OBJECTIVES: The objective of this study was to investigate the clinical decision support (CDS) functions and digitalization of clinical documents of Electronic Medical Record (EMR) systems in Korea. This exploratory study was conducted focusing on current status of EMR systems. METHODS: This study used a nationwide survey on EMR systems conducted from July 25, 2018 to September 30, 2018 in Korea. The unit of analysis was hospitals. Respondents of the survey were mainly medical recorders or staff members in departments of health insurance claims or information technology. This study analyzed data acquired from 132 hospitals that participated in the survey. RESULTS: This study found that approximately 80% of clinical documents were digitalized in both general and small hospitals. The percentages of general and small hospitals with 100% paperless medical charts were 33.7% and 38.2%, respectively. The EMR systems of general hospitals are more likely to have CDS functions of warnings regarding drug dosage, reminders of clinical schedules, and clinical guidelines compared to those of small hospitals; this difference was statistically significant. For the lists of digitalized clinical documents, almost 93% of EMR systems in general hospitals have the inpatient progress note, operation records, and discharge summary notes digitalized. CONCLUSIONS: EMRs are becoming increasingly important. This study found that the functions and digital documentation of EMR systems still have a large gap, which should be improved and made more sophisticated. We hope that the results of this study will contribute to the development of more sophisticated EMR systems.
Appointments and Schedules ; Decision Support Systems, Clinical ; Electronic Health Records ; Health Information Exchange ; Hope ; Hospitals, General ; Humans ; Inpatients ; Insurance, Health ; Korea ; Medical Informatics ; Medical Records ; Medical Records Systems, Computerized ; Surveys and Questionnaires

OBJECTIVES: Nursing curricula for undergraduate nursing students need to reflect the information technology used in current nursing practice. A smart-device Academic Electronic Medical Record (AEMR) application can help nursing students access and document records for the clinical practicum. We conducted a pilot study to evaluate the usability of an AEMR application before applying it to the clinical nursing practicum. METHODS: A previously developed EMR application was modified as an AEMR to access patient information at bedside and to practice documentation. We added several features to the current EMR application to create an AEMR environment. We created a series of document forms and several useful scales on an external application, which included nursing admission notes, vital signs, and intake/output. The case scenarios and tasks were created by a research team to evaluate aspects of AEMRs, including their usability and functionality. Five nursing students completed 15 tasks using a think-aloud method with a tablet device. RESULTS: Minor usability issues were identified and rectified. All participants indicated that they became familiar with the application with little effort. They said that the application icons were intuitive, which helped them find patient information more quickly and accurately. CONCLUSIONS: The application will improve timely access to patient data and documentation for nursing students. We are confident that this AEMR application will enhance nursing students' experience with their clinical practicum, and help them to better understand patient conditions and document them with ideal accessibility.
Curriculum ; Education, Nursing ; Electronic Health Records* ; Humans ; Medical Records Systems, Computerized ; Mobile Applications ; Nursing Records ; Nursing* ; Pilot Projects ; Students, Nursing ; Vital Signs ; Weights and Measures

OBJECTIVES: The purpose of this study was to investigate changes in child and adolescent outpatients at a university hospital in Daegu from 2004 to 2013. METHODS: The subjects were first-visit patients under 18 years old, who visited Dongsan Medical Center, Keimyung University, from January 1, 2004 to December 31, 2013. Computerized medical records of 2,738 patients (male 1,906, female 832) were reviewed. RESULTS: The ratio of male to female was 2.3 : 1 in the period of study. The most prevalent age category was 7-9 years. The mean age was 10.12+/-4.68 years (9.84+/-4.59 years in males, 10.76+/-4.81 years in females). The ratio of child and adolescent patients to total outpatients was 27.0%. The most common diagnostic category was the attention-deficit hyperactivity disorder (ADHD) group, followed by the mental retardation (MR) group. In males, the ADHD, MR, communication disorder groups were more prevalent, but in females, the MR, ADHD, depressive disorder groups were more prevalent. CONCLUSION: The female to male ratio and total mean age were on the rise. The ADHD group was the most prevalent and the depressive disorder group was also on the rise in this period.
Adolescent* ; Child* ; Communication Disorders ; Daegu ; Depressive Disorder ; Female ; Humans ; Intellectual Disability ; Male ; Medical Records Systems, Computerized ; Outpatients*

