코딩시뮬레이션을 이용한 의사 및 심사간호사와 의무기록사의 질병코딩 차이 연구

배순옥 ( Soon Ok Bae ),강길원 ( Gil Won Kang ),부유경 ( Yoo Kyung Boo ),이영 ( Young Lee ),최해선 ( Hae Sun Choi ),최혜영 ( Hye Young Choi ) 한국보건정보통계학회 2015 보건정보통계학회지 Vol.40 No.3

Objectives: The objective of this study is to investigate the difference in disease coding of doctors, medical insurance review nurses and medical record administrators who are directly involved in disease coding in hospital. Methods: Thirteen virtual medical records were developed for common diseases. The study subjects were requested to select principal diagnosis and other diagnoses for the each record. The survey was conducted through web pages specially developed for coding simulation. 29 doctors, 74 medical insurance review nurses, and 100 medical record administrators participated in this survey. Results: There was large difference in the concordance rate between the study subjects’ answer and coding guidelines published by the National Statistical Office. Concordance rate was high in medical record administrators (93.6%) but low in doctors (43.1%) and medical insurance review nurses (35.6%). The difference was noticeable in the way of using Z codes as principal diagnosis. Also large difference existed in the way of coding symptom under treatment and underlying disease. Conclusions: This study shows that there are large differences in disease coding depending on the occupation. To decrease this difference, it is needed to refine the coding guidelines and strengthen the education about them.

병원전처치에 대한 의학적 지도관리 : 구급업무일지 분석을 통한 사후관리 Retrospective Run Record Review

정구영,김찬웅 대한응급의학회 1999 대한응급의학회지 Vol.10 No.4

Background : Emergency Medical Technicians can do emergency care only under the control of the physicians. Emergency medical services system(EMSS) in Korea is now extended from the level of basic life support(BLS) to advanced life support(ALS). Unfortunately we don't have any official medical control system yet. We and regional EMSS, 119 rescue team(BLS), have had monthly joint meeting to validate and improve the prehospital care since August, 1998. Methods : From August, 1998 to February, 1999, 1,708 patients were transported to Ewha Mokdong Hospital by regional 119 rescue team. Eight hundred and six(47.2%) run record were collected and analyzed. The appropriateness of the prehospital care were evaluated based on the comparison of assessment data and treatment data in each run record. The run reccord were divided into 5 groups; 1) necessary-adequate, 2) necessary-inadequate, 3) necessary-undo, 4) unnecessary-done, and 5) unnecessary-undo. 1) and 5) were judged as acceptable, and 2),3), and 4) as unacceptable. Results : Among 806 transported patients, 60.8% required one of more emergency care. 21.0% of required care were not provided, and 20.7% of provided care were not adequate. 78.8% of unprovided and 75.9% of inadequate care were 'airway and oxygen supply'. Overall unacceptable rate was decreased from 31.7% to 17.0% during first 5 months, but it rose up again to 24.7% after 2 months. Cardiopulmonary resuscitation(CPR) was performed in 29 prehospital cardiac arrest victims and admitted to ICU in 5 cases. CPR was not provided jin 8 necessary situations, and unnecessary CPR was done in 3 cases. Conclusion : EMSS in Korea also need a kind of medical control system, even for BLS level. Major portion of the quality assurance program could be 'airway and oxygen supply', but attention should be focused in cardiac arrest victims and CPR. Record keeping and reliance of run record data are now pending problems. Fire department should develop a formal medical control system and the referring hospital should have an organization for maintaining the quality of prehospital care.

