KR100760955B1 - System of managing electrical medical information and method of generating electrical medical information - Google Patents

Abstract

The present invention relates to an electronic medical record management system and an electronic medical record management method. The electronic medical record management system stores basic customer information and medical information of the client (patient), and retrieves the customer information and medical information when the client receives medical care, and provides only digital pens or voices for the items requiring additional records. Use it to record. The official certificate is inserted into the electronic medical record thus created to generate a general document file, and the generated document file is encoded along with the customer information and medical information to generate a medical record message. The medical records management system decodes medical records and medical information from medical records generated by medical records and manages them by database.

Medical records, electronic documents, HL7  

Description

SYSTEM OF MANAGING ELECTRICAL MEDICAL INFORMATION AND METHOD OF GENERATING ELECTRICAL MEDICAL INFORMATION}

1 is a schematic conceptual diagram of an electronic medical record management system and a client terminal according to an embodiment of the present invention;

2 is a flowchart illustrating a method of generating medical record information in a client terminal according to an embodiment of the present invention;

3A and 3B are diagrams illustrating a user interface of a medical recording module of a client terminal according to an embodiment of the present invention, respectively.

3C is a view showing a state where the medical record document is executed in the general-purpose viewer program,

4 is a diagram illustrating a format of a primary medical record message according to an embodiment of the present invention;

5 is a flowchart illustrating a method of processing a secondary medical record message in an electronic medical record management system and a local medical system according to an embodiment of the present invention;

6 is a diagram illustrating a format of a secondary duty record message according to an embodiment of the present invention.

The present invention relates to an electronic medical record management system and an electronic medical record generating method.

Medical institutions, such as hospitals, managed medical records by using paper documents (charts). Medical institutions have a legal obligation to keep these medical records for a certain period of time. This results in high costs due to the space for keeping medical records made of paper documents. As an alternative, electronic medical records are being introduced. However, such an electronic medical record management system does not use the existing prescription delivery system, and thus requires a new prescription delivery system, which is expensive in hospital.

In particular, the recent revision to the Medical Law has allowed medical institutions to keep electronic medical records instead of paper documents. However, since the electronic medical record has a problem of forgery regarding medical records, there is a problem of legal certification in order to have a legal effect according to the medical law and the electronic signature law.

And since medical records are not shared among hospitals using different systems, patients often receive the same medical care when they move to hospitals, and they have to visit their own medical records in person. There is inefficiency.

SUMMARY OF THE INVENTION The present invention has been made in an effort to provide an electronic medical record management system and an electronic medical record generating method capable of generating an electronic medical record having legal effect.

Another object of the present invention is to provide an electronic medical record management system and an electronic medical record generating method capable of generating an electronic medical record that can be shared with medical information.

In order to solve this problem, according to an aspect of the present invention, there is provided a method of generating an electronic medical record in a client terminal connected via a network and a local medical system storing the medical information of the customer. According to this method, the medical care information is received from the local medical care system, the medical care information is output, and the medical record which is the result of the medical care is recorded. Next, an authorized certificate is stored together with the medical record to generate a medical record document, and the medical record message is generated by adding customer information and information of the medical record document to the medical record document. And transmits the medical record message to the local medical system.

According to an embodiment of the present invention, time information received from an authorized time server is further added to the medical record information.

According to another embodiment of the present invention, the medical record document is stored in a format readable by a general purpose viewer running on a computer.

According to another feature of the invention, there is provided an electronic medical record management system connected via a network with at least one local medical system. The electronic medical record management system of the present invention includes a push server for receiving a first medical record message from the local medical system, and decoding the medical record information and the customer information from the first medical record message and storing the data for each customer. Include a database. Here, the medical record message includes customer information about the client who has been treated and medical record information indicating the result of treating the client.

DETAILED DESCRIPTION Hereinafter, exemplary embodiments of the present invention will be described in detail with reference to the accompanying drawings so that those skilled in the art may easily implement the present invention. As those skilled in the art would realize, the described embodiments may be modified in various different ways, all without departing from the spirit or scope of the present invention. In the drawings, parts irrelevant to the description are omitted in order to clearly describe the present invention. Like reference numerals designate like parts throughout the specification.

1 is a schematic conceptual diagram of an electronic medical record management system, a local medical system and a client terminal according to an embodiment of the present invention.

As shown in FIG. 1, the electronic medical record management system 100 according to the embodiment of the present invention is connected to at least one local medical care system 200 through a network, and the local medical care system 200 is at least one. The client terminal 300 is connected through a network. The local medical system 200 may be installed in a medical institution such as a hospital, and a wireless or wired network may be used as the network.

