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The Korean Journal of Gastrointestinal Endoscopy Review 전자내시경의무기록을위한내시경보고서 조유경 가톨릭대학교의과대학서울성모병원소화기내과학교실 The Endoscopic Report for Endoscopic Electronic Medical Records Yu Kyung Cho, M.D. Department of Internal Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea Electronic medical record systems for endoscopic data have evolved from simple endoscopy report generators to endoscopy unit managers. These systems may improve patient care and enhance endoscopy unit efficiency and productivity. Regarding endoscopists, the introduction of automated endoscopic reporting using endoscopic electronic medical records should permit database establishment. The systematic development of the structure and content of endoscopic reports is mandatory before it is possible to create large, clinically useful databases of endoscopic reports. An accurate endoscopic report is based on the use of standard terminology, a standard classification method, and image and video recordings. The minimal standard terminology was developed as a minimum list of terms that could be included in a computer system for endoscopic reporting. A standard framework of endoscopic reports using standard terminology and a minimal checklist of endoscopic images are also needed for quality assurance. (Korean J Gastrointest Endosc 2010;41:189-195) Key Words: Electronic medical record, Endoscopy 교신저자. 조유경가톨릭대학교의과대학서울성모병원소화기내과학교실 (137-701), 서울시서초구반포동 505 전화 : 02-2258-6024 팩스 : 02-2258-2053 이메일 : ykcho@catholic.ac.kr 접수. 2010 년 7 월 31 일승인. 2010 년 9 월 30 일 서론정보화에맞추어국내의료기관에서전자의무기록시스템 (electronic medical record, EMR) 의도입이확산되고있다. EMR 은환자의모든정보를전산화하여의료기관의수기작업을최소화하고종이차트에서전자차트로의단순한전환이아니라환자대기시간감소, 정보저장의편의성, 환자기록에대한의료인의접근용이, 정보의다양한활용, 비용절감등유무형의가치가엄청나다. 그러나 EMR 도입에앞서의무기록의서식및내용의표준화, 보안문제등이아직해결되어야할문제이다. 내시경기록도마찬가지로이전의수기또는구술과받아쓰기를이용한기존기록방법에서점차전자내시경의무기록 (endoscopic electronic medical record) 으로변화하는추세이다. 전산화된내시경기록은임상연구와질관리가가능하도록내시경결과의데이터베이스생성을가능하게한다. 1 그러기위해서는처음부터내시경보고서의구조를계획할때부터표준보고서의형식과데이터입력필드들을갖추고, 표준화된용어를선택하여결 과를입력하는것이중요하다. 유럽소화기내시경학회에서는내시경보고서는 1) 표준내시경용어와 2) 표준분류방법을사용하여기술되어야하고 3) 전산화, 4) 영상또는동영상기록이있어야한다고말하고있다. 2 전자내시경의무기록의장점을가장잘이용하기위해서는표준용어와표준형식을갖추는것이가장중요하다. 본론 1. 표준내시경용어 내시경소견을기록하는목적은크게정보의교환과자료의저장이다. 내시경수련의의교육수단이며의료소송을대비한증거가되기도한다. 내시경을의뢰한의사에게, 또는환자의전원시, 추적내시경검사시, 내시경의사간의사교환을위해서는자기만아는용어보다는전세계적으로통용되는표준내시경용어를사용하여야한다. 3 1994년 World Organization of Digestive Endoscopy (Organization Mondiale d'endoscopie Digestive; OMED) 의내시경 Vol. 41, No. 4 October, 2010 (189-195) 189