BACKGROUND: Bipolar hip hemiarthroplasty (BH) was known to require a large amount of transfusion. And, patients who underwent BH were extreme old age and had underlying medical diseases such as hypertension and diabetes mellitus. The aim of this study was to evaluate packed RBC (Red blood cell) transfusion and pre- and intraoperative variables during BH in elderly patients over 75 years in one university hospital. METHODS: A total of 36 patients who underwent BH from September 2013 to August 2014 in our hospital were evaluated through a retrospective study using computerized medical records and archived documents. RESULTS: Average age of patients was 81.5+/-5.3 years and packed RBC transfusion was performed in 41.6% of all enrolled patients. There was no significant difference in age, weight, height, and time of operation between transfused patients and non-transfused patients. Intraoperative volume of packed RBC transfusion was 0.6 (minimum value: 0, maximum value: 4) units. CONCLUSION: Preparation of blood components such as packed RBC is required in elderly patients over 75 years who were planned BH.
Aged* ; Diabetes Mellitus ; Hemiarthroplasty* ; Hip ; Humans ; Hypertension ; Medical Records Systems, Computerized ; Retrospective Studies

BACKGROUND: Fresh frozen plasmas (FFPs) do not seem to be effectively managed compared to red blood cells and prophylactic transfusions of FFPs still occur in many cases. We evaluated appropriateness of FFP transfusion and analyzed the conditions of FFP usage in a regional hospital. METHODS: The conditions of FFP usage were investigated over one year from January 2012 to December 2012 using computerized medical records and archived documents. Results of coagulation tests before transfusion, appropriateness of FFP usage, and the reason for discarding FFP were investigated, and the assessment of the appropriateness of FFP transfusion was based on the transfusion guidelines published by the Korea Centers for Disease Control and Prevention. RESULTS: During the study period, 2,675 units of FFP were transfused to 364 patients over 752 episodes. FFP transfusions were inappropriate in 33.1% of episodes, and empirically used FFPs without performing pre-transfusion coagulation tests or when the test results were in the reference range occupied 25.7% of inappropriate FFP transfusions. Improper use of FFPs was most common in the Department of Emergency Medicine. During the three-year period, discarding rate of FFPs was 1.3% and the most common cause was the death or worsening condition of patients. Discarding FFPs was greatest in the Department of Thoracic Surgery and Cardiology. CONCLUSION: Many FFPs were inappropriately transfused. This was due to a general lack of understanding of the transfusion guidelines among physicians. Continuous training and education as well as ongoing monitoring of FFP usage are necessary.
Cardiology ; Centers for Disease Control and Prevention (U.S.) ; Education ; Emergency Medicine ; Erythrocytes ; Humans ; Korea ; Medical Records Systems, Computerized ; Plasma* ; Reference Values ; Thoracic Surgery

While Korea had the highest rate of increase in per capita health expenditures from 1997 to 2007 among The Organization for Economic Cooperation and Development (OECD) countries, it is necessary in all countries to establish sustainable health care systems that efficiently use the existing effective treatment methods. For dealing with the overwhelming health care crisis, the European Union and the United States (US) have launched Health Technology Assessment (HTA) and Comparative Effectiveness Research (CER) programs, respectively. Further, the Federal Coordinating Council for Comparative Effectiveness Research in US has considered the development of the CER data infrastructure to be the primary investment needed in order to reform the national health care system. The main reason is that investment in data infrastructure can potentially generate significant additional investment in CER. In addition, the Council stressed the need for coordination between CER and health information technology through a distributed network of electronic health records. These directions and decisions on driving CER in the US may provide an invaluable lesson on solving some healthcare problems in Korea. However, barriers to the potential contribution of the existing databases to CER must be overcome, including interoperability, privacy protection and confidentiality, and active participation of the holders of the related databases.
Biomedical Technology ; Comparative Effectiveness Research ; Confidentiality ; Delivery of Health Care* ; Electronic Health Records ; European Union ; Health Expenditures ; Investments ; Korea ; Medical Informatics ; Medical Record Linkage ; Medical Records Systems, Computerized ; Privacy ; United States

