CDSS用于电子病历质量控制的开发设计与应用  

Development and Application of CDSS for Electronic Medical Record Quality Control

作　　者：梁志刚[1] 罗德芳 魏岚[1] 黄跃[1] LIANG Zhi-gang;LUO De­fang;WEI Lan(Xuanwu Hospital Capital Medical University,Beijing 100053,P.R.C)

机构地区：[1]首都医科大学宣武医院,北京市100053 [2]北京惠每云科技有限公司,北京市100088

出　　处：《中国数字医学》2021年第3期23-27,共5页China Digital Medicine

基　　金：国家重点研发计划-神经变性病国家注册登记数据库和临床大数据共享平台建立(编号:2018YFC1312002)。

摘　　要：目的:利用人工智能技术实时干预医疗行为,提高全量电子病历质量,最终提升大数据决策支持能力和终末医疗质量。方法:开发设计基于人工智能技术的临床决策支持系统(CDSS),与电子病历系统深度集成后,对医疗过程进行节点监测和管控,一旦发现电子病历中存在质量缺陷即触发质控规则提醒。结果:CDSS从临床业务流程出发设计,可主动提醒和防范医疗缺陷,并可实时监控病历的完成情况与质量,加强医疗过程质量稽查。结论:CDSS对提高电子病历质量作用明显,通过在电子病历界面设置卡控分级管理功能,能够更好地提高临床规范性,将医疗质量管理规范真正落到实处。Objective: This article aims to use artificial intelligence technology to real-time intervene in medical behavior, improve the quality of full electronic medical record, and ultimately improve big data decision support capabilities and end-of-life medical quality. Methods: Develop and design a clinical decision support system(CDSS) based on artificial intelligence technology, which is deeply integrated with the electronic medical record system for node monitoring and control of the medical process. Once a quality defect in the electronic medical record is found, it will trigger the quality control rule reminder. Results: The CDSS is designed from the clinical business process to actively remind and prevent medical defects, and can monitor the completion and quality of medical record in real time, and strengthen the quality inspection of the medical process. Conclusion: CDSS has a significant effect on improving the quality of electronic medical record. By setting the card-controlled hierarchical management function in the electronic medical record interface, the clinical standardization can be better improved, and the medical quality management standards can be truly implemented.

关 键 词：CDSS 电子病历 质量控制 人工智能 医疗大数据 

分 类 号：R319[医药卫生—基础医学] TP391[自动化与计算机技术—计算机应用技术]