scholarly journals Integrating semantic and fuzzy dimensions into electronic medical records: Case of cerebral palsy information system

2018 ◽  
Vol 7 (4) ◽  
pp. 60
Author(s):  
Hanen Ghorbel ◽  
Sirine Farjallah
Keyword(s):  
Cerebral Palsy ◽  
Semantic Web ◽  
Medical Record ◽  
Electronic Medical Record ◽  
Medical Records ◽  
Medical Information ◽  
University Hospital ◽  
Dual Model ◽  
Web Environment ◽  
Meta Modeling

The meta-modeling of medical records helps standardize and capitalize the expert’s knowledge domain. It promotes the interoperability knowledge and the reuse of clinical concepts, i.e., archetypes. It also promotes high quality electronic medical record system (EMRS) design, which helps provide better care service delivery. As a result, different standards of medical informatics use the dual model to support interoperability between Medical Information Systems. We particularly quote ISO/EN 13606 and OpenEHR. However, the use of these standards still presents challenges. Apart from political reasons, the main obstacles to the adoption of these standards include: (1) a lack of guides and methodological tools to facilitate the construction of EMRS using two conceptual levels. Designers must have languages, approaches and tools to assist them in the modeling of archetypal EMRS; (2) a lack of methodologies for semantic activities on the content of electronic health records in the semantic web environment; (3) and a lack of management of uncertainties and inaccuracies that may exist in the medical field. Theconstruction of an approach to modeling EMRS according to the dual model approach, considering the uncertainties, inaccuracies and semantics of these systems, is a difficult task, given the challenges to emancipate. In literature, we don’t find such an approach. We, therefore, defined one in this paper. Our goal is to guide the designer in all stages of developing a new generation of EMRS, from analysis and specification of requirements to implementation. To achieve this goal, we have created an approach to support the following activities: (1) clinical concepts and information management and meta-modeling in accordance with the openEHR standard, (2) integration of the semantic dimension into EMRS considered to enable the execution of semantic activities in the semantic web environment; and (3) integration of the fuzzy dimension into electronic medical record data structures. As a contribution, we defined an approach called Fuzzy SemanticOpenEHR allowing the integration of semantic and fuzzy dimensions into EMRS modeled using the openEHR standard. Fuzzy SemanticOpenEHR intends to help and equip the designer during the different phases of creating a fuzzy ontology. Thanks to the mechanisms offered by this approach, we have been able to obtain a fuzzy ontological basis that can serve as a knowledge base that can support the semantic interoperability between EMRS, the deduction of new knowledge and the taking of knowledge’s clinical decision. To test our contribution, we proceeded to the realization of a prototype of tools realized for the pediatric neurology service of the university hospital “Hédi Chaker Sfax - Tunisia” and the association of the handicapped persons safeguard of Sfax. This prototype is a framework called “XML 2 FuzzyOWL”. Then, we tested this framework using a case of a disease which is “Cerebral Palsy”.

scholarly journals HealthyBlock: Blockchain-Based IT Architecture for Electronic Medical Records Resilient to Connectivity Failures

2020 ◽  
Vol 17 (19) ◽  
pp. 7132
Author(s):  
Omar Gutiérrez ◽  
Giordy Romero ◽  
Luis Pérez ◽  
Augusto Salazar ◽  
Marina Charris ◽  
...  
Keyword(s):  
Medical Record ◽  
Electronic Medical Record ◽  
Electronic Medical Records ◽  
Medical Records ◽  
Medical Information ◽  
High Efficiency ◽  
Electronic Medical Record System ◽  
Security And Privacy ◽  
Record System ◽  
Treatment And Prevention

