智能化门诊诊前病史采集系统构建与应用  

Construction and application of intelligent outpatient pre-admission medical history collection system

作　　者：王治 朱卫国 康红 曾可 刘海民 张涛[4] 张锋 陈良 Wang Zhi;Zhu Weiguo;Kang Hong;Zeng Ke;Liu Haimin;Zhang Tao;Zhang Feng;Chen Liang(Outpatient Department,Peking Union Medical College Hospital,Chinese Academy of Medical Sciences,Beijing 100730,China;State Key Laboratory of Difficult Severe and Rare Diseases,Department of General Medicine,Peking Union Medical College Hospital,Chinese Academy of Medical Sciences,Beijing 100730,China;Information Center,Peking Union Medical College Hospital,Chinese Academy of Medical Sciences,Beijing 100730,China;Department of Dermatology,Peking Union Medical College Hospital,Chinese Academy of Medical Sciences,Beijing 100730,China;Anhui iFLYTEK Medical Co.,Ltd.,Hefei 230088,China)

机构地区：[1]中国医学科学院北京协和医院门诊部,北京100730 [2]中国医学科学院北京协和医院疑难重症及罕见病国家重点实验室全科医学科,北京100730 [3]中国医学科学院北京协和医院信息中心,北京100730 [4]中国医学科学院北京协和医院皮肤科,北京100730 [5]安徽讯飞医疗股份有限公司,合肥230088

出　　处：《中华医院管理杂志》2022年第3期208-212,共5页Chinese Journal of Hospital Administration

基　　金：中国医学科学院医学与健康科技创新工程项目(2021-I2M-1-056)。

摘　　要：数字化和智能化技术是推动医疗服务模式转型创新、提升服务质量的重要动力。为提高临床应用业务系统智能化水平、改善门诊患者就医体验,北京协和医院于2020年2月研发智能化门诊诊前病史采集系统。该系统主要包括人工智能能力层、应用服务层、能力资源层和接口层等软件技术架构及硬件部署与安全体系架构设计,通过与医院信息系统对接,利用移动终端,实现患者自助提交诊前病史信息,并生成结构化病史资料供接诊医生调用。截至2021年11月,诊前病史采集系统已覆盖医院80%的科室,总计服务168万人次,患者填写率达60%,患者病史采集时长和医生门诊电子病历书写时长不断缩短,极大提高了门诊医疗服务效率。Digital and intelligent technology is an important driving force to promote the transformation and innovation of medical service mode and improve service quality.In February 2020,Peking Union Medical College Hospital established an intelligent outpatient pre-admission medical history collection system in order to improve the intelligent level of clinical application business system and the medical experience of outpatients.The system consisted of artificial intelligence capability layer,application service layer,capability resource layer and user application layer and hardware technology architecture.By docking with the hospital information system and using mobile terminal App,patients could submit pre-admission medical history information by themselves,and generate structured patient history for the visiting doctors to call.By November 2021,the pre-admission medical history collection system had covered 80%of the departments of the hospital,serving 1.68 million people in total,and the patient filling rate had reached 60%.The duration of patient′s medical history collection and the duration of doctor′s outpatient electronic medical record writing had been continuously shortened,greatly improving the efficiency of outpatient medical services.

关 键 词：门诊患者 病史采集 病史模板 病史记录 智能语音 

分 类 号：R197.32[医药卫生—卫生事业管理]