CN109741193A - A kind of medical insurance Single diseases control charge system and method - Google Patents
A kind of medical insurance Single diseases control charge system and method Download PDFInfo
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- CN109741193A CN109741193A CN201811534663.6A CN201811534663A CN109741193A CN 109741193 A CN109741193 A CN 109741193A CN 201811534663 A CN201811534663 A CN 201811534663A CN 109741193 A CN109741193 A CN 109741193A
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Abstract
The present invention provides a kind of medical insurance Single diseases control charge system and method, wherein system includes the data acquisition module for obtaining inpatient expense itemized bill, further includes with lower module: being defined and the single case management module of decision rule management for carrying out Single diseases to Single diseases essential information；For, in conjunction with Single diseases definition and the decision rule, determining whether patient belongs to the Single diseases determination module of Single diseases according to the expense itemized bill；The Single diseases control module of expenses managing and controlling is carried out for the control catalogue according to Single diseases total cost, drug and consumptive material.The Single diseases decision rule and regular enforcement engine that the present invention is established according to system, it is judged automatically by system, the automatic treatment process of system is provided for medical institutions' Single diseases patient's screening, the burden of oneself check-up through statistical means of medical insurance work personnel is alleviated, while having prevented the careless omission of artificial judgment.
Description
Technical field
The present invention relates to the technical field of medical insurance Single diseases control expense, especially a kind of medical insurance Single diseases control charge system and side
Method.
Background technique
Single disease payment mode refers to through unified medical diagnosis on disease classification, scientifically makes determining for each disease
Volume repay standard, social security mechanism according to the standard be hospitalized person-time to designated medical organization pay hospitalization cost so that medical treatment money
Using standardization, i.e. medical institutions' resource consumption and the quantity, disease complexity and service of the inpatient treated is strong in source
It spends directly proportional.
In order to contain the excessive growth of medical expense, mitigates the expense burden of patient, promote standardized management level, more
The management mode of single disease payment is come into effect come more medical and health organizations.But the medical insurance department of medical institutions is directed to
The management mode of single disease payment can not only be carried out complete by simply being screened in existing hospital information system
The complete Single diseases patient in face determines, also cannot the medical insurance to Single diseases patient carry out scientific and normal process pipe
Control.
The patent of invention of Publication No. CN105224807A discloses a kind of case auditing rule extracting method and device,
Case checking method and system, the extracting method include: to carry out word segmentation processing to each case in training case set, are obtained
To multiple participles, training case set includes multiple cases of preset Single diseases；The word co-occurrence graph of multiple participles is constructed, often
A vertex of a participle as word co-occurrence graph, and the weight in the sideline between two vertex is to divide corresponding to two vertex
Co-occurrence number of the word in training case set；According to word co-occurrence graph, keyword is obtained from multiple participles；According to acquired
The keyword arrived forms keyword set；The case auditing rule for the Single diseases being directed to, case are extracted from keyword set
Auditing rule is the orderly keyword sequence formed by several keywords in keyword set.The disadvantages of the method are as follows single disease
The auditing rule of kind must be obtained by the training of a large amount of case set, and accuracy be not easily controlled；Additionally, due to the training side
Case is according to discharge case load according to carrying out participle training, therefore is mainly used for carrying out Single diseases judgement to discharged patients, can not
In-patients are accurately determined, so can not to in-patients quickly establish Single diseases after, carry out subsequent charging item pipe
Control.
Summary of the invention
In order to solve the above technical problems, a kind of medical insurance Single diseases control charge system proposed by the present invention and method, according to
The Single diseases decision rule and regular enforcement engine that system is established, are judged automatically by system, are suffered from for medical institutions' Single diseases
Person's screening provides the automatic treatment process of system, alleviates the burden of oneself check-up through statistical means of medical insurance work personnel, shuts out simultaneously
The careless omission of artificial judgment absolutely.
