CN110600098A - Automatic clinical chemistry auditing method, system, device and storage medium - Google Patents

Automatic clinical chemistry auditing method, system, device and storage medium Download PDF

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Publication number
CN110600098A
CN110600098A CN201910735423.0A CN201910735423A CN110600098A CN 110600098 A CN110600098 A CN 110600098A CN 201910735423 A CN201910735423 A CN 201910735423A CN 110600098 A CN110600098 A CN 110600098A
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information
detection
automatic
auditing
rule
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CN201910735423.0A
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Chinese (zh)
Inventor
周迎春
刘志辉
徐倩
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First Affiliated Hospital of Guangzhou University of Chinese Medicine
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First Affiliated Hospital of Guangzhou University of Chinese Medicine
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Priority to CN201910735423.0A priority Critical patent/CN110600098A/en
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    • GPHYSICS
    • G16INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR SPECIFIC APPLICATION FIELDS
    • G16HHEALTHCARE INFORMATICS, i.e. INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR THE HANDLING OR PROCESSING OF MEDICAL OR HEALTHCARE DATA
    • G16H10/00ICT specially adapted for the handling or processing of patient-related medical or healthcare data
    • G16H10/60ICT specially adapted for the handling or processing of patient-related medical or healthcare data for patient-specific data, e.g. for electronic patient records
    • GPHYSICS
    • G16INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR SPECIFIC APPLICATION FIELDS
    • G16HHEALTHCARE INFORMATICS, i.e. INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR THE HANDLING OR PROCESSING OF MEDICAL OR HEALTHCARE DATA
    • G16H15/00ICT specially adapted for medical reports, e.g. generation or transmission thereof

Abstract

The invention discloses a method, a system, a device and a storage medium for clinical chemistry automatic audit, wherein the method comprises the following steps: acquiring medical record information and detection information of a patient; combining the medical record information, the detection information and a preset auditing rule to perform clinical chemistry automatic auditing, and outputting a detection result after the automatic auditing is completed; the auditing rule comprises a critical value judgment rule, a range auditing rule, a Delta checking rule and a joint judgment rule. According to the invention, the medical record information and the detection information of the patient are acquired, and the clinical chemistry is automatically audited by combining the preset audit rule without manual audit, so that the working pressure of inspectors is reduced, the report audit efficiency is improved, the report issuing time is indirectly shortened, and the method can be widely applied to the technical field of automatic processing of computer data.