This paper describes the design process and implementation process of electronic film system. The establishment of electronic film system allowed us to aggressively reduce film use and costs and to demonstrate a positive return.
Medical Records Systems, Computerized ; Radiology Information Systems ; instrumentation ; X-Ray Film

We have designed a mobile operating room information management system. The system is composed of a client and a server. A client, consisting of a PC, medical equipments, PLC and sensors, provides the acquisition and processing of anesthesia and micro-environment data. A server is a powerful computer that stores the data of the system. The client gathers the medical device data by using the C/S mode, and analyzes the obtained HL7 messages through the class library call. The client collects the micro-environment information with PLC, and finishes the data reading with the OPC technology. Experiment results showed that the designed system could manage the patient anesthesia and micro-environment information well, and improve the efficiency of the doctors' works and the digital level of the mobile operating room.
Anesthesia ; Anesthesiology ; instrumentation ; Humans ; Medical Records Systems, Computerized ; Mobile Health Units ; Monitoring, Intraoperative ; methods ; Operating Room Information Systems ; Operating Rooms

OBJECTIVES: The purpose of this paper is to describe the components of a next-generation electronic nursing records system ensuring full semantic interoperability and integrating evidence into the nursing records system. METHODS: A next-generation electronic nursing records system based on detailed clinical models and clinical practice guidelines was developed at Seoul National University Bundang Hospital in 2013. This system has two components, a terminology server and a nursing documentation system. RESULTS: The terminology server manages nursing narratives generated from entity-attribute-value triplets of detailed clinical models using a natural language generation system. The nursing documentation system provides nurses with a set of nursing narratives arranged around the recommendations extracted from clinical practice guidelines. CONCLUSIONS: An electronic nursing records system based on detailed clinical models and clinical practice guidelines was successfully implemented in a hospital in Korea. The next-generation electronic nursing records system can support nursing practice and nursing documentation, which in turn will improve data quality.
Data Accuracy ; Evidence-Based Practice ; Humans ; Korea ; Medical Records Systems, Computerized ; Nursing Records* ; Nursing* ; Semantics ; Seoul ; Triplets

OBJECTIVES: Chronic kidney disease (CKD) is an important cause of excess cardiovascular mortality and morbidity; as well as being associated with progression to end stage renal disease. This condition was largely unheard of in English primary care prior to the introduction of pay-for-performance targets for management in 2006. A realist review of how informatics has been a mechanism for national implementation of guidance for the improved management of CKD. METHODS: Realist review of context, the English National Health Service with a drive to implement explicit national quality standards; mechanism, the informatics infrastructure and its alignment with policy objectives; and outcomes are describe at the micro-data and messaging, meso-patient care and quality improvement initiatives, and marco-national policy levels. RESULTS: At the micro-level computerised medical records can be used to reliably identify people with CKD; though differences in creatinine assays, fluctuation in renal function, and errors in diabetes coding were less well understood. At the meso-level more aggressive management of blood pressure (BP) in individual patients appears to slow or reverse decline in renal function; technology can support case finding and quality improvement at the general practice level. At the macro-level informaticians can help ensure that leverage from informatics is incorporated in policy, and ecological investigations inform if there is any association with improved health outcomes. CONCLUSIONS: In the right policy context informatics appears to be an enabler of rapid quality improvement. However, a causal relationship or generalisability of these findings has not been demonstrated.
Blood Pressure ; Clinical Coding ; Creatinine ; Diabetes Mellitus ; Dietary Sucrose ; England ; General Practice ; Health Policy ; Humans ; Informatics ; Kidney Failure, Chronic ; Kidney Function Tests ; Medical Informatics ; Medical Records ; Medical Records Systems, Computerized ; National Health Programs ; Primary Health Care ; Quality Improvement ; Quality of Health Care ; Renal Insufficiency ; Renal Insufficiency, Chronic