한방정신요법의 의안 분석

정선영 ( Seon Yeong Jeong ),김재영 ( Jae Yeong Kim ),조명의 ( Myoung Ui Cho ),고영탁 ( Young Tak Kho ) 대한한방신경정신과학회 2016 동의신경정신과학회지 Vol.27 No.2

Objectives: The aim of this systemic review was to summarize medical records of Korean medicine based psychotherapy and investigate its therapeutic mechanism. Methods: We searched articles on Korean neuropsychiatry in Korean databases. Subsequently, we selected and analyzed medical records on Korean medicine based-psychotherapy that met inclusion criteria. Results: Fifty-five medical records were included. They were classified into the following 5 categories. Five minds mutual restriction therapy in 19 medical records; counseling and persuading therapy in 12 medical records; moving essence and changing Qi therapy in 10 medical records; Kyungjapyungji psychotherapy in 2 medical records; and suggestion psychotherapy in 11 medical records. Conclusions: The results indicated that emotion is mainly used for cure. Buddhism affects Korean medicine based psychotherapy. Korean medicine based psychotherapy corresponds to western psychotherapy such as short-term dynamic psychotherapy (STDP), supportive psychotherapy, cognitive therapy, behavior therapy, and guided imagery.

디지털치료기기 정보관리 체계에 대한 법적 고찰

권오탁 국회입법조사처 2022 입법과 정책 Vol.14 No.1

“Digital Therapeutics” is a software medical device used to treat a patient's disease. Patients can download them on computers or mobile phones and use them for therapeutic purposes. However, a doctor's prescription is required and medical records are stored in Digital Therapeutics. Developers of Digital Therapeutics manage and utilize patient medical records. It also delivers collected information to doctors and provides it to other researchers. Therefore, personal information protection can be an important issue. Developers of Digital Therapeutics are not medical personnel. So, the Personal Information Protection Act applies. However, the Personal Information Protection Act does not specialize in medical information management. So improvement is needed. First, it is necessary to prepare facilities, manpower, equipment standards, and verification procedures to safely manage patient medical records. It is also necessary to consider ways to reduce the burden of information management on Digital Therapeutics developers. Second, it is not efficient to form and operate a separate Data Review Committee. This is because there is already an Institutional Review Board stipulated by law. Therefore, it is necessary to maintain the c onsistency of the examination system through deliberation by the Institutional Review Boards. This will increase the reliability of the overall information management system.

History and Trends of “Personal Health Record” Research in PubMed

김정은,정홍주,David W. Bates 대한의료정보학회 2011 Healthcare Informatics Research Vol.17 No.1

Objectives: The purpose of this study was to review history and trends of personal health record research in PubMed and to provide accurate understanding and categorical analysis of expert opinions. Methods: For the search strategy, PubMed was queried for ‘personal health record, personal record, and PHR’ in the title and abstract fields. Those containing different definitions of the word were removed by one-by-one analysis from the results, 695 articles. In the end, total of 229 articles were analyzed in this research. Results: The results show that the changes in terms over the years and the shift to patient centeredness and mixed usage. And we identified history and trend of PHR research in some category that the number of publications by year, topic, methodologies and target diseases. Also from analysis of MeSH terms, we can show the focal interest in regards the PHR boundaries and related subjects. Conclusions: For PHRs to be efficiently used by general public, initial understanding of the history and trends of PHR research may be helpful. Simultaneously, accurate understanding and categorical analysis of expert opinions that can lead to the development and growth of PHRs will be valuable to their adoption and expansion.