Description

Automatic clinical chemistry auditing method, system, device and storage medium
Technical Field
The invention relates to the technical field of automatic processing of computer data, in particular to an automatic clinical chemistry auditing method, system, device and storage medium.
Background
With the introduction of automation and informatization technologies into clinical laboratories, clinical chemistry manual operations have almost been replaced by large fully-automatic instruments, but report auditing links are still mainly completed manually. The examiner usually makes an audit judgment and confirms whether the clinical chemistry examination reports pass the audit one by one according to the work experience and professional knowledge, and the examination reports which do not pass the audit are further processed, such as specimen review, medical history inquiry, clinical communication and the like. With the increasing number of the detected samples, the pressure of the examination reports of the inspectors is also increasing, and clinical application hopes that the clinical laboratory further accelerates the detection speed and shortens the report issuing time. At present, no perfect automatic auditing technology can improve auditing efficiency.
Disclosure of Invention
In order to solve the above technical problems, an object of the present invention is to provide an automatic clinical chemistry audit method, system, device and storage medium with higher audit efficiency.
The first technical scheme adopted by the invention is as follows:
an automatic clinical chemistry auditing method comprises the following steps:
acquiring medical record information and detection information of a patient;
combining the medical record information, the detection information and a preset auditing rule to perform clinical chemistry automatic auditing, and outputting a detection result after the automatic auditing is completed;
the auditing rule comprises a critical value judgment rule, a range auditing rule, a Delta checking rule and a joint judgment rule.
Further, the medical record information includes age information, sex information, office information, specimen type information, unique identification information, disease diagnosis information, medication history information, and treatment history information.
Further, the detection information comprises monitoring data in the analysis process of the detection sample and detection data obtained after the analysis of the detection sample;
the monitoring data comprises sample basic information, sample quality information and instrument state information;
the detection data comprises detection result information and comparison information with historical detection results.
Further, the step of performing clinical chemistry automatic audit by combining the medical record information, the detection information and a preset audit rule, and outputting a detection result after the automatic audit is completed specifically comprises the following steps:
s1, screening the detection items to be checked out from the detection information in sequence;
s2, judging whether the detection items meet the requirements according to the critical value judgment rule, if so, executing a step S3; otherwise, the examination item is judged not to pass the examination, and the step S1 is returned to;
s3, judging whether the medical history information corresponding to the detection item exists or not according to the medical record information, if so, executing a step S4; otherwise, go to step S5;
s4, judging whether the detection item meets the requirement or not by combining the treatment history information and the Delta check rule, if so, judging that the detection item passes the audit; otherwise, the examination item is judged not to pass the examination, and the step S1 is returned to;
s5, judging whether the detection item meets the requirement according to the range checking rule, if so, judging that the detection item passes the checking; otherwise, the examination item is judged not to pass the examination, and the step S1 is returned to;
s6, judging whether all the detection items are checked, if so, executing a step S7; otherwise, return to step S1;
s7, judging whether all the detection items pass the examination, if so, executing a step S8; otherwise, marking the detection items which fail to pass the audit, and forwarding the manual audit after stopping the automatic audit;
s8, judging the detection items to carry out joint examination according to joint judgment rules, judging whether the detection items which do not meet the requirements exist, if so, marking the detection items which do not meet the requirements, stopping automatic examination, and forwarding manual examination; otherwise, the automatic audit is judged to be passed, and an audit report is automatically generated.
Further, the step S1 specifically includes the following steps:
detecting and judging whether the indoor quality control and the working state of the instrument are normal according to the instrument state information, and sending alarm information when the working state is judged to be abnormal;
and sequentially screening items with numerical inspection results from the detection information as the detection items to be audited.
The second technical scheme adopted by the invention is as follows:
an automated clinical chemistry audit system comprising:
the information acquisition module is used for acquiring medical record information and detection information of a patient;
the automatic auditing module is used for performing clinical chemistry automatic auditing by combining the medical record information, the detection information and a preset auditing rule, and outputting a detection result after the automatic auditing is finished;
the auditing rule comprises a critical value judgment rule, a range auditing rule, a Delta checking rule and a joint judgment rule.
Further, the medical record information includes age information, sex information, office information, specimen type information, unique identification information, disease diagnosis information, medication history information, and treatment history information.
Further, the detection information comprises monitoring data in the analysis process of the detection sample and detection data obtained after the analysis of the detection sample;
the monitoring data comprises sample basic information, sample quality information and instrument state information;
the detection data comprises detection result information and comparison information with historical detection results.
The third technical scheme adopted by the invention is as follows:
an automatic generation device of computer code, the memory is used for storing at least one program, and the processor is used for loading the at least one program to execute the method.
The fourth technical scheme adopted by the invention is as follows:
