CN111667894A - RETE algorithm rule engine-based hospital electronic medical record quality monitoring and management system - Google Patents
RETE algorithm rule engine-based hospital electronic medical record quality monitoring and management system Download PDFInfo
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Abstract
The invention relates to the technical field of electronic medical record quality monitoring and management, and discloses a hospital electronic medical record quality monitoring and management system based on a RETE algorithm rule engine and a disease knowledge base. The system establishes a unified quality control standard by constructing the disease knowledge map, understanding the connotation of medical records, screening defects, judging the rationality of disease diagnosis and treatment, improving the work efficiency of medical record quality control, solving the problem of insufficient coverage of medical records and defects in the existing quality control service, realizing automatic quality control, reducing the workload of manual quality control and the subjective factors of quality control personnel, and flexibly butting or integrating the system with the existing information system in a hospital according to the requirements of the hospital.
Description
Technical Field
The invention relates to the technical field of electronic medical record quality monitoring and management, in particular to a hospital electronic medical record quality monitoring and management system based on a RETE algorithm rule engine.
Background
With the development of IT technology and the continuous deepening of medical health system reform, the modern hospitals pay attention to the information-based construction of hospitals, and various clinical information systems taking medical records as the core, such as: outpatient and inpatient doctor workstations, nurse workstations, LIS, PACS, ECG information systems, pathology information systems, EMRS, surgical anesthesia management systems, intensive care management systems, etc., have become very popular. With the improvement of the informatization degree of hospitals, the quality of medical records brings new series of problems, for example, some hospitals put more efforts on the problems of shortening the average hospitalization days and accelerating the turnover number of sickbeds, but neglect the relationship between the quality of medical records and the medical quality, some doctors do not seriously implement the regulation and regulation of writing the medical records, some doctors are not strong in management measures on the quality of medical records, even some doctors do not think about individual diseases of patients, abuse a case template, seriously copy and sometimes even stretch the hat to wear, so that serious quality problems such as the same disease course records for multiple days are caused, and a plurality of hidden dangers are left for the quality safety of medical records.
The existing quality control mode of the first page of the medical records cannot meet the requirements of hospitals for improving the quality of the medical records, performing management on the performance of doctors and performing information management, so that how to perform the information quality control and management on the first page of the medical records becomes the key point of research and practice of hospitals.
Disclosure of Invention
The invention aims to provide a hospital electronic medical record quality monitoring and management system based on a RETE algorithm rule engine, so as to solve the problems in the background technology.
In order to achieve the purpose, the invention provides the following technical scheme: a hospital electronic medical record quality monitoring and management system based on a RETE algorithm rule engine and a disease knowledge base comprises components of a medical ontology, a natural language processing technology, a machine learning component knowledge graph, the RETE algorithm rule engine, a hospital overview, quality control rules, quality control analysis reports, medical record data statistics and link quality control.
Preferably, the medical term ontology support is to construct a medical term ontology library according to a seven-step process, extract a related concept description ontology model, and form an ontology library composed of concepts, attributes, instances and relations among related concepts, where a specific process and system composition are shown in fig. 1.
Preferably, the natural language processing technology comprises electronic case documents, normative electronic case texts, short text topic cases, semi-structured case texts, a custom dictionary, segmented case texts, doubly labeled case texts, syntactic relations among named entities, entity recognition and corresponding modification extraction, an entity recognizer, a universal structured data source and structural analysis and research work of data.
Preferably, the specific steps of the machine learning component knowledge graph are that a disease knowledge graph is constructed by performing deep machine learning on knowledge of 2000 kinds of inspection and examination libraries, 1000 kinds of disease libraries, 9000 kinds of medicine libraries and the like, an AI intelligent model with diagnosis capability is further constructed on the basis of the knowledge graph and is used for judging compliance, reasonability and accuracy of medical decision, judging disease diagnosis and required differential diagnosis, and developing an artificial intelligent medical record quality control system on the basis.
Preferably, the Rete algorithm is an efficient pattern matching algorithm, and is used for realizing a production rule system (space is used for time exchange, and memory is used for matching speed).
Preferably, the hospital-wide overview comprises a total number of quality control rules (specification total number, quality control standard, standard term, standard dictionary and the like), a total number of medical records in the hospital (machine quality control number, manual quality control number, class A, class B and class C quality control number and the like), a quality control monthly score, a department score and the like.
