CN103513781A - Accurate and fast electronic medical record entering system - Google Patents
Accurate and fast electronic medical record entering system Download PDFInfo
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Abstract
The invention discloses an accurate and fast electronic medical record entering system which is composed of an intelligent medical input module, a medical term correcting module and a term acquiring module. Entering of an electronic medical record is achieved through the entering system, traditional Chinese medicine clinical terms from the real world can be applied to the traditional Chinese medicine clinical scientific research work in the real world in a standardized mode, accordingly, information can be collected accurately and efficiently in the clinical work, a clinical electronic medical record which meets a quality control requirement can also be generated, meanwhile, errors can be corrected timely, novel traditional Chinese medicine clinical terms can be acquired, the novel terms are examined and approved, and quick and accurate writing of the traditional Chinese medicine clinical electronic medical record is guaranteed.
Description
Technical field
The present invention relates to electronic health record technical field, specifically refer to a kind of realization electronic health record input system quickly and accurately.
Background technology
Along with the development of computing machine and Internet technology, current most of hospital has realized the electronization of clinical case history.But following 3 class problems of ubiquity still at present.
First, the typing of electronic health record at present is mainly adopted in two ways, i.e. pre-structure case history typing mode and rear structured patient record typing mode.Rear structuring typing mode adopts the mode of natural language to carry out typing conventionally, be applied to the typing of free text type electronic health record, this kind of mode input speed is very fast, but the information obtaining is non-structured, needs data to carry out a large amount of operational processes in the scientific research in later stage; Pre-structure mode is often referred to uses case history template to generate electronic health record, realizes the structuring of electronic health record by case history template before case history typing, is applied to the typing of structured electronic patient record.Structuring typing mode relatively, pre-structure input speed can be slower conventionally, and along with structurized content is more and more, input speed can be more and more slower.
Secondly the structuring of electronic health record has just guaranteed the logical organization of medical record writing, its input content is not controlled.Lacking unified standard makes the information between each medical institutions cannot compatible intercommunication.Electronic health record will be realized and interconnecting, and should make the term of input is standard, again the mistake of input is known to medical terminology and corrects.
Last most of electronic health record all carries out typing with natural language form, even structurized electronic health record is also natural language form when each data element typing.Due to clinical diagnosis and treatment process is described from teaching material different, in actual diagnosis and treatment process, can produce many new medical terminologys simultaneously.And these new medical terminologys can only be entered in terminology bank or database by manual mode conventionally, the slow renewal of terminology candidates.
Summary of the invention
The present invention proposes a kind of realization electronic health record input system quickly and accurately, by intelligent medical science load module, medical terminology correction module and term acquisition module three parts, formed, make it when guaranteeing efficiency of inputting, realize the standardization typing of medical terminology, and can catch in real time the new term producing in clinic diagnosis process.
1, intelligent medical science load module
This module realizes a kind ofly not only can but also can carry out the method for fast medical term input at free text type electronic health record in structured electronic patient record, by phonetic associating mode, for user provides medical terminology candidate item, reach the object of Rapid input, in the situation that there is no suitable medical terminology, support the typing of general Chinese character simultaneously.This module is also for the new medical terminology of Real-time Obtaining provides basis.Module specifically comprises seven submodules: load module, medical terminology storehouse, conventional dictionary, allocation list, association's algorithm, output module, update module.
(1) load module: for inputting medical terminology, user carries out the input of medical terminology by the position of keyboard cursor in electronic health record.Similar to general input method demonstration, all candidate item show in batches.First from medical terminology library searching, go out the medical terminology matching with current input Pinyin, by association's algorithm, sort; Secondly from conventional dictionary, search out the everyday words matching with current input Pinyin, all everyday words are all presented at after medical terminology.
