Abstract
Background
Digital healthcare's advance has underscored an urgent requirement for solid medical record quality control, critical for data integrity, surpassing manual methods’ inadequacies.
Objective
The goal was to develop an AI system to manage medical record quality control comprehensively, using advanced AI like reinforcement learning and NLP to boost management's precision and efficiency.
Methods
This AI system uses a closed-loop framework for real-time record review using natural language processing techniques and reinforcement learning, synchronized with the hospital information system. It features a data layer for monitoring, a service layer for AI analysis, and a presentation layer for user engagement. Its impact was evaluated by comparing quality metrics pre- and post-deployment.
Results
With the AI system, quality control became fully operational, with review times per record plummeting from 4200 s to 2 s. The share of Grade A records rose from 89.43% to 99.21%, and the system markedly minimized formal and substantive record errors, enhancing completeness and accuracy. The implementation of the artificial intelligence-based medical record quality control system optimizes the quality control process, dynamically regulates the diagnostic behavior of medical staff, and promotes the standardization and normalization of clinical medical record writing.
Conclusions
The AI-driven system significantly upgraded the management of medical records in terms of efficiency and accuracy. It provides a scalable approach for hospitals to refine quality control, propelling healthcare towards heightened intelligence and automation, and foreshadowing AI's pivotal role in future healthcare quality management.
Keywords
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