a storage medium having stored therein processor-executable instructions for performing the method as described above when executed by a processor.
The invention has the beneficial effects that: according to the invention, the medical record information and the detection information of the patient are acquired, and the clinical chemistry is automatically audited by combining the preset audit rule, so that manual audit is not required, the working pressure of inspectors is reduced, the efficiency of report audit is improved, and the time for report issuing is indirectly shortened.
Drawings
FIG. 1 is a flow chart of the steps of an automated clinical chemistry audit method of the present invention;
FIG. 2 is a block diagram of an automatic clinical chemistry audit system according to the present invention;
FIG. 3 is a logic diagram illustrating an automatic audit in an exemplary embodiment.
Detailed Description
As shown in fig. 1, the present embodiment provides an automatic clinical chemistry auditing method, which includes the following steps:
a1, acquiring medical record information and detection information of a patient;
a2, performing clinical chemistry automatic audit by combining medical record information, detection information and preset audit rules, and outputting a detection result after the automatic audit is completed;
the auditing rule comprises a critical value judgment rule, a range auditing rule, a Delta checking rule and a joint judgment rule.
According to the method, the medical record information and the detection information of the patient are acquired, and the clinical chemistry is automatically audited by combining the preset audit rule, so that manual audit is not needed, the working pressure of inspectors is reduced, the report audit efficiency is improved, and the report issuing time is indirectly shortened.
At present, automatic auditing is also established in part of large-scale three hospitals in China, but the auditing range mostly adopts a reference interval, the passing rate is lower because the limiting range is too narrow, and most projects in the embodiment can improve the passing rate of automatic auditing on the premise of ensuring the auditing quality by adopting a reportable range as an initial rule.
The medical record information includes age information, sex information, clinic information, specimen type information, unique identification information (information for identifying the specimen, such as a bar code), disease diagnosis information, medication history information, and treatment history information. The information can be collected through an in-patient system of a hospital or an out-patient electronic medical record system, and the information at least comprises the following components: patient age, sex, office of visit (hospitalization), specimen type, unique identifier (hospitalization or outpatient number), disease diagnosis, medication history and treatment history, etc.
The detection information comprises monitoring data in the process of analyzing the detection sample and detection data obtained after analyzing the detection sample, the patient sample is sent to a laboratory after being collected, and data generated after corresponding detection processes are carried out, wherein the data is derived from automatic monitoring equipment or manual review data and specifically comprises the monitoring data and the detection data. The detection data includes: sample basis information (i.e., date and time of sample sampling, type or source of sample, sample priority, etc.), sample quality information (including hemolysis, lipemia, jaundice, and clot information); instrument state (including calibration, whether quality control is in control, instrument alarm information, detection method specificity, sample dilution state, etc.); the detection result (result alarm, detection unit, result annotation, etc.). The detection data includes: comparison of multiple historical test results of the same patient (namely Delta check), test results of multiple test items of the same sample, test results of other samples of the same patient and the like.
After the medical record information and the detection information are obtained, the background server automatically checks the detection items by combining the obtained information and a preset checking rule. The automatic audit rules are a set of "toolsets" composed of boolean logic algorithms, the most common rules being: AND (AND), OR (OR), NOT AND (NAND), NOT OR (NOR). The auditing rule comprises a critical value judgment rule, a range auditing rule, a Delta checking rule and a joint judgment rule. Referring to fig. 3, the specific detection process is as follows:
b1, screening the detection items to be audited from the detection information in sequence;
b2, judging whether the detection items meet the requirements according to the critical value judgment rule, if so, executing a step B3; otherwise, judging that the examination item is not checked, and returning to execute the step B1;
b3, judging whether the medical history information corresponding to the detection item exists or not according to the medical record information, if so, executing the step B4; otherwise, step B5 is executed;
b4, judging whether the detection item meets the requirements or not by combining the treatment history information and the Delta check rule, if so, judging that the detection item passes the audit; otherwise, judging that the examination item is not checked, and returning to execute the step B1;
b5, judging whether the detection item meets the requirement according to the range checking rule, if so, judging that the detection item passes the checking; otherwise, judging that the examination item is not checked, and returning to execute the step B1;
b6, judging whether all the detection items are checked, if so, executing the step B7; otherwise, returning to execute the step B1;
b7, judging whether all the detection items pass the examination, if so, executing the step B8; otherwise, marking the detection items which fail to pass the audit, and forwarding the manual audit after stopping the automatic audit;
b8, judging the detection items to carry out joint examination according to the joint judgment rule, judging whether the detection items which do not meet the requirements exist, if so, marking the detection items which do not meet the requirements, stopping automatic examination, and forwarding manual examination; otherwise, the automatic audit is judged to be passed, and an audit report is automatically generated.
The critical value determination rule is specifically as shown in table 1 below:
TABLE 1 Critical value determination rules
