JP2003016194A - Private health insurance system and private health insurance method - Google Patents

Abstract

PROBLEM TO BE SOLVED: To provide an insurance system with which the application of the highly advanced medicine of high quality can be applied in a reliable medical institution close to a life area and which includes a substantially continued evaluation system including a patient satisfaction level with respect to the medical institution. SOLUTION: An HMO server having a reference point calculating means calculating a medical institution identifying reference point and an HMNO web page where the calculated result is inserted, a health insurance supply company server provided with a superior medical institution data list where the name of the medical institution which exceeds the previously decided reference point is registered and the database of a subscriber entering a health insurance commodity that the health insurance supply company supplies, an insurance IRC terminal having a function for supplying health insurance information to the medical institution and the patient and an insurance auditing function, a medical IRC terminal supplying medical system information to the medical institution and the patient and a medical consultant IRC terminal supplying improvement information on the medical facility identifying reference point to the medical institution are connected through an electric communication line.

Description

Detailed Description of the Invention

[0001]

BACKGROUND OF THE INVENTION 1. Field of the Invention The present invention relates to a membership-based health insurance system, and more particularly to a private health care system applicable to a disease designated by a pre-certified medical institution.

[0002]

2. Description of the Related Art Conventionally, in Japan, the health insurance system includes health insurance and national health insurance. Health insurance is divided into union health insurance and government-run health insurance. National health insurance is a state-run health insurance. In any health insurance, the implementation of the universal health insurance system is obligatory under the guidance of the Ministry of Health and Welfare, and in accordance with the spirit of equality, it plays a major role as a system for providing low-cost medical services to all Japanese citizens after World War II. Has been fulfilled. In addition, a service that can reduce the cost of ordinary treatments other than special treatments has been provided due to the regulation of the point calculation system for receipts and the regulation based on the calculation of drug cost points.

[0003]

[Problems to be Solved by the Invention] Now, in Japan, problems such as an increase in chronic diseases occurring as problems of an aging society, discovery of new diseases, revival of diseases thought to be overcome in the past, declining birthrate, etc. Therefore, both the health insurance association and the national health insurance are facing serious financial difficulties. In the “Yakuji Handbook 2001 (Jiho)”,
The health insurance association recorded a deficit of a maximum of 203.3 billion yen, and 340 associations accounted for 21.4% of the total, and the deficit amount of national health insurance was 322 billion yen. Therefore, it must be predicted that it will be difficult to provide the desired medical care as it is.

As another problem, it is a reality that it is currently difficult to provide high-quality medical care, and this must be pointed out. This is also based on the "Pharmaceutical Handbook 2001 (Jiho)", but since 1997, the Japan Medical Function Evaluation Organization has started a hospital evaluation business by a third party in an effort to evaluate the quality of medical institutions and medical care. However, in reality, the items to be evaluated are biased toward the system, structure, and equipment of the hospital, and the evaluation of the quality and contents of medical care that patients most want to know and the evaluation of patient satisfaction have not yet been evaluated. Although it is difficult to evaluate the therapeutic effect neutrally, in the future, how to incorporate medical results into the evaluation project will become an issue. It has also been pointed out that only hospital-related persons such as former directors and former female managers evaluate hospital functions, and patients do not participate. However, patient satisfaction and quality of medical care are still in the research stage because it is difficult to put them on the system because the evaluation varies depending on each patient and the treatment result.

Therefore, in order to solve the above problems, an object of the present invention is to receive high-quality advanced medical treatment in a reliable medical facility closely related to a living area, and further to include patient satisfaction with a medical institution. It is to provide a health insurance system that includes a substantial and continuous evaluation system.

[0006]

[Means for Solving the Problems] In order to solve the above problems, the private health insurance system according to the present invention is a medical institution certification for judging whether or not a private health insurance provider can apply private health insurance. A reference point calculating means for calculating a medical institution certified reference point based on the reference database and the medical institution certified reference database, and an HMO for posting the calculation result.
(Health Maintenance Organization: HMO) An HMO server having a web page, a product database in which the content of health insurance products provided by a health insurance provider is registered, and the medical institution certification reference points exceed predetermined reference points. The health insurance provider server that includes a list of excellent medical institution data in which the name of the medical institution is registered and a database of subscribers who subscribe to health insurance products provided by the health insurance provider, and the medical institution certification reference point Insurance IRC (Insurance Research Coordinator) with excellent medical institution server that exceeds a predetermined reference point and health insurance information provision and insurance audit function for medical institutions and patients
Terminal, a medical IRC terminal that provides medical system information to medical institutions and patients, and a medical consultant IRC terminal that provides medical institution improvement reference points for medical facility certification reference points to each other through a telecommunication line. We provide medical services using private health insurance to patients who have been enrolled in private health insurance provided by a private health insurance provider by regularly auditing excellent medical institutions connected through provide.

The medical institution certification standard database comprises a numerical standard established from the number of personnel of each medical institution by job type, ancillary equipment type, ancillary equipment number, internal organization conditions and internal agreement conditions, and evaluation numerical standards of facility maintenance plans. This makes it possible to objectively and easily evaluate a medical institution based on a certain standard.

The reference point calculating means answers and inputs the question items based on the medical institution certification standard database of the web page provided on the HMO server, and based on a predetermined calculation formula based on the input data. By the means having the function of causing the CPU of the HMO server to calculate and displaying the calculation result on the web page, the evaluation of medical institutions can be performed quickly and easily even in a remote place if it is connected by a telecommunication line. be able to.

The excellent medical institution server is a medical record database for HMO diagnosis which is composed of a medical record in which the diagnosis result by the doctor of the HMO patient is described, an insurance application check list database which is composed of insurance application information of each diagnosis, a medical institution and private health. By having a database for contact matters for sharing or exchanging information of insurance providers, a clearer claim can be implemented by a third party intervening in the calculation of points for hospital health insurance.

[0010] The health insurance provider server joins the private health insurance, the authorized medical institution information database in which the information of the authorized medical institution applicable to the private health insurance is registered, the product information database in which the insurance products of the private health insurance are registered. By having a private health insurance subscriber information database consisting of registered information of registered subscribers and a private health insurance web page, it can be an observer who actively checks whether appropriate medical care is provided by the health insurance company. .