Preferably, the quality control rules comprise national health information standards of Weijian Commission, quality assessment standards of medical records of various provinces, ICD10/11/9 and quality control standards of electronic medical records of various hospitals.
Preferably, the quality control analysis report supports multi-level multi-role viewing departments and overall hospital medical record home page quality control comprehensive analysis reports, the analysis report comprises medical record home page scores, rating standards, deduction reasons and the like, and meanwhile, the report is exported in PDF and Word formats.
Preferably, the medical record data statistics comprise home page quality control scoring statistics, quality control module analysis and quality control defect detail statistics, and the quality control module analysis comprises visual display of statistical results such as case module defect proportion, quality control standard defect proportion and the like.
Preferably, the link quality control system performs quality control on data of a medical record home page according to quality control rules, quality control result information is fed back to a doctor, the doctor can modify the medical record information in the medical record home page quality control system according to the quality control results, the system checks the modified information in real time after the doctor loses focus on the modified information, feedback is prompted in time, the data of the medical record home page quality control system after the completion is returned to an electronic medical record, the medical record home page information can be submitted to a medical record room for quality control coding after the quality control is passed, the doctor prints the medical record home page and files the medical record home page, the medical record cannot be continuously completed by the doctor, a temporary storage function is provided in a humanized mode, and the doctor can conveniently and continuously fill in the medical record information next time.
Compared with the prior art, the invention has the beneficial effects that:
(1) according to the invention, through 2000 inspection and examination libraries, 1000 disease libraries, 9000 medicine libraries and the like, a disease knowledge map is constructed, the connotation of medical records is understood, defect screening is carried out, the rationality of disease diagnosis and treatment is judged, the work efficiency of medical record quality control is improved, the problem that medical records and defects in the existing quality control service are not covered enough pain points is solved, a unified quality control standard is established by the system, automatic quality control is realized, the workload of manual quality control and the subjective factors of quality control personnel are reduced, the system can be flexibly butted or integrated with the existing information system in a hospital according to the requirements of the hospital, not only can the final medical records be comprehensively quality controlled, but also the operating medical records can be instantly reminded, the quality control link is advanced, so that the quality control process is optimized, and the efficiency is improved;
(2) the system automatically applies the built-in and self-defined quality control rules to all medical records in the system, and presents the judgment result of each quality control rule to a user; simultaneously, can pinpoint to specific quality control defect part, the user can compare quality control result and original text at same page, carries out artifical the inspection to can revise the judged result, simultaneously, the user can mark the medical record that has artifical the inspection, so that it filters fast, look over read and do not read the medical record, and the quality control content includes: the medical record home page, the admission and discharge records, the medical record, the operation and the operation, various informed consent and the like are dispersed in different systems, and the quality control office can perform quality control audit on all documents in a quality control interface and can trace to the original document, thereby facilitating the development of quality control work;
(3) the system performs multidimensional statistical analysis on the distribution of scores, grades, defect reasons and the like of all medical records, and can also check the quality statistical results of specific types of medical records by screening departments, disease types, defect reasons, doctors, time ranges and the like, so that a user can conveniently and comprehensively know the quality conditions of medical records of the hospital population, all departments, the causes of the defects of the medical records, the change of the quality conditions of the medical records along with time and the like.
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FIG. 1 is a body of medical terms of the present invention;
FIG. 2 illustrates the natural language processing technique of the present invention;
FIG. 3 is a first system diagram of a knowledge-graph of the present invention;
FIG. 4 is a system diagram of a knowledge-graph of the present invention;
FIG. 5 is a diagram comparing the system before the introduction of the RETE algorithm engine and after the introduction of the RETE rules engine.
Detailed Description
The technical solutions in the embodiments of the present invention will be clearly and completely described below with reference to the drawings in the embodiments of the present invention, and it is obvious that the described embodiments are only a part of the embodiments of the present invention, and not all of the embodiments. All other embodiments, which can be derived by a person skilled in the art from the embodiments given herein without making any creative effort, shall fall within the protection scope of the present invention.
