人工智能电子病历质量控制技术应用效果研究

Research on the application effect of artificial intelligence electronic medical record quality control technology

目的:评价人工智能技术应用于电子病历(EMR)质量控制系统的效果,为推进人工智能EMR质量控制技术提供理论依据。方法:选取2022年5-10月医院EMR的运营数据,其中5月份为测试数据,从医院层面、医生层面、科室层面和核心医疗制度层面采用人工智能监控系统对6-10月份EMR质量控制的数据进行对比研究,检验人工智能EMR质量控制技术的应用效果。结果:医院EMR书写违规情况由6月份的48%降至10月份的37%,甲级病历比率由3.4%增长到5.6%;违规数量最高的前10个科室6-10月份的EMR书写违规数量均显著下降,差异有统计学意义(F=16.15,P<0.05);违规数量最高的前10名医生6-10月份的EMR书写违规数量均显著下降,差异有统计学意义(F=5.77,P<0.05);违规数量最高的前10名核心医疗制度6-10月份的违规数量均显著下降,差异有统计学意义(F=10.46,P<0.05)。结论:人工智能EMR质量控制技术能够降低病历缺陷率,提高病历质量。

Objective:To evaluate the effect of the application of artificial intelligence technology to electronic medical record quality control system,and to provide a theoretical basis for the promotion of artificial intelligence electronic medical record quality control technology.Methods:The operation data of electronic medical record of the hospital from May to October 2022 was selected,a comparative study on the quality control of electronic medical records based on artificial intelligence monitoring system was conducted from four aspects of hospital level,doctor level,department level and core medical system,and the application effect of artificial intelligence electronic medical record quality control technology was tested.Results:The violations of electronic medical record violations in the hospital decreased from 48% in June to 37% in October,and the proportion of grade A cases increased from 3.4%to 5.6%,the number of violations of electronic medical records for the top 10 departments with the highest number of violations decreased significantly from June to October,the difference was statistically significant(F=16.15,P<0.05).The number of electronic medical record violations of the top 10 doctors with the highest number of violations decreased significantly from June to October,and the difference was statistically significant(F=5.77,P<0.05).The top 10 core medical systems in terms of number of violations all saw a significant decrease in the number of violations from June to October,the difference was statistically significant(F=10.46,P<0.05).Conclusion:Artificial intelligence electronic medical record quality control technology can reduce the defect rate of medical records and improve the quality of medical records.