恶性肿瘤结构化病理系统的数据管理与应用实践  

Data Management and Application Practice of Structured Pathology System for Malignant Tumor

作　　者：杨晓宇 宛惠 徐金建[1] YANG Xiaoyu;WAN Hui;XU Jinjian(Peking University Third Hospital,Beijing 100191,China)

机构地区：[1]北京大学第三医院信息管理与大数据中心,北京市100191 [2]北京大学数学科学学院,北京市100871

出　　处：《中国卫生信息管理杂志》2024年第3期425-430,共6页Chinese Journal of Health Informatics and Management

摘　　要：目的依托相关临床指南,构建适用于肺癌和结直肠癌的结构化病理系统,提高病理诊断报告逻辑性和关键诊断指标报告率。方法本研究提出一种针对肺癌和结直肠癌的前结构化病理诊断报告处理方案,通过搭建结构化病理系统,实现病理诊断报告的全程规范化填写、智能化录入、结构化存储,并回顾性分析病理诊断报告的逻辑性和关键诊断指标的报告率。结果将病理诊断报告结构化处理过程前移至录入阶段,同时优化病理诊断报告的录入方式,实现两个癌种病理诊断报告逻辑性的明显优化和关键诊断指标报告率的显著提高,其中约90%的关键诊断指标报告率提高至100%。结论本研究提出的结构化病理系统方案,有效提高病理科医生和临床医生工作效率的同时,能大大降低文本二次处理对病理数据价值再利用的限制。Objective Based on clinical guidelines,we have developed a structured pathology system for lung and colorectal cancer.We have also improved the logic of pathology diagnostic reports and increased the reporting rate of key diagnostic indicators.Methods This study presents a pre-structured scheme for processing pathology diagnostic reports for lung and colorectal cancer.The scheme enables standardized filling,intelligent entry,and structured storage of pathology diagnostic reports by building a structured pathology system.The study also includes a retrospective analysis of the logic of pathological diagnostic reports and the reporting rate of key diagnostic indicators.Results By creating a structured pathology system for lung and colorectal cancer,the processing of pathological diagnostic reports is optimized from traditional manual entry to standardized,intelligent,and structured entry.This achieves a significant improvement in the logic of pathology diagnostic reports for both types of cancer and a 100% reporting rate of key diagnostic indexes,up from about 90%.Conclusion The proposed scheme in this study effectively enhances the efficiency of pathologists and clinicians while greatly reducing the limitations of secondary processing of text on the reuse of pathology data.

关 键 词：病理诊断 结构化数据 恶性肿瘤 全流程质量控制 

分 类 号：R-058[医药卫生] R197.3