病案首页智能辅助编码技术应用探析  

Intelligent-assisted coding technology in review and entry of ICD codes on medical record’s first pages

作　　者：张君莹[1] 谢培亮 张敏[1] ZHANG Junying;XIE Peiliang;ZHANG Min(Cancer Hospital of Nanjing Medical University//Jiangsu Cancer Hospital//Jiangsu Institute of Cancer Research,Nanjing 210009,China;Drum Tower Hospital,the Affiliated Hospital of Nanjing Medical School,Nanjing 210008,China)

机构地区：[1]南京医科大学附属肿瘤医院//江苏省肿瘤医院//江苏省肿瘤防治研究所,江苏南京210009 [2]南京大学医学院附属鼓楼医院,江苏南京210008

出　　处：《现代医院》2024年第11期1761-1763,1768,共4页Modern Hospitals

基　　金：江苏省医院协会医院管理创新研究课题(JSYGY-3-2024-228);江苏省肿瘤医院科研基金项目(ZG202001)。

摘　　要：目的设计病案首页ICD智能辅助编码应用系统,通过病案信息数据采集,实现病案首页ICD编码智能审核与录入,提高首页编码审核与录入的准确性与效率。方法构建病案首页编码规则库,跨系统获取临床信息,通过编码智能分析,模拟人工编码审核与录入操作步骤,在编码审核与录入中引入智能系统;采用编码员手动编码、智能编码系统编码、人机协同编码三种编码方式,对肿瘤疾病进行编码审核与录入对比分析。结果相比于传统人工编码审核与录入模式,病案首页ICD智能编码系统在保证编码准确性及完整性的基础上,提升了病案首页编码审核及录入效率。智能编码系统在编码效率方面优势突出,人机协同编码在编码准确性与效率方面相对于人工手动编码有较好的提升。结论在病案首页编码方面,可以充分利用人工智能技术,通过病案首页ICD智能辅助编码审核系统;系统自动化审核与录入,可以有效提升病案首页编码审核与录入的准确性;采用人机互动编码模式,在提升编码审核与录入效率的同时,编码的准确性也有所提升。Objective The ICD intelligent-assisted coding system for the first pages of medical records enhances the intelligent review and entry of ICD codes on medical records through data collection of medical records information,and improving accuracy and efficiency.Methods The coding rule library for the first page of medical records was constructed,clinical information across systems was obtained,the operation steps of manual coding review and entry was simulated through coding intelligent analysis,and an intelligent system was introduced into coding review and entry.Three coding methods,namely coding manually by coders,by the intelligent coding system,and by a man-machine collaboration,were adopted to conduct coding review and entry.The coding results were compared between the three methods.Results Compared to manual coding method,the ICD intelligent-assisted coding system exhibited the same accuracy and completeness of coding but a significant increase in coding efficiency.The method of human-machine collaborative coding had a better improvement in coding accuracy and efficiency as well compared with the manual coding.Conclusion Artificial intelligence technology has superiority in coding entry on the first page,through the ICD Intelligent Assisted Coding Review and Entry System.for it can increase the accuracy of review and entry.The method of human-machine collaboration enhance both the efficiency and accuracy in coding review and entry.

关 键 词：病案首页 人工智能 ICD 肿瘤 

分 类 号：R197.323[医药卫生—卫生事业管理]