코로나19 입원환자의 치료 약제와 이상사례 분석

강동윤,이상봉,이동엽,김지현,문승희,이귀진,최보윤,김예슬,임재형 대한약물역학위해관리학회 2023 약물역학위해관리학회지 Vol.15 No.2

This study aimed to assess the status and characteristics of adverse events caused by treatments of coronavirus disease 2019 (COVID-19) in hospitalized patients in Korea. Methods: The medical records of patients hospitalized with COVID-19 at 30 medical institutions nationwide from January 1, 2020 to November 30, 2021 were retrospectively reviewed. Data of clinical characteristics; type of COVID-19 treatments; symptoms and severity of adverse events according to CTCAE classification; and prognosis of each patient were analyzed and presented descriptively. Results: Adverse events were observed in 853 of 5,740 (14.9%) hospitalized patients with COVID-19: 732 (85.8%), mild; 106 (12.4%), moderate; and 15 (1.8%), severe. Serious adverse events were observed in 70 (1.2%) patients, with 56 prolonged hospitalizations and four deaths. Adverse events were more frequently found in patients with a lower-than-normal body mass index or many concomitant medications. Moreover, 4,912 patients (85.6%) received multiple medications for treatment of COVID-19, wherein the drugs most mainly administered were steroids (66.4%), antibiotics (59.5%), and remdesivir (52.6%). Adverse events were relatively common in patients administered immunoglobulin, other antiviral drugs, and interleukin-6 inhibitors. Each patient with adverse events had an average of 3.8 symptoms. The most frequent symptoms were increased hyperbilirubinemia (n = 256), nausea (n = 216), and pruritis (n = 188). Conclusion: The incidence of adverse events in hospitalized patients with COVID-19 in Korea was approximately 14.9%. The type of treatment of COVID-19 might affect the incidence and prognosis of specific adverse events. Clinicians should consider the possible adverse effects of each medication before initiating treatment

Assessing Reliability of Medical Record Reviews for the Detection of Hospital Adverse Events

Ock, Minsu,Lee, Sang-il,Jo, Min-Woo,Lee, Jin Yong,Kim, Seon-Ha The Korean Society for Preventive Medicine 2015 Journal of Preventive Medicine and Public Health Vol.48 No.5

Objectives: The purpose of this study was to assess the inter-rater reliability and intra-rater reliability of medical record review for the detection of hospital adverse events. Methods: We conducted two stages retrospective medical records review of a random sample of 96 patients from one acute-care general hospital. The first stage was an explicit patient record review by two nurses to detect the presence of 41 screening criteria (SC). The second stage was an implicit structured review by two physicians to identify the occurrence of adverse events from the positive cases on the SC. The inter-rater reliability of two nurses and that of two physicians were assessed. The intra-rater reliability was also evaluated by using test-retest method at approximately two weeks later. Results: In 84.2% of the patient medical records, the nurses agreed as to the necessity for the second stage review (kappa, 0.68; 95% confidence interval [CI], 0.54 to 0.83). In 93.0% of the patient medical records screened by nurses, the physicians agreed about the absence or presence of adverse events (kappa, 0.71; 95% CI, 0.44 to 0.97). When assessing intra-rater reliability, the kappa indices of two nurses were 0.54 (95% CI, 0.31 to 0.77) and 0.67 (95% CI, 0.47 to 0.87), whereas those of two physicians were 0.87 (95% CI, 0.62 to 1.00) and 0.37 (95% CI, -0.16 to 0.89). Conclusions: In this study, the medical record review for detecting adverse events showed intermediate to good level of inter-rater and intra-rater reliability. Well organized training program for reviewers and clearly defining SC are required to get more reliable results in the hospital adverse event study.

Assessing Reliability of Medical Record Reviews for the Detection of Hospital Adverse Events

옥민수,이상일,이진용,조민우,김선하 대한예방의학회 2015 Journal of Preventive Medicine and Public Health Vol.48 No.5

Objectives: The purpose of this study was to assess the inter-rater reliability and intra-rater reliability of medical record review for the detection of hospital adverse events. Methods: We conducted two stages retrospective medical records review of a random sample of 96 patients from one acute-care general hospital. The first stage was an explicit patient record review by two nurses to detect the presence of 41 screening criteria (SC). The second stage was an implicit structured review by two physicians to identify the occurrence of adverse events from the positive cases on the SC. The inter-rater reliability of two nurses and that of two physicians were assessed. The intra-rater reliability was also evaluated by using test-retest method at approximately two weeks later. Results: In 84.2% of the patient medical records, the nurses agreed as to the necessity for the second stage review (kappa, 0.68; 95% confidence interval [CI], 0.54 to 0.83). In 93.0% of the patient medical records screened by nurses, the physicians agreed about the absence or presence of adverse events (kappa, 0.71; 95% CI, 0.44 to 0.97). When assessing intra-rater reliability, the kappa indices of two nurses were 0.54 (95% CI, 0.31 to 0.77) and 0.67 (95% CI, 0.47 to 0.87), whereas those of two physicians were 0.87 (95% CI, 0.62 to 1.00) and 0.37 (95% CI, -0.16 to 0.89). Conclusions: In this study, the medical record review for detecting adverse events showed intermediate to good level of inter-rater and intra-rater reliability. Well organized training program for reviewers and clearly defining SC are required to get more reliable results in the hospital adverse event study.

