Implementation of Chest X-ray Observation Report Entry System / 대한의료정보학회지

OBJECTIVES: X-rays are widely used in medical examinations. In particular, chest X-rays are the most frequent imaging test. However, observations are usually recorded in a free-text format. Therefore, it is difficult to standardize the information provided to construct a database for the sharing of clinical data. Here, we describe a simple X-ray observation entry system that can interlock with an electronic medical record system. METHODS: We investigated common diagnosis indices. Based on the indices, we have designed an entry system which consists of 5 parts: 1) patient lists, 2) image selection, 3) diagnosis result entry, 4) image view, and 5) main menu. The X-ray observation results can be extracted in an Excel format. RESULTS: The usefulness of the proposed system was assessed in a study using over 500 patients' chest X-ray images. The data was readily extracted in a format that allowed convenient assessment. CONCLUSIONS: We proposed the chest X-ray observation entry system. The proposed X-ray observation system, which can be linked with an electronic medical record system, allows easy extraction of standardized clinical information to construct a database. However, the proposed entry system is limited to chest X-rays and it is impossible to interpret the semantic information. Therefore, further research into domains using other interpretation methods is required.

Development of Critical Pathway for Laparoscopic Assisted Vaginal Hysterectomy by CPA program / 대한의료정보학회지

OBJECTIVE: The aim of this study was to develop critical pathway for post operation care of laparoscopic assisted vaginal hysterectomy with time and cost effectiveness using a clinical pathway assistant program (MDCPA(TM), MDware Co.) METHODS: Procedure was done with the following steps; establishment of conceptual framework, development of preliminary critical pathway using CPA program, expert validity test, and confirmation of final critical pathway. RESULTS: Preliminary critical pathway was extracted by CPA program, and this result was verified by expert validity test. The process of data collection and analysis to develop the preliminary critical pathway was accomplished automatically by CPA program. The patients' hospitalization period in the aspect of time and cost effectiveness was confirmed as 6 days, and each item of assessment, test, medication, treatment, diet, activity, and teaching were finalized. CONCLUSION: The CPA program can automate the complicated process, which contains collecting and cleaning the large size EMR data, classifying and confirming the items in critical pathway, so that the time and cost to develop a critical pathway can be reduced. This program is expected to be used for development of critical pathway in a variety of clinical settings in the aspect of time and cost effectiveness.