용어위원회를중심으로유럽소화기내시경학회, 미국과일본의소화기내시경학회의대표들이모여범세계적으로통용될수있는, 내시경데이터의전자기록에필요한최소한의표준내시경용어를수록한 minimal standard terminology (MST) 를제시하였다. 내시경기기, 술기가발전하고진단이확대되면서 OMED 의용어위원회에서 MST를지속적으로개정하고있는데가장최근의 MST 3.0에는내시경초음파, 캡슐내시경, 소장내시경관련용어와확대된내시경진단과적응증, 새로운치료와부작용, 최신분류법등이새로포함되어있다. 대한소화기내시경학회에서도 1994년소화기내시경학용어집을발간하였고 1996 년에는상부위장관내시경소견기재요강안을마련한바있으나이후로는내시경용어개정작업이지속적으로이루어지지못하는실정이다. MST는서로다른내시경센터간, 또는국가간내시경데이터를적절하게비교, 공유하기위해내시경결과기록에사용되 는어떤컴퓨터시스템에서도사용이가능한최소한의용어를정의하고자하는목적으로제정되었다. MST는결과를데이터베이스화하고통계분석을가능하게하며수기나타이프기록의필요성을줄이는장점이있다. MST는내시경보고서를작성할때사용되는내시경관련소프트웨어의기본이되며표준보고서의용어 ( 내용 ) 와구조를지정하고내시경기록시스템간에내시경이미지저장과전송을가능하게한다. MST는소견의적절한묘사를위한소프트웨어를완벽하게제공하지않지만내시경결과소프트웨어를개발할때필요한용어의목록을선택하고프로그램의구조를만드는데가이드로서의역할을한다. 4 유럽소화기내시경학회에서는모든내시경보고서는 MST에근거를두어작성되어야한다는것을강조하고있다. 올림푸스의 Endobase, 후지논의 ADAM medical documentation system과같은전자내시경의무기록소프트웨어들은 MST를이용한데이터의저장과내시경보고서생성이가능하다. in length Table 1. Classifications Presented in the Minimal Standard Terminology 3.0 LA classification of erosive Grade A Mucosal break <5 mm esophagitis 14 Grade B Mucosal break >5 mm Grade C Mucosal break continuous between >2 mucosal folds Grade D Mucosal break >75% of esophageal circumference Size classification of esophageal varices 15 Grade 1 = Small and nontortuous esophageal varices, flattened with insufflation Grade 2 = Tortuous esophageal varices but covering less than 50% of the radius of the distal esophagus Grade 3 = Large and tortuous esophageal varices covering more than 50% of the radius of the distal esophagus Paris classification of neoplastic lesions 16 Japanese Gastric Cancer Association classification of superficial neoplastic lesions 17 Type 0 - Superficial polypoid, flat/depressed, or excavated tumors Type 1 - Polypoid carcinomas, usually attached on a wide base Type 2 - Ulcerated carcinomas with sharply demarcated and raised margins Type 3 - Ulcerated, infiltrating carcinomas without definite limits Type 4 - Nonulcerated, diffusely infiltrating carcinomas Type 5 - Unclassifiable advanced carcinomas Protruding - Pedunculated 0-1p - Sessile 0-1s Non-protruding and nonexcavated - Slightly elevated 0-IIa - Completely flat 0-IIb - Slightly depressed 0-IIc - Elevated and depressed types 0-IIc+IIa 0-IIa+IIc Excavated - Ulcer 0-III - Excavated and depressed types 0-IIc+III 0-III+IIc Forrest classification of ulcer Forrest Ia Arterial, spurting hemorrhage bleeding 18 Forrest Ib Oozing hemorrhage Forrest IIa Visible vessel g=vessel <2 mm, G=vessel >2 mm Forrest IIb Adherent clot Forrest IIc Hematin-covered lesion Forrest III No signs of recent hemorrhage 190 The Korean Journal of Gastrointestinal Endoscopy

