• Title/Summary/Keyword: electronic record standard

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Adoption of MFER and HL7 Standard for Shared Electronic Medical Record (공유 전자의무기록을 위한 MFER과 HL7 표준 적용)

  • Kim, Hwa-Sun;Park, Chun-Bok;Hong, Hae-Sook;Cho, Hune
    • The Transactions of The Korean Institute of Electrical Engineers
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    • v.57 no.3
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    • pp.501-506
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    • 2008
  • Medical environments incorporate complex and integrated data networks to transfer vast amounts of patient information, such as images, waveforms, and other digital data. To assure interoperability of images, waveforms and patient data, health level seven(HL7) was developed as an international standard to facilitate the communication and storage of medical data. We also adopted medical waveform description format encoding rule(MFER) standard for encoding waveform biosignal such as ECG, EEG and so on. And, the study converted a broad domain of clinical data on patients, including MFER, into a HL7 message, and saved them in a clinical database in hospital. According to results obtained in the test environment, it was possible to acquire the same HL7 message and biosignal data as ones acquired during transmission. Through this study, we might conclude that the proposed system can be a promising model for electronic medical record system in u-healthcare environment.

The Study of Metadata Model to Identify Electronic Medical Record (전자의무기록 식별을 위한 메타데이터의 연구)

  • Hong, Sung Ho;Kim, Young Seop
    • 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.

Evaluation of Appraisal and Disposal Function of the Standard Records Management System (표준기록관리시스템 평가·폐기 기능 평가)

  • Lee, Bo-Ram
    • The Korean Journal of Archival Studies
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    • no.38
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    • pp.37-73
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    • 2013
  • Legislative stability of the production and management of electronic records and the enhancement of infrastructure have reached significant levels through relentless efforts of academic and public institutions in the field. In addition, appraisal and disposal of records also have to be done by retention periods, business functions, administrational and historical values, and certain procedures. The law specifies that public institutions must assign record managers. The underlying reason is for record managers to arbitrate the review process when records are to be evaluated and discarded and to prevent unauthorized disuses. It is also for just evaluations with the professionalism. Evaluation and discard of records have significant meanings in record management. Thus, these processes need to be handled properly in the standard record management system. Evaluation should be proceeded by the law enacted under the task functional and social agreement. Since, the record discard is decided through the technical and logical process, the support for evaluation and discard works are important above all things. In this paper, I deducted functional requirements of standard record management system by analyzing methods including the analysis of legislation and standard related to electronic records and the examination of the user's manual of record management system. I researched through the interviews of the record managers in public institutions. Based on this research, I deducted the implications for the evaluation of standard record management system and the estimation of functional requirements for discard. I also discussed future directions of improvements and follow-up studies.

Analysis of Standard Nursing Statements Recorded in an Electronic Nursing Record System and User Satisfaction (전자간호기록에 사용된 표준간호진술문 활용실태와 시스템 사용자 만족도)

  • Jung, Joo Hee;Myung, Geun Hee;Kang, Kyung Hyun;Park, Eun Hee
    • Perspectives in Nursing Science
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    • v.9 no.2
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    • pp.146-153
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    • 2012
  • Purpose: The aims of this study were to analyze the frequency of standard nursing statements used in the Electronic Nursing Record (ENR) and to evaluate the degree of satisfaction by users of the ENR system. Methods: We retrospectively reviewed the ENR of 1914 patients who were admitted to our center between 1 May 2011 and 31 May 2011. Additionally, we collected questionnaires from 100 doctors and 300 nurses to evaluate the satisfaction of the users. Results: The frequency of use for the following standard nursing statements was investigated: standard nursing assessment statements (43.6%), standard nursing diagnosis statements (61.8%), standard nursing plan statements (46.7%), standard nursing intervention statements (56.9%), and standard nursing evaluation statements (41.7%). The mean satisfaction score was 3.03 out of 5 in the nurse's group, and 3.11 in the doctor's group. The nurses said the advantages of the ENR system were as follows: easy to access, informative, and standardized terms. However 75.7% of the nurse answered that they cannot express actual nursing situations exactly with the currently limited standard nursing statements. Conclusion: Development of various standard nursing statements is needed to meet the demands of the users. As a result, the use of the ENR system would become easier and more efficient for its users.

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The Consideration about an Electronic Medical Record Security Standardization (전자의무기록 보안표준화에 대한 고찰)

  • Park, Doo-Hee;Song, Jae-Young;Lee, Nam-Yong
    • Journal of Information Management
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    • v.36 no.1
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    • pp.125-154
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    • 2005
  • Due to the development of Internet and the collection and usage of the individual information, the infringements of the personal data have been increased rapidly. Regarding the personal data protection in the medical industry, it is clearly described in 'Act on Promotion of Information and Communication Network Utilization and information Protection, etc.'. the law is ratified on the basis of the service provider, therefore, it has its own limitation to be applied to medical industry. Therefore, this paper is to set the security standard and to discuss the range of legal application and considerations on its basis for the domestic medical institution at the electronic medical record system. We exemplify specific applicable content of the electronic signature in the electronic medical record also, present a security assessment item in electronic medical system and set the criteria for the security standard in the medical industry.

