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
郝安琪 1沈洁2
作者信息
- 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;上海市病历质量管理质量控制中心,上海 200033
- 折叠
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.
Abstract
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Key words
electronic medical record/medical record quality control/connotation quality control/quality control/natural language processing(NLP)/post-structured/grade A medical records引用本文复制引用
出版年
2024
国家科技期刊平台
NSTL
万方数据