And when the range value of a certain item is detected to exceed the range of the dangerous value, directly judging that the item is unqualified, and skipping to detect the next detection item if the examination of the detection item is not passed. If the detection item meets the requirement, whether treatment history information corresponding to the detection item exists is searched and judged according to the medical record information, namely whether the patient has items similar to detection treatment before, if the detection is identified, the corresponding treatment history information is obtained, the detection item is continuously detected by combining the treatment history information and the Delta check rule, if the detection item meets the audit requirement, the audit is passed, otherwise, the audit is not passed. Wherein the Delta check rule is shown in Table 2 below:
TABLE 2 Delta check rule
If the patient detects the detection item for the first time, namely the corresponding treatment history information does not exist, continuing to check according to the range check rule, judging whether the detection item conforms to the range check rule, and if so, judging that the detection item passes the check; otherwise, the examination item is not approved. Wherein, the range audit rule is as shown in table 3 below (the audit upper and lower limits of different reference systems are adjusted according to the reportable performance range):
TABLE 3 Range audit rules
Sequentially detecting each detection item, recording whether each detection item meets the requirement, judging whether all the detection items are checked, and if not, continuing to check; if the audit is finished, whether detection items which cannot pass the audit exist is judged, if yes, the detection items are marked, such as highlight marks or symbol marks, detection results with the marks are output and converted into manual detection, and the audit accuracy is improved. If the single detection of all the detection items passes the audit, then the detection items are jointly detected according to the joint judgment rule, because the associated detection items exist in the detection result, when the joint audit passes, the detection result is free from problems, and an audit report is automatically generated and output. If the combined audit is not passed, the problem is indicated, and manual audit is required to be converted, so that the accuracy of audit is improved. Wherein, the joint judgment rule is as shown in the following table 4:
TABLE 4 Joint judgment rules
Further, in a preferred embodiment, the step B1 specifically includes steps B11 to B12:
b11, detecting and judging whether the indoor quality control and the working state of the instrument are normal according to the instrument state information, and sending alarm information when the abnormality is judged;
and B12, sequentially screening items with numerical test results from the detection information as the detection items to be checked.
Whether the working states of the quality control and the instrument in the detection room are normal or not is judged in real time according to the state information of the instrument, and when the work is abnormal, alarm information is sent out, so that the work personnel can conveniently and timely process the abnormal or inaccurate detection items, and the condition that subsequent audit cannot be performed is avoided. The detection items to be audited can be numerical types, and i can also be other types.
By the method, the detection result can be automatically checked, the checking efficiency of clinical chemistry is greatly improved, and the report issuing speed of a medical laboratory is indirectly improved. In addition, the throughput rate is improved: automatic auditing is also established in part of large-scale three hospitals in China at present, but the auditing range adopts a reference interval more, and the passing rate is lower because the limiting range is too narrow generally. And the detected items are more complete: in the existing clinical chemistry automatic auditing technology, the maximum number of automatic auditing projects is 5, and the automatic auditing technology comprises a large number of immune projects.
As shown in fig. 2, the present embodiment further provides an automatic clinical chemistry audit system, including:
the information acquisition module is used for acquiring medical record information and detection information of a patient;
the automatic auditing module is used for performing clinical chemistry automatic auditing by combining the medical record information, the detection information and a preset auditing rule, and outputting a detection result after the automatic auditing is finished;
the auditing rule comprises a critical value judgment rule, a range auditing rule, a Delta checking rule and a joint judgment rule.
Further, in a preferred embodiment, the medical history information includes age information, sex information, clinic information, specimen type information, unique identification information, disease diagnosis information, medication history information, and treatment history information.
Further as a preferred embodiment, the detection information includes monitoring data during the analysis of the detection sample and detection data obtained after the analysis of the detection sample;
the monitoring data comprises sample basic information, sample quality information and instrument state information;
the detection data comprises detection result information and comparison information with historical detection results.
The clinical chemistry automatic auditing system of the embodiment can execute the clinical chemistry automatic auditing method provided by the method embodiment of the invention, can execute any combination of the implementation steps of the method embodiment, and has corresponding functions and beneficial effects of the method.
The present embodiment further provides an automatic computer code generation apparatus, wherein the memory is used for storing at least one program, and the processor is used for loading the at least one program to execute the method.
The automatic computer code generation device can execute the automatic clinical chemistry auditing method provided by the method embodiment of the invention, can execute any combination of the implementation steps of the method embodiment, and has corresponding functions and beneficial effects of the method.
The present embodiments also provide a storage medium having stored therein processor-executable instructions for performing the method as described above when executed by a processor.
The storage medium of this embodiment can execute the clinical chemistry automatic auditing method provided by the method embodiments of the present invention, can execute any combination of the implementation steps of the method embodiments, and has corresponding functions and beneficial effects of the method.
While the preferred embodiments of the present invention have been illustrated and described, it will be understood by those skilled in the art that various changes in form and details may be made therein without departing from the spirit and scope of the invention as defined by the appended claims.

