2. Discussion on the Research Results
This study was conducted by analyzing the results of logistics regression according to the related factors and by postulating the possible causes to explain these results in the absence of any related precedent study.
As a result of the multiple logistics regression analysis, the factors independently influencing the unpreparedness of the required documents were the patient age, issuance channel, treatment department, treatment hospital, residential district, applicant of issue, and inpatient record among the type of medical record. Each of these factors is discussed below.
Regarding the patient age, unpreparedness of all age category divided at 10-year intervals was significantly higher compared to below the age of 10. For the reason why unpreparedness of below the age of 10 was lowest, we presumed that their parents applied issue as agent of them and because of their high concern for children' affairs they strictly prepared relevant documents. The tendency of unpreparedness increased with increasing age to a maximum for the patients over 70-year-old. The probability of unpreparedness was judged to be increased for the elderly due to poor ability to recognize, low familiarity with related information, and higher probability of preferring informal relation rather than formal relation in cases related with the applicant himself. However, by focusing on the examples issued in a hospital, the probability of the hospital being more permissive in applying a guide on elderly patients could have been applied.
Related with the high unpreparedness of the relevant documents for those in parental authority or authorized in age groups of under 19-year-old and more than 65-year-old, the following cases correspond to that a particular case experienced by the present researcher who was in charge of managing medical reports and issuing copies. For example, there were many cases of an inability to confirm the identity when the guardian of pediatric patients who had received treatment that day requested issue of copy. Many patients and guardians did not have medical insurance cards or other identification with them in visiting medical institution after medical insurance card being computerized. Especially, there were many cases of grandfather or maternal grandfather instead of parent coming to the medical institution for pediatric patients, and there were cases such as a change of family relation like cohabitation, divorce, living separately that increased the difficulty in confirming the identity due to the change of legal qualification, requesting for a copy of the medical record of a child under age not living together after divorce, and requesting issue of copy with the copy of resident registration before divorce of a mentally retarded spouse as evident. Cases such as requesting a copy of medical report of cohabitant in de facto relationships could be included in such examples. The majority of medical institutions notify in detail on the procedure of issuing copy and the required document through their homepage because such cases occur frequently. Nevertheless, they still experience cases of requesting of issue without preparation of related documents. Although this could be considered a problem of an applicant for issue of copy not checking, it remains a common case for those working in related fields that there are many cases of issuing copy with an abbreviated procedure of confirming document so as not to trouble the applicant at private medical institutions. Those in charge of issuing copy frequently experience such situations that contravene the related directive from the Ministry of Health and Welfare. The problem of proving the identity of the guardian for a person under the age of 19 is expected to be gradually improved through increased publicity, but there remain cases that are difficult to settle in such way. The case of an elderly person not having a certificate of seal impression is typical. In such a case, authorization through certificate of seal impression may not be possible, or may need frustrating procedure that take a long time in urgent situation. In such special cases, examples of violating the directive are increasing in order to avoid troubles with customers. In such cases, medical institutions confirmed the identity by various methods. The doctor certifying an identification of a patient or a nurse confirming the patient or guardian based on recognition in process of nursing are typical examples. As a result of this research, although identifications were confirmed using routine means or with internal directives in the case of unprepared documents, most of these cases were presumed to lack documents.
Thus, it is necessary to improve consciousness of people on such as spread of recognition that corresponding responsibility follows on exercising the right to self-decision using and controlling medical information. And the medical institution notifies to check it's homepage on issuing copy before applying, and any special measures that need to be prepared for a patient or guardian having difficulty in following such means.
The partially amended legislative bill of the medical law in December, 2008 has clarified the incomplete section of the existing law on reading the patient treatment records. Compared with the existing medical law, this legislative bill restricts the reading of the record to only the patient himself, spouse of the patient, ascendant/descendant in a direct line, or ascendant in a direct line of the spouse having written consent of the patient and certification showing family relations, and allows the application for reading and issuing copy on only the 'Code of Criminal Procedure/Code of Civil Procedure/National Health Insurance Law/Medical Aid Law/Workmen's Accident Compensation Law/Automobile Third Party Liability Law/Military Service Law/Law on School Accident Prevention and Compensation/Law on Defoliant Aftereffect Patient Support.' Nevertheless, similar illegal examples will likely arise after revision of the law. Therefore, it is necessary to formulate guidelines based on real situation. Joint work between the academic society and the related government departments is recommendable.
