With the advancement of high-quality development in the healthcare system, the quality of the home page of medical records has become increasingly prominent, as an important data source for hospital management, performance evaluation, and medical insurance payment. In 2022, a grade-A tertiary hospital took improving the quality of the main diagnosis and surgical operations related data on the home page of medical records as the core goal, and constructed a quality control system for the home page of inpatient medical records based on the national medical security disease diagnosis-related groups (CHS-DRG). This system included two parts: the CHS-DRG grouper and early warning rules for high-risk medical records, which could issue warnings for abnormal data in the grouping results. Then, based on this system, a human-machine collaborative quality control mechanism for the home page of medical records, namely " system warning-coder review-communication between coders and clinical doctors", was established and applied since January 2022, realizing closed-loop management of quality control for the home page of medical records. Compared with 2020-2021, the accuracy rates of main diagnosis filling, main surgeries filling, and main diagnosis coding in 2022-2023 increased by 16.31, 12.45, and 1.70 percentage points respectively ( P<0.05); the number of diagnosis items increased by 0.91 ( P<0.05), and the coding time consumption decreased by 4.59 d ( P<0.05). Meanwhile, after the application, the quality improvement effect on the non-DRG payment group was higher than that on the DRG payment group ( P<0.05). The application of this system not only helps to improve the information-based means of medical record quality control and enrich the method system of medical record quality control, but also comprehensively improves the quality and work efficiency of the home page of medical records under different payment methods, which can provide reference for other hospitals to continuously improve the quality control work of the home page of medical records.

With the advancement of high-quality development in the healthcare system, the quality of the home page of medical records has become increasingly prominent, as an important data source for hospital management, performance evaluation, and medical insurance payment. In 2022, a grade-A tertiary hospital took improving the quality of the main diagnosis and surgical operations related data on the home page of medical records as the core goal, and constructed a quality control system for the home page of inpatient medical records based on the national medical security disease diagnosis-related groups (CHS-DRG). This system included two parts: the CHS-DRG grouper and early warning rules for high-risk medical records, which could issue warnings for abnormal data in the grouping results. Then, based on this system, a human-machine collaborative quality control mechanism for the home page of medical records, namely " system warning-coder review-communication between coders and clinical doctors", was established and applied since January 2022, realizing closed-loop management of quality control for the home page of medical records. Compared with 2020-2021, the accuracy rates of main diagnosis filling, main surgeries filling, and main diagnosis coding in 2022-2023 increased by 16.31, 12.45, and 1.70 percentage points respectively ( P<0.05); the number of diagnosis items increased by 0.91 ( P<0.05), and the coding time consumption decreased by 4.59 d ( P<0.05). Meanwhile, after the application, the quality improvement effect on the non-DRG payment group was higher than that on the DRG payment group ( P<0.05). The application of this system not only helps to improve the information-based means of medical record quality control and enrich the method system of medical record quality control, but also comprehensively improves the quality and work efficiency of the home page of medical records under different payment methods, which can provide reference for other hospitals to continuously improve the quality control work of the home page of medical records.

December of 2019 witnessed the outbreak of new coronavirus pneumonia in Wuhan city and a few localities. As a designated hospital, Tongji Hospital is designated as a hospital for the diagnosis and treatment of numerous patients of such a disease. Based on the medical cloud platform, the hospital has initiated a regional remote diagnosis center; based on its IT system, the hospital to operate its epidemic prevention and management mechanism, set up the self-service system for patients at the fever clinic, launched its online diagnosis and treatment services, and established a hospital epidemic supervision platform. By strengthening the informational support needed for epidemic prevention and control, the hospital has enhanced its efficiency of epidemic prevention and control, reducing the risk of cross-infection, and ensuring data security. Its experiences offer references for informationization support for other regions and hospitals in China.

December 2019 witnessed the outbreak of COVID-19 in Wuhan city and its rapid spread to other parts of China, and overseas as well. Tongji Hospital, as a designated hospital for treatment of critically ill patients, shoulders the diagnosis and treatment tasks of numerous critically ill patients of such a disease. For the purpose of handling their medical records and effectively preventing the nosocomial infection of the disease, the hospital puts in place both the electronic signature system of patients based on a Wechat applet and a paperless medical record total solution based on the data center. These measures overcome the challenges incurred by patients’ signature on paper-based records and medical records archiving during the epidemic. On the other hand, they can not only downsize the paper-based medical records, minimize the risk of infection caused by paper-based medical records via contacts, but also effectively save the hospital of its operating costs and improve its efficiency of clinical work.

As a designated hospital, Tongji Hospital shoulders the task of diagnosis and treatment of numerous patients of the disease. Based on the medical cloud platform, the hospital has initiated a regional remote diagnosis center; leveraging its IT system, the hospital initiates its epidemic prevention and management mechanism, sets up a self-service system for patients at the fever clinic, launches its online diagnosis and treatment services, and establishes a hospital epidemic supervision platform. By strengthening the informational support needed for epidemic prevention and control, the hospital has enhanced its efficiency of epidemic prevention and control, reducing the risk of cross-infection, and ensuring data security. Its experiences offer references for informationization support for other regions and hospitals in China.