The current information systems for the registration and control of electronic medical records (EMR) present a series of problems in terms of the fragmentation, security, and privacy of medical information, since each health institution, laboratory, doctor, etc. has its own database and manages its own information, without the intervention of patients. This situation does not favor effective treatment and prevention of diseases for the population, due to potential information loss, misinformation, or data leaks related to a patient, which in turn may imply a direct risk for the individual and high public health costs for governments. One of the proposed solutions to this problem has been the creation of electronic medical record (EMR) systems using blockchain networks; however, most of them do not take into account the occurrence of connectivity failures, such as those found in various developing countries, which can lead to failures in the integrity of the system data. To address these problems, HealthyBlock is presented in this paper as an architecture based on blockchain networks, which proposes a unified electronic medical record system that considers different clinical providers, with resilience in data integrity during connectivity failure and with usability, security, and privacy characteristics. On the basis of the HealthyBlock architecture, a prototype was implemented for the care of patients in a network of hospitals. The results of the evaluation showed high efficiency in keeping the EMRs of patients unified, updated, and secure, regardless of the network clinical provider they consult.

scholarly journals Aspek Hukum Rekam Medis atau Rekam Medis Elektronik sebagai Alat Bukti Dalam Transaksi Teurapetik

2017 ◽  
Vol 3 (2) ◽  
pp. 359-383 ◽  
Author(s):  
Sudjana Sudjana
Keyword(s):  
Medical Record ◽  
Electronic Medical Record ◽  
Medical Records ◽  
Health Workers ◽  
Legal Aspects ◽  
Literature Study ◽  
Descriptive Research ◽  
Positive Law ◽  
Approach Method ◽  
Administrative Sanctions

This study aims to obtain information on: first, the obligation to create and conceal Electronic Medical Record and its juridical consequences; Secondly, due to the law of absence or error in the manufacture of Electronic Medical Records and the position of Electronic Medical Record as a tool in the theoretical transactions.The research method used is normative juridical approach method, analytical descriptive research specification, research phase is done through literature study to examine primary law material, secondary law material, and tertiary law material. Data collection techniques are conducted through document studies, conducted by reviewing documents on positive law. Furthermore, the method of data analysis is done through normative qualitative.The results of the study indicate: Legal aspects of Medical Record or Electronic Medical Record   in Teurapetik Transactions related to: first, the obligation of health workers in coaching and health services to make Medical Record or Electronic Medical Record correctly and responsible for secrecy because it is the opening of Medical Record or Electronic Medical Record without With the permission of the patient having the consequences of criminal law. The absence or misuse of the Medical Record or Electronic Medical Record means that health workers may be subject to criminal, civil and administrative sanctions. Second, the position of  Medical Record or Electronic Medical Record is evidence in the form of a letter (if given outside the court), and expert information (if delivered in court).

Overview Statement on Medical Records

PEDIATRICS ◽  
1975 ◽  
Vol 56 (2) ◽  
pp. 329-329 ◽  
Author(s):  
Hugh C. Thompson ◽  
Stanton J. Barron ◽  
John P. Connelly ◽  
Andrew Margileth ◽  
Richard Olmsted ◽  
...  
Keyword(s):  
Medical Record ◽  
Medical Records ◽  
Medical Information ◽  
Third Party ◽  
Specific Information ◽  
Multiple Sources ◽  
Chart Audit ◽  
Working Together ◽  
The One ◽  
The Individual

Historically, medical records have been maintamed by individual physicians to record specific information concerning patients. This information was often understandable only to the writer. The data were of outstanding events. This was thought to be sufficient documentation for patient care. Records are now read by others than the individual physicians. Groups of physicians working together often share the same patients and their records. Patients may have multiple sources of care. Our population has become more mobile which makes it necessary to transfer vast amounts of medical information. The medical record many times is the one instrument which gives a complete and continuous documentation of the patient's medical history. Third-party payers are requesting access to medical records to document services provided. Chart audit is being tested as a mechanism for evaluating physician performance. Records must reflect what the physician does in order to be useful in such an appraisal. Much clinical research on the delivery of health care depends on accurately kept records which are easily interpreted. A chart is also a legal document for the protection of the physician as well as the patient. Thus, records will be used in other than traditional ways. Proper confidentiality must be maintained when such uses are necessary. Physicians generally agree as to the essential content of a medical record. However, there is little unanimity as to the structure of the chart. No one system of keeping records is now appropriate for all situations. The maintenance of adequate charts requires additional cost in both time and money.

