基于后结构化技术的临床病种库系统设计与应用  

Design and application of clinical disease database system based on post-structured technology

作　　者：李楠[1,2] 王觅也[2,3] 郑涛 李言生 江大鹏 黄勇 LI Nan;WANG Mi-ye;ZHENG Tao;LI Yan-sheng;JIANG Da-peng;HUANG Yong(Information Center,West China Hospital of Sichuan University,Chengdu 610041,China;Engineering Research Center of Medical Information Technology of Ministry of Education,Chengdu 610041,China;Internet Hospital Management Office,West China Hospital of Sichuan University,Chengdu 610041,China;DHC Mediway Technology Co.,Ltd.,Beijing 100089,China;West China Second University Hospital,Sichuan University/West China Women's and Children's Hospital,Chengdu 610041,China)

机构地区：[1]四川大学华西医院信息中心,成都610041 [2]医疗信息化技术教育部工程研究中心,成都610041 [3]四川大学华西医院互联网医院管理办公室,成都610041 [4]东华医为科技有限公司,北京100089 [5]四川大学华西第二医院/华西妇产儿童医院,成都610041

出　　处：《医疗卫生装备》2024年第4期20-26,共7页Chinese Medical Equipment Journal

基　　金：国家重点研发计划项目(2020YFC2003404)。

摘　　要：目的:为解决传统临床病种库系统存在的依赖大量人工判断、缺乏辅助标注、电子病历数据可用性差等问题,设计一种基于后结构化技术的临床病种库系统。方法:先通过I2B2标准以及双向长短期记忆网络(bi-directional long short-term memory,BiLSTM)模型构建实体识别模型,形成病历模板库,然后组合病历模板库形成关系模板,抽取复杂的医学实体,实现电子病历的后结构化。之后,基于电子病历后结构化技术构建包括病历结构化、结构化评估、数据标注、常规功能和系统管理5个模块的临床病种库系统。结果:该系统可以将电子病历文本转化为结构化语言,提供更精细化的数据要素提取、更智能的结构化服务,提高了临床和科研工作的效率。结论:该系统提高了临床病种的数据可用性,减轻了用户数据加工的工作强度,保证了数据应用的高质量,为医学研究、临床辅助决策打下了坚实的基础。Objective To design a post-structured technology-based clinical disease database system to solve the problems of the traditional disease database system in dependence on manual judgment,lack of auxiliary annotation and poor availability of electronic medical record data.Methods An entity recognition model was constructed with I2B2 standard and bi-directional long short-term memory(BiLSTM)model to form a medical record template library,and some relational templates were generated and complex medical entities were extracted to realize post-structuring of electronic medical records.Then a clinical disease database system was established based on the post-structured electronic medical record technology,which was composed of the modules for medical record structuring,structured assessment,data annotation,routine functions and system management.Results The system developed transformed the text of electronic medical records into structured language,contributed to data element extraction and intelligent structured service and enhanced the efficiency of clinical treatment and scientific research.Conclusion The system developed improves the data availability of clinical diseases,reduces the workload of user data processing,ensures the quality of data application and lays a foundation for assisted decision making during clinical treatment and scientific research.

关 键 词：后结构化技术 临床病种库 电子病历 病历结构化 

分 类 号：R318[医药卫生—生物医学工程] TP311[医药卫生—基础医学]