基于自然语言处理的肿瘤专科病历质控系统建设

Construction of a Quality Control System for Oncology Medical Records Based on Natural Language Processing

目的/意义通过建立电子病历内涵质控系统,实现病历书写标准化与规范化,提高医院病历质量。方法/过程基于医院医疗数据搭建智能中台,结合自然语言处理、机器学习技术形成具有肿瘤专科特色的知识库、规则库,实现电子病历“前置审核、全面覆盖、过程监管、闭环管理”的全新质控模式。结果/结论应用基于自然语言处理的肿瘤专科病历质控系统后,质控覆盖率由1%提升至100%,甲级病案率提升至96%以上,具有较好的实时性与准确率,为医院病历高质量发展奠定坚实的信息化基础。

Purpose/Significance Through the establishment of a quality control system for electronic medical record(EMR)content,the standardization and normalization of medical record writing is realized,and the quality of hospital medical record is improved.Method/Process The intelligent medical data center is built based on hospital medical data,and the knowledge base and rule base with tumor specialty characteristics are formed by combining natural language processing(NLP)and machine learning technology.The new quality control mode of“pre-audit,comprehensive coverage,process supervision and closed-loop management”of EMR is realized.Result/Conclusion After the application of the medical record quality control system based on NLP,the quality control coverage rate increased from 1%to 100%,and the rate of class A medical records increased to more than 96%,with good real-time and accuracy,providing a solid information foundation for the high-quality development of hospital medical records.