(2) medical terminology storehouse: for storing the input required term of medical domain and the various attributes of term, for association's input provides basis.Term in medical terminology storehouse is stored in the mode of dictionary tree, to improve retrieval, the input speed of medical terminology.In terminology bank, store the title of term, the classification of the description of term, term, disease kind, the term under the source of term, term occurs whether document section, term are the information such as standard terminology at certain sick occurrence number, term of planting in certain document section;
(3) conventional dictionary: storage everyday words and phrase.
(4) allocation list: write with XML form, determine current carry out free text type electronic health record or the typing of structured electronic patient record by configuration parameter, store various parameters, for the calculating of association's algorithm simultaneously.Parameter in allocation list comprises: the affiliated sick kind of case history, the title of data element and the document section under data element.Allocation list is mainly used in distinguishing the type of current typing.If parameter is empty in allocation list, illustrate that current is in the typing of carrying out free text type electronic health record; Otherwise be in the typing of carrying out structured electronic patient record, information that simultaneously can store electrons case history needs in allocation list.Regulation according to the Ministry of Public Health to electronic health record structure, electronic health record is comprised of data element, data group, document section, clinical documentation section.Term all in electronic health record data element partly carry out typing.
(5) association's algorithm: according to configuration parameters different in allocation list, the term searching out is calculated to its matching value by association's algorithm, by showing after the descending sequence of matching value.Association's algorithmic formula is as follows:
MatchValue(w)＝Freq
ds，dn，s(w)/MAX(Freq(w))+Std(w)+Ctg
d(w) 1.1
Wherein w represents certain term, and MatchValue (w) represents the matching value of term,
Freq
ds, dn, s(w)/MAX (Freq (w)) represents the frequency that term w occurs in certain sick ds of kind, certain diagnosis dn, certain document section s;
(6) output module: for searching out the term matching with current input Chinese character or phonetic, user can use mouse or keyboard to select the term that will input as the word that will input.If term to be entered, in candidate prompting, cannot according to system suggestion not carry out typing, with utilize general input method similar, directly carry out the input of Chinese character.
(7) update module: after medical record writing, according to new typing from the term in medical terminology storehouse, upgrade the number of times that corresponding term in medical terminology storehouse is sickly planted, occurred in document section at this, for association's algorithm next time, calculate.
2, medical terminology correction module
It is a kind of at free text type electronic health record or in structured electronic patient record that this module provides, and the medical terminology of input carried out to the method for intelligent correction.After typing finishes, detect the not term in medical terminology storehouse of typing, search term similar to typing term in medical terminology storehouse prompting, for user, select.If confirm, there is no typing mistake, carry out the automatic error-correcting of next term to be detected.This module comprises five submodules altogether: load module, contrast terminology bank, medical terminology storehouse, correction module, output module.
(1) load module: catch the term of typing, its value derives from the output module in intelligent medical science input system, using the term in medical terminology storehouse not as input term;
(2) contrast terminology bank: storage system is in service, the wrong term of correcting correct term corresponding thereto;
(3) medical terminology storehouse: the term of medical domain and the various attributes of term that storage input is required, for the calculating of similarity, as the basis of intelligent correction.In medical terminology storehouse, store the title of term, the classification of the description of term, term, disease kind, the term under the source of term, term occurs whether document section, term are the information such as standard terminology at certain sick occurrence number, term of planting in certain document section;
(4) correction module: regard the term in term to be corrected and medical terminology storehouse as character string, if term to be corrected is not in contrast terminology bank, from medical terminology storehouse, selecting has with term to be corrected the term that 60% character is identical, according to the editing distance of these terms and term to be corrected, ascending term is sorted;
(5) output module: the term list that output draws through error correction algorithm, and whether the term that contrasts user's selection is consistent with input term, if inconsistent, the term of user being selected is as correct term, deposits contrast terminology bank in together with the wrong term when input; If consistent, do not operate.
