• Journal of Society of Preventive Korean Medicine
• /
• v.18 no.3
• /
• 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.

• Fire Science and Engineering
• /
• v.24 no.1
• /
• pp.64-71
• /
• 2010

Records of 255 patients was analyzed statistically according to the contents of the record form. T patients' records were collected through the visit of emergency department in one hospital by the 119 Emergency Medical Services system from January 1 to February 8, 2009. In conclusion, the total entry was the investigation of 119 ambulance run report in 62.1% of subjects. The highest record of receiving hospital item was 100.0% and the lowest record of medical control item was 0.4% of subjects. Increasing the entry of 119 ambulance run report in efficient emergency medical information delivery media needed to suggest that increasing the number of specialists on the staff, medical staffs have an active interest and feedback, rule to item arrangement of prehospital ambulance run report, continuous education in the importance of record.

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

• Quality Improvement in Health Care
• /
• v.9 no.2
• /
• 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.

• Journal of Digital Convergence
• /
• v.10 no.2
• /
• pp.193-200
• /
• 2012

The existing EMR method placing computer servers in hospitals could expose patients' personal information to hospital officers and people for wrong purposes. In addition, if medical malpractice occurs, the possibility of distorting medical records might be higher because patients' medical records are stored in hospitals. This study provides an electronic medical record with a security system to solve patients' information disclosure. The electronic medical record system could be utilized as an important information when medical malpractice occurs. This system can provide higher security services certifying patients safely and efficiently as well as protecting patients' personal information.

• The Journal of Korea Institute of Information, Electronics, and Communication Technology
• /
• v.13 no.3
• /
• pp.250-261
• /
• 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.

• Journal of Digital Convergence
• /
• v.11 no.6
• /
• pp.213-219
• /
• 2013

The purpose of this study is to suggest a plan for which Medical Record Technician, who has main task as efficient creation and management of medical information, is changed successfully to health information manager in IT-based medical environment. According to this research objective, it carried out an analysis on future model(To-be) for being changed into health information manger in addition to analysis of the current situation for task as medical record technician. The subject materials of analyzing the present status included 1) state-exam subjects for medical record technician 2) qualification examination subjects for health information manger 3) analytical data of the current task for domestically medical record technicians 4) symposiums and educational topics for the recent 3 years in Korean Medical Record Association. Future-model(To-be) data included 'HIM Professional Roles in E-HIM (R)' suggested by AHIMA(American Health Information Management Association). Through a comparative analysis of these materials, a role of being needed currently medical record technicians' new entry was analyzed to be Business change manager, IT training specialist, Consumer advocate, Clinical alerts and reminders manager, and Enterprise application specialist.

• Quality Improvement in Health Care
• /
• v.9 no.1
• /
• 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
• /
• v.12 no.2
• /
• 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
• /
• v.48 no.5
• /
• 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.