Using elliptic curve cryptosystem (ECC) and SHA-1 message digest algorithms to get the Electronic Health Record (EHR)'s digital finger print, then sending the digital finger print to another unattached organization through the internet, no information about the finger print will be stored on the local server. The system is designed to be a middleware and you can check out whether the EHR has been modified or not by using the finger print generated by the middleware, so as to ensure the EHR's originality and authenticity effectively.
Algorithms ; Electronic Health Records ; Medical Records Systems, Computerized ; Systems Integration

With the electronic medical records information system as the core of hospital information platform design, this paper introduces the design of the system which is structured for electronic medical records, and the advantage and effectiveness is also introduced. From the aspects of the concept, system framework, data integration, right frame and safety control, identity index and a clinical pathway, etc, the paper introduces the basic idea and process of the hospital information platform design, with the hospital recording electronic medical records as the core.
Electronic Health Records ; Hospital Information Systems ; Medical Records Systems, Computerized

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

The user experience (EX) of current Electronic Medical Record systems (EMR) is needed to improve. This paper proposed a new method to enhance EX of EMR. Firstly, system template and text characterization are used to make the EMR data structured. Then, the structured date are mined based on mining the association rules of incremental updating data to find the association of the elements of template of EMR and the values of elements. Finally, with the help of mined results, the users of EMR are able to input data effectively and quickly.
Data Mining ; methods ; Electronic Health Records ; Information Systems ; Medical Records Systems, Computerized ; User-Computer Interface

We try to use information extraction technology in some parts of the medical records and extract disease information to accumulate experience for extracting complete information from medical records. This paper attempts to use dictionary and rules to achieve the named entity recognition. Information extraction is based on shallow parsing and use pattern sentence matching method with the help of a 3 levels finite state automaton.
Algorithms ; Electronic Health Records ; Information Storage and Retrieval ; methods ; Medical Informatics ; instrumentation ; methods ; Medical Records Systems, Computerized ; Software

OBJECTIVES: Computer-based patient record (CPR, Electronic medical record) 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. The purpose of this study was to develop a practical domestic model and theoretical basis for CPR for psychiatric patients. This model can be applied in other clinical departments. METHODS: The contents and types of items to be included in the data-base were determined through consensus meetings of investigators on the basis of our previous works on the 'comprehensive assessment of symptoms and history in psychiatric disorders' and analysis of structure and items of medical records. The computer program(Asan Medical Center Psychiatric Information System, APIS, version 1.0) was developed using Oracle 7-3-4, Power builder 4.0, Hangul Windows NT and TCP/IP as a programming, development tools, system operation and transmission protocol. RESULTS: The characteristics of APIS are as follows. 1) APIS ensures comprehensive and high quality psychiatric record through combinations of free-text and structured data format and through many available 'help pop-up windows' of required items for better documentations. 2) APIS provides convenient and efficient ways of data input, particularly for narrative input of texts, with various tools such as 'template copy', various 'pop-up lists for block or phrase copy'. 3) APIS enables users to create and modify the template files or scales for research. 4) APIS which adopted principles of POMR (Problem Oriented Medical Record) makes cumbersome management of problem titles very convenient 5) APIS also provides additional statistics necessary for hospital audit and managements as well as mail communication and schedule management of department. 6) Access to APIS requires authorized ID and password where several levels of privileges (view only, edit allowed, master) are assigned to secure the data. And also modification of data was not allowed after completion of medical record except by persons with master ID. User's password and the data before modification can be traced. CONCLUSIONS: Our study results demonstrate the practical model and theoretical basis for CPR for psychiatric patients. We believe that this model and methods contained in this program can also be applied for developments of CPR for other clinical departments.
Appointments and Schedules ; Cardiopulmonary Resuscitation ; Consensus ; Documentation ; Electronic Health Records ; Humans ; Information Systems ; Medical Informatics ; Medical Records ; Medical Records Systems, Computerized* ; Postal Service ; Research Personnel ; Weights and Measures

This is a research to enhance the application of natural language understanding and ontology in the Chinese medical text semantic annotation and content analysis, and so to provide technology support for the computer-readable electronic medical records (EMR). The Chinese EMR information extraction and statistical analysis of related subjects in accordance to the user's demands were performed through building the named entity rules, the classified word list and field ontology by using GATE platform on the basis of EMR text set's construction and pre-processing. The automatic and artificial semantic annotation of EMR text set was implemented. The situation of drugs used in medicinal treatment and the distribution of patients' age and sex were obtained. The ontology-based semantic information extraction can improve the function of computer for text understanding, and the discovery of knowledge in EMR through field ontology is feasible.
Artificial Intelligence ; China ; Electronic Health Records ; instrumentation ; Information Storage and Retrieval ; methods ; Medical Records Systems, Computerized ; Practice Patterns, Physicians'

OBJECTIVE: The raw material of quality improvement is information, whose building block is data. Data in an electronic medical record system have many secondary uses beyond their primary role in patient care, including research and organizational management. This study investigates the data quality of clinical observations recorded using a structured data entry format and assesses the impact of erroneous data. METHODS: A total of 4,580,846 input events from 3,348 inpatients, gathered over a three year period in a teaching hospital, were analyzed by using a 2-by-2 conceptual matrix framework for the appropriateness of data types and semantics. The data were classified into three categories: fully usable, partially usable, and not usable. RESULTS: The fully usable data constituted 88.6% of the correctly entered data the remaining 11.4% were erroneous. Among the erroneous data, 0.8% were partially usable (n=3,929), and the remaining 99.2% (n= 510,437) were identified as needing further assessment to improve their quality. CONCLUSION: Clinical information systems have increasingly used structured data entry or record templates, but the low quality of collected data has severely limited their secondary use potential.
Electronic Health Records ; Electronics ; Electrons ; Hospitals, Teaching ; Humans ; Information Systems ; Inpatients ; Medical Records Systems, Computerized ; Patient Care ; Quality Improvement ; Data Accuracy ; Semantics

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: This study explored the reuse of data captured by nurses to support nursing decisions related to pressure-ulcer care. METHODS: To examine the existence of coded data in an electronic nursing record system for the identified concepts, we used the electronic nursing documents of a teaching hospital in Gyeonggi-Do, in Korea. A surgical intensive care unit (SICU) was selected as the test unit due to the high incidence of pressure ulcers. The concepts were identified from literature review and refined through the involvement of staff nurses. RESULTS: We found that 93.4% of the necessary concepts were matched semantically with data items at the input level of the electronic medical record system. Eighteen concepts (60%) were directly matched with the data variables of structured electronic nursing records. Five concepts (16.7%) were matched into more than two items. Including the standard nursing statements coded in Nurses' notes, five concepts were mapped more. CONCLUSIONS: More than 90% of the concepts were matched successfully, which suggests that the secondary use of the routine data collected in an EMR system could be used to develop an automated risk assessment tool for pressure ulcers.
Electronic Health Records ; Electronics ; Electrons ; Hospitals, Teaching ; Incidence ; Critical Care ; Korea ; Medical Records Systems, Computerized ; Nursing Records ; Pressure Ulcer ; Risk Assessment