In case of issuance channel, unpreparedness of the required documents document was 13.3 times higher when the issue was requested 'in hospital' than when requested through the outpatient clinic. This was attributed to the greater ease in confirming a patient through various channels in the hospital.
Regarding the treatment department, obstetrics and gynecology was significantly lower than internal departments, which was attributed to the higher possibility of problems caused by the application of a stricter standard.
Regarding the treatment hospital, the unpreparedness of 'B' and 'E' hospitals was significantly lower than that of 'A' hospital. In the case of 'E' hospital among them, as a public hospital, it was possible to have a organizational culture to obey standard protocol related with issuing .
Regarding the residential area of applicant for issue with Seoul as the standard group, the differential rate of Gwangju/Jeonnam/Jeonbuk/Jeju was very low at 0.1. In the case of Jeju area that was island, this was attributed to be strictly prepared by considering that all 5 hospitals were in inland. But, in the case of Honam area, the possibility of a local hospital such as 'E' hospital applying a strict directive, resulting in discrimination in this area, could not be excluded.
Regarding the application subjects, all subjects except insurance companies were significantly higher in unpreparedness compared to the applicant himself. On bivariate analysis, the completion rate of the required documents in the case of the applicant himself was 95.9%, compared to the completion rate of insurance companies. This high completion rate was attributed to the absence of any identification requirement through documents, which simplified the required documents compared to other subjects of application. On the contrary, cases other than the applicant himself were attributed to the requirement to prepare more documents other than identification. The differential rate was especially high in spouse, relative, and third party, suggesting that the related directive was simplified for confirming the identity by means other than documents in the case of a patient applicant for issue of kinship. However, this needs to be examined carefully because there are many cases of documents unprepared in the case of third party. This suggests the necessity of preparing a particular guide in this area and of firmly establishing strict application criteria. However, the unpreparedness of the required documents was significantly the lowest compared to self application in the case of insurance companies with a total of 6 cases in a year. This was attributed to the fact that the insurance company as an applicant for issue knows the related laws well and is likely to thoroughly prepare related documents, and the medical institution has stricter standards on demand of this subject of application. In other research related to this [
9], the response of the subjects in a survey related with whether to open actual data of personal treatment managed by National Health Insurance Corporation to the question, 'Is it better for the private insurance company to provide personal disease information so as to reduce insurance fraud and thus reduced the insurance bill of health insurance product?', 38.3% of the respondents answered positively, and 33.3% negatively, and the difference in the response exceeded the error tolerance (3.1%). This result was attributed to the presumption that this situation was beneficial to oneself. On the question, "Do you agree with the National Health Insurance Corporation providing personal disease information to private insurance companies?" without assuming specific situation, 70.5% opposed, and only 25.7% agreed. The question of whether to provide disease information to private insurance companies is controversial worldwide due to the opposing interests of these companies and the patients, even as private insurance companies set high demands on treatment information of the patients. Nevertheless, 'absolutely disapproval' is the general principle taken by each nation except the US where the combination of insurance company and medical institute such as managed care is permitted [
9]. Considering this, it is necessary to control thoroughly medical record and for people to recognize that necessity.
Regarding the use of issue, unpreparedness was higher for submissions to insurance company and National Pension Corporation compared to for submit to other hospital for treatment. This suggests that a smoothed standard rather than a strict standard was applied, and therefore that adequate relevant measures need to be prepared.
The number of issues was also the independent related factor, and the unpreparedness of the required documents of more than 51 sheets was significantly lower than that of those under 5. The necessity of more copies meant higher possibility of being related to legal dispute such as lawsuit, which were attribute to the subject of application for issue thoroughly prepares documents, and the stricter standards and guides applied by medical institutions. Regarding the cost, unpreparedness of the required documents with 2.56 USD to 3.40 USD was significantly lower than that under 0.85 USD (the cost to issue 1 copy varied among the five hospitals), which supports the above assumption.