There is provided a kind of medical insurance Single diseases control charge systems for the first object of the present invention, including for obtaining inpatient
The data acquisition module of expense itemized bill further includes with lower module:
Single case management module: for carrying out Single diseases definition and decision rule management to Single diseases essential information；
Single diseases determination module: for being defined and the judgement according to the expense itemized bill in conjunction with the Single diseases
Rule, determines whether patient belongs to Single diseases:
Single diseases control module: for carrying out expense pipe according to the control catalogue of Single diseases total cost, drug and consumptive material
Control.
Preferably, the single case management module is used to each Single diseases be divided into N number of diagnosis and treatment item rule group G.
In any of the above-described scheme preferably, the diagnosis and treatment item rule group G points are to include group and exclusion group.
In any of the above-described scheme preferably, the working method of the Single diseases determination module the following steps are included:
Step 01: extracting the charging item inventory information in the data acquisition module；
Step 02: determining whether Single diseases respectively comprising group rule and exclusion group rule using described.
In any of the above-described scheme preferably, the charging item inventory information includes patient's admission number, charging item
At least one of code (diagnosis and treatment item coding), total cost and expense unit price.
In any of the above-described scheme preferably, the step 01 further includes raw according to the charging item inventory information
At single patient diagnosis and treatment item set DP.
In any of the above-described scheme preferably, the single patient diagnosis and treatment item set DP includes all charges of patient
Project, single charging item DPn, single cost coefficient Zn, total cost CnWith expense unit price Pn。
In any of the above-described scheme preferably, the single cost coefficient Zn=Cn/Pn。
In any of the above-described scheme preferably, the decision rule of the Single diseases are as follows:
1) the decision rule group G for defining Single diseases, takes G one by onenRule group judgement, defines GnUnder comprising group a rule be
RI, exclusion group rule are RO；
2) whole diagnosis and treatment of patient will cover whole diagnosis and treatment items in RI, and meet ZnIn the coefficient model of RI { min-max }
When enclosing, G is representednRI rule pass through；
3) as long as whole diagnosis and treatment of patient have one to appear in RO diagnosis and treatment item, and meet ZnWhat it is in RO { min-max } is
When number range, G is representednRO rule do not pass through；
4)GnRI and RO when all passing through, the G that the patient meets the Single diseases can be representednRule；
5) only have one group of rule to meet in G rule group, which can be included in the primary dcreening operation library of the Single diseases；
6) if all rule organizes none satisfaction of G, represents the patient and do not meet the Single diseases.
In any of the above-described scheme preferably, the Single diseases control module is used for total value control, medicine control, consumption
At least one of material control and Anesthetic Fee control.
In any of the above-described scheme preferably, the total value control refers to the Single diseases according to ownership, inquires patient's
Whether Hospitalization expenses are more than Single diseases limit, in excess of the quota to be reminded.
In any of the above-described scheme preferably, the medicine control refers to the Single diseases according to ownership, inquires list disease
Kind medicine control inventory carries out limitation management to doctor's advice medication.
In any of the above-described scheme preferably, the consumptive material control refers to the Single diseases according to ownership, askes the Single diseases
Consumptive material controls inventory, uses progress limitation management to doctor's advice consumptive material.
In any of the above-described scheme preferably, the Anesthetic Fee control refers to the Single diseases according to ownership, inquires the list
Whether disease Anesthetic Fee limit is more than Single diseases limit standard, is reminded more than Anesthetic Fee limit standard.
There is provided a kind of medical insurance Single diseases control charging methods for the second object of the present invention, including obtain inpatient expense
Itemized bill, further comprising the steps of:
Step 1: Single diseases definition and decision rule management are carried out to Single diseases essential information；
Step 2: according to the expense itemized bill in conjunction with Single diseases definition and the decision rule, determining patient
Whether Single diseases are belonged to；
Step 3: carrying out expenses managing and controlling according to the control catalogue of Single diseases total cost, drug and consumptive material.
