• Title/Summary/Keyword: management of electronic medical records

Search Result 88, Processing Time 0.028 seconds

A Study on Current Status Analysis and Improvement Plans for Electronic Medical Records of Closed Medical Institutions (폐업 의료기관 전자의무기록 관리현황 및 개선방안 연구)

  • Choi, Kippeum;Kim, Hwi Eon;Jang, Ji Hye;Oh, Hyo-Jung
    • Journal of Korean Society of Archives and Records Management
    • /
    • v.20 no.3
    • /
    • pp.55-76
    • /
    • 2020
  • Although most medical institutions in Korea use electronic medical records (EMR), there are many problems in the management and preservation of records when such medical institutions are closed. Records of closed medical institutions need to be systematically managed; however, the rate of closed medical institutions transferring records to public health centers is significantly low. Given that each medical institution has a different system and format, public health centers often cannot access records. In addition, there are no management standards that suit the reality of public health centers and the specificity of EMR. Recently, a strengthened Medical Law has been passed wherein records of closed medical institutions should be kept by health centers; therefore, this study focused on drawing up measures for efficient records management by public health centers. To this end, the relevant laws and management status were identified and an interview was conducted. After analyzing the problems, improvement plans in institutional, technical, and administrative aspects were proposed.

A Study of Comparing the Paper-Based Medical Record with the Electronic Medical Record on the Level of Medical Record Completeness and the Accordance (종이의무기록과 전자의무기록의 기재 충실도 및 일치도 비교 연구 : 의사의 입원.퇴원기록지와 간호사의 입원.퇴원간호정보기록지를 중심으로)

  • Shin, A-Mi;Jung, Sun-Ju;Lee, In-Hee;Son, Chang-Sic;Park, Hee-Joon;Kim, Yoon-Nyun;Youn, Kyung-Il
    • Korea Journal of Hospital Management
    • /
    • v.15 no.1
    • /
    • pp.1-12
    • /
    • 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.

  • PDF

A Study on the Analysis and Methods to Improve the Medical Records Management in a Large University Hospital (대형 대학병원의 의무기록관리 현황분석 및 개선방안에 관한 연구)

  • Lee, Ju-Yeon;Kim, Yong;Kim, Geon
    • Journal of Korean Society of Archives and Records Management
    • /
    • v.13 no.1
    • /
    • pp.107-134
    • /
    • 2013
  • Many hospitals introduce the electronic medical record systems (EMRS) to implement a digital type of hospital. However, there are various problems in managing and preserving medical records. Systems, such as OCS, PACS, and EMR, are independently operated without formal standards related to medical records management. To manage medical records effectively, distributed medical records including paperand electronic-type should be managed in an integrated manner. With its analysis of the current status in the management of medical records of J University Hospital, this study proposes methods to solve the problems extracted from the results of the analysis, and a management model for an integrated medical records management based on the process of records management of ISO 15489.

A Study on the Importance of the Assessment of Records Management Metadata Elements Related to the Electronic Medical Records Management System for Medical Records Managers (전자의무기록 관리시스템 관련 기록관리 메타데이터 요소들에 대한 의무기록 관리자의 중요도 평가 연구)

  • Lee, Eun-Mi;Kim, Myeong;Yim, Jin Hee
    • Journal of Korean Society of Archives and Records Management
    • /
    • v.13 no.3
    • /
    • pp.151-171
    • /
    • 2013
  • To comprehend the importance and necessity of record management metadata standard implemented in an electronic medical records system, a survey was undertaken to 50 medical records managers in charge of 5 major hospitals in Seoul. Analysis of the survey results was performed by averaging the responses given by those who answered the survey. SPSS was utilized for statistical analysis. Managers of medical records placed importance on metadata that are related to security of records, such as "levels of security", "types of access to medical records", "levels of authorization granted to personnel", and "users accessing medical records". It shows that these managers need the functions of privacy protection in ERMS. Metadata on "external disclosure" had the lowest level but those surveyed with more than 7 years of experience placed greater importance in this area more those surveyed with less than 7 years of experience in a hospital. This shows that managers need the functions of external disclosure to meet the needs of third partiesfor medical research and medical education.

