support information use was statistically different among hospitals according to the number of sick beds(p=.041), or $3.16{\pm}1.75$ for fewer than 300 sick beds, $4.28{\pm}2.42$ for 300 to 500 and $4.86{\pm}3.18$ for more than 500. The college course that was regarded as most important by most of the surveyed medical record administrators, or 53(37.2%) was medical terminology, followed by statistics by 36 of the respondents(18.5%) and EMR, 25(12.8%) in order. To make EMR truly effective requires reforming the university curriculum of medical record administration and giving more attention and more supports to training for better computerization, realizing that medical record administrators serve as a true manager of health and medical information, not a person who just paper-based medical information. In addition to managing health and medical information, medical record administrators are expected to have more roles in the future, for example, providing high-quality clinic knowledge and medical information that are necessary for efficient hospital management and medical research to survive competition.

• 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.

• 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.

• The KIPS Transactions:PartD
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• v.9D no.6
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• pp.1127-1136
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• 2002

In the medical field. the desire of the hospital information system based on the advanced computer technology has been increased because hospital staffs wanted to provide better medical services to their patients by using it. So, the electronic medical records have emerged to share and exchange medical and healthcare information stored in database. In this paper. we developed an electronic medical record system using XML. This system includes four modules : data repository. document structure manager, document writter and XML automatic generator. For the purpose of evaluating the usability of the electronic medical records of our system, we also applied it to out-patient medical records in the department of orthopedic surgery.

• The Journal of Korean Institute of Communications and Information Sciences
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• v.33 no.5B
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• pp.379-385
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• 2008

For the sharing and exchange of information between medical clinics, the clinical document has to be built on a standardized protocol such as a HL7-CDA. But it is difficult to exchange information between medical clinics because clinical document such as electronic medical record that include text and image, have different structure of document and type of expression. In this paper, we propose the electronic medical record system based on HL7-CDA that can share and exchange clinical information between medical institute. For this purpose, we have to design the schema of the clinical document architecture after we select the essential items of medical record and define templates. The proposed system can minimize integrating process and save parsing time when clinical information exchange and refer, by converting electronic medical record to base64 encoding scheme and integrate it in a XML document.

• Journal of Society of Preventive Korean Medicine
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• v.18 no.3
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• pp.11-21
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• 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.