OBJECTIVES: The objective of the study was to create a roadmap for the adoption of Electronic Health Record (EHR) in India based an analysis of the strategies of other countries and national scenarios of ICT use in India. METHODS: The strategies for adoption of EHR in other countries were analyzed to find the crucial steps taken. Apart from reports collected from stakeholders in the country, the study relied on the experience of the author in handling several e-health projects. RESULTS: It was found that there are four major areas where the countries considered have made substantial efforts: ICT infrastructure, Policy & regulations, Standards & interoperability, and Research, development & education. A set of crucial activities were identified in each area. Based on the analysis, a roadmap is suggested. It includes the creation of a secure health network; health information exchange; and the use of open-source software, a national health policy, privacy laws, an agency for health IT standards, R&D, human resource development, etc. CONCLUSIONS: Although some steps have been initiated, several new steps need to be taken up for the successful adoption of EHR. It requires a coordinated effort from all the stakeholders.
Education ; Electronic Health Records* ; Health Information Exchange ; Health Policy ; Humans ; India* ; Jurisprudence ; Medical Informatics ; Privacy ; Social Control, Formal

OBJECTIVES: Clinical documents (CDs) have evolved from traditional paper documents containing narrative text information into the electronic record sheets composed of itemized records, where each record is expressed as an item with a specific value. We defined medical record (MR) items to be information entities with a specific value. These entities were then used to compile form-based clinical documents as part of an electronic health record system (EHR-s). METHODS: We took a reusable bottom-up developmental approach for the MR items, which provided three things: efficient incorporation of the local needs and requirements of the medical professionals from various departments in the hospital, comprehensive inclusion of the essential concepts of the basic elements required in clinical documents, and the provision of a structured means for meaningful data entry and retrieval. This paper delineates our experiences in developing and managing medical records at a large tertiary university hospital in Korea. RESULTS: We collected 63,232 MR items from paper records scanned into 962 CDs. The MR item database was constructed using 13,287 MR items after removing redundant items. During the first year of service users requested changes to be made to 235 (1.8%) attributes of the MR items and also requested the additional 9,572 new MR items. In the second year, the attributes of 70 (0.5%) of the existing MR items were changed and 3,704 new items were added. The number of registered MR items increased by 72.0% in the first year and 27.9% in the second year. CONCLUSIONS: The MR item concept provides an easier and more structured means of data entry within an EHR-s. By using these MR items, various kinds of clinical documents can be easily constructed and allows for medical information to be reused and retrieved as data. The success of the use of MR items in a large tertiary university hospital system provides evidence that verifies our approach as being an efficient means of user-oriented and structured data entry, enabling the easy reuse of medical records.
Electronic Health Records ; Electronics ; Electrons ; Medical Records

Electronic Health Records ; Humans ; Medical Records ; Odontodysplasia

OBJECTIVE: Applications to extract medical information from electronic medical records(EMRs) confront some serious obstacles such as spelling errors, ambiguous abbreviations, and unrecognizable words. Those obstacles hinder the process of finding medical entities, relations, and events. We present an efficient EMR refinement system for the purpose of medical information extraction from EMRs, not just for traditional text error correction. METHODS: The EMR refinement system has been designed and implemented through following steps: 1) Build domain constrained dictionary database, 2) Correct spelling errors in Korean-English EMR documents, 3) Resolve ambiguous abbreviations in the bilingual documents. The resulting EMR documents are now machine readable and can be applied to various applications including information extraction. RESULT: Precision rate of the refinement system for spelling error correction is 80.4% and for disambiguating abbreviations/acronyms is 94.7%. CONCLUSION: We developed an EMR refinement system to correct spelling errors and resolve ambiguous abbreviations as well as unrecognizable words. Our system can enhance the reliability of medical records and contribute to develop further application systems in the field of text mining and information extraction.
Data Mining ; Electronic Health Records ; Electronics ; Electrons ; Medical Records