The HMO server includes a medical institution database recording internal information of registered excellent medical institutions, a private health insurance database including benefit calculation condition data of private health insurance, and medical care including patient medical plan generation condition data. An IRC that records the care database and the certification criteria for certifying an IRC that consults a patient or medical institution.
By providing the certification standard database, the medical evaluation method will be clarified, and the subject of medical evaluation will be clarified by the IRC.

The medical institution database is calculated by calculating the number of personnel by occupation used to calculate the reference point, the type of auxiliary equipment, the number of auxiliary equipment, the numerical values provided from the internal organization conditions and the internal contract conditions, and the evaluation numerical values of the facility maintenance plan. It becomes easier to objectively evaluate the medical institution by using the reference points.

The private health insurance database includes insurance benefit-corresponding disease selection standard data for selecting a disease to be diagnosed and treated, insurance benefit-corresponding diagnostic standard data for clarifying a diagnosis target for each disease, and an insurance premium for a doctor. Payment data for the insured, which is the calculation criterion for setting the deadline, and the insurance payment data for the insured, which is the calculation criterion for the insurance premiums paid to the insured, and payments to the insured Set up insurance benefit explanation data that records requirements and insurance application standards for doctors for explanation, continuous treatment management data of insured diseases to investigate medical care status for chronic diseases, and enrollment criteria for health insurance HMO that calculates the insurance member membership certification standard data, insurance consultation data for members to provide detailed health insurance information to health insurance members, and the balance of the insurance system
By providing the insurance amount balance management data and the insurance fee setting reference data of a new insurance product according to the needs of the insured who is a member, it becomes possible to collectively manage the basis for calculating health insurance.

The medical care database is a patient medical guidance database for registering a daily life guidance method for people with lifestyle-related diseases and sending necessary information to the patient, patient value data, lifestyle model and patient. Patient medical plan guidance standard data for predicting the disease predicted from the genetic information of the patient and the medical history of the patient according to age, and further calculating the necessary medical expense amount for each period, and the expected emergency for each patient Emergency response guidance standard data including a list of responders who should register the countermeasures for the situation and contact them further, member medical institution introduction data that records information on medical institutions with high medical institution certified reference points, and insured medical care Clinic information provision data consisting of virtual reality video information of medical institutions for selecting institutions,
By providing health care support data including exercise method information including preventive medicine information, food calorie information and meal recipe information, and medical needs data consisting of patient needs information for medical care, it is possible to provide appropriate timing for patients. Appropriate information can be easily provided, and preventive medicine as well as treatment can be implemented.

The IRC certification standard database is test information for testing medical knowledge, health insurance knowledge, medical management knowledge, interpersonal relationship adjustment ability, dialogue ability, related person adjustment ability, schedule management ability, computer operation ability and data analysis ability. And IRC certification information database consisting of standard information for judging evaluation points of test results, evaluation item information and evaluation standard information of medical institutions, supervision item information and supervision standard information of private health insurance system, and patient care IRC training consisting of an IRC work database consisting of information, a program for CRC experienced beginners, a program for experienced CRCs for clinical research coordinators, and an updated program for experienced IRCs to renew the qualifications of experienced IRCs Number of years in charge of IRC registered with database and hospital in charge By consisting of the IRC playback database for re-employment registration of the IRC management database and turnover IRC consisting of a constant update record, the support system of medical evaluation subject became clear.

In the private health insurance method according to the present invention, a medical consultant IRC terminal is connected to an HM via an electric communication line.
The joining examination process of connecting to the O server to calculate the medical institution certification reference point, the examination result transmitting process of transmitting the calculated medical institution certification reference point to the HMO server and registering it in the medical institution database, and the medical institution. After the maintenance, the medical IRC terminal and the medical IRC terminal are again connected to the HMO server via the telecommunication line to recalculate the medical institution certified reference point and achieve the medical institution certified reference point. Become.

In the private health insurance method according to the present invention, the health insurance providing company server registers the information of the person who applied for private health insurance in the private health insurance subscriber information database, and the telecommunications from the member terminal through the insurance joining process. When you connect to the private health insurance web page through the line, the product information providing process that provides the information of the product information database, and the health insurance providing company server provides information on the certified medical institutions that can apply multiple private health insurance after the medical institution maintenance process. The process of providing
The step of connecting the insurance IRC terminal with the private health insurance database of the HMO server via the telecommunication line to receive the information provision, and the medical IRC terminal H through the telecommunication line
The process of connecting with the medical care database of the MO server and receiving information, and the terminal for insurance IRC or medical I regularly.
An auditing process for calculating a medical institution certified reference point by connecting to the HMO server from the RC terminal via the electric communication line, and the calculated score to the health insurance provider server via the electric communication line to the insurance IRC terminal or medical device. An audit result reporting process of transmitting from the IRC terminal and registering it in the private health insurance database.

[0018]

BEST MODE FOR CARRYING OUT THE INVENTION An embodiment of the present invention will be described below with reference to the attached FIG. The private health insurance (Health Maintenance Organization: HMO) system (hereinafter referred to as an HMO system) according to the present invention includes an HMO server 2 that manages an HMO system as a reference database, and a private management that manages a health insurance database of a private health insurance company. A health insurance server 4, an excellent medical institution server 6 that meets the criteria set by the HMO system, a medical consultant IRC terminal 8 that is a network terminal for IRC with medical consultant capabilities, and an IR that has insurance knowledge.
An insurance IRC terminal 10, which is a network terminal for C,
A system in which a medical IRC terminal 12, which is a network terminal for IRC having medical knowledge, and a member terminal 14, which is a network terminal for a patient who subscribes to private health insurance, are connected to each other via the Internet 3, which is a telecommunication line. is there. In order to use the Internet 3, a part thereof may be a general telephone line, a wireless line, or a leased line.

The HMO server 2 is a component of the HMO system, and is based on the medical institution standard database 16 and the medical institution standard database for determining whether or not a private health insurance provider can apply the private health insurance. Reference point calculating means 18 and HMO for calculating medical institution certified reference points
A web page 20, a medical institution database 22 that records internal information of registered excellent medical institutions, a private health insurance database 24 that includes benefit calculation condition data for private health insurance, and a medical care database 26 that includes patient medical plan generation condition data. And an IRC certification standard database 28 that records certification standards for certifying IRC for consulting patients and medical institutions.

