Implementation of chest X-ray observation report entry system

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. © 2010 The Korean Society of Medical Informatics.