• Quality Improvement in Health Care
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• v.15 no.1
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• pp.113-120
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• 2009

문제: 의무기록 질 관리의 어려움 목적: 의무기록의 질 향상 의료기관: 고려대학교 의료원 안암병원 의료정보팀 질 향상 활동: 의무기록의 질 향상을 위해 입퇴원기록지 24시간 이내 작성율 향상, 입원기록지 24시간 이내 작성율 향상, 외과계 N-C 기재율 감소, 경과기록지 작성율 향상, 일일입퇴원기록지 작성율 향상, STAFF 서명 완성일 단축 활동을 하였다. 개선효과: 의무기록 작성에서 같은 내용을 반복 작성해야 하는 번거로움을 해소하였고, 작성자(의료진) 중심의 프로그램 개선과 개발된 프로그램의 지속적인 모니터링으로 의무기록의 질이 향상되었다.

• Korean Journal of Digital Imaging in Medicine
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• v.10 no.2
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• pp.33-37
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• 2008

To keep the online medical records available to anyone without constraint of time and space, introducing EMR (Electronic medical record), which is a clinical support management system. The purpose of this study is to develop interface standard of clinical test device. Integration and sharing of medical information is faced with enormous obstacles because medical organizations and associated companies are separately developing the interface. I hope that multi-function management system with workstation concept is operated to efficiently transmit clinical device result data based on this study. Transfer of precise medical result data available for decision making will improve quality of health care service.

• Quality Improvement in Health Care
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• v.11 no.1
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• pp.4-14
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• 2004

Background : To examine the problems involved in writing practice of death certificates, we compared the determination of underlying cause of death for vital statistics using recorded underlying cause of death in issued death statistics. Methods : We collected 688 mortality certificates issue in year of 2,000 from 3 university hospitals. And we also collected vital statistics from ministry of statistics. The causes of death were coded by experienced medical record specialists. And causes of death determined at ministry of statistics for national vital statistics were mapped to causes of death recorded at each death certificates. The rate that underlying causes of death for vital statistics were derived from underlying causes of death recorded at issued death certificates were analysed. Results : 64.5% of underlying cause of death for could be derived from underlying cause of death recorded at issued death certificates, 8.6% derived from intermediate cause of death, and 3.9% derived from direct cause of death. In 23% of cases, underlying cause of death could not be derived using issued death certificates. The rate that underlying cause of death for vital statistics could be derived from underlying cause of death recorded at death certificates was different between 3 university hospitals. And the rate was also different between death certificates and postmortem certificates. We classified the causes of death using 21 major categories. The rate was different between diseases or conditions that caused death too. Conclusion : When we examined the correctness of death certificate writing practice using above methods, correctness of writing could not be told as satisfactory. There was difference in correctness of writing between hospitals, between death certificates and postmortem certificates, and between diseases and conditions that caused death. With this results, we suggested some strategy to improve the correctness of death certificate writing practice.

• Journal of the Korea Society of Computer and Information
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• v.17 no.9
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• pp.113-125
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• 2012

We developed a Smartphone application based on PHR(Personal Health Records) provided by a tertiary hospital to provide users personalized diet, exercise contents. It uses Relevance ratio algorithm of diet and excercise being correlated with diseases listed on PHR to provide personalized contents to management of individual diseases and record the amounts of food taken and exercise along with calories consumed through exercise. Besides, developed U-Health Service also considering users' conditions and conveniences, as a service to use contents and record suitable for the individuals who share the information on restaurants locations, their menus, and nutrition based on users' location information.

• Women's Health Nursing
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• v.17 no.3
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• pp.275-284
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• 2011

Purpose: The purpose of this study was to identify nursing intervention performed by nurses on gynecological nursing units. Methods: The instrument in this study is based on the fifth edition of Nursing Interventions Classification (NIC) (2008). Data was collected by Electronic Medical record from August, 2010 to October, 2010 at one hospital and analyzed by using frequencies in the Microsoft Excel 2010 program. Results: Of a total of 82 NIC, domains of the nursing interventions showed higher percentages for physiological: basic (36.3%) and physiological: complex (34.5%). The classes of nursing interventions showed higher percentage for health system medication (12.1%), perioperative care (10.0%), and drug management (8.6%). The most frequently used top interventions were Discharge Planning. The thirty least used interventions was environmental management. Top thirty most frequently used interventions belonged to the domain of physiological: basic (37.9%), physiological: complex (31.1%), and behavioral (5.4%). Conclusion: These findings will help in the establishment of a standardized language for gynecological nursing units and enhance the quality of nursing care.