The medical institution certification standard database 16 is one of the databases of the HMO server 2, and is a numerical standard provided based on the number of personnel by occupation of the medical institution, the type of auxiliary equipment, the number of auxiliary equipment, internal organization conditions, and internal contract conditions. And a numerical standard for evaluation of facility maintenance plans.

The number of personnel by occupation of this medical institution includes the number of doctors and nurses in each department such as internal medicine, surgery, pediatrics and brain surgery,
It also means the number of other dedicated staff, the number of medical technicians such as those who handle radiation measurement equipment, the number of medical clerical staff, the number of full-time and part-time workers, and the number of night shift workers. As for the number of employees by type of medical institution, an appropriate number of beds is determined in advance, and the increase or decrease with respect to the appropriate number is added to the reference score. Furthermore, if the number is small, the criteria for re-examination will be to increase the number of employees and achieve them within the specified period.

In addition, in the kind of accessory equipment and the number of accessory equipment, the kind of accessory equipment is a kind in which a medical institution has an X-ray imaging device, an MRI device, a CT scan device and the like. The number of attached facilities means the number of devices that are additionally owned. Having these facilities will have the effect of raising the reference point, but the required number of medical technicians will be required, and the balance between maintenance cost, personnel cost, number of times of use and inspection cost will be standard. Added to the points.

Further, the internal organization condition is that the internal organization of a medical institution includes a predetermined organization, the subject of responsibility and authority is clearly defined, and the proxy order of delegation of authority in the absence is clearly defined by internal rules. Being attached is a condition for high scores.

In addition, the internal contract condition is given a high score when the internal contract is written and the compliance with the contract and a record of its implementation are recorded, and no score is provided when there is no contract.

The reference point calculating means 18 is a component of the HMO server 2, and makes each judgment criterion including the above-mentioned conditions into points such as a five-level evaluation according to its state, and corresponds to each judgment criterion of a medical institution. It is a program for digitizing the state of each medical institution and calculating it as a score when the state is selected by the selection method.

The HMO web page 20 is also a component of the HMO server 2, and has a function of allowing a registered person to register and browse data, and a function of calculating and displaying a reference point from the registered data. Have and. Here, as the items to be registered in advance, the private health insurance server 4, the excellent medical institution server 6, the medical consultant IRC terminal 8, the insurance IRC terminal 10, the medical IRC terminal 12,
A person who normally uses the member terminal 14 is applicable.

The medical institution database 22 is one of the databases of the HMO server 2, and has been used for the calculation of the reference points already evaluated by this system. It is a database of medical institutions that have already been evaluated, which consists of the numerical values established from the terms and conditions, the evaluation numerical values of the facility development plan, and the calculated reference points.

The private health insurance database 24 is also one database of the HMO server 2, and the insurance benefit corresponding disease selection standard data 26 for selecting the disease to be diagnosed and treated.
And insurance benefit support diagnostic standard data 28 that clarify the diagnostic target for each disease, and insured targeted insurance payment standard data 30 that is the calculation standard for the deadline setting for paying the insurance premium to the doctor.
The insurance benefit description that records the insurance premium payment standard data 32 for the insured, which is the calculation standard of the insurance premiums to be paid to the insured, and the requirements for payment to the insured and the insurance application standard for doctors for explanation. Data 34 and continuous treatment management data 36 for diseases covered by insurance for investigating the status of medical care provision for chronic diseases
And insurance member enrollment certification standard data 38 that sets the enrollment criteria for health insurance, insurance consultation data 40 for members to provide detailed health insurance information to health insurance members, and HMO insurance amount for calculating the balance of the insurance system. Balance management data 42
By providing the insurance premium setting reference data 44 of a new insurance product according to the needs of the insured who is a member, it is possible to collectively manage the basis for calculating health insurance.

The insurance benefit-compatible disease selection standard data 26 is a constituent element of the private health insurance database 24, which is one of the databases of the HMO server 2 as described above, and targets all disease targets. , We will proceed with diseases for which the evaluation of diagnostic treatment has been established. It is a manual for selecting disease covered by insurance according to the facility,
It is the standard information for selecting what kind of insurance target diseases can be introduced by the selected medical institution. In other words, it is a standard for always obtaining information on the latest diagnostic treatment method, and referring to it to determine the disease covered by insurance at the medical institution.

The insurance benefit corresponding diagnostic standard data 28 is also a component of the private health insurance database 24, and the diagnostic standard is set for each disease. For example, diagnostic criteria for diabetes, inflammatory diseases, allergic diseases, hyperlipidemia, rheumatic diseases, urinary system diseases, hypertension, etc. are set for insurance benefits.

The insurance payment reference data 30 for the insured is also included in the private health insurance database 24, and is the reference data regarding the timing of payment. For example, the first payment is the reference data for determining the example in which the insured applies for the payment and receives the diagnosis confirmation from the doctor before payment. In addition, there is room to confirm the adequacy of diagnostic treatment at regular intervals of about half a year or one year and adjust the payment amount.

The insurance premium reference data 32 for the insured is also a part of the private health insurance database 24, and is the reference data for determining the amount of insurance payment according to various conditions. For example, depending on the underlying illness, complications, and the circumstances of compliance, the amount of insurance payment must be changed. Depending on the content of insurance, it is possible to cover all complications with insurance, and in the case of non-compliance patients, it may be exempt from insurance. This manual shows the criteria for such cases.

The insurance benefit explanation data 34 also constitutes the private health insurance database 24, and comprises explanation data for the insured person and explanation data for medical personnel. The explanation data for the insured person is data showing a procedure for specifically explaining in what case and how much amount is paid. On the other hand, the explanation data for medical personnel is data indicating the judgment criteria and the procedure of the insurance claim method when insurance is applied.

The continuous treatment management data 36 of the disease covered by insurance is also one of the components of the private health insurance database 24, and it is confirmed that appropriate and high-quality medical care is continuously provided for the insurance benefit disease. It is management data for doing. The target is a chronic disease, and we will confirm the chart, patient satisfaction survey, and expense processing confirmation.

