智慧医疗背景下智慧病历系统的研究与应用  

Design and Application of Wisdom Electronic Medical Record System Under the Background of Wise Medical

作　　者：车滢霞 严丽霞[1] 秦锡虎 陈强[1] 张锋[1] 郑晓渊[1] CHE Yingxia;YAN Lixia;QIN Xihu;CHEN Qiang;ZHANG Feng;ZHENG Xiaoyuan(Center of Information,Changzhou NO.2 People’s Hospital,Changzhou Jiangsu 213000,China;Office of Administrative,Changzhou NO.2 People’s Hospital,Changzhou Jiangsu 213000,China)

机构地区：[1]常州市第二人民医院信息科,江苏常州213000 [2]常州市第二人民医院院办公室,江苏常州213000

出　　处：《中国医疗设备》2022年第12期105-108,共4页China Medical Devices

基　　金：江苏省卫生健康委员会信息化课题(X2017001)。

摘　　要：目的为解决传统电子病历数据利用率低、病历质控滞后等问题,设计一种智慧病历系统。方法基于数据元模型构建标准化医疗术语,并通过调用标准化医疗术语,实现电子病历的全结构化录入及存储,并基于规则引擎的质控系统对病历进行全流程质控,构建智能评估体系对病历及诊疗数据进行自动评估,同时支持任意维度对病历进行检索及导出。结果知识库已累计产生20万余条标准化医疗术语,7.6亿余条医疗数据,具有医学意义的医疗数据占比84%。病案首页自动生成率由19.97%提升至77.99%,甲级病历率由96.21%提高至99.01%,疾病诊断相关组结算率由90.08%提升至97.99%,在新冠疫情防控过程中做到了不漏诊、院内零感染。结论智慧病历系统有效提高了病历数据利用率、病历质量及医疗质量。Objective To solve the problems of low rate of traditional electronic medical record data and lagging quality control of medical record,to propose a wisdom electronic medical record system.Methods Standardized medical terms were built based on the data element model,the full-structured input and storage of electronic medical records was realized by calling standardized medical terms,the whole process quality control of medical records was carried out through the quality control system based on rule engine.An intelligent evaluation system was built to automatically evaluate medical records and diagnosis and treatment data,and support the retrieval and export of medical records from any dimension.Results The knowledge base has accumulated more than 200000 standardized medical terms and 760 million pieces of medical data,and medical data with medical significance accounted for 84%.The automatic generation rate of medical record homepage has increased from 19.97%to 77.99%,the rate of grade A medical records has increased from 96.21%to 99.01%,and the diagnosis related groups settlement rate has increased from 90.08%to 97.99%.In the process of COVID-19 prevention and control,there has been no missed diagnosis and 0 infection in the hospital.Conclusion The intelligent medical record system effectively improves the utilization rate of medical record data,medical record quality and medical quality.

关 键 词：智慧医疗 智慧病历系统 标准化医疗术语 全流程质控 智能评估 

分 类 号：R197.32[医药卫生—卫生事业管理]