基于人工智能的CDSS系统实时电子病历质量控制

Experience of Quality Control of Real-time Electronic Medical Record in CDSS System based on Artificial Intelligence

病案质量控制是医院医疗质量管理的重要组成部分,实时病案质控系统的构建和完善对保证病案质量有重要意义,特别是病案的内涵质控大多为人工进行,效率低同质化水平差,成本高是医院质量管理提升过程中的难点。由医务处牵头,与临床科室、信息中心共同制定电子病历包括住院病案首页的质控规则,包括形式质控和内涵审核两部分。集成医院多个业务系统数据,包括医院信息系统、影像归档和通信系统、实验室信息管理系统、计算机化病案系统,进行数据清洗,存储、整合,通过自然语言处理,建立基于人工智能的临床辅助决策系统,无缝衔接于电子病历系统中,实现电子病历实时、动态质控,达到质控关口前移,及时纠正病案缺陷,保证医疗质量和安全。

Quality control of medical records is an important part of hospital medical quality management. The construction and improvement of real-time medical record quality control system is of great significance to ensure the quality of medical records, especially the connotation quality control of medical records is mostly carried out manually, with low efficiency, poor homogenization level and high cost, which are the pain points and difficulties in the process of improving hospital quality management. Led by the medical department of a hospital, together with clinical departments and Information Center, the quality control rules of electronic medical records including the front page of medical records are formulated. The quality control includes two parts: formal quality and connotation audit. Integrate the data of multiple hospital business systems(including His, PACS, LIS, EMR) for data cleaning, storage and integration, and establish a clinical assistant decision system based on artificial intelligence through natural language processing, Seamless connection in the electronic medical record system to achieve real-time and dynamic quality control of electronic medical records. After the use of the system, the defect rate of medical records decreased significantly, and the quality control management efficiency was greatly improved. The quality control gateway was moved forward, and the defects of medical records were corrected in time to ensure the medical quality and safety.