基于人工智能的全程病历质控系统的构建与应用  

Construction and application of whole-process quality control system for medical records based on artificial intelligence

作　　者：张瑜[1] 吴青松[2] 胡和 高志宏[1] 孙桢[1] 王华晓[1] Zhang Yu;Wu Qingsong;Hu He;Gao Zhihong;Sun Zhen;Wang Huaxiao(Information Department,the First Affiliated Hospital of Wenzhou Medical University,Wenzhou 325000,Zhejiang Province,China;Department of Medical Quality Management Division,the First Affiliated Hospital of Wenzhou Medical University,Wenzhou 325000,Zhejiang Province,China Department of Medical Quality Management Division,the First Affiliated Hospital of Wenzhou Medical University)

机构地区：[1]温州医科大学附属第一医院信息处,浙江温州325000 [2]温州医科大学附属第一医院医疗质量管理处,浙江温州325000

出　　处：《中国数字医学》2022年第10期83-87,共5页China Digital Medicine

摘　　要：目的:基于人工智能技术构建智能全程病历质控系统,实现对电子病历的全流程智能质控。方法:解读病历质控相关标准和规范,构建质控规则知识库;通过自然语言处理技术,实现病历文书的语义理解;利用机器学习和深度学习方法,构建自我更新的可视化临床医学知识图谱;利用临床决策推理引擎,提高病历内涵质控的准确度。结果:通过环节质控对运行中的病历进行实时监管,可及时发现医生不合规行为以及病历书写缺陷;通过事后的终末质控,可实现全院病历的全面检查。结论:全程病历质控系统可实现对电子病历全程、动态、智能的闭环分析与管理,满足医院对于电子病历质量以及医生诊疗过程合理性全方位把控的需求。Objective To build an intelligent whole-process quality control system for medical records based on artificial intelligence technology, so as to realize whole-process intelligent quality control of medical records. Methods Relevant national and provincial standards and norms of medical records quality control were interpreted to build a knowledge base of quality control rules. Semantic understanding of medical records was realized through natural language processing technology. A self-updating visual clinical medical knowledge map was built using machine learning and deep learning methods. And the accuracy of quality control of medical records was improved by using clinical decision reasoning engine. Results Real-time supervision of medical records in operation through link quality control can detect doctors’ non-compliance behavior and the writing defects of medical records. Through the final quality control afterwards, a comprehensive examination of the medical records of the whole hospital can be realized. Conclusion The whole-process medical records quality control system can realize the whole-process,dynamic and intelligent closed-loop analysis and management of electronic medical records, and meet the needs of hospitals for all-round and reasonable control of electronic medical records quality and the rationality of doctors’ diagnosis and treatment process.

关 键 词：病历质控 人工智能 医学知识图谱 内涵质控 

分 类 号：R319[医药卫生—基础医学]