基于人工智能的电子病历质控体系的建设与研究  

Construction and research of the quality control system of electronic medical record based on AI technology

作　　者：刘晓娇 朱玉婷 李瑞瑶 鲍瀛 Liu Xiaojiao;Zhu Yuting;Li Ruiyao;Bao Ying(Department of Information Management,Nanjing Drum Tower Hospital,Nanjing 210008,Jiangsu Province,China)

机构地区：[1]南京鼓楼医院信息管理处,南京210008

出　　处：《中国数字医学》2022年第11期68-74,共7页China Digital Medicine

基　　金：南京大学现代医院管理与发展研究所课题项目;南京鼓楼医院医学发展医疗救助基金会资助项目(NDYG2021041)。

摘　　要：目的:通过信息化手段,建立一套有效的、智能化的、可执行的电子病历质控体系,对医院电子病历书写质量进行管控,以规范电子病历书写、提高医疗质量。方法:利用人工智能技术,基于一体化信息平台、临床数据中心(CDR),依据电子病历书写规范及质控规则,实现电子病历的质量控制,自动生成每月质控报表。结果:通过完善电子病历智能质控体系,结合信息系统,提高了临床电子病历书写的规范性。采用SPSS 23.0对系统上线前后病历质控情况进行统计分析,差异具有统计学意义(P<0.05)。结论:电子病历智能质控体系的建立,有助于临床书写病历的标准化和规范化,提高医疗质量,同时为管理部门提供决策支持。Objective To establish an effective,intelligent,and executable quality control system of electronic medical record(EMR) by means of information technology,so as to control the quality of EMR,standardize its writing and improve medical care quality.Methods The quality control of EMR was realized by using AI technology based on the integrated information platform and the clinical data center(CDR),which enabled the quality control of EMR and automatically generated monthly quality control report in accordance with electronic medical record writing specifications and quality control rules.Results Based on the information system and by improving the intelligent quality control system of EMR,the writing of clinical EMR was more standardized.SPSS 23.0 was used to statistically analyze the quality control of EMR before and after the system was launched,and the difference was statistically significant(P <0.05).Conclusion The establishment of the intelligent quality control system of EMR is helpful to standardize and regulate the writing of clinical EMR,to improve medical quality,and provide decision-making support for management departments.

关 键 词：电子病历 智能质控 人工智能 CDR 决策支持 

分 类 号：R319[医药卫生—基础医学]