目的 设计一套基于智能病案归档系统的医疗过程无纸化办公平台，以实现医疗过程的无纸化办公。方法 以某三级甲等医院为例，基于实验室信息系统、医院信息系统、影像归档和通信系统等信息系统，完成数字证书认证系统、信息集成平台、病案质控系统、病案数据库及索引库、数据灾难备份体系等的设计。在“病案可信归档系统V1.0”软件基础上引入AI全病案质控系统，升级为“病案可信归档系统V2.0”，建立一套无纸化办公的管理机制，实现病案全生命周期智能化管理。结果 基于智能病案归档系统的医疗过程无纸化办公平台应用后，病案7 d内归档率由72.66%提高至96.87%，甲级病案占比由97.74%提高至99.14%，差异均有统计学意义（P<0.001）。借助无纸化办公平台，查询病案资料时间平均缩短了157.56 s，无纸化病案调取份数也有大量提高；危急值30 min内处置及时率由78.58%提高至88.86%，差异均有统计学意义（P<0.001）；医院每年节省经济成本约496万元。结论 基于智能病案归档系统的医疗过程无纸化办公平台的应用，切实提升了医院病案归档水平和医疗过程无纸化水平，实现了医院病案档案的高效管理和利用、充分发挥了无纸化管理优势，提高了工作效率，提升了患者体验，使病案更好地服务于医疗。
Abstract
Objective To design a paperless office platform for medical process based on intelligent medical record archiving system, in order to achieve paperless office of medical process. Methods Taking a grade Ⅲ-A hospital as an example, based on information systems such as laboratory information system, hospital information system and picture archiving and communication system, etc., the digital certificate authentication system, information integration platform, medical record quality control system, medical record database and index library, data disaster backup system were designed. On the basis of the “Medical Record Trusted Archiving System V1.0” software, an AI full medical record quality control system was introduced and upgraded to the “Medical Record Trusted Archiving System V2.0”. A paperless office management mechanism was established to achieve intelligent management of the whole life cycle of medical records. Results After the application of the medical process paperless office platform based on the intelligent medical record archiving system, the filing rate of medical records within 7 d increased from 72.66% to 96.87%, and the proportion of Class A medical records increased from 97.74% to 99.14%, and the differences were statistically significant (P<0.001). With the help of a paperless office platform, the average time for querying medical records has been reduced by 157.56 s, and the number of paperless medical records retrieved has also significantly increased; the timely disposal rate within 30 min of the critical value increased from 78.58% to 88.86%, and the differences were statistically significant (P<0.001). The hospital saved approximately 4.96 million yuan in economic costs annually. Conclusion The application of the medical process paperless office platform based on intelligent medical record archiving system has effectively improved the level of hospital medical record archiving and medical process paperless. The hospital has achieved efficient management and utilization of medical records, fully leverages the advantages of paperless management, improves work efficiency, enhances patient experience, and enables medical records to better serve healthcare.
关键词
智能病案；归档；无纸化办公；医疗过程；医院管理；全生命周期
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Key words
intelligent medical record; archiving; paperless office; medical process; hospital management; whole life cycle
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中图分类号：
R197.32
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脚注
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基金
自治区区域协同创新专项-科技援疆计划（2022E02028）。
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