Table 1. Continued Kudo classification of colon polyp surface pattern* 19 Bismuth classification of cholangiocarcinoma 20 Type I: Extrahepatic involvement only Type II: Extrahepatic and hilar involvement Type IIIa: Extrahepatic, hilar and right-sided segmental involvement Type IIIb: Extrahepatic, hilar and left-sided segmental involvement Type IV: Extrahepatic and bilateral segmental involvement *In the large bowel, the organization of the surface epithelium, or pit pattern, has been analyzed with magnification and contrast and grossly classified into 5 patterns or types, which can be grouped into 3 categories: type I and type II (non neoplastic); type IIIS, IIIL, and IV (low-grade and high-grade intramucosal neoplasia); and type V, with distorted epithelial crests or an amorphous surface (carcinoma with suspicion of submucosal invasion). 내시경용어와구조에는유연성이있어야하며사용자의요구와피드백을받아지속적으로개정되어야한다. 또한표준내시경용어는쉽게이해되고정확한정의를가지고있어야하며, 일반적인용어이고사용시저작권등에의한제한이없어야한다. 표준용어를만든목적이전산을의사교환이가능하도록데이터베이스를생성하는데있으므로표준용어의수는가능한제한하여야한다. 가능하면내시경용어를처음에정의할때텍스트로나열하는것보다는영상을이용하는것이정확하다. 내시경소견을기록할때는널리소통되고있는표준분 류법을이용하여야한다. MST 3.0의부록에표준분류법을 Table 1에제시하였다. 2. 내시경보고서 1) 내시경보고서의권장안 : 내시경보고서의완성도로내시경의질을측정할수있다. 여러나라의내시경학회마다권장하는내시경보고서는약간씩차이가있어어떤항목은항상포함되고어떤항목은기관에따라포함되기도하고포함되지않기도한다. Vol. 41, No. 4 October, 2010 (189-195) 191

우리나라의국가암조기검진위내시경, 대장내시경질평가를담당하는대한소화기내시경학회에서도위내시경결과보고서와대장내시경결과보고서의권장안을마련하였다. 5 위내시경결과보고서에포함될내용으로 1) 검사일, 2) 환자등록번호, 3) 내시경시술자, 4) 중요병력및특이사항, 5) 약제사용 ( 마취제, 진통제, 진정제등 ), 6) 생검유무, 7) 관찰소견, 8) 진단명, 9) 합병증의기입을권고하였다. 대장내시경결과지는위에열거한항목외에장정결상태, 맹장삽입여부를포함하도록하였다. 1차또는 2차의료기관에서주로담당하는암검진내시경의경우특히위, 대장내시경검사결과보고서만으로상급의료기관으로의뢰할수있는충분한정보를가지는것이중요하다. 미국소화기내시경학회 6 와유럽소화기내시경학회 2,7 에서권장하는위내시경, 또는대장내시경보고서는위의항목이외에도검사의적응증, 동의서획득유무, 내시경시술자뿐아니라내시경보조자와마취의사, 사용된내시경기기, 검사소견의자세한기술과향후추적계획, 합병증발생시그결과까지모두추가할것을권고하고있다. 2) 전자내시경의무기록의작성 : 전자내시경의무기록의가장큰장점은내시경자료를데이터베이스화하고저장, 관리하는것이다. 내시경보고서를작성하기위해자유롭게텍스트로입력할수도있고풀다운메뉴에서용어를선택하여입력할수있다. 대부분의시스템이풀다운메뉴와자유텍스트 (free text) 입력기능을모두가지고있다. 증상, 결과의자세한설명, 합병증이나또는권고사항처럼복잡하거나자세한설명이필요한경우에는자유텍스트형식이더좋을수도있다. 하지만데이터베이스화를위해서는소견을서술형또는자유텍스트로쓰 기보다는각입력필드마다, 최소표준용어를이용한풀다운메뉴를만들고이중적합한용어를선택하는것이좋다. 각입력필드마다용어를선택하여입력하는방식은적은시간으로결과기록지를생성할수있고자유텍스트보다정확하고간결하며데이터처리가용이하다. 검사의적응증과진단명도가능한최소표준용어 (MST) 또는국제질병코드 (International Classification Diseases, ICD-10) 와매치하여자동으로연결되도록하는것이좋다. 8 3. 내시경영상기록 내시경결과는반드시영상기록으로남겨야한다. 내시경사진은정보전달과자료보관목적뿐아니라, 교육, 수검자에대한설명, 내시경질관리의자료로활용될수있다. 환자와의사, 의사와의사간의정보전달을위해서는잘서술된기록보다잘찍은영상기록이더욱중요하다. 1) 위내시경촬영권장부위 : 유럽소화기내시경학회에서내시경정도관리를고려하여상부위장관내시경검사가검사가완전하고적절히시행되었음을검증하기위한방법으로, 병변이없더라도식도 2장, 위 4장, 십이지장 2장등최소 8개의내시경사진을찍도록권장한바있다 (Fig. 1). 2 사진을촬영하는부위는 1 상부식도, 상절치로부터 20 cm 떨어진부위, 2 위식도접합부, Z line 상방 2 cm 부위 ( 식도염이나바렛식도에서중요한위치임 ), 3 분문부 ( 내시경을반전시켜분문부와위저부가모두보이도록촬영 ), 4 위소만측의상부, 공기로충분히부풀린후위체부전체가보이도록촬영, 5 위각 ( 내시경을부분반전시켜내시경선단을위각밑에위치시키고촬영 ), 6 전체전정부의모습이보이도록전정부촬영, 7 십이지장구부 Figure 1. Recommended pictures for endoscopic reports (European Society of Gastrointestinal Endoscopy). 2 Figure 2. Recommended pictures for colonoscopic reports (European Society of Gastrointestinal Endoscopy). 2 192 The Korean Journal of Gastrointestinal Endoscopy

