基于人工智能的病历质控系统的设计与应用  

Design and Application of Medical Record Quality Control System Based on Artificial Intelligence

作　　者：丁佳丽 史亚香[1] 焦蕴[1] DING Jia-li;SHIYa-xiang;JIAO Yun(Information Center,Zhongda Hospital Southeast University,Nanjing 210009,Jiangsu Province,P.R.C.)

机构地区：[1]东南大学附属中大医院网络信息中心,210009

出　　处：《中国数字医学》2021年第2期45-48,53,共5页China Digital Medicine

基　　金：国家自然科学基金(编号:81501453);南京市科技发展计划项目(编号:201805006);江苏省重点研发计划(社会发展)项目(编号:BE2016782)。

摘　　要：目的:探索有效提升病历质控效率和质量的方法。方法:通过质控规则拆解、质控引擎开发等,借助人工智能技术构建病历质控系统,应用于病历文书的环节质控和终末质控。结果:系统可实现病历的时效性、完整性等形式缺陷的筛查,实现对病历文书的术语规范性、数据一致性、逻辑一致性、诊断充分性、处置必要性等内涵缺陷质控,且系统具备数据集中展示、缺陷统计分析、结果反馈及互动等功能。结论:系统可协助质控员完成全量病历形式质控及内涵质控,质控缺陷的覆盖面得到提升,质控效率提高100%。Objective:To explore method to improve the efficiency of medical record quality control.Methods:Through the disassembly of quality control rules,the development of quality control engine,we have constructed the quality control system of medical records with the help of artificial intelligence technology,and applied it to connotation quality control and final quality control.Results:The medical record quality control system can not only judge the completeness and effectiveness of the medical record,but also the terminology standardization,data logical consistency,diagnostic adequacy,disposal necessity of medical records.In addition,the system has multiple functions including centralized data display,data statistical analysis,and result feedback.Conclusion:The system can complete the whole quantity of medical records and the connotation of the quality control of automatic quality control,improve the quality defects of coverage,quality efficiency increased by 100%.

关 键 词：人工智能 自然语言处理技术 内涵质控 形式质控 

分 类 号：R319[医药卫生—基础医学]