Healthc Inform Res.  2010 Dec;16(4):305-311. 10.4258/hir.2010.16.4.305.

Implementation of Chest X-ray Observation Report Entry System

• Seo ST
• Park HJ
• Kim MS
• Son CS
• Park HS
• Jeon HC
• Jung CY
• Kim YN

• KMID: 2284544
• DOI: http://doi.org/10.4258/hir.2010.16.4.305

Abstract

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.

Keyword

Chest X-ray; Electronic Medical Record; Standardized Clinical Information; Entry System; Picture Archiving and Communication System

MeSH Terms

Electronic Health Records
Humans
Semantics
Thorax

Figure

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  Figure 1 Medical record elements. POMR: problem-oriented medical record, Hx: history, PE: physical examination, R/O: rule out, OP: operation, SOAP: subjective-objective-asessment-plan.

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  Figure 2 Example of results report. (A) Laboratory result. (B) Observation report.

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  Figure 3 System process. DB: database, EMR: electronic medical record, OCS: order communication system, PACS: picture archiving and communication systems.

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  Figure 4 Applicable field of observation results using the proposed entry system.

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  Figure 5 The configuration of the proposed system.

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  Figure 6 Example of searching for specific patient.

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  Figure 7 Implemented indexes and input options.

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  Figure 8 Results extraction as excel format.

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