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李科威,丁长松,王泽亮,梁昊.病历形态的转变：从模板化到网格化[J].湖南中医药大学学报英文版,2021,41(1):23-26.[Click to copy
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| This paper
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| 病历形态的转变：从模板化到网格化 |
| 李科威,丁长松,王泽亮,梁昊 |
| (湖南中医药大学数字中医药协同创新中心, 湖南 长沙 410208;科凌力智能医学软件(深圳)有限公司, 广东 深圳 570100;湖南中医药大学信息科学与工程学院, 湖南 长沙 410208;湖南中医药大学数字中医药协同创新中心, 湖南 长沙 410208;湖南中医药大学中医诊断学湖南省重点实验室, 湖南 长沙 410208) |
| 摘要: |
| 当前病历的主流形态是电子病历（EMR）模板式形态。分析模板病历的问题，提出从人工智能（AI）思路与技术视角，对比阐述一种新的病历形态，即网格病历形态；并以同步临床决策支持（CDS）为条件，论述建构网格病历的基本方法、基本形态、基本操作和主要优势，展示其解决临床问题的多种能力。 |
| 关键词: 电子病历 医学人工智能 临床流程重组 模板病历 网格病历 临床决策支持 |
| DOI：10.3969/j.issn.1674-070X.2021.01.005 |
| Received:April 22, 2020 |
| 基金项目:国家重点研发计划项目（SQ2017YFC170323）；湖南省科技创新计划项目（2020RC2061）；湖南中医药大学科研基金项目（2018XJJJ05）。 |
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| The Transformation of Medical Record Morphology: from Templating to Meshing |
| LI Kewei,DING Changsong,WANG Zeliang,LIANG Hao |
| (Digital Chinese Medicine Collaborative Innovation Center of Hunan University of Chinese Medicine, Changsha, Hunan 410208, China;Colingli Intelligent Medical Software(Shenzhen) Co., Ltd., Shenzhen, Guangdong 570100, China;School of Information Science and Engineering of Hunan University of Chinese Medicine, Changsha, Hunan 410208, China;Digital Chinese Medicine Collaborative Innovation Center of Hunan University of Chinese Medicine, Changsha, Hunan 410208, China;Hunan Provincial Key Laboratory of Traditional Chinese Medicine Diagnostics of Hunan University of Chinese Medicine, Changsha, Hunan 410208, China) |
| Abstract: |
| At present, the main morphology of medical record is the template of electronic medical record (EMR). This article analyzed the problem with the medical record template, from the perspective of artificial intelligence (AI) and technology to compare and expound the new record morphology, that is, the morphology of medical record meshing. Based on the condition of synchronous clinical decision support (CDS), this paper discussed the basic methods, basic forms, basic operations and main advantages of constructing meshing medical records, and showed its various abilities to solve clinical problems. |
| Key words: electronic medical record artificial intelligence in medicine clinical process reengineering medical record template medical record meshing clinical decision support |
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