3, term acquisition module
This module provides a kind of and automatically carry out the method that new clinical medical term obtains when free text type electronic health record or the typing at structured electronic patient record, the new clinical term producing for the Input Process obtaining at electronic health record.This module specifically comprises six submodules, and four function sub-modules and two database submodules, be respectively: term trapping module, term authorization module, term administration module, removing module and interim terminology bank and medical terminology storehouse.
(1) term trapping module: system can be by the new medical terminology occurring in this module automatic acquisition electronic health record.If in the Input Process of structured electronic patient record, the value of data element is not in medical terminology storehouse, and system stores the value of this data element in interim terminology bank into automatically by term trapping module.Need canned data to also have this data element place document name section, term is in this document section occurrence number; If in the typing of free text type electronic health record, the value of input, not in medical terminology storehouse, is carried out new terminology identification by term recognition technology, and new terminology is stored in interim terminology bank.
(2) term authorization module: all terms in interim terminology bank are authorized, by a user, each term in interim nomenclature is authorized, after term by authorization is called term administration module term information is remarked additionally, deposit medical terminology storehouse in; By the term of authorization, temporarily do not stay in interim terminology bank, finally by removing module, directly delete interim terminology bank.
(3) term administration module: according to the various attributes of term in medical terminology storehouse, supplement by the various attribute informations of the term after authorization, comprise the title of term, the classification of the description of term, term, disease kind, term under the source of term, term occur whether document section, term are standard terminology etc. at certain sick occurrence number, term of planting in certain document section.
(4) removing module: for deleting interim terminology bank.
(5) medical terminology storehouse: for storing the input required term of medical domain and the various attributes of term.In terminology bank, store the title of term, the classification of the description of term, term, disease kind, the term under the source of term, term occurs whether document section, term are the information such as standard terminology at certain sick occurrence number, term of planting in certain document section;
(6) interim terminology bank: the new terminology obtaining for being stored in electronic health record Input Process, and store the document section at term place, term is in this document section occurrence number.
The invention has the beneficial effects as follows, by this system, can realize writing fast and accurately tcm clinical practice electronic health record, and the clinical term of input is carried out to certain error correcting, obtain the new clinical terms of Traditional Chinese Medicine that clinic diagnosis process occurs simultaneously, and the medical terminology of newly obtaining is unified and semantic interpretation accurately, be convenient to the further application of new terminology.The case history typing realizing by this system, can make from the standardization of real world clinical terms of Traditional Chinese Medicine be applied in the work of real world clinical research, thereby both can be accurate in guarantee clinical position, Information Monitoring efficiently, can generate again the clinical electronic health record that meets Quality Control requirement, can also ensure the clinical terms of Traditional Chinese Medicine that obtains timely new generation simultaneously, and the mode of authorizing by many people, the medical terminology of newly obtaining is unified and semantic interpretation accurately, be convenient to the further application of new terminology, quick for more tcm clinical practice electronic health records, write accurately.
Accompanying drawing explanation
Fig. 1 is system flowchart of the present invention.
Fig. 2 is intelligent medical science load module process flow diagram.
Fig. 3 is medical terminology correction module process flow diagram.
Fig. 4 is term acquisition module process flow diagram.
Embodiment
The symptom in main suit in typing structuring diabetes case history of take is example.
(1), in example, be to carry out typing in structuring diabetes case history, therefore allocation list content is not empty.The allocation list of writing with XML language is as follows.
(2) if current need to be in main suit typing symptom " left upper extremity pain ", and term exists in medical terminology storehouse.In certain data element of main suit, first utilize load module typing " left upper extremity ", according to each parameter in allocation list and association's algorithm, calculate, front 5 candidate item are " left upper extremity pain ", " left upper extremity is numb ", " left upper extremity is ached ", " left upper extremity contraction pain ", " left upper extremity shouting pain ".Utilize load module to show all candidate item, and front 5 candidate item are shown at first.
If a) current candidate item comprises the term of wanting typing, can by mouse-click or the upper and lower key of keyboard and enter key is selected " in left upper extremity pain ”， main suit, show.After typing, by update module, upgrade " left upper extremity pain " in medical terminology storehouse and appear at the number of times in diabetes case history main suit.