The insurance member membership certification standard data 38 is also included in the private health insurance database 24, and the insurance is a membership system, and a standard for being a member is set. This is the standard data for investigating health status, income, occupation, etc. and judging the appropriateness as a member.
The MO web page is entered and the suitability is calculated with reference to this data to determine the suitability.

The member insurance consultation data 40 also constitutes the private health insurance database 24 and is data for providing consultation services to members. If you select a question from multiple items and enter the conditions, the optimum answer will be selected from this data and output. For a guide intended to facilitate various consultations, assuming various cases such as wanting to know information on other medical institutions, consultation regarding changes in medical institutions, consultation regarding increase / decrease in insurance premiums, etc. Data.

The HMO insurance amount balance management data 42 is also one of the components of the private health insurance database 24, and the total amount of insurance premiums and the total amount of insurance payments are constantly checked, and the insurance system is operated without any economic problems. It is data for confirming that

The insurance premium setting standard data 44 is also data for constituting the private health insurance database 24, determining the needs of the insured who are members, and then creating a basic insurance system according to the needs. . After that, we will make further adjustments to the insurance conditions with the members to create insurance that the members are satisfied with. Regarding insurance types, it is premised that a system as parts is systematically prepared so that various combinations can be made. The above is the data of the private health insurance database 24.

The medical care database 26 is one of the databases of the HMO server 2, and is a database for patient medical guidance 46 for registering a method of daily life guidance for people with lifestyle-related diseases and sending necessary information to the patient. And patient value data, lifestyle models, genetic information of patients, and patient medical history for predicting diseases that are predicted from the patient's medical history according to age and calculating the necessary medical expenses at each time. The plan guidance standard data 48, the emergency response guidance standard data 50 including a list of responders who should register the countermeasures for the anticipated emergency situation for each patient and further contact, and the information of the medical institution having a high medical institution certification reference point The member medical institution introduction data 52 recorded, the clinic information provision data 54 including virtual reality image information of the medical institution for the insured to select the medical institution, and the preliminary information. Provided with calorie information of the exercise method information and food, including medical information and health management support data 56 including the meal recipe information, and medical needs data 58 consisting needs information of the patient to the medical.

The patient medical care guidance database 46 constitutes the medical care database 26 included in the HMO server 2,
It is data for giving medication instruction and daily life instruction. It is data that can be searched by a selection method and can obtain an answer required by a method of answering a question. Regarding diseases that are said to be lifestyle-related diseases for patients,
Drug administration and daily life guidance are important and essential for effective utilization of medical expenses. Therefore, it is data showing not only guidance by a doctor or pharmacist but also a procedure regarding support by direct mail, Internet 3, telephone, fax, direct visit, etc. and selection of the method within a medically possible range.

The patient medical care plan guidance standard data 48 is also one of the components of the medical care database 26, and is referred to for the purpose of planning for predicting the progress of the medical condition of the patient and performing an appropriate treatment at an appropriate time. Data to The future medical expenses are predicted to some extent based on the patient's own values, the individual lifestyle of the patient, and the gene of the patient. Another predictor is the underlying illness and medical history, and it is possible to create an expense plan for individual patient medical expenses from these combinations. It is a procedure manual for the cost planning.

The emergency response guidance standard data 50 also constitutes the medical care database 26 and is data for clarifying the response in an emergency. In the case of an emergency, the procedure data at the clinic is to establish a communication network between other doctors and staff in the clinic, and for the outside, the procedure data on the selection of facilities that can accept emergency patients and the presentation of their information are available on the HMO Web. Shown on the page.

Further, the member medical institution introduction data 52 also constitutes the medical care database 26 and is data for providing the medical institutions judged as excellent to the private health insurance members. This data is also posted on the HMO web page and made available to members. However, since it is most important to understand the requests of the members when introducing them, it is necessary to thoroughly investigate the background information of the members.

Moreover, the clinic information providing data 54 also constitutes the medical care database 26, and the purpose is to select the most suitable medical facility by the virtual experience of the insured person on the Internet 3. It is business data related to management and maintenance of provided information for that purpose. For example, video data in a medical institution for displaying as a 3D image is recorded and disclosed on the HMO web page. At the request of the viewer, the actual treatment image, the hospital image, etc. are recorded in advance in order to appreciate any virtual experience, and a plurality of options are provided to show that the story changes depending on the viewer's selection.

The health management support data 56 also constitutes the medical care database 26, and records a wide range of information including preventive methods such as exercise methods, calorie calculations, meal recipes, and dietary therapy. The data may be published on the HMO web page, and the data may be disclosed by direct mail or the like, if necessary.

The medical needs data 58 is also the data of the medical care database 26, and is a data in which a questionnaire or request page is permanently provided on the HMO web page, the results are constantly aggregated, and other request information is registered. Is. Since private health insurance is a membership system, the medical needs of each member are considered to be strong and diverse. Therefore, in order to determine the needs of individual patients, it is necessary to have technology that can retrieve medical information from all angles and basic knowledge about medical databases. Furthermore, there is a need for information management that can share the needs obtained. The above is the data of the medical care database 26.

The IRC certification standard database 28 is HMO
This is one of the databases of the server 2, and is a test for testing medical knowledge, health insurance knowledge, medical management knowledge, interpersonal relationship adjustment ability, dialogue ability, related person adjustment ability, schedule management ability, computer operation ability, and data analysis ability. I consisting of information and standard information for judging the evaluation score of the test result
RC certification information database 60, IRC business database 62 consisting of medical institution evaluation item information and evaluation standard information, private health insurance system supervision item information and supervision standard information, and patient care information, and IR business beginner target program Registered IRC with IRC training database 64 consisting of program for CRC experienced person for clinical research coordinator and update program for experienced IRC person to update qualification of experienced IRC person
IRC consisting of the number of years in charge, hospital in charge, and certification update record
I for reemployment registration of management database 66 and turnover IRC
The RC reproduction database 68.