( 내시경선단을유문륜바로지난부위에위치시키고촬영 ), 8 십이지장제2부 ( 내시경선단을십이지장유두부근처에위치시키고촬영 ) 등이다. 이화상으로내시경검사가완전히이루어졌음을알수있다. 병변의사진과수술받은환자는문합부사진을추가하도록하고있다. 2) 대장내시경촬영권장부위 : 병변이없더라도전체의대장을충분히관찰하였음을증명하기위해대장의부위별로촬영하는것이좋다. 유럽소화기내시경학회는일반적으로 8 부위의촬영을권장한다 (Fig. 2). 2 8 부위는 1 항문연으로부터 2 cm 위치에서전체직장을바라보며촬영, 2 구불결장중간부위, 3 비만곡부직하방하행결장에서촬영 ( 비만곡부는고정점이면서때로비장이푸르게비쳐보이므로이를사진으로남기면좋다 ), 4 비만곡부바로근위부의원위횡행결장에서촬영, 5 간만곡부바로원위부근위횡행결장에서촬영 ( 간만곡부의검푸른간음영이보이도록촬영한다 ), 6 간만곡부바로근위부원위상행결장, 7 회맹판, 8 충수개구부 ( 이는전대장을관찰했음을증명하는지표가된다 ) 등이다. 한편융모에의한회장점막의특징적모양이나타나도록회장말단사진을촬영하는것도추천된다. 직장에서내시경을반전시켜항문쪽을촬영하는것도추천된다. 내시경을빼면서사진을촬영하는경우에는역순으로찍으면된다. 3) 의료영상저장전송시스템 (PACS) 을이용한영상기록 : 의료영상저장전송시스템이도입된후보다많은사진을찍는경향이있다. 전자내시경의무기록은사진인쇄가필요하지않고내시경영상의디지털저장및비디오가가능하며언제든지영상의재검토가가능하다. 디지털이미지는보통 jpeg파일로저장되며, 한사진에약 100 150 kb의저장용량을필요로하고고해상도디지털이미지는더큰용량이필요하다 (600 kb). 9 내시경영상을무제한으로찍으면충분한저장용량이필요하여프로그램의성능에영향을미칠수있다. 적절한내시경영상기록을위해서는 PACS 수가의현실화가검토되어야할것이다. 4. 전자내시경의무기록 전자내시경의무기록시스템은일반적으로시간과비용을절감하고질향상, 연구데이터를수집과편의를위해사용된다. 전자내시경의무기록시스템은 (1) 비용이저렴하고, (2) 접근이자유롭고 (3) 표준화내시경용어를사용해야하며 (4) 내시경영상이미지는의료용디지털영상및통신표준 (digital imaging and communications in medicine, DICOM) 을준수하고, (5) 개인정보및보안규정을준수하여야한다. 10 법적으로전자서명이기재되어야하고작성된전자의무기록은누출, 변조, Table 2. The Features of Electronic Endoscopic Medical Record Systems 21 1. Features for gastrointestinal endoscopy reports 1) Endoscopic report generation 2) High quality endoscopic image capture and management 3) Some of the nursing documentation can be captured electronically 4) Medicolegal requirements for medical records - Users should electronically finalize the reports, the date, and the time with a password of signature - Once a report has been signed, it should not be alterable - If the physician wants to change something, it should be done as a separate addendum, which is also timed, dated, and signed 5) Risk management monitoring - Endoscopic quality control by reporting and reviewing unplanned complications 2. Information exchange issues 1) Interface/integrate with hospital electronic medical record 2) Patients and referring physicians can receive immediate typed reports and pictures 3) Link to pathology electronic medical record - Improved communication between the endoscopists and pathologists 4) Remote access to endoscopic reports using internet 3. Education/training/research issues 4. Endoscopy unit system administration issues 1) Education material for patients 2) Allow trainees to be part of reports 3) Clinical research 4) Easy download of images and video for presentations and publications 1) Technical and administrative support for endoscopy unit management 2) Patient scheduling 3) Endoscopy unit statistics 4) Endoscopic accessories/instrument tracking and billing/coding 5) Automated backup for main servers Vol. 41, No. 4 October, 2010 (189-195) 193