• Toxicological Research
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• v.35 no.4
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• pp.319-330
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• 2019

Adverse drug reactions (ADRs) constitute key factors in determining successful medication therapy in clinical situations. Integrative analysis of electronic medical record (EMR) data and use of proper analytical tools are requisite to conduct retrospective surveillance of clinical decisions on medications. Thus, we suggest that electronic medical recording and human genetic databases are considered together in future directions of pharmacovigilance. We analyzed EMR-based ADR studies indexed on PubMed during the period from 2005 to 2017 and retrospectively acquired 1161 (29.6%) articles describing drug-induced adverse reactions (e.g., liver, kidney, nervous system, immune system, and inflammatory responses). Of them, only 102 (8.79%) articles contained useful information to detect or predict ADRs in the context of clinical medication alerts. Since insufficiency of EMR datasets and their improper analyses may provide false warnings on clinical decision, efforts should be made to overcome possible problems on data-mining, analysis, statistics, and standardization. Thus, we address the characteristics and limitations on retrospective EMR database studies in hospital settings. Since gene expression and genetic variations among individuals impact ADRs, pharmacokinetics, and pharmacodynamics, appropriate paths for pharmacovigilance may be optimized using suitable databases available in public domain (e.g., genome-wide association studies (GWAS), non-coding RNAs, microRNAs, proteomics, and genetic variations), novel targets, and biomarkers. These efforts with new validated biomarker analyses would be of help to repurpose clinical and translational research infrastructure and ultimately future personalized therapy considering ADRs.

• Journal of the Korea Society of Computer and Information
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• v.16 no.11
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• pp.189-200
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• 2011

With rapid development and contribution of IT technology IT fushion healthcare service which is a form of future care has been changed a lot. Specially, as IT technology unites with healthcare, because delicate personal medical information is exposed and user's privacy is invaded, we need preperation. In this paper, u-healthcare service model which can manage patient's ID information as user's condition and access level is proposed to protect user's privacy. The proposed model is distinguished by identification, certification of hospital, access control of medical record, and diagnosis of patient to utilize it efficiently in real life. Also, it prevents leak of medical record and invasion of privacy by others by adapting user's ID as divided by user's security level and authority to protect privacy on user's information shared by hospitals.

• Journal of Pharmacopuncture
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• v.21 no.3
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• pp.195-202
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• 2018

Objectives: The study was to survey use of electronic medical records in subjects of Korean medicine doctors working for Korean medicine organizations and to contemplate ways to develop utilization of electronic medical records. Methods: On August 2017, it conducted online self-reported survey on subjects of Korean medicine doctors at Korean hospitals and clinics who agreed to participate in the study. A total 40 doctors in hospital and 279 doctors in clinic were included. The surveyed contents include kinds of electronic chart, reason for not using electronic medical records and problems with creation of medical records. Results: It finds that 100% of those working at Korean medicine hospitals and 86.4% of those at Korean medicine clinics have used electronic medical records. Subjects answered the biggest reason for not using electronic medical records was inconvenience. The most serious problems with creation of electronic medical records at Korean medicine organizations found in the study include there was no method of creation of medical records and no standardized terminology for use in electronic medical records. Conclusion: For utilization of electronic medical records at Korean medicine organizations, standardization of terminology, development of EMR in favour of its users and development of strategy that motivates use of EMR are required.

• Journal of Korean Biological Nursing Science
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• v.15 no.4
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• pp.164-172
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• 2013

Purpose: The aim was to measure the real-time trans-mission effect of blood-pressure and blood-glucose value based on u-healthcare for saving the time and effort of nursing recording time. Methods: This study used a u-healthcare system based on the international standards for the exchange of health information. In order to verify the effectiveness of the u-healthcare, a clinical trial for the system regarding blood-pressure and blood-glucose targeting of patients with endocrine disorders at KNUH from February 7 to 9, 2012 was performed. Results: According to the analyzed results, of the 86 times the 11 patients were tested, measuring blood-pressure and blood-glucose using the u-healthcare system, we found the time differences between the real-time transfer recording method and existing hospital records that were used in the hospital. Based on the average time interval, there was a difference of 1,090.45 seconds (18.17 minutes). Conclusion: Therefore, it's cumbersome that nurses in the hospital have to record the numerical values of the measured blood-pressure and blood-glucose manually and input the recorded values directly into the electronic nursing record system. However, it was found in terms of the newly designed system, that it could save time and effort for nurses, since measured information is sent to the hospital information system on a real-time basis.

• Journal of the Semiconductor & Display Technology
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• v.13 no.1
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• pp.97-99
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• 2014

Since 2010, issues for data sharing and data exchanging in hospital information systems have been emerged. In order to solve the issues, standards should be applied to develop the systems and there should be no ambiguities between terminologies in the systems. In this paper, the terminology mapping system for narrative clinical records was implemented. The term mapping precision was 83.4%. This system could help to upgrade the text based clinical system and it would be expected to support for high quality clinical services.