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: This study aims to investigate the suitability of electronic health record (EHR) systems in Korea for global certification and to propose functions for future global systems by comparing and analyzing the certification criteria for Certification Commission for Health Information Technology (CCHIT) Certified Ambulatory EHR with BESTCare, which is the EHR system at Seoul National University Bundang hospital. METHODS: Domain expert groups were formed to analyze the inclusion of BESTCare functions and the types of differences for each of the CCHIT Certified 2011 Ambulatory EHR Certification Criteria. The types of differences were divided into differences in functions (F), differences in business processes (B), and differences in government policies (P). RESULTS: Generally, the criteria that showed differences in functions pertained to the connection between the diagnosis/problem list and order, the alert and warning functions for medication-diagnosis interactions, and the reminder/instruction/notification messages related to the patient's immunization status; these absent functions were enhanced clinical decision support system (CDSS) functions related to patient safety and healthcare quality. Differences in government policies were found in the pharmacy's electronic prescription functions, while differences in business processes were found in the functions constrained by the local workflow or internal policy, which require some customization. CONCLUSIONS: Functions that differed between the CCHIT certification criteria and the BESTCare system in this study should be considered when developing a global EHR system. Such a system will need to be easily customizable to adapt to various government policies and local business processes. These functions should be considered when developing a global EHR system certified by CCHIT in the future.
Certification ; Commerce ; Electronic Health Records ; Electronic Prescribing ; Immunization ; Korea ; Medical Informatics ; Patient Safety ; Quality of Health Care

No abstract available.
Cooperative Behavior ; Electronic Health Records ; Electronics ; Electrons ; Medical Informatics ; Wine

OBJECTIVE: Seoul National University Bundang Hospital is the first full digital hospital with electronic medical record(EMR) system in Korea. We evaluated the user's satisfaction on the EMR system at 15 months from its beginning. METHODS: A total of 105 doctors and 503 nurses participated in this study. The questionnaire was composed of four domains: user satisfaction between paper records and EMR, User perceived improvement of work efficiency with EMR, user interface satisfaction and advantage/ disadvantage of EMR. A Likert-type 5-point scale was used for the degree of satisfaction, with 5 indicating 'very satisfied'. RESULTS: Doctors were more satisfied with EMR system than paper records, especially on editing (3.33 vs. 2.73, p<0.05) and retrieval (3.68 vs. 2.23, p<0.05). However, the degree of satisfaction was not significantly different from that of paper records in terms of input (3.22 vs. 3.03, p>0.05). Nurses were more satisfied with EMR system than paper records, e.g., editing (3.51 vs. 2.74, p<0.05), retrieval (4.07 vs. 2.51, p<0.05) and input (3.82 vs. 2.90, p<0.05). Also, doctors and nurses showed satisfaction for most of user interfaces. CONCLUSION: Users seem to be satisfied with the EMR system. EMR system should have a flexible system to improve the input system, the structured forms, and the standardized terminology according to the need of users.
Electronic Health Records* ; Electronics, Medical ; Korea ; Surveys and Questionnaires ; Seoul*

OBJECTIVE: This is designing the part of Electronic Medical Record using HL7 Development Framework and Reference Information Model to realize the building medical standard data model for sharing medical record between heterogeneous hospital systems. METHODS: The process used development of HL7 specifications consists of the following seven activities: 1.Project initiation. 2.Requirements Documentation. 3.Specification Modeling. 4.Specification Documentation. 5.Specification Approval. 6. Specification Publication. 7.Implementation Profiling. Each activity is briefly described in the subsections that follow and described in detailed in the methodology chapters that follow this introduction.3. Result. The steps, after 4 step, needs to standardized the results. So we didn't followed that steps1). RESULTS: We got the diagrams at each steps of the HDF methodology: 1.A dynamic description. 2.A static description of the concepts involved in the business process. 3.A Use Case model which identifies the system involved in the actual HL7 data/information exchange1). CONCLUSION: It was confirmed that HL7 RIM could take in the domestic demands of medical records, and concrete methodology was applied in practice. It can be a good reference for the hospitals constructing new information system and for the enterprises developing medical information systems to apply the HL7 version 3 to their works.
Commerce ; Electronic Health Records* ; Health Level Seven* ; Health Status* ; Information Systems ; Medical Records ; Publications