The local medical system 200 includes a medical information server 210 and a medical record storage server 220, and manages medical record messages that are electronically transmitted from the client terminal 300. Here, the medical information server 210 and the storage server 220 may be formed integrally, or may be formed separately to communicate with each other in a network. The medical information server 210 records the patient's personal information and medical history information related to the patient's past prescriptions, for example, an order communication system (OCS) server. The medical record storage server 220 stores the medical record message transmitted from the client terminal 300, adds an identifier (ID) to the message, and transmits the medical record message to the electronic medical record management system 100. As such, the procedure of adding and delivering the message ID may be performed through a push agent (not shown).

The client terminal 300 is provided with a medical record module 310 and the authentication module 320, the medical record module 310 is electronically transmitted from the authentication module 320 to the medical record input to the client terminal 300 A medical record document is created by adding a certified certificate. The authentication module 320 provides the medical record module 310 with an authorized certificate corresponding to the person in charge of the client terminal 300 or the terminal 300. The authentication module 320 receives a public certificate having a predetermined validity period from the authentication server 400 and stores the public certificate in a temporary storage medium such as a hard disk or a USB memory stick of the client terminal 300, and stores the stored public certificate. It may be provided to the medical record module 310. Alternatively, the authentication module 320 may receive an authorized certificate from the external authentication server 400 in real time whenever the medical record module 310 requests, and transmit it to the medical record module 310.

In addition, the authentication module 320 provides an authorized certificate to the medical record module 310, and authenticates the identity using the certificate when generating the electronic medical record in the medical record module 310. At this time, the electronic medical records are stored with the authentication information, and the certification stored medical records document is validated through the validity test through an accredited certification authority. In addition, the authentication information is composed of information on the authentication time and information on the authenticator. The information on the authentication time includes authentication time information provided from the time server built in the authentication server 400 or operated by an authorized certification authority. The information of the authenticator may be a license number or a social security number of the authenticator (doctor), and such information is information for identifying the authenticator.

In this way, since the authentication time is stored together with the authentication record through the authentication module 320, tampering with time is impossible. When the generated medical record document is modified and stored, the original file and the modified file remain separately. Therefore, the modified contents can be managed. In addition, the medical record document is stored as a document that can be read by a general-purpose viewer program, and if the document is attempted to be tampered with by another editing program, the document is in violation of the integrity of the document into which the certificate is inserted. Integrity violation can be made through the validation check described above.

The medical record module 310 and the authentication module 320 are stored in a recording medium which is manufactured as a program and can be read by an electronic device such as a computer.

In addition, the electronic medical record management system 100 includes a push server 110 and a database 120, and the push server 110 collects the customer information and the medical record document in the medical record message transmitted from the local medical system 200. Decoded and stored in the corresponding field of the database 120 for each customer.

Hereinafter, a method of processing a medical record in the electronic medical record management system 100, the local medical system 200, and the client terminal 300 according to an exemplary embodiment of the present invention will be described in detail with reference to FIGS. 2 to 6. do.

2 is a flowchart illustrating a method of generating a medical record document in a client terminal 300 according to an embodiment of the present invention. 3A and 3B are diagrams illustrating a user interface of the medical record module 310 of the client terminal 300 according to an exemplary embodiment of the present invention. 3C is a diagram showing a state where the medical record document is executed in the general-purpose viewer program. 4 is a diagram illustrating a format of a primary medical record message according to an embodiment of the present invention.

As shown in FIG. 2, a client terminal (hereinafter referred to as "the person in charge") who first prepares a medical record such as a doctor before starting treatment for a person to be treated (hereinafter referred to as a "customer") is a client terminal. The medical record module 310 is executed through the 300 (S210). The medical record module 310 communicates with the medical information server 210 to retrieve medical care information about the corresponding customer from the medical information server 310 (S220). Then, as shown in FIG. 3A, the medical record module 310 provides the user interface displaying the medical care information of the corresponding client through the client terminal 300. In this way, if the person in charge does not need to record the duplicate contents again, only the updated medical record after the medical treatment needs to be recorded.

The medical information includes customer information and medical history information, and the customer information may include personal information such as social security number, name, address, and contact information of the client, and the medical history information may include information about the past medical history of the client. have. The user interface is divided into a screen area for displaying personal information such as customer information, a bookmark area 311 for moving a screen related to medical treatment, and an area 312 for displaying actual contents. In addition, the content display area 312 is divided into an area 312a for displaying the medical information which is basically called according to the customer and an area 312b for the medical personnel to enter a medical record after the medical treatment.