B), if do not comprise the term of wanting typing in the candidate item of current demonstration, by mouse or keyboard Backwards selection, show the demonstration of candidate item below, until the demonstration of the candidate item that occurs comprising term to be entered.Again by mouse-click or the upper and lower key of keyboard and enter key is selected " shows in left upper extremity pain ”， main suit.After typing, by update module, upgrade " left upper extremity pain " in medical terminology storehouse and appear at the number of times in diabetes case history main suit.
(3) if current symptom term " left upper extremity swelling " that need to typing is correct in main suit, and term does not exist in medical terminology storehouse.In certain data element of main suit, first utilize load module typing " left upper extremity ", according to each parameter in allocation list and association's algorithm, calculate, front 5 candidate item are " left upper extremity pain ", " left upper extremity is numb ", " left upper extremity is ached ", " left upper extremity contraction pain ", " left upper extremity shouting pain ".Utilize load module to show all candidate item, and front 5 candidate item are shown at first.Due to current, treat that typing term does not exist in medical terminology storehouse, through association's algorithm, calculate, in the candidate item of load module prompting, there is no " left upper extremity swelling ", directly utilize load module, carry out the input of " swelling ".Because this term is not in terminology bank, therefore never call update module, and call term acquisition module, carry out obtaining of new terminology.
(4) the not term in medical terminology storehouse completing for typing, carry out correction process.If the term of current typing is correct term,, as typing term " left upper extremity swelling ", from contrast, search for terminology bank and whether exist " left upper extremity swelling,, the correct term of correspondence.If there is no, by medical terminology correction module, from medical terminology storehouse, pick out the candidate term similar to it " left upper extremity enlargement ", " left upper extremity pain ", " left upper extremity is numb ", " left upper extremity is ached ", " left upper extremity contraction pain ", " left upper extremity shouting pain " etc., but it is not the term that will input, therefore do not select by mouse or keyboard, system still can show " left upper extremity swelling ", because input is consistent with output, does not operate; If the term of current typing is wrong term, as typing term " swollen of left upper extremity ", first from contrast terminology bank, searches for and whether have correct term " left upper extremity swelling " corresponding to " swollen of left upper extremity ".If exist, directly carry out the prompting " left upper extremity swelling " of correct term; If there is no, pass through correction module, can from medical terminology storehouse, pick out candidate's term " left upper extremity swelling ", " left upper extremity enlargement " " left upper extremity pain ", " left upper extremity is numb ", " left upper extremity is ached ", " left upper extremity contraction pain ", " left upper extremity shouting pain " etc., after selecting by mouse or keyboard, system is revised as " left upper extremity swelling " by " swollen of left upper extremity " automatically to be exported.Wrong term when the correct term " left upper extremity swelling " that simultaneity factor is selected user and input " swollen of left upper extremity " deposits contrast terminology bank in, is convenient to later correction process.
(5) for typing, the term in medical terminology storehouse not, utilize term trapping module to catch after new terminology, deposited in interim terminology bank.By calling term authorization module, examine all terms in interim terminology bank, by a user to the term in interim terminology bank " left upper extremity swelling " authorize.
A) after authorization is passed through, call the title of term administration module complementary terms, the classification of the description of term, term, disease kind, the term under the source of term, term occurs whether document section, term are standard terminology at certain sick occurrence number, term of planting in certain document section.Information is supplemented complete, deposits term in medical terminology storehouse.Authorized after all terms in interim terminology bank, called removing module and directly delete interim terminology bank.
B) authorization is not passed through, and term is stayed in interim terminology bank, until the authorization of all terms is complete, calls removing module and directly deletes interim terminology bank.