Preferably, the step 1 includes that each Single diseases are divided into N number of diagnosis and treatment item rule group G.
In any of the above-described scheme preferably, the diagnosis and treatment item rule group G points are to include group and exclusion group.
In any of the above-described scheme preferably, the step 2 includes following sub-step:
Step 21: extracting the charging item inventory information in the data acquisition module；
Step 22: determining whether Single diseases respectively comprising group rule and exclusion group rule using described.
In any of the above-described scheme preferably, the charging item inventory information includes patient's admission number, charging item
At least one of code (diagnosis and treatment item coding), total cost and expense unit price.
In any of the above-described scheme preferably, the step 21 further includes raw according to the charging item inventory information
At single patient diagnosis and treatment item set DP.
In any of the above-described scheme preferably, the single patient diagnosis and treatment item set DP includes all charges of patient
Project, single charging item DPn, single cost coefficient Zn, total cost CnWith expense unit price Pn。
In any of the above-described scheme preferably, the single cost coefficient Zn=Cn/Pn。
In any of the above-described scheme preferably, the decision rule of the Single diseases are as follows:
1) the decision rule group G for defining Single diseases, takes G one by onenRule group judgement, defines GnUnder comprising group a rule be
RI, exclusion group rule are RO；
2) whole diagnosis and treatment of patient will cover whole diagnosis and treatment items in RI, and meet ZnIn the coefficient model of RI { min-max }
When enclosing, G is representednRI rule pass through；
3) as long as whole diagnosis and treatment of patient have one to appear in RO diagnosis and treatment item, and meet ZnWhat it is in RO { min-max } is
When number range, G is representednRO rule do not pass through；
4)GnRI and RO when all passing through, the G that the patient meets the Single diseases can be representednRule；
5) only have one group of rule to meet in G rule group, which can be included in the primary dcreening operation library of the Single diseases；
6) if all rule organizes none satisfaction of G, represents the patient and do not meet the Single diseases.
In any of the above-described scheme preferably, the step 3 includes total value control, medicine control, consumptive material control and fiber crops
It is liquor-saturated to take at least one of control.
In any of the above-described scheme preferably, the total value control refers to the Single diseases according to ownership, inquires patient's
Whether Hospitalization expenses are more than Single diseases limit, in excess of the quota to be reminded.
In any of the above-described scheme preferably, the medicine control refers to the Single diseases according to ownership, inquires list disease
Kind medicine control inventory carries out limitation management to doctor's advice medication.
In any of the above-described scheme preferably, the consumptive material control refers to the Single diseases according to ownership, askes the Single diseases
Consumptive material controls inventory, uses progress limitation management to doctor's advice consumptive material.
In any of the above-described scheme preferably, the Anesthetic Fee control refers to the Single diseases according to ownership, inquires the list
Whether disease Anesthetic Fee limit is more than Single diseases limit standard, is reminded more than Anesthetic Fee limit standard.
The invention proposes a kind of medical insurance Single diseases control charge systems and method to judge patient by the diagnosis and treatment item of patient
Affiliated Single diseases judge problem for the screening that medical institutions solve Single diseases patient, while carrying out to the patient for being included in Single diseases
The medical insurance process management and control of Single diseases.
Detailed description of the invention
Fig. 1 is the module map of a preferred embodiment of medical insurance Single diseases control charge system according to the invention.
Figure 1A is the expansion system module of the embodiment as shown in Figure 3 of medical insurance Single diseases control charging method according to the invention
Figure.
Fig. 2 is the flow chart of a preferred embodiment of medical insurance Single diseases control charging method according to the invention.
Fig. 3 is the flow chart of another preferred embodiment of medical insurance Single diseases control charging method according to the invention.
Fig. 4 is the Single diseases decision rule of the embodiment as shown in Figure 3 of medical insurance Single diseases control charging method according to the invention
Schematic diagram.
Fig. 5 is the Single diseases control expense structure of the embodiment as shown in Figure 3 of medical insurance Single diseases control charge system according to the invention
Schematic diagram.