The IRC certification information database 60 is IRC
It is one of the databases of the certification standard database 28, and is a database for certifying the IRC in contact with the customer in this system. The IRC's main task is to evaluate the quality of medical care and medical care, and to supervise whether the HMO system is properly implemented in that medical care. Therefore, IRC has special skills with sufficient knowledge about medical care and insurance. Can be said to be a person. Also, the evaluation work in the medical field includes the ability to maintain good interpersonal relationships, the ability to interact, the ability to coordinate with people, the ability to manage schedules, the ability to operate computers,
Data analysis capabilities, etc. are required. In addition, it is necessary for the patient to have the humanity to take care from the patient's standpoint, such as the need to explain the applicable insurance. Therefore, IRC is CRC (Clinical Research Coordi
It is considered more desirable to have clinical trial experience as a nator). It is desirable to have a history of performing at least two protocols. From such a background, in order to prove that the IRC has suitable abilities, the IRC certificate shall be issued in accordance with proper procedures after confirming both knowledge and experience.

The IRC business database 62 is also IR
It is a component of the database of the C certification standard database 28, and is a judgment database of IRC work. IRC
The main work of the is roughly divided into evaluation of medical institutions, supervision of proper implementation of this system, and patient care.

This database is a database for fulfilling these auxiliary functions. It calculates the evaluation points of medical institutions, displays a list of check items for each implementation period for supervision of proper implementation, records them, and conducts aptitude implementation. This is a database for calculating evaluation points, displaying a list of check items for each patient's implementation time, and recording them.

The medical institutions are evaluated based on the medical institution selection / evaluation manual. The subject of evaluation is classified into several stages according to the size of the facility, doctors, inspection equipment, and other equipment. In addition, the medical contents shall be confirmed by browsing the medical chart. Based on records of basic diseases, complications, concomitant medications, and adverse event response, and the results of patient satisfaction surveys, the quality of medical care is similarly evaluated and classified in several stages. A comprehensive evaluation is finally obtained from these two types of evaluations. As a matter of course, he is also a skilled person who has the ability to monitor the adequacy of insurance application costs.

Further, the IRC training database 64 is also I
The database of the RC certification standard database 28 is configured, and the data for IRC check is recorded with the schedule creation tool of the training program and the knowledge and experience check rules for each point of the schedule.
Further, IRC training data developed using this tool is also recorded in this database.

In addition, the IRC management database 66 is also I
It is one of the databases of the RC certification standard database 28, and is a database for managing a plurality of IRCs in parallel at the same time. It is a database that has both a work schedule and an education schedule so that each IRC is not overloaded.

There are various capabilities as an IRC, and in order to dispatch the IRC at the national level, it is necessary to sufficiently manage and follow up on its performance. Management data such as number of years in charge, hospital in charge, certificate update record, and so on.

The IRC reproduction database 68 is also a component of the database of the IRC certification standard database 28, and is a database for preparing to register and rehire an IRC that has once left the job. It is a management manual for IRC who intends to return to the future if the person in charge of IRC leaves the job for his own convenience. IRC
Is a special skill worker, and it is necessary to prepare an environment where he can return. The above are the components of the IRC certification standard database 28 and the configuration of the HMO server 2.

The private health insurance server 4 is the HMO server 2
Similarly to the Internet 3, it is connected to a telecommunications line such as the Internet 3 and has a certified medical institution information database 70 in which the registered medical institution information applicable to the private health insurance is registered, and a product information database 72 in which the insurance products of the private health insurance are registered. ,
It has a private health insurance subscriber information database 74 consisting of registration information of subscribers who have private health insurance, and a private health insurance web page 76.

The authorized medical institution information database 70 is one of the databases of the private health insurance server 4, and provides the members with a list of medical institutions certified by this health insurance provider and information about the contents of each medical institution. It will be published from page 76.

The product information database 72 is also a database of the private health insurance server 4, and the private health insurance product information provided by this health insurance company is disclosed on the web page 76. Non-members can also select health insurance here and apply for membership.

Further, the private health insurance subscriber information database 74 is also one of the databases of the private health insurance server 4, and is H out of the member information grasped by the health insurance provider.
It is a subscriber database that can be opened to MO systems and medical institutions.

The private health insurance web page 76 constitutes the private health insurance server 4, the HMO server, the medical institution, and the IR.
C, Used by a patient as a tool for providing or collecting information to the private health insurance server 4. The above is the configuration of the private health insurance server 4.

The excellent medical institution server 6 is also the HMO server 2
And Internet 3 as well as private health insurance server 4.
HMO diagnostic chart database 78 that is connected to a telecommunication line such as a medical record in which the diagnosis result by the doctor of the HMO patient is described, an insurance application checklist database 80 that includes insurance application information of each diagnosis, and a medical institution. It has a contact information database 82 for sharing or exchanging information on private health insurance providers. Good medical institutions
After a normal medical institution has reviewed the internal system, only the medical institution that has undergone the HMO system examination and is certified is a medical institution that is registered. The excellent medical institution server 6 publishes the above-mentioned database, and receives the health insurance information and the IRC information from the HMO server 2 and the private health insurance server 4, and communicates the information.

The HMO diagnostic chart database 78 is one database of the excellent medical institution server 6, and is provided as a database attached to the medical institution server as a diagnostic record created by the medical institution and shared with the HMO server 2 and the private health insurance server 4. Being monitored.

The insurance application checklist database 8
0 is also one of the databases of the excellent medical institution server 6, and records the type and cost of health insurance applied to each diagnosis and the name of applicable disease.

The contact information database 82 is also constructed as one database of the excellent medical institution server 6, and is a communicator Sean tool shared with the HMO server 2 and the private health insurance server 4 and in which information for the medical institution is entered. The above is the configuration of the excellent medical institution server 6.

Medical consultant IRC terminal 8 is HM
Like the O server 2, private health insurance server 4, and excellent medical institution server 6, the medical consultant IRC is connected to the telecommunications line such as the Internet 3 and provides the medical institution with the improvement information of the medical facility certification reference point. It is a terminal. The terminal device may be a personal computer, a mobile terminal device, a mobile phone device, or any other device that can be connected to a network, and more preferably includes an image device, a character input device, and a pointing device. The medical consultant IRC uses the terminal 8 to survey the medical institution, accesses the HMO web page 20 and inputs the survey result at any time. After the input, the evaluation score is calculated and displayed on the HMO web page 20. Further, the elements lacking in the medical institution and the improvement plan are simultaneously displayed on the terminal screen. Based on these results, the medical consultant IRC will propose an improvement method more suitable for the local area.