Claims (6)
1. an electronic health record input system quickly and accurately, is characterized in that, this input system is comprised of intelligent medical science load module, medical terminology correction module and term acquisition module three parts:
(1) intelligent medical science load module: this module realize a kind of both can be at free text type electronic health record, can in structured electronic patient record, carry out the method for fast medical term input again, by phonetic associating mode, for user provides medical terminology candidate item, reach the object of Rapid input; In the situation that there is no suitable medical terminology, support the typing of general Chinese character simultaneously;
(2) medical terminology correction module: this module provides a kind of at free text type electronic health record or in structured electronic patient record, carries out the method for intelligent correction to the medical terminology of input; After typing finishes, detect the not term in medical terminology storehouse of typing, search in medical terminology storehouse and also point out with the similar term of typing term, for user, select, if confirm, there is no typing mistake, carry out the automatic error-correcting of next term to be detected;
(3) term acquisition module: this module provides a kind of when free text type electronic health record or the typing at structured electronic patient record, automatically carry out the method that new clinical medical term obtains, the new clinical term producing for the Input Process obtaining at electronic health record.
2. a kind of input system of electronic health record quickly and accurately according to claim 1, it is characterized in that, intelligent medical science load module comprises load module, medical terminology storehouse, conventional dictionary, allocation list, association's algorithm, output module, seven submodules of update module:
(1) load module: for inputting medical terminology, first go out from medical terminology library searching the medical terminology matching with current input Pinyin, sort by association's algorithm; Then from conventional dictionary, search out the everyday words matching with current input Pinyin, all everyday words are all presented at after medical terminology;
(2) medical terminology storehouse: for storing the required term of medical domain and the various attributes of term of input, comprise the title of term, the classification of the description of term, term, disease kind, term under the source of term, term occur whether document section, term are the information such as standard terminology at certain sick occurrence number, term of planting in certain document section; Term in medical terminology storehouse is stored in the mode of dictionary tree;
(3) conventional dictionary: storage everyday words and phrase;
(4) allocation list: write with XML form, the parameter of storage comprises the affiliated sick kind of case history, the title of data element and the document section under data element; If parameter is empty in allocation list, illustrating current is in the typing of carrying out free text type electronic health record, otherwise is in the typing of carrying out structured electronic patient record;
(5) association's algorithm: according to configuration parameters different in allocation list, the term searching out is calculated to its matching value by association's algorithm, by showing after the descending sequence of matching value, association's algorithmic formula is:
MatchValue(w)=Freq
ds，dn，s(w)/MAX(Freq(w))+std(w)+CtF
d(w)
Wherein w represents certain term, and MatchValue (w) represents the matching value of term, Freq
ds, dn, s(w)/MAX (Freq (w)) represents the frequency that term w occurs in certain sick ds of kind, certain diagnosis dn, certain document section s;
(6) output module: for searching out the term matching with current input Chinese character or phonetic, user can use mouse or keyboard to select the term that will input as the word that will input; If term to be entered, in candidate's prompting, does not directly carry out the input of Chinese character;
(7) update module: after medical record writing, according to new typing from the term in medical terminology storehouse, upgrade the number of times that corresponding term in medical terminology storehouse is sickly planted, occurred in document section at this, for association's algorithm next time, calculate.
3. a kind of input system of electronic health record quickly and accurately according to claim 1, is characterized in that, medical terminology correction module comprises load module, contrast terminology bank, medical terminology storehouse, correction module, 5 submodules of output module:
(1) load module: catch the term of typing, its value derives from the output module in intelligent medical science input system, using the term in medical terminology storehouse not as input term;
(2) contrast terminology bank: storage system is in service, the wrong term of correcting correct term corresponding thereto;
(3) medical terminology storehouse: the term of medical domain and the various attributes of term that storage input is required, for the calculating of similarity;
(4) correction module: regard the term in term to be corrected and medical terminology storehouse as character string, if term to be corrected, not in contrast terminology bank, is selected the term sequence close with term character to be corrected from medical terminology storehouse;
(5) output module: the term list that output draws through error correction algorithm, and whether the term that contrasts user's selection is consistent with input term, if inconsistent, the term of user being selected is as correct term, deposits contrast terminology bank in together with the wrong term when input; If consistent, do not operate.