Fig. 6 is the flow chart of another preferred embodiment of medical insurance Single diseases control charging method according to the invention.
Specific embodiment
The present invention is further elaborated with specific embodiment with reference to the accompanying drawing.
Embodiment one
As shown in Figure 1, a kind of medical insurance Single diseases control charge system includes data acquisition module 100, single case management module
110, Single diseases determination module 120 and Single diseases control module 130.
Data acquisition module 100 is for obtaining inpatient expense itemized bill.
Single case management module 110 is used to carry out Single diseases definition and decision rule management to Single diseases essential information,
Each Single diseases are divided into N number of diagnosis and treatment item rule group G.Diagnosis and treatment item rule group G points are to include group and exclusion group.
Single diseases determination module 120 is used to be sentenced in conjunction with Single diseases definition with described according to the expense itemized bill
Set pattern then, determines whether patient belongs to Single diseases.The working method of Single diseases determination module is the following steps are included: described in extraction
Charging item inventory information in data acquisition module generates single patient diagnosis and treatment item according to the charging item inventory information
Mesh set DP, charging item inventory information include patient's admission number, charging item code (diagnosis and treatment item coding), total cost
At least one of with expense unit price, single patient diagnosis and treatment item set DP includes all charging items of patient, single charging item
DPn, single cost coefficient Zn, total cost CnWith expense unit price Pn, single cost coefficient Zn=Cn/Pn；Using described comprising group
Rule and exclusion group rule determine whether Single diseases respectively.The rule of Single diseases are as follows: 1) the rule group G for defining Single diseases, by
One takes GnRule group judgement, defines GnUnder comprising group rule be RI, exclusion group rule be RO；2) whole diagnosis and treatment of patient will be covered
Whole diagnosis and treatment items in RI are covered, and meet ZnIn the coefficient range of RI { min-max }, G is representednRI rule pass through；3) suffer from
As long as whole diagnosis and treatment of person have one to appear in RO diagnosis and treatment item, and meet ZnIn the coefficient range of RO { min-max }, generation
Table GnRO rule do not pass through；4)GnRI and RO when all passing through, the G that the patient meets the Single diseases can be representednRule；
5) only have one group of rule to meet in G rule group, which can be included in the primary dcreening operation library of the Single diseases, be included in behind primary dcreening operation library i.e.
Assert that the patient needs to carry out the management control of Single diseases；6) if all rule organizes none satisfaction of G, represents the patient and be not inconsistent
Close the Single diseases.
Single diseases control module 130 is used to carry out expense according to the control catalogue of Single diseases total cost, drug and consumptive material
Control.Single diseases control module 130 is for total value control, medicine control, consumptive material control and Anesthetic Fee control.Total value controls
Refer to the Single diseases according to ownership, whether the Hospitalization expenses for inquiring patient are more than Single diseases limit, in excess of the quota to be reminded；
Medicine control refers to the Single diseases according to ownership, inquires the Single diseases medicine control inventory, carries out limitation pipe to doctor's advice medication
Reason；Consumptive material control refers to the Single diseases according to ownership, askes Single diseases consumptive material control inventory, limits doctor's advice consumptive material use
Tubulation reason；Anesthetic Fee control refers to the Single diseases according to ownership, inquires whether the Single diseases Anesthetic Fee limit is more than Single diseases limit
Volume standard is reminded more than Anesthetic Fee limit standard.
As shown in Figure 1A, system further includes management database 140, performance appraisal module 150, over range auditing module 160
Take interface module 170 with control.