Benefits of Information Technology in Healthcare: Artificial Intelligence, Internet of Things, and Personal Health Records

장혜정,최재영,심재선,김미희,최모나 대한의료정보학회 2023 Healthcare Informatics Research Vol.29 No.4

Objectives: Systematic evaluations of the benefits of health information technology (HIT) play an essential role in enhancinghealthcare quality by improving outcomes. However, there is limited empirical evidence regarding the benefits of IT adoptionin healthcare settings. This study aimed to review the benefits of artificial intelligence (AI), the internet of things (IoT), andpersonal health records (PHR), based on scientific evidence. Methods: The literature published in peer-reviewed journals between2016 and 2022 was searched for systematic reviews and meta-analysis studies using the PubMed, Cochrane, and Embasedatabases. Manual searches were also performed using the reference lists of systematic reviews and eligible studies frommajor health informatics journals. The benefits of each HIT were assessed from multiple perspectives across four outcomedomains. Results: Twenty-four systematic review or meta-analysis studies on AI, IoT, and PHR were identified. The benefitsof each HIT were assessed and summarized from a multifaceted perspective, focusing on four outcome domains: clinical,psycho-behavioral, managerial, and socioeconomic. The benefits varied depending on the nature of each type of HIT and thediseases to which they were applied. Conclusions: Overall, our review indicates that AI and PHR can positively impact clinicaloutcomes, while IoT holds potential for improving managerial efficiency. Despite ongoing research into the benefits ofhealth IT in line with advances in healthcare, the existing evidence is limited in both volume and scope. The findings of ourstudy can help identify areas for further investigation.

상한론 증상에 근거한 진료기록부 작성에 대한 제언

김상운 ( Kim Sang-un ),이홍규 ( Lee Hong-kyu ),정현종 ( Jung Hyun-jong ) 대한한의진단학회 2014 大韓韓醫診斷學會誌 Vol.18 No.2

Objectives This study intends to present the writing of standardized medical records based on Korean medicine on the basis of the Sanghanron symptoms. Methods 1. Excluding the sentences unrelated to the Sanghanron symptoms, the symptoms in the rest of sentences were extracted. 2. Classifying the extracted symptoms as per the review of system, the similar symptoms were integrated. 3. Calculating the frequencies of each symptom, each strain rate was calculated. Results & Conclusion: 1. Resulting from the analysis on 378 sentences in Sanghanron, a total of 1566 different symptoms were extracted. 2. As results out of total, the symptom related to the temperature sensation accounted for 17.9%, that related to sweat did 6.5%, that related to pulse did 12.4%, that related to eye and nose and mouth and tongue and throat as well as thirst did 7.7%, that related to stool did 11.6%, that related to urination and urinary organs did 4.9%, that related to language and mind and sleep and agitation as well as heart did 10.0%, and that related to vomiting and abdomen as well as digestive organs did 15.4%. 3. There were found many symptoms were described in accordance with the severity of basic expressions. For examples, in case of fever, there were mild fever and high fever, and in case of sweat, there were profuse sweating and slightly sweating. 4. To create the medical records for cold damage disease, it may necessary to consider the factors to be recorded as per each symptom and write the detail of each symptom.