scholarly journals Nurses’ perceptions about and confidence in using an electronic medical record system

2017 ◽  
Vol 27 (2) ◽  
pp. 110-117 ◽  
Author(s):  
Ahmad H Abu Raddaha
Keyword(s):  
Health Care ◽  
Medical Record ◽  
Electronic Medical Record ◽  
Survey Design ◽  
Electronic Medical Record System ◽  
University Hospital ◽  
Cross Sectional Survey ◽  
Record System ◽  
Cross Sectional ◽  
Nurses Perceptions

Introduction: Nurses are among the largest potential users of electronic medical record (EMR) systems in health care settings. Yet little is known about their perceptions and confidence toward using such systems. This study explored nurses’ perceptions toward and confidence in using the EMR system. Predictors for confidence status in using the system among nurses were postulated. Methods: A cross-sectional survey design was used. A sample of 169 nurses were recruited from a general governmental university hospital in Muscat, Oman. Results: Most of study participants did not have prior experience with EMR systems elsewhere. About half (52.1%) perceived that they were confident in using the system. A logistic regression model showed nurses who (a) had six or more years of experience in using the system, (b) perceived that their suggestions regarding improving the system were taken into consideration by the system managing team, (c) perceived that the changes introduced in the system were important to their work, and (d) perceived that the information retrieved through the system was updated, to be more likely confident in using the system. Discussion: When customizing the EMR system, the informatics team that manages the system is invited to more consider suggestions for improvement that are raised by nurses. More training on the system is suggested to increase confidence among nurses who had little experience in using the system. In order to enhance the preparation of future nurses with contemporary technology-driven health care practices, nursing schools officials are encouraged to include general computer information technology training into nursing curricula.

scholarly journals Improvement of patient safety through implementation of electronic medical records

2017 ◽  
Vol 1 (4) ◽  
pp. 111-112
Author(s):  
Elahe Gozali ◽  
Marjan Ghazisaiedi ◽  
Malihe Sadeghi ◽  
Reza Safdari
Keyword(s):  
Patient Safety ◽  
Medical Record ◽  
Electronic Medical Record ◽  
Electronic Medical Records ◽  
Medical Records ◽  
Access To Health Care ◽  
Clinical Care ◽  
Drug Management ◽  
Bar Code

Introduction: Today, with the complexity of the process of conducting activities, the increase in diversity and the number of hospital services, and the increase in the expectations of clients - consistent with the fast technological advances - most of the hospitals in Iran have turned to mechanized systems to organize their daily activities and to register the patients' information and the care provided. One of these technologies is electronic medical records, which is known as a valuable system to evaluate patients' information in hospitals. The purpose of this paper was to examine the advantages of running electronic medical records in patient safety. Methods: This study is a review paper based on a structured review of papers published in the Google Scholar, SID, Magiran, Pubmed, and Science Direct databases (from 2007 to 2015) and the books on the benefits of implementing electronic medical records in patient safety and the related keywords. Results: Clinical information systems can have a significant effect on the quality of the outputs and patient safety. Various studies have indicated that the physicians with access to clinical guidelines and features such as computer reminders, doctors who did not have these features, presented more appropriate preventive care. Studies show that electronic medical records play a crucial role in improving the quality of patient health and safety services. Moreover, electronic medical record system is usually in connection with other technological tools: electronic drug management records,  electronic record of time and date of drug management are usually associated with bar code technology. Among the benefits of this system is the possibility to record clinical care by the treatment team, which would be especially beneficial for patient's bedside record. If the treatment personnel forgets to ask the patient a particular question, system reminds him/her. Furthermore, electronic medical record is able to remind the nurses of the patient's allergic reactions and medical history without the need for the patient to remind, which improves patient safety. Conclusion: Implementation of electronic medical records boosts up the quality of health services, patient safety, people's access to health care services, and the speed of patients treatment, leading to lower healthcare costs. Thus, considering the benefits mentioned and some other benefits of this kind, one can use this technology in clinical care provided to patients to come up with a safe and effective clinical care.