A Case Study on the Application of Requirements Standard of Systems for Government-Affiliated Organizations (기록관리 시스템 기능요건 표준의 정부산하공공기관 적용에 관한 사례 연구)

  • Kim, Hyung-Joo;Kim, Soo-Heon
    • Journal of the Korean BIBLIA Society for library and Information Science
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    • v.28 no.2
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    • pp.35-56
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    • 2017
  • The government-affiliated organizations are required the autonomous record preservation and management, considering their management independence and specialty. In absence of general record management system for government-affiliated organizations, establishment of the standard; Functional requirements of systems with record management for government-affiliated organizations, etc. NAK/S 24:2014(v1.0) is meaningful because it can consensus the functional requirements and directions which are considered when organizations develop in-house record management systems. This study aims to analyze functional requirements and suggest procedures and strategies for application of the standard in the case of development of the record management system.

Clinical Pathway Verification through Process Mining

  • Jung, Jong-Duk;Kim, Suk-Hoon;Yeo, Hyun-Jin
    • Journal of the Korea Society of Computer and Information
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    • v.23 no.4
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    • pp.115-120
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    • 2018
  • A Clinical Pathway(CP) is standard process to way of treat diseases or injuries which is adapted to each hospital based on National Clinical Practice Guideline(CPG). Since CP is standard guideline for doctors and nurses working in a hospital, making and modifying CP is one of the most important administrational work for hospital and also rare work because once it is fixed, it's not changed whether there are new kind of disease discovered or new treatment is developed. However, in present, patient's waiting time during hospital residence process, is discussed as service competitive for patients. In this research, we utilize process mining tool to verify patients treatment process follows CP with EMR(Electronic Medical Record) in a sample hospital, and suggest modifcation point of CP through verification.

A Study of Standard Model for Electronic Document Archiving (전자문서 아카이빙 표준모델 연구)

  • Lee, Won-Young;Kang, Jin-Young
    • Journal of the Korean Society for information Management
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    • v.22 no.2 s.56
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    • pp.147-164
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    • 2005
  • Requirements concerning production of electronic documents and storage are stipulated in the act on document management of public institutions revised in 2003. However, provisions or standards for long term preservation of electronic documents are insufficient and in need of strengthening. This study aims to provide standard factors for long term preservation of electronic documents and thus lay foundation for long term preservation related matters for the establishment of management strategy, ISO 15489 management factor is analyzed as a necessary framework for long term preservation of electronic record at a production stage. Preservation description information is derived from ISO 14721 which is suggesting document management systems to archival institutions. Through this case study, standard registry factors reflecting ISO 15489 and 14721's are suggested in an attempt to improve the act and system environment for long term preservation and archiving.

Development and Lessons Learned of Clinical Data Warehouse based on Common Data Model for Drug Surveillance (약물부작용 감시를 위한 공통데이터모델 기반 임상데이터웨어하우스 구축)

  • Mi Jung Rho
    • Korea Journal of Hospital Management
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    • v.28 no.3
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    • pp.1-14
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    • 2023
  • Purposes: It is very important to establish a clinical data warehouse based on a common data model to offset the different data characteristics of each medical institution and for drug surveillance. This study attempted to establish a clinical data warehouse for Dankook university hospital for drug surveillance, and to derive the main items necessary for development. Methodology/Approach: This study extracted the electronic medical record data of Dankook university hospital tracked for 9 years from 2013 (2013.01.01. to 2021.12.31) to build a clinical data warehouse. The extracted data was converted into the Observational Medical Outcomes Partnership Common Data Model (Version 5.4). Data term mapping was performed using the electronic medical record data of Dankook university hospital and the standard term mapping guide. To verify the clinical data warehouse, the use of angiotensin receptor blockers and the incidence of liver toxicity were analyzed, and the results were compared with the analysis of hospital raw data. Findings: This study used a total of 670,933 data from electronic medical records for the Dankook university clinical data warehouse. Excluding the number of overlapping cases among the total number of cases, the target data was mapped into standard terms. Diagnosis (100% of total cases), drug (92.1%), and measurement (94.5%) were standardized. For treatment and surgery, the insurance EDI (electronic data interchange) code was used as it is. Extraction, conversion and loading were completed. R language-based conversion and loading software for the process was developed, and clinical data warehouse construction was completed through data verification. Practical Implications: In this study, a clinical data warehouse for Dankook university hospitals based on a common data model supporting drug surveillance research was established and verified. The results of this study provide guidelines for institutions that want to build a clinical data warehouse in the future by deriving key points necessary for building a clinical data warehouse.

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Study on the Categorical Structure Standardization for Representation of 3D Human Body Position System

  • Choi, Byung-Kwan;Choi, Eun-A;Nam, Moon-Hee
    • Journal of information and communication convergence engineering
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    • v.18 no.4
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    • pp.260-266
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    • 2020
  • This study presents the categorical structure for ther epresentation of a 3D human body position system in the WD stage after NP approval by the International Organization for Standardization (ISO), analyzes the needs of electronic medical record users and establishes future implementation plans for expanding its use in Korea. Research was conducted on the needs of doctors, nurses, health and medical information managers, and radiology departments, which are the main stakeholders of electronic medical records. The overall requirements for electronic medical records were derived from the results, and the requirements for each stage of use of electronic medical records were analyzed. Based on the results of the study, the study proposes plans to expand the use of the categorical structure for the representation of the 3D human body position system, and also aims to establish a standard system for health and medical terminology in Korea and contribute to the development of health and medical information standards through international standardization.