훼손되어서는안된다. 전자내시경의무기록은쉽게배울수있어야한다. 특히내시경실통계및데이터베이스검색이많은경우쉬운정보검색은필수이다. 웹기반의전자차트는서버가위치한병원외장소에서의료기록의저장이가능하여의료정보의가용성을높이고환자와의사모두진료기록의접근성을향상시킨다. 웹기반의전자차트는쉽게접근할수있는반면철저한보안이필요하다. 전자내시경의무기록과병원의전자의무기록간의인터페이스는안전해야한다. 전자내시경의무기록과연결되는인터넷은서버보안과비밀번호를통해보안이유지되어야하며환자를식별할수있는기록이있다면교육이나데모목적으로사용해서안된다. 전자내시경의무기록으로만들어진보고서는영구기록으로서버를매일백업하여야하며지속적으로데이터베이스를안전하게유지하기위해자동업그레이드가필요하다. 내시경분야에서전자내시경의무기록시스템은간단한내시경결과보고서의작성을넘어포괄적인내시경실관리시스템으로발전하고있다. 11 전자내시경차트는내시경의사의효율뿐아니라내시경실관리의효율을높일수있다. 내시경의사의관점에서는내시경결과지의자동생성, 영상의캡쳐, 저장, 영상및동영상관리, 연구목적의데이터베이스검색을용이하게할뿐아니라내시경실관리의관점에서는내시경간호차트의작성, 내시경실통계, 기구또는경비청구. 환자스케줄과예약관리, 내시경실기구관리등을가능하게한다 (Table 2). 전자내시경의무기록시스템은높은투자비용이들어가지만수기나구술방식의결과보고서작성에비해시간과비용이절약되고작업공간을절약할수있다. 12,13 종이차트관리를위한인건비, 종이차트보관비용, 사진인쇄용지비용뿐아니라종이차트를찾고이송하고, 의사가검토할때까지걸리는시간과인력과비교하여전자차트는손쉽게찾아볼수있으므로그만큼비용과환자대기시간을줄일수있다. 결론우리나라의국가암조기검진위내시경의거의대부분을의원및병원에서담당하므로내시경보고서의가장중요한요구사항은상급병원으로의뢰할정보가충분히담긴, 즉전원이가능한의무기록이되어야한다는것이다. 내시경보고서만으로전원이가능하려면표준용어와표준분류법을사용하여결과를기술하도록하여야한다. 예를들어융기병변에서 Yamada 분류, 평탄한병변에서조기위암의내시경분류같은국제화된표준용어를반드시사용해야한다. 표준약어를사용하여야하며만성위축성위염을 CAG, 만성표재성위염을 CSG로간단하게표시하는것은지양되어야할것이다. 앞으로전자의무기록시스템이널리사용되는시대임을생각한다면내시경결과 보고서를가능하면 MST같은표준내시경용어를사용하여작성하는것이가장바람직하다. 하지만표준내시경용어에적응하는데시간이오래걸리고, 전자내시경의무기록시스템이개원가에서는현재도입이진행중인현실과많은내시경시행의사가 free text 형식에익숙한현실을고려한다면점진적으로이런방향으로사용을권장하는학회주도의사업이중요하다고하겠다. 많은양의내시경을소화하여야하는개원의의입장에서는의무기록을자세하게남기는데시간이많이걸리고, 부담이될수있다. 그러므로서술기록보다는영상기록을잘남기는것이중요하고 4장보다가능한 8장이상의사진을찍는것이좋다. 많은양질의사진을찍을수있도록 PACS 수가의현실화가이루어지도록해야할것이다. 요약 내시경분야에서전자내시경의무기록시스템은간단한내시경결과보고서의작성을넘어포괄적인내시경실관리시스템으로발전하고있다. 전자내시경의무기록시스템은내시경의사의효율뿐아니라내시경실관리의효율을높일수있다. 전산화된내시경기록은임상연구와질관리가가능하도록내시경결과의데이터베이스생성을가능하게한다. 그러기위해서는내시경보고서의구조를계획할때부터표준보고서의형식을표준화된용어를선택하여결과를입력하는것이중요하다. 이미최소표준용어가내시경의전산기록을위해개발되어사용되고있다. 권장내시경보고서의사용과양질의영상기록은내시경질관리면에서도중요하다. 색인단어 : 전자내시경의무기록, 내시경 참고문헌 1. Kuhn K, Gaus W, Wechsler JG, et al. Structured reporting of medical findings: evaluation of a system in gastroenterology. Methods Inf Med 1992;31:268-274. 2. Rey JF, Lambert R; ESGE Quality Assurance Committee. ESGE recommendations for quality control in gastrointestinal endoscopy: guidelines for image documentation in upper and lower GI endoscopy. Endoscopy 2001;33:901-903. 3. Korman LY. Standardization in endoscopic reporting: implications for clinical practice and research. J Clin Gastroenterol 1999;28:217-223. 4. Delvaux M, Korman LY, Armengol-Miro JR, et al. The minimal standard terminology for digestive endoscopy: introduction to structured reporting. Int J Med Inform 1998;48:217-225. 5. http://www.endoscopyquality.or.kr/ 6. Quality improvement of gastrointestinal endoscopy: guidelines 194 The Korean Journal of Gastrointestinal Endoscopy

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