scholarly journals P232 Assessing effectiveness and patient perceptions of a novel electronic medical record for the management of inflammatory bowel disease

2021 ◽  
Vol 15 (Supplement_1) ◽  
pp. S281-S281
Author(s):  
P Kaazan ◽  
T Li ◽  
W Seow ◽  
J Bednarz ◽  
J Pipicella ◽  
...  
Keyword(s):  
Inflammatory Bowel Disease ◽  
Chronic Disease ◽  
Medical Record ◽  
Electronic Medical Record ◽  
Medical Records ◽  
Data Capture ◽  
Patient Portal ◽  
Specific Data ◽  
Qualitative Feedback ◽  
Inflammatory Bowel

Abstract Background There is an increasing prevalence of chronic disease worldwide, resulting in multiple management challenges. Inflammatory bowel disease (IBD) is an exemplar chronic disease requiring optimal longitudinal coordinated care. We propose that Crohn’s Colitis Care (CCCare), a novel IBD-specific electronic medical record intended to improve IBD care is effective and acceptable to patients. We aimed to assess both the effectiveness of CCCare for data capture and patients’ acceptability of CCCare. Methods Methods: The study was conducted at two tertiary Australian hospitals with dedicated IBD services: Royal Adelaide Hospital and Liverpool Hospital. The effectiveness of CCCare was examined by comparing IBD-specific data completeness between pre-existing medical records and CCCare. Acceptability was assessed with quantitative and qualitative feedback through the CCCare patient portal and with standardized paper-based questionnaires administered to a convenience sample of IBD clinic patients in two unmatched pre-CCCare and post-CCCare exposure cohorts. Descriptive statistics and multivariable regression models were applied to specifically examine overall ratings of CCCare acceptability using a 10-point numeric scale; factors associated with acceptability before exposure to the system and whether exposure or security concerns influenced its acceptability. Results In all 73 cases reviewed, there was data gain when using structured CCCare fields compared to IBD documentation in usual medical records. Acceptability assessment through the patient portal feedback of 287 patients showed that the majority were very likely to recommend it to others (score, 8.56 ± 2.2 on a scale of 0–10). Common themes of concern among the 22 respondents with qualitative feedback were related to the novelty and limited experience of CCCare. Study questionnaires indicated that the overall acceptability in the combined cohort (n=310) was very high (8.4 ± 2.1; scale of zero to ten) with more than three-quarters of patients rating acceptability as at least 8 out of 10. Self-reported information technology (IT) literacy was positively associated with acceptability. Exposure had a small positive affect on acceptability while the level security concerns had little impact on acceptability. Conclusion The IBD-specific electronic medical record CCCare is effective in facilitating enhanced completeness of IBD-specific data capture in comparison to pre-existing medical records. It is highly acceptable to patients, especially those with reasonable IT literacy. Patient concerns about privacy and security of EMRs did not significantly influence acceptability.

scholarly journals Diabetes Risk Data Mining Method Based on Electronic Medical Record Analysis

2021 ◽  
Vol 2021 ◽  
pp. 1-11
Author(s):  
Yang Liu ◽  
Zhaoxiang Yu ◽  
Yunlong Yang
Keyword(s):  
Data Mining ◽  
Medical Record ◽  
Electronic Medical Record ◽  
Electronic Medical Records ◽  
Medical Records ◽  
Diabetes Risk ◽  
Mining Method ◽  
Training Set ◽  
Medical Field ◽  
Data Mining Method