Next, as shown in FIG. 3b, the person in charge inputs a medical record such as medical record and prescription according to medical care to the medical record module 310 after the customer is treated at step S230. In this case, the medical record may be input to the medical record input area 312b by a digital pen and / or voice. When the client terminal 300 is a tablet computer, the medical personnel may input the medical record to the medical record module 310 by writing a medical record directly on the terminal 300 using a digital pen. In addition, when the tablet pad is connected to the client terminal 300 through an interface, a medical record may be created by the digital pen on the tablet pad. In this way, the medical record created by the digital pen is input to the medical record module 310 in the form of an image. When the medical record is input as a voice, the medical record module 310 may store the voice after compressing the voice through a compression codec. At this time, the certificate is stored in the inserted form, which is stored in the form that can be played in the attachment or dedicated viewer in the dedicated viewer.

When the person in charge stores the medical record after completing the input of the medical record module 310, the medical record module 310 calls the authentication module 320 (S240). The authentication module 320 checks the validity through an authorized certificate corresponding to the client terminal 300 of the person in charge or the person in charge and, if the certificate is valid, provides the certificate and authentication information to the medical record module 320 (S250). ). And the medical record module 310 generates a medical record document by combining the medical information, medical records, certificates and authentication information of the customer (S260). In this case, the medical record document is generated in a format capable of simultaneously displaying multimedia information and text information such as an image and / or voice. For example, it may be a format that can be read by a general-purpose viewer program such as Adobe Acrobat, DejaVu, FlashPaper, and compact shared document (CSD). In addition, the medical record module 310 may store the date on which the medical record is generated and the information of the person who created the medical record in the medical record document.

As shown in Fig. 3C, when the medical record document is executed by the general-purpose viewer program, it is displayed along with the medical record whether the certificate (signature) is valid, the date and time of authentication, and the like. In particular, the time information displayed on the left side of the screen in "2005-03-23 16:52:15" indicates the authorized authentication time.

Next, the medical record module 310 adds tag information to the medical record document to generate a primary medical record message 311 (S270), and generates the generated primary medical record message 311 by the local medical system 200. Transfer to (S280). The medical record module 310 receives tag information from the medical information server 210, and the tag information may be information according to standard protocols to be utilized even between heterogeneous systems. In the embodiment of the present invention, the tag information is described as information according to the health level 7 (HL7) protocol.

As shown in FIG. 4, the primary medical record message 311 includes a tag consisting of a message header (MSH) segment, a customer information (PID) segment, and a document notification (TXA) segment. And a medical record field consisting of a field 311a and an observation (OBX) observation segment. The message header MSH consists of a header of the medical record message 311, and the customer information PID includes personal information such as a social security number, a name, an address, and a contact number of the customer. The enterprise document information (TXA) has information on the medical record document included in the medical record message 311, and specifically, the document type, the file name of the document, the date of document authentication, the date of document creation, the document confidentiality status, the document authenticator And so on. Such customer information and transcription document information is collected and generated from the corresponding customer information in the database of the medical information server 210.

In the observation identifier (OBX) segment, the medical record document received from the client terminal 300 is stored with information encoded according to the size of the medical record message 311, and other medical information is encoded and stored together. Specifically, the Observation Identifier (OBX) segment has information about a client's specific medical history (eg, hospital information, illness name, treatment name, etc.) and a medical record document.

Next, a method of processing the secondary medical record message in the electronic medical record management system 100 according to an embodiment of the present invention will be described with reference to FIGS. 5 and 6. 5 is a flowchart illustrating a method of processing a secondary medical record message in the electronic medical records management system 100 and the local medical system 200 according to an embodiment of the present invention, and FIG. It is a figure which shows the format of a secondary duty record message.

As shown in FIG. 5, the storage server 120 of the local duty system 200 stores the primary duty record message 311 received from the client terminal 300 (S510). As shown in FIG. 6, the storage server 120 adds a message ID (identifier) for identifying each message to the received medical record message 311 to generate a secondary medical record message 121 ( In operation S520, the generated medical record message 121 is transmitted to the electronic medical record management system 100 (S530). In this case, the medical record message 121 may be secured by being transmitted through a secure communication such as a secure socket layer (SSL) / transport layer security (TLS) communication.

When the push server 110 of the electronic medical record management system 100 receives the secondary medical record message 121, the push server 110 checks the message ID and transmits a confirmation message to the storage server 220 (S540). In this way, it is possible to check whether the message is received for each message ID. Next, the push server 110 decodes the medical record document included in the Observational Observation (OBX) segment in the secondary medical record message 121 and stores it in the corresponding field of the database 120, and also stores the customer information (PID) segment. And other information included in the transcription document information (TXA) segment and decoded in the corresponding field of the database 120 (S550). The push server 110 stores data for each customer based on the customer information when the push server 110 stores the database 120.