Referring to fig. 1-5, the present invention provides a technical solution: a hospital electronic medical record quality monitoring and management system based on a RETE algorithm rule engine and a disease knowledge base comprises a component of a medical ontology, a natural language processing technology, a machine learning component knowledge graph, a RETE algorithm rule engine, a hospital overview, a quality control rule, a quality control analysis report, medical record data statistics and link quality control, wherein medical term ontology support is to construct a medical term ontology base according to a seven-step process, extract a related concept description ontology model to form an ontology base consisting of concepts, attributes, examples and relations among related concepts, the specific process and system composition are shown in figure 1, the natural language processing technology comprises an electronic case document, a standard electronic case document, a short text theme case, a semi-structured case document, a custom dictionary, a case document after word segmentation, a doubly labeled case document, a syntactic relation between named entities and syntactic relation, The method comprises the specific steps of carrying out deep machine learning on knowledge such as 2000 kinds of inspection and examination libraries, 1000 kinds of disease libraries, 9000 kinds of medicine libraries and the like to construct a disease knowledge map, further constructing an AI intelligent model with diagnostic capability on the basis of the knowledge map for judging the compliance, rationality and accuracy of medical decision and judging disease diagnosis and required differential diagnosis, developing an artificial intelligent medical record quality control system on the basis, wherein a Rete algorithm is an efficient mode matching algorithm and is used for realizing a production rule system (space time changing and internal memory exchange matching speed), and a hospital overview comprises the total number of quality control rules (standard total number, standard total number, Quality control standards, standard terms, standard dictionaries and the like), total medical record numbers (machine quality control numbers, manual quality control numbers, first-second-third-class quality control numbers and the like) of the whole hospital, quality control monthly scores, department scores and the like, quality control rules comprise national health care commission health information standards, quality assessment standards of medical records of various provinces, ICD10/11/9 and quality control standards of electronic medical records of various hospitals, quality control analysis reports support multi-level and multi-role examination departments and whole hospital medical record head page quality control comprehensive analysis reports, analysis reports comprise medical record head page scores, assessment grade standards, deduction reasons and the like, meanwhile, reports are derived in PDF and Word formats, medical record data statistics comprise head page quality control score statistics, quality control module analysis and quality control defect detail statistics, quality control module analysis comprises module defect proportion, quality control standard defect proportion and other statistical results visualization display, the link quality control system performs quality control on data of a medical record home page by means of quality control rules, quality control result information is fed back to a doctor, the doctor can modify medical record information in the medical record home page quality control system according to quality control results, the system checks the modified information in real time after the doctor loses focus on the modified information, feedback is prompted in time, data of the medical record home page quality control system after the completion is returned to an electronic medical record, quality control codes can be submitted to a medical record room after the quality control of the medical record home page information passes, the doctor prints the medical record home page and files the medical record, the medical record cannot be continuously completed by the doctor, the system is humanized and provides a temporary storage function, and the doctor can conveniently and continuously fill in the medical record information next time.
The working principle is as follows: when the invention is used, more than 2000 inspection and examination libraries, more than 1000 disease libraries, more than 9000 medicine libraries and the like construct disease knowledge maps to understand the connotation of medical records, and carries out defect screening, judges the rationality of disease diagnosis and treatment, improves the working efficiency of medical record quality control, solves the problem of pain point of insufficient medical record and defect coverage in the existing quality control service, establishes a unified quality control standard by the system, realizes automatic quality control, reduces the workload of manual quality control and the subjective factors of quality control personnel, can be flexibly butted or integrated with the existing information system in a hospital according to the requirements of the hospital, can carry out comprehensive quality control on the final medical records, can also carry out instant prompt on the operating medical records, and brings forward the quality control link, the system automatically applies the built-in and self-defined quality control rules to all medical records in the system and presents the judgment result of each quality control rule to the user; simultaneously, can pinpoint to specific quality control defect part, the user can compare quality control result and original text at same page, carries out artifical the inspection to can revise the judged result, simultaneously, the user can mark the medical record that has artifical the inspection, so that it filters fast, look over read and do not read the medical record, and the quality control content includes: the system comprises a medical record homepage, a hospital entrance record, a medical course record, an operation and an operation, various informed consent and the like, is dispersed in different systems, quality control office can carry out quality control examination and verification on all documents in a quality control interface, can trace to the original document, is convenient for the development of quality control work, carries out multidimensional statistical analysis on the distribution of scores, grades, defect reasons and the like of all medical records, can also check the quality statistical results of specific types of medical records by screening departments, disease types, defect reasons, doctors, time ranges and the like, is convenient for users to comprehensively know the quality conditions of the medical records in the hospital, the defect reasons of the medical records, the change of the quality conditions of each medical record along with time and the like, respectively carries out quality control evaluation on multiple modification histories of one medical record, and judges the state and score change of each quality control defect, and can check the content, the quality control and the like of each medical record on the system, Quality control evaluation, score change and the like so as to track whether the doctor corrects the case defect.