In today’s society, the development of information technology is very rapid, and the transmission and sharing of information has become a development trend. The results of data analysis and research are gradually applied to various fields of social development, structured analysis, and research. Data mining of electronic medical records in the medical field is gradually valued by researchers and has become a major work in the medical field. In the course of clinical treatment, electronic medical records are edited, including all personal health and treatment information. This paper mainly introduces the research of diabetes risk data mining method based on electronic medical record analysis and intends to provide some ideas and directions for the research of diabetes risk data mining method. This paper proposes a research strategy of diabetes risk data mining method based on electronic medical record analysis, including data mining and classification rule mining based on electronic medical record analysis, which are used in the research experiment of diabetes risk data mining method based on electronic medical record analysis. The experimental results in this paper show that the average prediction accuracy of the decision tree is 91.21%, and the results of the training set and the test set are similar, indicating that there is no overfitting of the training set.

scholarly journals The Implementation of Electronic Medical Record (EMR) in The Development Health Care System in Indonesia

2021 ◽  
Vol 4 (3) ◽  
Author(s):  
Nuke Amalia ◽  
Muh Zul Azhri Rustam ◽  
Anna Rosarini ◽  
Dina Ribka Wijayanti ◽  
Maya Ayu Riestiyowati
Keyword(s):  
Health Care ◽  
Information Technology ◽  
Medical Record ◽  
Electronic Medical Record ◽  
Medical Records ◽  
Health Sector ◽  
Developed Countries ◽  
The United States ◽  
Long Time ◽  
The Cost

The development of information technology is now growing rapidly, including in the health sector. According to WHO, medical record is an important compilation of facts about a patient's life and health. The development of information technology in medical records is the electronic medical record (EMR). Developed countries, such as the United States and Korea have implemented EMR for a long time. In developing countries such as Indonesia, the development of EMR is still in progress because its implementation requires many factors to build a system or replace from manual medical records. Eventually, it is hoped that in the future all health care will use the EMR to resume patient datas from admission to discharge. The purpose of this study is to analyse the implementation and preparation of EMR in health care in Indonesia. This study is a literature review on the implementation and preparation of EMR in health care in Indonesia. The review is dome from 28 literature sources (Google-Scholar database). Total of 8 articles were obtained from 2017 to 2021. The results show that there are benefits after switching to EMR, even though some health care only used EMR in certain units. The highest benefit is reducing the cost of duplicating paper for printing. Also there is still limited human resources and tools for implementing EMR in Indonesia. The implementation of this EMR will enable the improvements of the service quality of the health care itself, especially in Indonesia.

scholarly journals ELECTRONIC MEDICAL RECORD AT RSIGM SULTAN AGUNG SEMARANG REVIEWED FROM THE COMPLETENESS AND THE SAFETY FORMAT SYSTEM

Jurnal Medali ◽  
2021 ◽  
Vol 3 (1) ◽  
pp. 20
Author(s):  
Adam Reza Pahlevi ◽  
Erdianto Setya Wardhana ◽  
Erna Dwi Agustin
Keyword(s):  
Medical Record ◽  
Electronic Medical Record ◽  
Electronic Medical Records ◽  
Medical Records ◽  
Inclusion Criteria ◽  
Health Ministry ◽  
Cross Sectional ◽  
Electronic Signature ◽  
Informed Consent Form ◽  
The Subject

Background: An electronic medical record is a medical system that can be used to store information about the track of a patient`s health. The completeness format of Electronic Medical Record used the format of Electronic Medical Record Guidance from Health Ministry Year 2015. The safety of electronic medical records has 6 aspects as follows privacy, integrity, authenticity, availability, access, control, non-rapadiatum.Method: This research aimed to know the description of the completeness format and the safety of The Electronic Medical Record at RSIGM Sultan Agung Semarang. This research used descriptive observational using a cross-sectional method. The subject of this study was Electronic Medical Records in March 2020. The samples were selected according to the inclusion criteria obtained from RSIGM Sultan Agung SemarangResult: The result of this research was used to know the description of the completeness of Electronic Medical Record Format and the safety of Electronic Medical Record at RSIGM Sultan Agung Semarang.Conclusion: The conclusion of this research showed Electronic Medical Record had been applied at RSIGM Sultan Agung Semarang but there are still lack in the informed consent form and the informed refusal, the safety of the electronic medical record was still lack in the electronic signature format.

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