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
    • /
    • v.29 no.3
    • /
    • pp.257-285
    • /
    • 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.

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
    • /
    • v.13 no.2
    • /
    • pp.63-66
    • /
    • 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.

An Fingerprint Authentication Model of ERM System using Private Key Escrow Management Server (개인키 위탁관리 서버를 이용한 전자의무기록 지문인증 모델)

  • Lee, Yong-Joon;Jeon, Taeyeol
    • Journal of the Korea Academia-Industrial cooperation Society
    • /
    • v.20 no.6
    • /
    • pp.1-8
    • /
    • 2019
  • Medical information is an important personal information for patients, and it must be protected. In particular, when medical personnel approach electronic medical records, authentication for enhanced security is essential. However, the existing public certificate-based certification model did not reflect the security characteristics of the electronic medical record(EMR) due to problems such as personal key management and authority delegation. In this study, we propose a fingerprint recognition-based authentication model with enhanced security to solve problems in the approach of the existing electronic medical record system. The proposed authentication model is an EMR system based on fingerprint recognition using PEMS (Private-key Escrow Management Server), which is applied with the private key commission protocol and the private key withdrawal protocol, enabling the problem of personal key management and authority delegation to be resolved at source. The performance experiment of the proposed certification model confirmed that the performance time was improved compared to the existing public certificate-based authentication, and the user's convenience was increased by recognizing fingerprints by replacing the electronic signature password.

Comparative Analysis of Vectorization Techniques in Electronic Medical Records Classification (의무 기록 문서 분류를 위한 자연어 처리에서 최적의 벡터화 방법에 대한 비교 분석)

  • Yoo, Sung Lim
    • Journal of Biomedical Engineering Research
    • /
    • v.43 no.2
    • /
    • pp.109-115
    • /
    • 2022
  • Purpose: Medical records classification using vectorization techniques plays an important role in natural language processing. The purpose of this study was to investigate proper vectorization techniques for electronic medical records classification. Material and methods: 403 electronic medical documents were extracted retrospectively and classified using the cosine similarity calculated by Scikit-learn (Python module for machine learning) in Jupyter Notebook. Vectors for medical documents were produced by three different vectorization techniques (TF-IDF, latent sematic analysis and Word2Vec) and the classification precisions for three vectorization techniques were evaluated. The Kruskal-Wallis test was used to determine if there was a significant difference among three vectorization techniques. Results: 403 medical documents were relevant to 41 different diseases and the average number of documents per diagnosis was 9.83 (standard deviation=3.46). The classification precisions for three vectorization techniques were 0.78 (TF-IDF), 0.87 (LSA) and 0.79 (Word2Vec). There was a statistically significant difference among three vectorization techniques. Conclusions: The results suggest that removing irrelevant information (LSA) is more efficient vectorization technique than modifying weights of vectorization models (TF-IDF, Word2Vec) for medical documents classification.

Analysis of Pain Records Using Electronic Nursing Records of Hospitalized Patients in Medical Units at a University Hospital (일개 대학병원 내과 병동 입원환자의 전자의무기록에 사용된 통증간호 기록 분석)

  • Park, Ihn Sook;Jang, Mi;Rew, Soon Ae;Kim, Hee Jin;Oh, Phil Joo;Jung, Hee Jung
    • Journal of Korean Clinical Nursing Research
    • /
    • v.16 no.3
    • /
    • pp.123-132
    • /
    • 2010
  • Purpose: This study was done to analyse nursing records to identify the nature of pain and actual conditions of pain management in patients hospitalized in one university hospital. Methods: The participants in this study were 783 patients with a length of stay of 3 to 30 days who were discharged from medical wards between June 1 and June 30, 2009. Data on nursing records related to pain management from these patients were reviewed using the Electronic Nursing Records (ENRs) system. Results: Over 30 percent of 10,702 nursing records related to pain assessment had no record on region, severity, nature or frequency of pain. About 30 percent of 13,638 nursing records related to pain intervention showed non-drug pain management techniques. Conclusion: Accurate and complete records on pain assessment including region, severity, nature and frequency of pain are essential to effectively manage patients' pain. Improvement in ENRs system for better assessment and management of pain is required as well as education programs on a standardized measuring tool for both nurses and patients.