Managing database 140 includes regulation management database 141, drug control database 142, consumptive material management database
143 and Single diseases database 144.Regulation management database 141 is used to manage the decision rule of each Single diseases, including
The diagnosis and treatment item rule of primary dcreening operation and the operation of two sieves and diagnositc decision rule；Drug control database 142 is for limiting each list
The rational use of medicines range of disease, establishes Single diseases drug storage, can play restriction effect to the scope of medication of Single diseases；Consumption
Material management database 143 is used to limit the reasonable consumptive material range of each Single diseases, establishes Single diseases consumptive material library, can be to list
The consumptive material range of disease plays restriction effect.Single diseases database 144 is for recording fixed Single diseases patient.
Performance appraisal module 150 is for after limiting Single diseases surplus/over-expense, the rewards and punishments measure to department, corresponding surplus to be encouraged
Encourage percentage and over-expense punishment percentage.
Over range auditing module 160 for being examined to drug, the consumptive material etc. of over range, without examination & approval cannot be just
Often lower doctor's advice.
Control take interface module 170 for and the operation systems such as hospital HIS dock, realize when opening the expenses such as doctor's advice to doctor,
Carry out the process control of the prompting of Single diseases expense, refusal high price consumptive material etc..Control expense interface includes: that total value is reminded, over range is managed
Interface is examined with over range.
Embodiment two
As shown in Fig. 2, executing step 200, inpatient expense itemized bill is obtained.Step 210 is executed, to Single diseases
Essential information carries out Single diseases definition and decision rule management, and each Single diseases are divided into N number of diagnosis and treatment item rule group G, are examined
Treatment project rule group G points are to include group and exclusion group.
Step 220 is executed, according to the expense itemized bill in conjunction with Single diseases definition and the decision rule, is sentenced
Determine whether patient belongs to Single diseases.It include: the charging item inventory information extracted in the data acquisition module, according to described
Charging item inventory information generates single patient diagnosis and treatment item set DP, and charging item inventory information includes patient's admission number, receives
Take at least one of item code (diagnosis and treatment item coding), total cost and expense unit price, single patient diagnosis and treatment item set
DP includes all charging items of patient, single charging item DPn, single cost coefficient Zn, total cost CnAnd expense unit price
Pn,；Single cost coefficient Zn=Cn/Pn.Single diseases are determine whether respectively comprising group rule and exclusion group rule using described.
The decision rule of Single diseases are as follows: 1) the rule group G for defining Single diseases takes G one by onenRule group judgement, defines GnUnder include group
Rule is RI, and exclusion group rule is RO；2) whole diagnosis and treatment of patient will cover whole diagnosis and treatment items in RI, and meet ZnIn RI
When the coefficient range of { min-max }, G is representednRI rule pass through；3) as long as whole diagnosis and treatment of patient have one to appear in RO
Diagnosis and treatment item, and meet ZnIn the coefficient range of RO { min-max }, G is representednRO rule do not pass through；4)GnRI and RO
When all passing through, the G that the patient meets the Single diseases can be representednRule；5) one group of rule meets in G rule group
The patient is included in the primary dcreening operation library of the Single diseases；6) if all rule organizes none satisfaction of G, represents the patient and do not meet the list
Disease.
Step 230 is executed, carries out expenses managing and controlling according to the control catalogue of Single diseases total cost, drug and consumptive material.Including
Total value control, medicine control, consumptive material control and Anesthetic Fee control, wherein total value control refers to the Single diseases according to ownership, inquiry
Whether the Hospitalization expenses of patient are more than Single diseases limit, in excess of the quota to be reminded；Medicine control refers to the list according to ownership
Disease inquires the Single diseases medicine control inventory, carries out limitation management to doctor's advice medication；Consumptive material control refers to according to ownership
Single diseases, ask Single diseases consumptive material control inventory, use progress limitation management to doctor's advice consumptive material；Anesthetic Fee control refers to basis
The Single diseases of ownership inquire whether the Single diseases Anesthetic Fee limit is more than Single diseases limit standard, are more than Anesthetic Fee limit standard
It is reminded.
Embodiment three
(1) Single diseases control charging method
As shown in figure 3, the control charging method of Single diseases includes Single diseases definition, Single diseases determine and Single diseases control expense executes
Three parts.