Claims (10)

1. An automatic clinical chemistry auditing method is characterized by comprising the following steps:
acquiring medical record information and detection information of a patient;
combining the medical record information, the detection information and a preset auditing rule to perform clinical chemistry automatic auditing, and outputting a detection result after the automatic auditing is completed;
the auditing rule comprises a critical value judgment rule, a range auditing rule, a Delta checking rule and a joint judgment rule.
2. The automated clinical chemistry auditing method of claim 1 where the medical record information includes age information, gender information, visit department information, specimen type information, unique identification information, disease diagnosis information, medication history information and treatment history information.
3. The automatic clinical chemistry auditing method according to claim 2, characterized in that the detection information includes monitoring data during the analysis of the detection samples and detection data obtained after the analysis of the detection samples;
the monitoring data comprises sample basic information, sample quality information and instrument state information;
the detection data comprises detection result information and comparison information with historical detection results.
4. The method for clinical chemistry automatic audit according to claim 3, wherein the step of combining medical record information, detection information and preset audit rules to perform clinical chemistry automatic audit and outputting detection results after the automatic audit is completed specifically comprises the following steps:
s1, screening the detection items to be checked out from the detection information in sequence;
s2, judging whether the detection items meet the requirements according to the critical value judgment rule, if so, executing a step S3; otherwise, the examination item is judged not to pass the examination, and the step S1 is returned to;
s3, judging whether the medical history information corresponding to the detection item exists or not according to the medical record information, if so, executing a step S4; otherwise, go to step S5;
s4, judging whether the detection item meets the requirement or not by combining the treatment history information and the Delta check rule, if so, judging that the detection item passes the audit; otherwise, the examination item is judged not to pass the examination, and the step S1 is returned to;
s5, judging whether the detection item meets the requirement according to the range checking rule, if so, judging that the detection item passes the checking; otherwise, the examination item is judged not to pass the examination, and the step S1 is returned to;
s6, judging whether all the detection items are checked, if so, executing a step S7; otherwise, return to step S1;
s7, judging whether all the detection items pass the examination, if so, executing a step S8; otherwise, marking the detection items which fail to pass the audit, and forwarding the manual audit after stopping the automatic audit;
s8, judging the detection items to carry out joint examination according to joint judgment rules, judging whether the detection items which do not meet the requirements exist, if so, marking the detection items which do not meet the requirements, stopping automatic examination, and forwarding manual examination; otherwise, the automatic audit is judged to be passed, and an audit report is automatically generated.
5. The clinical chemistry automatic auditing method according to claim 4, characterized in that said step S1 specifically includes the following steps:
detecting and judging whether the indoor quality control and the working state of the instrument are normal according to the instrument state information, and sending alarm information when the working state is judged to be abnormal;
and sequentially screening items with numerical inspection results from the detection information as the detection items to be audited.
6. An automatic clinical chemistry audit system, comprising:
the information acquisition module is used for acquiring medical record information and detection information of a patient;
the automatic auditing module is used for performing clinical chemistry automatic auditing by combining the medical record information, the detection information and a preset auditing rule, and outputting a detection result after the automatic auditing is finished;
the auditing rule comprises a critical value judgment rule, a range auditing rule, a Delta checking rule and a joint judgment rule.
7. The automated clinical chemistry audit system according to claim 6 wherein the medical record information includes age information, gender information, visit department information, specimen type information, unique identification information, disease diagnosis information, medication history information and treatment history information.
8. The clinical chemistry automatic auditing system of claim 7, characterized in that the test information includes monitoring data during test sample analysis and test data obtained after test sample analysis;
the monitoring data comprises sample basic information, sample quality information and instrument state information;
the detection data comprises detection result information and comparison information with historical detection results.
9. An apparatus for automatic generation of computer code, comprising a memory for storing at least one program and a processor for loading the at least one program to perform the method of any one of claims 1 to 5.
10. A storage medium having stored therein processor-executable instructions, which when executed by a processor, are configured to perform the method of any one of claims 1-5.
CN201910735423.0A 2019-08-09 2019-08-09 Automatic clinical chemistry auditing method, system, device and storage medium Pending CN110600098A (en)

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CN111833009A (en) * 2020-06-09 2020-10-27 温冬梅 Intelligent auditing software system for whole laboratory
CN112185576A (en) * 2020-11-02 2021-01-05 广州创惠信息科技有限公司 Method and system for determining auditing index for auditing test result
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CN111797952A (en) * 2020-06-09 2020-10-20 南岳生物制药有限公司 Intelligent plasma quality interpretation instrument and quality detection method thereof
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CN112185576A (en) * 2020-11-02 2021-01-05 广州创惠信息科技有限公司 Method and system for determining auditing index for auditing test result
CN112700833A (en) * 2021-01-14 2021-04-23 四川大学华西医院 Medical examination report centralized auditing method, system, storage medium and electronic device
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CN113762097A (en) * 2021-08-18 2021-12-07 合肥联宝信息技术有限公司 Automatic document auditing method and device and computer readable storage medium
CN113921128A (en) * 2021-09-16 2022-01-11 博奥赛斯(重庆)生物科技有限公司 Automatic medical detection data software auditing method and electronic equipment
CN113921128B (en) * 2021-09-16 2022-07-26 天津流水线医疗器械有限公司 Automatic medical detection data software auditing method and electronic equipment
CN114464278A (en) * 2022-04-11 2022-05-10 广东凯普生物科技股份有限公司 Intelligent auditing and disposal guide system for new corona nucleic acid detection data

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Application publication date: 20191220