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Application Effect of an Intelligent Medical Record Writing Assistant in Inpatient Medical Record Practice
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摘要: 目的 探究自主研发的病历智能书写助手在提升患者出院记录书写效率和书写质量方面的有效性，并调研分析临床医生对病历智能书写助手的满意度。方法 本研究为前瞻性随机对照试验研究。选取2024年1月25日—6月25日中国医学科学院阜外医院冠心病病区的临床医生为研究对象，采用整群随机分配方法，将4个病区按1:1随机分配，每个病区内的医生及所撰写的病历随病区进入相应组别。试验组应用病历智能书写助手，纳入医生46名，共收集病历4105份；对照组应用传统病历书写方式，纳入医生41名，共收集病历4680份。主要评价指标为病历书写效率和书写质量，次要评价指标为医生使用病历智能书写助手的满意度。结果 试验组医生书写病历出院记录的平均时长显著低于对照组（ 5.73min比8.69min，P<0.001）；分层分析显示，试验组住院天数≤5 d和>5 d患者的病历书写时长均较对照组短（ 5.59 min比8.34 min，8.50 min比12.27 min，P均<0.001） ；试验组的病历优质率显著高于对照组（ 94.06%比81.82%，P<0.001）。调查显示，多数临床医生（ 80%）高频率使用病历智能书写助手，且对其生成信息的准确性、完整性及使用体验的满意度均较高。结论 病历智能书写助手可显著提升病历书写效率，同时优化病历书写质量，临床医生对其满意度较高。本研究验证了病历智能书写新模式应用于临床的有效性，为未来该模式的深度应用与推广提供了范式。Abstract: Objective To investigate the effectiveness of a self-developed intelligent medical record writing assistant in enhancing the efficiency of discharge record writing and improving the quality of discharge records, and to assess physicians' satisfaction with the assistant. Methods This study was conducted as a prospective cluster-randomized controlled trial. From January 25 to June 25, 2024, clinicians in the coronary heart disease ward of Fuwai Hospital, Chinese Academy of Medical Sciences were selected as the research object . Using the method of cluster-randomized allocation, the four wards were randomly assigned 1:1, with physicians and their medical records assigned to the corresponding group based on the ward. The experimental group utilized the intelligent medical record writing assistant, with 46 physicians included and 4,105 medical records collected. The control group used traditional writing methods, with 41 physicians included and 4,680 medical records collected. Primary outcome measures included quantitative analysis of medical record writing efficiency and medical record quality. Secondary outcomes assessed physicians' satisfaction with the use of the intelligent medical record writing assistant. Results The average writing time for discharge records in the experimental group was significantly shorter than that in the control group (5.73 min vs. 8.69 min, P<0.001). Stratified analysis revealed writing times medical records for patients with ≤ 5 days and >5 days of hospitalization (experimental group vs. control group) were 5.59 min vs. 8.34 min and 8.50 min vs. 12.27 min, respectively (all P<0.001). The rate of quality medical records (evaluated immediately after system submission) was significantly higher in the experimental group than in the control group (94.06% vs. 81.82%, P<0.001). The questionnaire survey indicated that the vast majority of physicians (80%) used the assistant frequently, and were highly satisfied with the accuracy, completeness, and user experience of the generated information. Conclusion The intelligent medical record writing assistant can significantly enhance the writing efficiency and optimize medical record quality concurrently, and physicians are highly satisfied with it. This study validates the effectiveness of the new model of intelligent medical record writing applied to clinical practice, and provides a paradigm for the in-depth application and promotion of this model in the future.
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