The result is registered in the medical institution database 22 of the HMO server 2.

The insurance IRC terminal 10 includes the HMO server 2,
Like the private health insurance server 4, the excellent medical institution server 6 and the medical consultant IRC terminal 8, it is connected to the telecommunications line such as the Internet 3 and has knowledge of insurance.
It is a network terminal for RC. As a terminal device,
Any device that can be connected to a network, such as a personal computer, a mobile terminal device, a mobile phone device, or the like,
Furthermore, it is more preferable to have an image device, a character input device, and a pointing device. The insurance IRC terminal 10 can be used only by the insurance IRC that has the access right. Insurance IR
C builds and operates the insurance application checklist database 80 of the excellent medical institution server 6 according to the private health insurance database 24.

The insurance IRC terminal 10 is connected to the private health insurance database 24 of the HMO server 2 and information using each database is displayed on the terminal screen. Insurance IRC
When the terminal 10 accesses the HMO web page, inputs data, and transfers the data to the HMO server, the result is calculated from the transferred data and the private health insurance database 24 and displayed on the terminal screen. By inputting the insurance benefit-compatible disease selection standard data 26 and the disease name, whether or not health insurance is supported is displayed on the terminal screen.

When the disease name is input using the insurance benefit support diagnostic criteria data 28, the health insurance benefit amount is displayed on the terminal screen.

When the disease name is input using the insurance payment reference data 30 for the insured, the procedure and payment method are presented on the terminal screen.

When the disease name is input using the insurance premium reference data 32 for the insured, the insurance payment amount is calculated and presented on the terminal screen.

By inputting the insurance benefit explanation data 34 and the disease name, a list of insurance products for the disease is displayed, and further detailed information is presented on the terminal screen.

By inputting the patient name using the continuous treatment management data 36 of the disease covered by insurance, the medical service provision status and the drug status are presented on the terminal screen. You can also enter and view the patient satisfaction survey on the terminal screen.

Furthermore, the insurance member participation authorization standard data 38
By inputting the information of the non-participating patient, the possibility of joining the health insurance of the non-participating patient is presented on the terminal screen. The member's insurance consultation data 40 can also be viewed, and if there is a response request, it will be answered.

The medical IRC terminal 12 is the HMO server 2,
The private health insurance server 4, the excellent medical institution server 6, the medical consultant IRC terminal 8 and the insurance IRC terminal 10 are connected to the telecommunication line such as the Internet 3 like the
It is a medical IRC terminal that provides medical system information to medical institutions and patients. The terminal device may be a personal computer, a mobile terminal device, a mobile phone device, or any other device that can be connected to a network, and more preferably includes an image device, a character input device, and a pointing device. The medical IRC terminal 12 can be used only by the medical IRC that has the access right. The medical IRC constructs and operates the HMO diagnostic chart database 78 of the excellent medical institution server 6 according to the medical care database 26.

The medical IRC terminal 12 is connected to the medical care database 26 of the HMO server 2 and information using each database is displayed on the terminal screen. When the medical IRC terminal 12 accesses the HMO web page, inputs data, and transfers the data to the HMO server, the result is calculated from the transferred data and the medical care database 26 and displayed on the terminal screen.

By inputting the patient medical guidance database 46 and the name of the disease, the precautions for the patient's diet and daily life are displayed on the terminal screen.

By inputting the patient medical care plan guidance reference data 48, the disease name, the patient's own sense of values, the patient's individual lifestyle, and the patient's gene, the occurrence timing and progress of the disease are predicted.

By inputting the emergency response guidance standard data 50 and the disease name or symptom, the optimum medical institution introduction and the measures to be taken are displayed on the terminal screen.

The member terminal 14 includes the HMO server 2, the private health insurance server 4, the excellent medical institution server 6, the medical consultant IRC terminal 8, the insurance IRC terminal 10 and the medical I.
Like the RC terminal 12, the member is connected to an electric communication line such as the Internet 3 and the member connects to the HMO server 2 and the private health insurance server 4 to browse the HMO web page 20 and the private health insurance web page 76. Here, member terminal 1
In No. 4, the connection is restricted and only some of the data can be connected.

Here, as the connectable data, insurance consultation data for members 40 and patient medical guidance database 46 are provided.
It is possible to connect to the emergency response guidance standard data 50, the member medical institution introduction data 52, the clinic information provision data 54, the health management support data 56, and the medical needs data 58.

Next, the method of private health insurance according to the present invention will be described with reference to FIGS. FIG. 2 shows a process of determining the application of private health insurance to a medical institution.

The first step is the medical consultant IRC.
This is a joining examination step of connecting the mobile terminal 8 to the HMO server 2 via an electric communication line to calculate a medical institution certification reference point (A2). Here, it is a process of determining whether or not the target medical institution can implement the HMO system from the medical consultant IRC terminal 8 as an investigation. HMO server 2
By connecting to, the shortage and improvement points of the target medical institution are posted on the screen of the medical consultant IRC terminal 8.

The second step is a step of transmitting the calculated medical institution certification reference point to the HMO server and transmitting the examination result to be registered in the medical institution database (A4). However, since the examination result is calculated by the HMO server 2, the examination result is registered in the medical institution database 22.

In the third step, after the medical institution is further prepared, the insurance IRC terminal and the medical IRC terminal are again connected to the HMO server via the electric communication line to recalculate the medical institution certification reference point and perform medical treatment. This is a medical institution development process that achieves the institutional certification reference point (A6).

Insurance for implementation of HMO system "Private health insurance introduction procedure" which is a standard from financial aspect and medical aspect, that is, HMO diagnostic chart database 78 and insurance according to private health insurance database 24 and medical care database 26. A system related to the application check table database 80 is constructed.

FIG. 3 is a flow chart showing the steps of implementing the HMO system according to the present invention.