Finally, unpreparedness of the required documents for in-hospital record among the original records was significantly higher compared to that for other documents. This was attributed to the compensating channel, which suggests that it is not a case of applying for issue documents related to the hospital. So, in the case of having in-hospital register, the patient living long at the medical institution may have been acquainted with the hospital staff, which simplified the procedure. In addition, a tolerant guide may have been applied to in-patient cases, considering that most of admission cases had came from more far from hospital than outpatient or emergent treatment.
The study results revealed that the medical records recorded by the medical institutions are used not just to facilitate communication between doctors in and out of the medical institution for treatment, but also at various other places with various purposes, and that copies are issued according to various requests. The hospital association sponsored by the Ministry for Health, Welfare and Family Affairs voluntarily publishes a guide for issuing copy to protect health information, but the documents required for third party or authorization are often not prepared by the applicants, and the medical institution issues the copy by confirming the identity through other channels if the submitted documents are lacking. So, it was clear that, at least on documents, the medical information of patient was managed in dangerous level. But, as a result of assumption considering customary issuing practice and checking the reason for such result directly through a person in charge and, we concluded that most of the hospitals were managing their procedure issuing medical records based on the principle. The results suggested that the hospitals interpreted the law flexibly for the convenience of their users as 'customers' within the permissible range in Korea. Thus, the efforts of hospitals to observe the relevant regulations should be carried out by clearly regulating authoritative interpretation not to have room for dispute.
The collective study results support the necessity of confirming the method and guidelines for confirming the consent required in the common copy issuing procedures in the case of treatment at other hospitals and for patients in hospital. So, when the person in question actually cannot authorize, or cannot prepare documents for authorization, a procedure is necessary that reflects the actual experience and customs, rather than the strict and regulated procedure. This is more necessary due to the difficulty in accurately reflecting all the aforementioned legal matters. It is possible by preparation of standardized realistic guide that widely accepted experience and customs of hospitals. And relevant academic society may make a role for this.
The results highlight the need for greater social effort to improve the level of recognition on health medical information of the people. I hope that this research meaningfully contributes to the start of such effort.
Regardless of the field, the reason why, with expending high cost, private information is preserved and managed is due to the necessity of that use. However, the use of such information holds the danger of violation of private life and human rights. In the health field, intimidation could be more serious, so the basic health law regulates 'confidentiality' as one of the human rights on health (Article 13). So, it is clear that this case is handled as the factor of fundamental rights. The leaking of any information without proper reason by the person in charge of handling and managing such information is punished severely, with both criminally and professional sanctions, and severe regulation is applied in all nations with similar health system to Korea's such as Germany, France, and Taiwan [
9].
With the increasing complexity of modern society, and the corresponding expansion in the amount of medical information and scope of use, various stake-holders are competing with each other for access rights to personal information. Therefore, the dangers associated with complications arising from improper utilization of information and privacy protection are increasing. Therefore, very 'delicate and elaborate approach' is required for maintaining both 'effective utilization' and 'privacy protection' [
10-
12].
Health information, including personal information produced in the process of patient treatment, is preserved and managed in the form of medical records. The issuance of medical records from medical institutions occurs via copies of the record in most nations including Korea. The danger of the leakage or misuse of patient medical records in the digital era is rapidly increasing, so management has discussed the concern over the access for the circulation of electronic documents. Although the management of electronic information is strictly limited, the media a copy of medical record in form of document which circulation of information increase is not. So, although the related laws and authoritative interpretations exist, 'delicate and elaborate access' has not been reached to settle examples in detail caused by conflict of used information. This demands more than the strict application in consistent and standardized form of the related authoritative interpretations and guidelines. So, the regulation must have feasibility and reality that can be applied to most of various examples occurring and able to occur as well as be clear without any confusion. Colliding with actual operation process, law and guide could be treated lightly or ruined, thereby preventing the law and guidelines from accomplishing genuine legislative purpose. Therefore, it is judged to be the urgently demanded theme for preparation of improved solution to study actual condition and relative factor of legal document requirement problem with situation related with issuing copy which groping of solving method was hard for not having organized research/organization though concerned staffs experience.