1, Single diseases define
Single diseases essential information is defined and is managed, Single diseases title, Main Diagnosis, expense quota, diagnosis and treatment item can be defined
Mesh judgment rule definition etc..The diagnosis and treatment item judgment rule definition of Single diseases is described in following emphasis.
As shown in figure 4, the present invention establishes a set of Single diseases decision rule based on diagnosis and treatment item, each Single diseases are sentenced
Set pattern is then made of multiple decision rule groups, mutually indepedent between the different decision rule group of same Single diseases, can independently be done
For the judgment basis of the Single diseases.It is divided again in each independent decision rule group in order to comprising two groups of rules of group and exclusion group.
Rule comprising group represents the rule that must satisfy, and the rule of exclusion group represents must incongruent rule.
Firstly, can divide multiple diagnosis and treatment item rule groups to each Single diseases, the principle that rule group divides is as follows:
(1) the fewer rule group the better.
(2) single rule group determines to meet the Single diseases by that can assert
It is divided into again comprising group and the two different rule types of exclusion group in each rule group.To include comprising a group definition
Diagnosis and treatment item and coefficient section (min-max), exclusion group define there can be no diagnosis and treatment item and coefficient section (min-
max)。
2, Single diseases determine
Step 1:
All charging item inventories of single patient are obtained by hospital interface, charging item inventory key message includes:
Patient's admission number, charging item code (diagnosis and treatment item coding), total cost, expense unit price, as shown in table 1.
Table 1
Single patient diagnosis and treatment item set DP, including all charging items of patient, single charging item DPn；Single expense
Coefficient Zn=total cost Cn/ expense unit price Pn。
Step 2:
" XX Single diseases " definition rule group G is obtained, takes G one by onenRule group judgement, it is assumed that GnUnder comprising group rule be RI,
Exclusion group rule is RO.
Whole diagnosis and treatment of patient will cover whole diagnosis and treatment items in RI, and meet ZnIn the coefficient range of RI { min-max }
When, represent GnRI rule pass through.
As long as whole diagnosis and treatment of patient have one to appear in RO diagnosis and treatment item, and meet ZnIn the coefficient of RO { min-max }
When range, G is representednRO rule do not pass through.
GnRI and RO when all passing through, the G that the patient meets " XX Single diseases " can be representednRule.As long as in G rule group
There is one group of rule to meet, which can be included in the primary dcreening operation library of " XX Single diseases ".
" XX Single diseases " if all rule group G none satisfaction, represent the patient and do not meet " XX Single diseases ".Continue
Determine whether the patient meets other Single diseases rule.
3, Single diseases control expense
As shown in figure 5, under doctor workstation when doctor's advice, carrying out doctor's advice control expense pipe to the patient for determining to enter Single diseases
Reason.Including total value control, medicine control, consumptive material control and Anesthetic Fee control.
It obtains patient according to doctor's advice first to be hospitalized serial number, whether inquiry is Single diseases patient, if it is Single diseases patient
Need to carry out the management of Single diseases doctor's advice control expense.
(1) total value controls
The Single diseases of ownership are judged according to patient, whether the Hospitalization expenses for inquiring patient are more than Single diseases limit, are surpassed
Limit is crossed to be reminded.
(2) medicine control
The Single diseases that ownership is judged according to patient, inquire the Single diseases medicine control inventory, limit doctor's advice medication
Tubulation reason.
(3) consumptive material controls
According to patient judge ownership Single diseases, inquire the Single diseases consumptive material control inventory, to the use of doctor's advice consumptive material into
Row limitation management.
(4) Anesthetic Fee controls
The Single diseases that ownership is judged according to patient, inquire whether the Single diseases Anesthetic Fee limit is more than Single diseases limit
Standard is reminded more than Anesthetic Fee limit limit standard.
