基于自然语言处理的智能病历质控系统的设计与应用  

Design and Application of Intelligence Medical Record Quality Control System Based on Natural Language Processing

作　　者：郝安琪 沈洁[2,3] HAO Anqi;SHEN Jie(Department of Information,Shanghai Sixth People’s Hospital,Shanghai 200033,China;Department of Medical Record and Statistics,Shanghai Sixth People’s Hospital,Shanghai 200033,China;Shanghai Medical Record Quality Management and Quality Control Center,Shanghai 200033,China)

机构地区：[1]上海市第六人民医院信息处,上海200033 [2]上海市第六人民医院病案统计室,上海200033 [3]上海市病历质量管理质量控制中心,上海200033

出　　处：《中国医疗设备》2024年第12期71-77,共7页China Medical Devices

基　　金：上海市人工智能重大专项“机器智能”(2021SHZDZX0102)。

摘　　要：目的为解决传统病历内涵质控覆盖率不足、准确率偏低的问题,构建智能电子病历质控系统,提升病历质控质量。方法基于自然语言处理构建高度结构化的病历数据库,利用病历质控引擎对病历文书进行内涵质控,实现电子病历全覆盖、全自动、全过程的质控功能。并比较智能病历质控系统上线前后的住院甲级病历率、病历质控平均分和内涵缺陷项目占比,分析系统对病历质量的影响。结果智能病历质控系统上线后,住院甲级病历率(76.60%)高于上线前(68.70%),病历质控平均分[(567.68±30.11)分]高于上线前[(550.01±46.78)分],且差异均有统计学意义(P<0.001);内涵缺陷项目占比较上线前明显下降(平均降幅3.52%)。结论智能病历质控系统可辅助临床医生和质控员高效、准确地完成医院临床病历质量控制,提高医院病历质量和医院管理水平。Objective In order to address the problems of insufficient coverage and low accuracy of the connotation quality control of traditional medical records,to construct an intelligent electronic medical record quality control system,so as to realize the improvement of the quality control of medical records.Methods A highly structured medical record database was constructed based on natural language processing,and the medical record quality control engine was used to carry out connotation quality control of medical record.And the quality control function of full coverage,automatic and whole process of electronic medical records was realized.The rate of grade A medical record,the average score of medical record quality control and the proportion of connotation defect items before and after the intelligent medical record quality control system were compared,and the impact of the system on the quality of medical record was analyzed.Results After the intelligent medical record quality control system was launched,the rate of grade A medical record(76.60%)was higher than that before the launch(68.70%);the average score of medical record quality control[(567.68±30.11)scores]was higher than that before the launch[(550.01±46.78)scores],and the differences were statistically significant(P<0.001).And the proportion of connotation defect items decreased significantly compared with that before the launch,with an average decrease of 3.52%.Conclusion Intelligent medical record quality control system can assist clinicians and quality controllers to efficiently and accurately complete the quality control of clinical medical records in hospital,which can improve the quality of medical records in hospitals and the level of hospital management.

关 键 词：电子病历 病历质控 内涵质控 质量控制 自然语言处理 后结构化 甲级病历 

分 类 号：R197.324[医药卫生—卫生事业管理]