门诊疾病诊断名称非规范化现状与对策分析

The Status and Countermeasures of Non-standardized Diagnosis Names of Outpatient Diseases

目的通过分析门诊疾病诊断数据,了解目前疾病诊断名称不规范现状,探索疾病诊断名称规范化的解决方案。方法从2018年上半年北京市部分医院上报的200万余条门诊疾病诊断数据中清洗出78万余条非规范化疾病诊断数据。对原始数据进行特征分析;其次对原始数据进行切词,并对疾病诊断的核心词汇和副词汇进行统计分析;最后通过计算机相似度匹配的方法进行归一化。结果特征分析显示疾病诊断的不规范主要表现为修饰语位置和书写形式差异、疾病简写和英文缩写的影响、错别字的影响、诊断颗粒度不一等形式;对疾病的核心词汇和副词汇统计分析发现,核心词汇中慢性病占比最高,其中高血压、糖尿病和心脏病分别占比为21.71%、16.82%、14.48%,在副词汇中前3位术后、慢性、型的占比分别为12.02%、11.91%、11.32%。结论慢性病相关诊断和术后等术语是疾病诊断名称规范化的主要方面,重点消除修饰语、中英文简写、错别字和颗粒度等因素的影响,建立统一、规范的疾病术语库。

Objectives To understand the current status of the non-standardization of disease diagnosis and to explore the standardization of disease diagnosis by analyzing the outpatient disease diagnosis data.Methods More than 780,000 non-standardized disease diagnosis data were screened from more than 2 million outpatient disease diagnosis data reported by some hospitals in 2018.Firstly,the original data was analyzed for characteristics.Secondly,the original data was cut,and then the core vocabulary and sub-vocabulary of the disease diagnosis were statistically analyzed.Finally,the original data was cut and de-duplicated based on a proprietary dictionary.Using the method of computer similarity matching makes it normalized.Results The characteristic analysis showed that the non-standardization factors of the disease diagnosis mainly include the influence of the difference of the position and writing form of the modifier,the influence of the disease abbreviations and English abbreviations,the influence of the typos,the influence of the diagnostic granularity,etc.The statistical analysis of the core vocabulary and sub-vocabulary of the disease found that chronic diseases accounted for the highest proportion,among which‘hypertension’,‘diabetes’and‘heart disease’accounted for 21.71%,16.82%,and 14.48% respectively in all core vocabulary.The top three sub-vocabulary were‘postoperative’,‘chronic’,‘type’with the proportion of 12.02%,11.91%,and 11.32%,respectively.Conclusions Terms such as chronic disease-related diagnosis and‘post-operation’were the main aspects of the standardization of disease diagnosis.The focus was eliminating the influence of modifiers,Chinese and English abbreviations,typos,granularity and other factors,and establishing a unified and standardized terminology database of disease diagnosis.