Example IV
According to the decision rule of Single diseases, hospital charge project list is docked, the list based on patient's charging item is realized
Disease patient's screening enforcement engine.All charging item inventories of single patient are obtained by hospital interface first, successively with list
Each independent rules group of disease is verified, and is proved to be successful, and bring patient is changed into corresponding Single diseases patient library.Originally simultaneously
The Single diseases patient that diagnosis and treatment item meets causes judgement not meeting Single diseases because of the entrance of new diagnosis and treatment item, can be with
It is rejected from Single diseases patient library.After patient discharge, determining Single diseases patient library is formed.
The Single diseases decision rule established according to system and regular enforcement engine.It is judged automatically by system, for medical treatment
Mechanism Single diseases patient's screening provides the automatic treatment process of system, alleviates oneself check-up through statistical means of medical insurance work personnel
Burden, while having prevented the careless omission of artificial judgment.
Embodiment five
As shown in fig. 6, the present invention provides a kind of medical insurance Single diseases control charge systems.Single diseases are solved for medical institutions to suffer from
The screening of person judges problem, while the medical insurance process management and control of Single diseases is carried out to the patient for being included in Single diseases.Major function
Module includes management server end and control expense interface two parts.
Management server end main functional modules include:
Single case management, regulation management, drug control, consumptive material management, performance appraisal, Single diseases patient library, expense prison
Control, over range auditing module.
Single case management: for defining Single diseases title, Anesthetic Fee limit, medical insurance reimbursement limit.
Regulation management: for managing the decision rule of each Single diseases, diagnosis and treatment item rule and two sieves including primary dcreening operation
Operation and diagnositc decision rule.
Drug control: for limiting the rational use of medicines range of each Single diseases, establishing Single diseases drug storage, can be right
The scope of medication of Single diseases plays restriction effect.
Consumptive material management: for limiting the reasonable consumptive material range of each Single diseases, establishing Single diseases consumptive material library, can be right
The consumptive material range of Single diseases plays restriction effect.
Performance appraisal: after limiting Single diseases surplus/over-expense, rewards and punishments measure to department, corresponding surplus rewards percentage
Than and over-expense punishment percentage.
Single diseases patient's library module: for the judgement to Single diseases patient, including primary dcreening operation library and two sieve libraries and confirmation library
With exclusion library.It can be carried out corresponding expenses managing and controlling after thering is the patient of Single diseases to determine.
Expense monitoring module: expense Statistical monitor on Single diseases patient realizes the situation that spends practical to patient
Statistics and comparison, realize and calculate to department's expense surplus/over-expense.
Over range auditing module: examining for drug, the consumptive material etc. to over range, without examination & approval cannot be normal
Lower doctor's advice.
Control take interface module for and the operation systems such as hospital HIS dock, realize when opening the expenses such as doctor's advice to doctor, into
The process control of the prompting of row Single diseases expense, refusal high price consumptive material etc..Control expense interface include: total value remind, over range control and
Over range examines interface.
Embodiment six
The secondary screening of Single diseases is done in patient discharge, referred to as two sieve.Two sieves are the final confirmations of discharge.Two sieves
Operation and diagnositc decision rule be to be examined according to the operation done and discharge after primary dcreening operation patient (having determined that as XX Single diseases) discharge
It is disconnected, do the range for being finally confirmed whether Single diseases.
Judgment rule is exactly to judge whether the discharge diagnosis of Single diseases primary dcreening operation patient and Single diseases confirmation diagnosis are identical,
Whether corresponding Single diseases confirmation operation was done.
For a better understanding of the present invention, the above combination specific embodiments of the present invention are described in detail, but are not
Limitation of the present invention.Any simple modification made to the above embodiment according to the technical essence of the invention, still belongs to
In the range of technical solution of the present invention.The highlights of each of the examples are the differences with other embodiments in this specification
Place, the same or similar part cross-reference between each embodiment.For system embodiments, due to its with
Embodiment of the method corresponds to substantially, so being described relatively simple, the relevent part can refer to the partial explaination of embodiments of method.
