• Title/Summary/Keyword: electronic medical records(EMR)

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Legal Status of Medical Personnel on Medical Records (환자의 의무기록 관련 의료인의 법적 지위)

  • Lee, Baek-Hyu
    • 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.

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An Automatic LOINC Mapping Framework for Standardization of Laboratory Codes in Medical Informatics (의료 정보 검사코드 표준화를 위한 LOINC 자동 매핑 프레임웍)

  • Ahn, Hoo-Young;Park, Young-Ho
    • Journal of Korea Multimedia Society
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    • v.12 no.8
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    • pp.1172-1181
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    • 2009
  • An electronic medical record (EMR) is the medical system that all the test are recorded as text data. However, domestic EMR systems have various forms of medical records. There are a lot of related works to standardize the laboratory codes as a LOINC (Logical Observation Identifiers Names and Code). However the existing researches resolve the problem manually. The manual process does not work when the size of data is enormous. The paper proposes a novel automatic LOINC mapping algorithm which uses indexing techniques and semantic similarity analysis of medical information. They use file system which is not proper to enormous medical data. We designed and implemented mapping algorithm for standardization laboratory codes in medical informatics compared with the existing researches that are only proposed algorithms. The automatic creation of searching words is being possible. Moreover, the paper implemented medical searching framework based on database system that is considered large size of medical data.

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SHA-256 based Encapsulated Electronic Medical Record Document Storage System (SHA-256 기반의 캡슐화된 전자의무기록 문서 저장 시스템)

  • Lee, Hyo-Seung;Oh, Jae-Chul
    • The Journal of the Korea institute of electronic communication sciences
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    • v.15 no.1
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    • pp.199-204
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    • 2020
  • With the development of IT. convergence systems are applied and operated in many different fields. A representative field among them is medical service, which develops in diverse types in combination with nano-technology and bio technology. However, there is a lack of technical innovation in terms of medical data operation and management. For example, data and documents are saved and integrated separately depending on their forms when electronic health records or data like SAM files are transmitted or kept. In other cases, such records and data are still kept after being recorded in paper. This study tries to design and implement the EMR system that makes it possible to capsulize forms of data and documents and to digitalize documents in work process as they are in terms of operation and storage. The system is expected to support efficient operation of electronic documents in the aspects of work and management.

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.

Analysis of Next-Generation EMR Technology (차세대 전자의무기록(EMR) 기술 분석)

  • Jung, Kyu-Hwan;Park, Seok-Cheon;Shim, Woo-Ho
    • Proceedings of the Korea Information Processing Society Conference
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    • 2012.04a
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    • pp.916-919
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    • 2012
  • EMR(Electronic Medical Records) 시스템은 기존의 의무 기록을 전산화 한 것으로 의료 서비스 시용자의 신체정보 및 진료정보 등을 전산화 하여 저장하는 시스템이다. 노령화 사회로 들어서게 되면서 많은 의료 소비자들이 의료 서비스 기관들에 발걸음이 잦아지고 각 환자마다 늘어나게 될 데이터를 좀 더 효율적으로 관리할 수 있는 EMR의 필요성이 대두되고 있다. 본 논문은 현재 IT트렌드의 흐름을 살펴보고 의료 정보 기술과 접목한 새로운 차세대 EMR 기술을 분석하고 그 발전 방향을 제시하고자 한다.

Patient Information Transfer System Using OAuth 2.0 Delegation Token (OAuth 2.0 위임 Token을 이용한 환자정보 전달 시스템)

  • Park, Jungsoo;Jung, Souhwan
    • Journal of the Korea Institute of Information Security & Cryptology
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    • v.30 no.6
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    • pp.1103-1113
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    • 2020
  • Hospitals store and manage personal and health information through the electronic medical record (EMR). However, vulnerabilities and threats are increasing with the provision of various services for information sharing in hospitals. Therefore, in this paper, we propose a model to prevent personal information leakage due to the transmission of patient information in EMR. A method for granting permission to securely receive and transmit patient information from hospitals where patient medical records are stored is proposed using OAuth authorization tokens. A protocol was proposed to enable secure information delivery by applying and delivering the record access restrictions desired by the patient to the OAuth Token. OAuth Delegation Token can be delivered by writing the authority, scope, and time of destruction to view patient information.This prevents the illegal collection of patient information and prevents the leakage of personal information that may occur during the delivery process.

Study on the Awareness, Satisfaction and Job Stress of Nurses using EMR System (EMR System을 이용하는 간호사의 인식도, 만족도와 직무스트레스에 관한 연구)

  • Oh, Jae-Woo;Han, Jin-Sook;Moon, Young-Sook
    • Journal of Digital Convergence
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    • v.10 no.8
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    • pp.257-264
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    • 2012
  • This study was conducted to arrange the basic data for the ways to operate the effective nursing programs and reduce job stress by grasping the awareness, satisfaction and job stress of the nurses due to the introduction of EMR(EMR : Electronic Medical Record) system and clarifying the relationship among them. Methods: Of the hospitals which introduced EMR, the study was conducted for 356 nurses who used EMR in a university hospital in D city and the data was collected from June 1 to June 30. The collected data was analyzed with real number, percentage, T-test, ANOVA, and Pearson correlation coefficient. Results: The results of the study above, it could be certified that the higher the satisfaction and awareness of the users of EMR were, the more the job stress of them decreased. Therefore, the qualitative nursing should be provided to the patients by reducing job stress with the improvement of the awareness and satisfaction of the nurses of EMR, and shortening the time in keeping the records of patients, in order to enhance the satisfaction of EMR, there should be a proper management, such as a regular EMR education, and there must be the ways to reduce the job stress of the nurses and strengthen the satisfaction of EMR.

The Design and Implementation of Continuity Health Care Record Management System based on Data Stream System (데이터스트림 처리 시스템에 기반한 연속적인 헬스케어 데이터 관리 시스템 설계)

  • Wu, Zejun;Li, Yan;Shin, Soong-Sun;Kim, Gyoung-Bae;Bae, Hae-Young
    • Proceedings of the Korea Information Processing Society Conference
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    • 2011.04a
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    • pp.1218-1221
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    • 2011
  • The development of the internet and information management has enabled new applications which include: Electronic medical record (EMR), intelligent transportation, environmental monitoring, etc. In this paper, we design and implement the Continuity Care Record(CCR) Data Stream management server that compiled with DSMS and DBMS in EMR system for processing, monitoring the incoming CCR data stream and storing the processed result with high-efficiency. The proposed system enables users not only to query stored CCR information from DBMS, but also enables to execute continue query for the real-time CCR Data Stream. By using of CCR Viewer Application users can view or update their personal health records even compare self health care records with standard health care records in order to monitor the healthy status, and the on line updating information would be minimized and medical error.

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.

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.