The fourth step is an insurance enrollment step in which the private health insurance server 4 registers the information of the person who applied for private health insurance in the private health insurance subscriber information database (B2). This is the process of enrollment in private health insurance and the registration process that accompanies it.

The fifth step is a product information providing step of providing information of the product information database when connecting to the private health insurance web page 78 from the member terminal through the electric communication line. Here, the information is provided through the medical IRC terminal 12 and the insurance IRC terminal 10, and the HMO is provided to the subscriber.
Install the system.

The sixth step is a step in which the private health insurance server 4 provides the certified medical institution information 6 to which a plurality of private health insurances that have undergone the medical institution maintenance process can be applied (B6). The data of the certified medical institution information database 70 is posted on the private health insurance web page 78, and a desired medical institution can be selected from a plurality of excellent medical institutions and the information can be displayed on the screen of each terminal.

The seventh step is a step in which the insurance IRC terminal 10 is connected to the private health insurance database 24 of the HMO server 2 via an electric communication line to receive medical information such as informed consent for insurance. (B
8). The private health insurance database 24 is a process for obtaining necessary health insurance information from the member insurance consultation data 40, the HMO insurance amount balance management data 42, and the like. In particular,
The patient's approval is obtained in advance, showing how the insurance covered by the patient is adapted to future treatment and when the compensation is performed.

The eighth step is a step in which the medical IRC terminal 12 is connected to the medical care database 26 of the HMO server 2 via an electric communication line to receive information (B1).
0). Medical IRC to understand the needs of patients correctly
It is the information providing process for care by.

The ninth step is to periodically carry out the HMO from the insurance IRC terminal or the medical IRC terminal via the electric communication line.
This is an audit process for connecting to a server and calculating a medical institution certification reference point (B12). "Private health insurance introduction procedure", that is, whether or not an appropriate medical diagnosis is made according to the private health insurance database 24 and the medical care database 26, and also the appropriateness of insurance application costs and the response to patients who are implementing this system Information is collected through the medical IRC terminal 12 and the insurance IRC terminal 10 and registered in the authorized medical institution information database 70.

In the tenth step, the calculated points are transferred to the private health insurance server 4 through the telecommunication line to the insurance IRC.
This is an audit result reporting step of transmitting from the medical terminal 10 or the medical IRC terminal 12 and registering it in the private health insurance database.

The audit result of each insurance area / diagnosis area is reported to the database to the insurance company to which the patient joins. The above is the method of private health insurance according to the present invention.

FIG. 4 presents a cost item structure diagram of the burden ratio of medical expenses in the method of private health insurance according to the present invention.
The basic diagnosis is paid in full by National Health Insurance or by the patient (A). On the other hand, the inspection and the image diagnosis are entirely borne by the private company introducing the HMO system (B). On the other hand, medication, injection, treatment, surgery, anesthesia, etc. may be partially borne by National Health Insurance or the patient (C).

[0097]

According to the present invention, by utilizing the HMO system, it is possible to compensate the "right to receive high-quality medical care" and increase the patient's profit.

Further, it becomes possible to objectively and organically operate a medical institution as a third party.

As a result, a general hospital ranking evaluation model is constructed, and by making these collected data open to the public, medical information can be made more open.

[0100] The subject can systematically manage medical expenses. It also provides data between insurance companies, medical institutions and patients. Furthermore, a medical institution diagnosis system by a third party will be constructed.

Furthermore, a practitioner network system is inevitably introduced in system implementation, and it is possible to build a medical system that is close to the community while making the most of the doctor's individual expertise.

Moreover, since the service is provided based on the clinical trial system, the clinic can provide the highest level of medical care.

[Brief description of drawings]

FIG. 1 is a block diagram of a private health insurance system according to the present invention.

FIG. 2 is a flowchart of medical institution examination in the method of private health insurance according to the present invention.

FIG. 3 is a flow chart of implementation of the method of private health insurance according to the present invention.

FIG. 4 is a block diagram of a charge expense item of the private health insurance system according to the present invention.

[Explanation of symbols]

2 HMO server 4 Private Health Insurance Server 6 excellent medical institution server 8 Medical consultant IRC terminal 10 Insurance IRC terminal 12 Medical IRC terminal 14 Member terminal 16 medical institution certification standard database 18 Reference point calculation means 20 HMO web page 22 Medical Institution Database 24 Private Health Insurance Database 26 Medical Care Database 28 IRC Certification Criteria Database 30 Insurance payment standard data for the insured 32 Insurance premium payment standard data for the insured 34 Insurance benefit explanation data 36 Continuous Treatment Management Data for Diseases Covered by Insurance 38 Insurance Membership Approval Standard Data 40 insurance consultation data for members 42 HMO insurance amount balance management data 44 Insurance premium setting standard data 46 Patient Medical Guidance Database 48 Patient Medical Plan Guidance Standard Data 50 Emergency response guidance standard data 52 Medical institution introduction data for members 54 Clinic information provision data 56 Health management support data 58 Medical Needs Data 60 IRC certified information database 62 IRC Business Database 64 IRC Training Database 66 IRC Management Database 68 IRC reproduction database 70 Certified Medical Institution Information Database 72 Product information database 74 Private Health Insurance Subscriber Information Database 76 Private Health Insurance Web Page 78 HMO diagnostic chart database 80 insurance application checklist database 82 Contact information database 82

Claims (12)

