构建可保护隐私的病历摘要框架，自动整合关键医疗信息
EHRSummarizer: A Privacy-Aware, FHIR-Native Reference Architecture for Source-Grounded EHR Summarization
- 基于FHIR标准提取并标准化病历数据，生成有来源依据的摘要
- 支持缺失数据处理与用药状态模糊性判断，保障摘要可靠性
- 适合医疗系统开发者及隐私合规团队参考落地
临床医生常需在分散的电子病历界面中拼凑患者病情、用药、近期就诊和长期趋势等信息。本文提出EHRSummarizer，一种面向隐私保护、原生支持HL7 FHIR R4标准的参考架构，用于结构化病历摘要。该架构从目标范围的高价值FHIR资源中检索数据，将其归一化为临床上下文包，并通过受限摘要阶段生成源文档可追溯的摘要，以支持病历审阅。系统明确了缺失数据处理、用药状态歧义处理、可用时对非结构化临床文档的受控使用，以及未来源-摘要可追溯性设计。本文描述的是参考架构与原型行为，未涉及临床验证、自主决策支持或临床效益证据。在合成与测试FHIR环境中进行的原型演示展示了端到端流程与输出格式；但未报告临床结果、对照工作流研究或基准性能。我们提出了以忠实性、遗漏风险、时间正确性、可用性、隐私性与运营监控为核心的评估计划，以指导后续机构评估。
原文摘要 · Abstract (English)
Clinicians routinely navigate fragmented electronic health record (EHR) interfaces to assemble a coherent picture of a patient's problems, medications, recent encounters, and longitudinal trends. This manuscript describes EHRSummarizer, a privacy-aware, FHIR-native reference architecture for structured EHR summarization. The architecture retrieves a targeted set of high-yield HL7 FHIR R4 resources, normalizes them into a clinical context package, and uses a constrained summarization stage to produce source-grounded summaries intended to support chart review. The architecture further clarifies missing-data status handling, medication-status ambiguity, controlled use of narrative clinical documents when available, and future source-to-summary traceability. The manuscript describes a reference architecture and prototype behavior rather than a validated clinical intervention, autonomous clinical decision-support system, or evidence of clinical benefit. Prototype demonstrations on synthetic and test FHIR environments illustrate end-to-end behavior and output formats; however, this manuscript does not report clinical outcomes, controlled workflow studies, or benchmark results. We outline an evaluation plan centered on faithfulness, omission risk, temporal correctness, usability, privacy, and operational monitoring to guide future institutional assessment.
Thank you to arXiv for use of its open access interoperability. PaperDance 不是 arXiv 官方产品；中文卡片由大模型生成，请以原文为准。