Disease coding method and system based on original diagnostic data and medical record file data

Abstract

The invention discloses a disease coding method and system based on original diagnosis data and case history file data. The method comprises following steps of receiving input data, wherein the inputdata comprises original diagnosis data and case history file data; pre-processing the input diagnosis data and case history file data; carrying out retrieval in a standard classification code ICD-10 and judging whether a result is obtained; if no, carrying out word segmentation processing, association conversion processing and searching matching tree processing on the original diagnosis data and screening out an optical result from processing results of a matching tree; and if the result is not the optimal result, screening out the optimal result from the case history file data, estimating thecoding accuracy of the result and outputting a coding result and an accuracy evaluation result. According to the invention, the problem of non-uniform standard diagnosis codes used by the medical mechanisms is effectively solved.

Description

technical field [0001] The present invention relates to the field of medical information technology and the field of artificial intelligence technology, in particular to a disease coding method and system based on original diagnosis data and medical record file data. Background technique [0002] With the continuous deepening and deepening of the country's layout of public medical care and medical reform, the all-round improvement of medical services has put forward urgent requirements for medical informatization. In terms of medical insurance, public health services, and hospital informatization management, medical informatization has developed from the process automation management that completes the entire process of recording to Internet + health care; under the current background of big data and artificial intelligence, medical informatization gradually touches the core of medical care. The core business is to provide auxiliary decision-making and guidance reference for...

AI Technical Summary

Problems solved by technology

This work is done manually, so it is subject to manpower, the quality of coders, the interpretation of standards and the grasp of the huge content of the coding dictionary, as well as the working years and experience, so the number of manual code matching is limited every day, and there are cases of misjudgment , and the degree of coding thickness and judgment standards also vary from person to person. In the comparison and exchange of data in different hospitals, these problems will be highlighted and magnified. has a difference

[0005] (2) The actual diagnosis of the doctor's personalized and custom input is not fully compatible with the standard diagnosis coding library

[0006] Because the diagnoses contained in the diagnosis coding database cannot completely cover the diagnoses actually used by doctors in their daily work, and for the same diagnosis, due to the particularity of Chinese, the expression of the same disease concept is extremely diverse and there is no uniform standard medical treatment in the industry. The standardization of terminology, the wording and structure of the diagnostic names used by different doctors are also different, varied, and the aliases used are very different; in addition, the update of the standard diagnostic dictionary takes a long time (national standard ICD10, last updated in 2009 8 years have passed since this update in 2017), which cannot cover the latest diseases and their names in time; and for the classification of specific diagnoses, the level of detail of the standard codes cannot meet the actual clinical requirements of doctors; and Or when a doctor writes a diagnosis, he will add some additional detailed information when writing the diagnosis, and the standard diagnostic code library can not reflect the distinction and classification of the additional information; moreover, when the doctor writes the diagnosis, he will also use some Only abbreviations or abbreviations familiar to the industry, and these are not included in the standard diagnostic coding library

Fundamentally speaking, doctors record disease information in detail from the perspective of diagnosis and treatment, rather than for classification and coding, so the incompatibility is deeply rooted and inevitable. When filling out the diagnosis, there are many errors in using program selection or handwritten coding

[0007] (3) The version of the standard diagnostic coding library is not uniform

[0010] (5) The existing coded data source only considers a single data source and does not consider multiple data sources; the result of a single data source is that the coding is incomplete and there are missing codes, which is not conducive to the use of later scientific research data

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