[Claims] 1. A medical institution certification standard database for determining whether a private health insurance provider is applicable to a private health insurance and a medical institution certification standard point is calculated based on the medical institution certification standard database. An HMO server having a means and an HMO web page on which the calculation result is posted, a product database in which the content of health insurance products provided by a health insurance provider is registered, and a reference point at which the medical institution certification reference point is predetermined. Health insurance provider server having a list of excellent medical institution data in which the names of medical institutions that have passed the above are registered and a database of subscribers who subscribe to health insurance products provided by the health insurance provider, and the medical institution certification standard Excellent medical institution server whose points exceed a predetermined reference point, and provision of health insurance information and insurance to medical institutions and patients An insurance IRC terminal with an audit function, a medical IRC terminal that provides medical system information to medical institutions and patients, and a medical consultant IRC that provides medical institutions with improved information on medical facility certification reference points.
Medical service using private health insurance for patients who have been enrolled in private health insurance provided by a private health insurance provider by regularly inspecting excellent medical institutions by being connected to each other through a telecommunication line A private health insurance system that provides medical information and insurance information. 2. The medical institution certification standard database includes a numerical standard established based on the number of personnel of each medical institution by job type, ancillary equipment type, ancillary equipment number, internal organization conditions and internal contract conditions, and an evaluation numerical standard of facility maintenance plans. The private health insurance system according to claim 1, wherein 3. The reference point calculating means answers and inputs a question item based on a medical institution standard database on a web page provided on the HMO server, and uses a predetermined calculation formula based on the input data. The private health insurance system according to claim 1, which is a means having a function of causing a CPU of the HMO server to perform calculation based on the result and displaying the calculation result on a web page. 4. The excellent medical institution server comprises an HMO diagnostic chart database consisting of a chart in which the diagnosis result by the doctor of the HMO patient is described, an insurance application checklist database consisting of insurance application information of each diagnosis, and a medical institution. 2. A database for contact matters for sharing or exchanging information of private health insurance companies.
Private health insurance system described. [Claim 5] The health insurance providing company server includes a certified medical institution information database in which certified medical institution information applicable to private health insurance is registered, a product information database in which insurance products of private health insurance are registered, and private health insurance. The private health insurance system according to claim 1, further comprising a private health insurance subscriber information database including registration information of subscribers who have subscribed to, and a private health insurance web page. 6. The HMO server stores a medical institution database recording internal information of registered excellent medical institutions, a private health insurance database including benefit calculation condition data of private health insurance, and patient medical plan generation condition data. An IR that records the medical care database that includes it and the certification criteria for certifying the IRC that consults with patients and medical institutions
The private health insurance system according to claim 1, further comprising a C certification standard database. 7. The medical institution database includes the number of personnel by occupation used for calculating the reference point, the type of auxiliary equipment, the number of auxiliary equipment, the numerical value provided from the internal organization condition and the internal contract condition, and the evaluation value of the facility maintenance plan, The private health insurance system according to claim 6, comprising a calculated reference point. 8. The private health insurance database includes insurance benefit corresponding disease selection criteria data for selecting a disease to be diagnosed and treated, insurance benefit corresponding diagnostic criteria data for clarifying a diagnosis object for each disease, and a doctor's information. The insurance payment standard data for the insured, which is the calculation criteria for setting the deadline for paying the insurance premium, the insurance payment standard data for the insured, which is the calculation standard for the insurance premiums paid to the insured, and the Insurance benefit explanation data that records payment requirements and insurance application standards for doctors for explanation, continuous treatment management data of insured diseases to investigate medical care status for chronic diseases, and enrollment criteria for health insurance The insurance member enrollment certification standard data that has been set, member insurance consultation data for providing health insurance detailed information to health insurance members, and HM that calculates the balance of the insurance system
7. The private health insurance system according to claim 6, further comprising: O insurance amount balance management data and insurance premium setting reference data for a new insurance product according to the needs of the insured who is a member. 9. The medical care database includes a patient medical care guidance database for registering a daily life guidance method for people with lifestyle-related diseases and sending necessary information to the patient, patient value data and a lifestyle model. The patient medical plan guidance standard data for predicting the disease predicted from the patient's genetic information and the patient's medical history according to age, and calculating the necessary medical expenses at each time, and the predicted data for each patient. Emergency response guidance standard data including a list of responders who should register and further contact emergency response measures, member medical institution introduction data that records information on medical institutions with high medical institution certified reference points, and insured person Clinic information provision data consisting of virtual reality video information of medical institutions for selecting medical institutions,
7. The health management support data including exercise method information including preventive medicine information, food calorie information and meal recipe information, and medical need data including patient need information for medical treatment. Private health insurance system. 10. The IRC certification standard database tests medical knowledge, health insurance knowledge, medical management knowledge, interpersonal relationship adjustment ability, dialogue ability, related person adjustment ability, schedule management ability, computer operation ability and data analysis ability. IRC certification information database consisting of test information and standard information for judging evaluation points of test results, evaluation item information and evaluation standard information of medical institutions, supervision item information and supervision standard information of private health insurance system, and patient It consists of an IRC work database consisting of care information of the above, a program for beginners of IR work and a program for CRC experienced persons for clinical research coordinators, and an update program for IRC experienced persons for renewing the qualifications of experienced IRC persons. IRC upbringing database and IRC registered years and hospitals in charge 7. The private health insurance system according to claim 6, further comprising: an IRC management database consisting of a certification update record and an IRC reproduction database for re-employment registration of job separation IRC. 11. A medical consultant IRC terminal is connected to an HMO server via an electric communication line to calculate a medical institution certified reference point, and a calculated medical institution certified reference point is transmitted to the HMO server. The examination result transmission process of registering in the medical institution database with the medical institution database, and after further establishing the medical institution, the insurance IRC terminal and the medical IRC terminal are again connected to the HMO server via the electric communication line to reestablish the medical institution certification reference point. A private health insurance method consisting of a medical institution maintenance process that calculates and achieves the medical institution certification reference point. 12. An insurance enrollment process in which a health insurance provider server registers information of a person who applied for private health insurance in a private health insurance subscriber information database, and from a member terminal to a private health insurance web page through a telecommunication line. A product information providing process that provides information of a product information database when connected, a process of a health insurance providing company server providing certified medical institution information applicable to a plurality of private health insurances that have undergone a medical institution maintenance process, and insurance IRC The step in which the terminal is connected to the private health insurance database of the HMO server via the telecommunication line to receive the information provision, and the terminal for medical IRC is connected to the medical care database of the HMO server via the telecommunication line to provide the information provision. The process of receiving and the HMO server from the terminal for insurance IRC or the terminal for medical IRC on a regular basis via an electric communication line. An auditing process for connecting with a medical institution standard point to calculate a medical institution certified reference point, and transmitting the calculated score from the insurance IRC terminal or medical IRC terminal to a health insurance company server via a telecommunication line to a private health insurance database. A private health insurance method consisting of an audit result reporting process to be registered.