Claims (10)
1. A hospital electronic medical record quality monitoring and management system based on a RETE algorithm rule engine and a disease knowledge base is characterized in that: the medical ontology comprises a component of a medical ontology, a natural language processing technology, a machine learning component knowledge map, a RETE algorithm rule engine, a hospital overview, a quality control rule, a quality control analysis report, medical record data statistics and link quality control.
2. The RETE algorithm rules engine and disease knowledge base based quality monitoring and management system for hospital electronic medical records according to claim 1, wherein: the medical term ontology support is that a medical term ontology library is constructed according to a seven-step process, relevant concept description ontology models are extracted, an ontology library composed of concepts, attributes, examples and relations among relevant concepts is formed, and the specific process and system composition are shown in fig. 1.
3. The RETE algorithm rules engine and disease knowledge base based quality monitoring and management system for hospital electronic medical records according to claim 1, wherein: the natural language processing technology comprises an electronic case document, a standard electronic case text, a short text topic case, a semi-structured case text, a self-defined dictionary, a case text after word segmentation, a double-labeled case text, a syntactic relation among named entities, entity recognition and corresponding modification extraction, an entity recognizer, a universal structured data source and structural analysis and research work of data.
4. The RETE algorithm rules engine and disease knowledge base based quality monitoring and management system for hospital electronic medical records according to claim 1, wherein: the specific steps of the machine learning component knowledge graph are that a disease knowledge graph is constructed by deep machine learning of knowledge of 2000 kinds of inspection and examination libraries, 1000 kinds of disease libraries, 9000 kinds of medicine libraries and the like, an AI intelligent model with diagnosis capability is further constructed on the basis of the knowledge graph and is used for judging the compliance, the reasonability and the accuracy of medical decision and judging disease diagnosis and required differential diagnosis, and an artificial intelligent medical record quality control system is developed on the basis.
5. The RETE algorithm rules engine and disease knowledge base based quality monitoring and management system for hospital electronic medical records according to claim 1, wherein: the Rete algorithm is an efficient pattern matching algorithm and is used for realizing a production rule system (space is used for changing time, and memory is used for changing matching speed).
6. The RETE algorithm rules engine-based quality monitoring and management system for hospital electronic medical records according to claim 1, characterized in that: the hospital-wide overview comprises the total number of quality control rules (standard total number, quality control standard, standard terms, standard dictionaries and the like), the total number of medical records in the hospital (machine quality control number, manual quality control number, class A, class B, class C and the like), the monthly degree score of quality control, the department score and the like.
7. The RETE algorithm rules engine-based quality monitoring and management system for hospital electronic medical records according to claim 1, characterized in that: the quality control rules comprise national health information standards of Weijian Commission, quality assessment standards of medical records of various provinces, ICD10/11/9 and quality control standards of electronic medical records of various hospitals.
8. The RETE algorithm rules engine-based quality monitoring and management system for hospital electronic medical records according to claim 1, characterized in that: the quality control analysis report supports multi-level and multi-role viewing departments and hospital-wide medical record home page quality control comprehensive analysis reports, the analysis report comprises medical record home page scores, rating standards, deduction reasons and the like, and meanwhile, the report is exported in PDF and Word formats.
9. The RETE algorithm rules engine-based quality monitoring and management system for hospital electronic medical records according to claim 1, characterized in that: the medical record data statistics comprises home page quality control scoring statistics, quality control module analysis and quality control defect detail statistics, and the quality control module analysis comprises visual display of statistical results such as case module defect proportion, quality control standard defect proportion and the like.
10. The RETE algorithm rules engine-based quality monitoring and management system for hospital electronic medical records according to claim 1, characterized in that: the link quality control system performs quality control on data of a medical record home page by means of quality control rules, quality control result information is fed back to a doctor, the doctor can modify the medical record information in the medical record home page quality control system according to the quality control result, the system checks the modified information in real time after the doctor loses focus on the modified information, feedback is prompted in time, the data of the medical record home page quality control system after the completion is returned to an electronic medical record, the medical record home page information can be submitted to a medical record room for quality control coding after the quality control of the medical record home page information passes, the doctor prints the medical record home page and files the medical record, the doctor cannot continuously complete the medical record, the system is humanized and provides a temporary storage function, and the doctor can conveniently and continuously fill the medical record information next time.
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