In this way, the electronic medical record management system 100 may manage the medical record certified by the customer. Since the medical record message is generated for each client, the medical record document and / or the medical record can be delivered when another medical institution or the client requires the medical record. In addition, access to the information stored in the database 120 may be restricted through a security authentication module such as a public key infrastructure (PKI) and an ID and password provided for each individual.

Next, a method of processing customer information and medical care information in the medical information server 210 of the local medical care system 200 according to an exemplary embodiment of the present invention will be described.

The medical information server 210 is connected to the terminal through a network. In general, when a customer first visits a medical institution, a user of the terminal (eg, a nurse, a receptionist, etc.) inputs customer information into the terminal and generates identification information. In this way, the customer information and identification information input to the terminal is transferred to the medical information server 210, the medical information server 210 stores the customer information based on the identification information. As an example of such identification information, a chart number generated for each customer may be used.

If the user of the terminal inputs the basic medical care history of the customer after the customer has completed the medical care, the medical care information is transmitted to the medical information server 210. The medical information server 210 stores the medical history as medical information according to a preset format based on the identification information. In this way, if the medical information is stored based on the identification information, the client does not have to re-enter the same contents when the client visits again, and also directly retrieves the information necessary when generating the medical record.

Although the embodiments of the present invention have been described in detail above, the scope of the present invention is not limited thereto, and various modifications and improvements of those skilled in the art using the basic concepts of the present invention defined in the following claims are also provided. It belongs to the scope of rights.

Thus, according to the embodiment of the present invention, it is possible to generate a certified medical electronic record having a legal effect in accordance with the medical law and the digital signature law in various forms, such as a digital pen or voice recording. The electronic medical records comply with standard protocols such as HL7 and are stored in a universal file format, allowing medical information to be shared between hospitals. These electronic medical records can be centrally managed and integrated into a centralized database so that doctors and patients can easily provide the information they need. It also automatically retrieves basic customer and care information when you create a medical record, so you don't have to enter duplicates. In addition, since the electronic medical record according to the embodiment of the present invention is legally authenticated and stored, it is possible to provide an electronic medical record as a litigation material in medical litigation. And with fewer paper charts, you can save space and administrative staff for paper charts.

Claims (16)

Claims [1] A method of generating an electronic medical record in a client terminal connected through a network and a local medical system storing medical information of a customer. Receiving medical care information about the client from the local medical care system and outputting the medical care information; Recording a medical record which is information of a client in addition to the medical care information; Storing a medical certificate along with the medical record to generate a medical record document, Generating a medical record message by adding additional information including customer information to the medical record document; and Delivering the medical record message to the local medical system Including, Generating the medical record document, The time information received from the authorized time server is further added to the medical record information, The medical record message, A first segment containing a message header, A second segment including customer information consisting of the personal information of the customer, A third segment including creation date, format information, file name of the medical record document, and A fourth segment containing said medical record document encoded in a certain size; Electronic medical record generation method comprising a. delete The method of claim 1, And said medical record document is stored in a format readable by a general purpose viewer running on a computer. The method of claim 3, And the format is capable of representing at least one of multimedia information and text information. delete The method of claim 1, The fourth segment further comprises a medical history of the customer. The method of claim 6, The medical record message is an electronic medical record generation method according to the health level 7 (HL7) protocol. The method according to any one of claims 1, 3 or 4, The past medical history and the customer information of the customer in the medical record document is provided in the medical information electronic medical record generation method. A computer-readable recording medium in which the electronic medical record generating method according to any one of claims 1, 3 or 4 is recorded. An electronic medical record management system connected via a network with at least one local medical system, Receiving a first medical record message from the local medical system, the medical record message includes a push server including the customer information about the patient receiving the medical care and the medical record information indicating the result of the medical treatment, A database which decodes the medical record information and the customer information from the first medical record message and stores them for each customer. Including, The first medical record message further includes a message identifier, The push server determines the local medical system that has transmitted the first medical record message from the message identifier and transmits a confirmation message to the determined local medical system, The first medical record message, A first segment comprising the message identifier, A second segment including a header of the medical record message, A third segment containing the customer information, A fourth segment including creation date, format information, file name of said medical record document, and A fifth segment containing said medical record document encoded in a certain size; Electronic medical record management system comprising a. delete delete The method of claim 10, The medical record document is an electronic medical record management system that stores a public certificate, a certified time and information of the authenticator. The method of claim 13, And the decoded medical record document has a format readable by a universal viewer executable on a computer. The method of claim 13, And the local medical record system receives the second medical record message from a client terminal and generates the first medical record message by adding the message identifier to the second medical record message. The method of claim 15, The first medical record message is an electronic medical record management system that is a message according to the health level 7 (HL7) protocol.

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