Claims (10)
1. a kind of medical insurance Single diseases control charge system, including the data acquisition module for obtaining inpatient expense itemized bill,
It is characterized in that, further including with lower module:
Single case management module: for carrying out Single diseases definition and decision rule management to Single diseases essential information；
Single diseases determination module: being used to be defined according to the expense itemized bill in conjunction with the Single diseases and the decision rule,
Determine whether patient belongs to Single diseases:
Single diseases control module: for carrying out expenses managing and controlling according to the control catalogue of Single diseases total cost, drug and consumptive material.
2. medical insurance Single diseases control charge system as described in claim 1, it is characterised in that: the single case management module is used for handle
Each Single diseases are divided into N number of diagnosis and treatment item rule group G.
3. medical insurance Single diseases control charge system as claimed in claim 2, it is characterised in that: the diagnosis and treatment item rule group G points are
Include group and exclusion group.
4. medical insurance Single diseases control charge system as claimed in claim 3, it is characterised in that: the work of the Single diseases determination module
Method the following steps are included:
Step 01: extracting the charging item inventory information in the data acquisition module；
Step 02: determining whether Single diseases respectively comprising group rule and exclusion group rule using described.
5. medical insurance Single diseases control charge system as claimed in claim 4, it is characterised in that: the charging item inventory information includes
At least one of patient's admission number, charging item code (diagnosis and treatment item coding), total cost and expense unit price.
6. medical insurance Single diseases control charge system as claimed in claim 5, it is characterised in that: the step 01 further includes according to
Charging item inventory information generates single patient diagnosis and treatment item set DP.
7. medical insurance Single diseases control charge system as claimed in claim 6, it is characterised in that: the single patient diagnosis and treatment item set
DP includes all charging items of patient, single charging item DPn, single cost coefficient Zn, total cost CnWith expense unit price Pn。
8. medical insurance Single diseases control charge system as claimed in claim 7, it is characterised in that: the single cost coefficient Zn= Cn/
Pn。
9. medical insurance Single diseases control charge system as claimed in claim 8, it is characterised in that: the decision rule of the Single diseases are as follows:
1) the decision rule group G for defining Single diseases, takes G one by onenRule group judgement, defines GnUnder comprising group rule be RI, exclude
Group rule is RO；
2) whole diagnosis and treatment of patient will cover whole diagnosis and treatment items in RI, and meet ZnIn the coefficient range of RI { min-max },
Represent GnRI rule pass through, RI { min-max } be include a group regular coefficient；
3) as long as whole diagnosis and treatment of patient have one to appear in RO diagnosis and treatment item, and meet ZnIn the coefficient range of RO { min-max }
When, represent GnRO rule do not pass through, RO { min-max } be exclusion group rule coefficient；
4) GnRI and RO when all passing through, the G that the patient meets the Single diseases can be representednRule；
5) only have one group of rule to meet in G rule group, which can be included in the primary dcreening operation library of the Single diseases；
6) if all rule organizes none satisfaction of G, represents the patient and do not meet the Single diseases.
10. a kind of medical insurance Single diseases control charging method, including obtain inpatient expense itemized bill, which is characterized in that further include
Following steps:
Step 1: Single diseases definition and decision rule management are carried out to Single diseases essential information；
Step 2: according to the expense itemized bill in conjunction with Single diseases definition and the decision rule, determining whether patient belongs to
In Single diseases；
Step 3: carrying out expenses managing and controlling according to the control catalogue of Single diseases total cost, drug and consumptive material.
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| CN201811534663.6A CN109741193A (en) | 2018-12-14 | 2018-12-14 | A kind of medical insurance Single diseases control charge system and method |
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Cited By (1)
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| CN114520036A (en) * | 2021-12-31 | 2022-05-20 | 望海康信(北京)科技股份公司 | Disease resource consumption control system, corresponding equipment and storage medium |
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Application publication date: 20190510 |