4. a kind of input system of electronic health record quickly and accurately according to claim 1, it is characterized in that, term acquisition module comprises term trapping module, term authorization module, term administration module, removing module and interim terminology bank and medical terminology storehouse totally 4 function sub-modules and 2 database submodules:
(1) term trapping module: system can be by the new medical terminology occurring in this module automatic acquisition electronic health record; If in the Input Process of structured electronic patient record, the value of data element is not in medical terminology storehouse, and system stores the value of this data element, data element place document name section, term in interim terminology bank in information such as this document section occurrence numbers automatically by term trapping module; If in the typing of free text type electronic health record, the value of input, not in medical terminology storehouse, is carried out new terminology identification by term recognition technology, and new terminology is stored in interim terminology bank;
(2) term authorization module: all terms in interim terminology bank are authorized by a user;
(3) term administration module: according to the various attributes of term in medical terminology storehouse, the various attribute informations of term by authorization are supplemented, comprise the title of term, the classification of the description of term, term, disease kind, term under the source of term, term occur whether document section, term are standard terminology etc. at certain sick occurrence number, term of planting in certain document section;
(4) removing module: for deleting interim terminology bank;
(5) medical terminology storehouse: for storing the required term of medical domain and the various attributes of term of input, comprise the title of term, the classification of the description of term, term, disease kind, the term under the source of term, term occurs that document section, term sickly plant whether number of times, term that certain document section occurs is the information such as standard terminology at certain;
(6) interim terminology bank: the new terminology obtaining for being stored in electronic health record Input Process, and the document section, term of storing term place are in this document section occurrence number.
5. a kind of input system of electronic health record quickly and accurately according to claim 3, it is characterized in that, in medical terminology correction module traditional Chinese medicine terminology bank, store the title of term, the classification of the description of term, term, disease kind, the term under the source of term, term occurs whether document section, term are the information such as standard terminology at certain sick occurrence number, term of planting in certain document section.
6. a kind of input system of electronic health record quickly and accurately according to claim 3, it is characterized in that, in medical terminology correction module, correction module is regarded the term in term to be corrected and medical terminology storehouse as character string, if term to be corrected is not in contrast terminology bank, from medical terminology storehouse, selecting has with term to be corrected the term that 60% character is identical, according to the editing distance of these terms and term to be corrected, ascending term is sorted.
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| CN104091058A (en) * | 2014-06-27 | 2014-10-08 | 北京君和信达科技有限公司 | Safety inspection conclusion submitting method and device |
| CN105302332A (en) * | 2014-07-25 | 2016-02-03 | 中国移动通信集团公司 | Pinyin input method and realization apparatus thereof |
| CN106682397A (en) * | 2016-12-09 | 2017-05-17 | 江西中科九峰智慧医疗科技有限公司 | Knowledge-based electronic medical record quality control method |
| CN108563618A (en) * | 2018-03-15 | 2018-09-21 | 链家网（北京）科技有限公司 | Change method and system on a kind of paper document line |
| CN109698018A (en) * | 2018-12-24 | 2019-04-30 | 广州天鹏计算机科技有限公司 | Medical text handling method, device, computer equipment and storage medium |
| CN110444264A (en) * | 2019-08-16 | 2019-11-12 | 宜昌市中心人民医院 | First page of illness case based on DRGs is intelligently filled in and training system |
| CN110444264B (en) * | 2019-08-16 | 2023-04-14 | 宜昌市中心人民医院 | DRGs-based medical record homepage intelligent filling and training system |
| CN110600095A (en) * | 2019-08-23 | 2019-12-20 | 和宇健康科技股份有限公司 | Quality control method and system for electronic medical record |
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