JP2021018812A - Medical fee analyzing device, medical fee analyzing method, and medical fee analyzing program - Google Patents

Abstract

To provide a medical fee analyzing device, a medical fee analyzing method, and a medical fee analyzing program that analyze medical fees so that insurance medical institutions can execute proper medical treatment and proper medical fee billing.SOLUTION: A medical fee analyzing device 10 includes: an acquisition unit 11 that acquires data derived from medical information for a predetermined period from a data set DB2 derived from medical information including both electronic receipt data and DPC data held by a medical institution; an extraction unit 12 that extracts data derived from the medical information related to a predetermined medical fee of the data derived from the medical information for the predetermined period; a first calculation unit 13 that calculates the number of times in which a predetermined medical fee can be calculated for the predetermined period for a plurality of insured persons corresponding to the extracted data derived from the medical information; and a second calculation unit 14 that calculates a calculation ratio by dividing the number of times in which the predetermined medical fee was calculated by the number of times in which the calculation is possible.SELECTED DRAWING: Figure 1

Description

The present invention relates to a medical fee analyzer, a medical fee analysis method, and a medical fee analysis program.

Conventionally, when an insurance medical institution such as a hospital provides medical treatment, a medical fee schedule set by the Ministry of Health, Labor and Welfare according to the medical treatment provided and the combination of diagnosed disease and treatment (DPC; Diagnosis Procedure Combination). The medical fee is calculated based on. The insurance medical institution prepares a medical fee statement (receipt) and sends it to the examination and payment institution in order to charge the examination and payment institution for medical fees. In recent years, from the viewpoint of improving the efficiency of medical office work and making medical practice transparent, the introduction of electronic medical fee statements (electronic receipts) is progressing. Furthermore, DPC target hospitals, DPC preparatory hospitals, hospitals that have submitted data submission additions, etc. have submitted data to the DPC investigation secretariat in accordance with the "Survey on Impact Assessment of DPC Introduction (including Special Survey)". , Has medical information data other than receipt data.

Regarding the electronic receipt, for example, in Patent Document 1 below, a basic registration screen of basic information including a message to be attached to the electronic receipt, a first registration screen of a target record for setting extraction conditions of the electronic receipt to be inspected, and The second registration screen of the reference record for setting the extraction conditions of the electronic receipt to be referred to to specify the electronic receipt to be inspected is displayed on the client terminal, and the set extraction conditions are set on the basic registration screen. A receipt secondary inspection support system that records as inspection items in association with basic information and inspects the extracted electronic receipt using the recorded inspection items is described.

Further, Patent Document 2 below describes a medical fee evaluation system that can easily check whether or not a medical fee request is properly made. Specifically, the receipt data for each patient is searched for whether or not data matching a predetermined medical fee item is included, and if it is included, the patient is counted as a target patient for the medical fee item request. At the same time, it is searched whether or not the medical fee item is included as the billing item of the receipt data of the patient, and the predetermined medical fee for the number of patients (the number of target patients) that meets the billing conditions of the predetermined medical fee item. A medical fee evaluation system that calculates the ratio of the number of items is described.

Further, Patent Document 3 below describes an efficient screen processing system for outpatient electronic receipts (statement of medical fees). For example, FIG. 14 shows one medical institution of "outpatient electronic receipt ER" according to the department of advocacy. A graph showing the average number of cases and the number of claims for "outpatient electronic receipt ER" by medical institution subject to examination is shown.

JP-A-2017-117383 Japanese Unexamined Patent Publication No. 2003-108662 Japanese Unexamined Patent Publication No. 2012-123444

With the progress of medical technology, medical treatment is becoming more fragmented and sophisticated, and the medical fee schedule is becoming more detailed and enormous for each category. Therefore, although there is an opportunity to provide medical treatment, it is not possible to provide medical treatment that should have been provided because the requirements for calculating medical treatment fees were not recognized, or specific medical treatment that is actually subject to medical fee addition. Even though it was provided, it could be overlooked without even being included in the calculation of medical fees.

For example, the calculation item such as the comprehensive drug evaluation adjustment management fee is a predetermined condition, that is, "a patient other than a hospitalized patient who has been prescribed 6 or more kinds of internal medicines (excluding those specified in particular)". When the complicated conditions such as "If the content of the prescription is comprehensively evaluated and adjusted, and the prescribed score is calculated only once a month when the number of internal medicines prescribed to the patient decreases by two or more types" As long as it is subject to calculation. If this condition is not recognized by medical personnel, it is uncalculated even if the medical practice is actually performed, or it is considered that the insured person is originally required and the insurance medical institution can provide it. There was a risk that the medical practice that should have been provided could not be provided.

The fact that the insured medical institution is not aware of the medical services that the insured may need in this way leads to a decrease in the medical fees that the insured medical institution should originally obtain, and also provides the insured with the original medical services. There is a risk that we will not be able to provide medical services that we were able to do.

Furthermore, the inventors of the present application have discovered that even if one of the receipt data and the DPC data is scrutinized, it may not be possible to grasp the appropriate opportunity to provide medical treatment as stipulated in the medical treatment fee. did.

Therefore, the present invention provides a medical fee analysis device, a medical fee analysis method, and a medical fee analysis program that analyze medical fees so that an insurance medical institution can realize proper medical practice and proper medical fee billing. ..

The medical fee reimbursement analyzer according to one aspect of the present invention is an acquisition unit that acquires data derived from medical information for a predetermined period from a data set derived from medical information including both electronic receipt data and DPC data held by a medical institution. And, among the data derived from the medical treatment information for the predetermined period, the extraction unit that extracts the data derived from the medical treatment information related to the predetermined medical fee, and the plurality of insured persons corresponding to the extracted data derived from the medical treatment information for the predetermined period. The first calculation unit that calculates the number of times a predetermined medical fee can be calculated, and the second calculation unit that calculates the calculation ratio by dividing the number of times a predetermined medical fee is calculated by the number of times that can be calculated. And.

The "electronic receipt data" in the present invention refers to the medical treatment items received by each patient in one month and the medical treatment fees calculated based on the medical treatment fee score table for the main purpose of claiming medical treatment fees for insurance medical treatment. Refers to electronic data created for each patient, including information. For that purpose, electronic receipt data does not include information such as discharge outcomes.

The "DPC data" in the present invention is "a method for calculating the amount of medical treatment in a hospital ward designated by the Minister of Health, Labor and Welfare" for the main purpose of assessing the impact of the introduction of DPC and reviewing the DPC system in the future. This information is collected and managed by the Ministry of Health, Labor and Welfare based on Paragraph 5, Item 3. For that purpose, electronic receipt data includes information on inpatient and outpatient medical fees, while DPC data may not include outpatient information in some hospitals.

According to this aspect, by calculating the ratio of the number of times actually calculated to the number of times that can be calculated for a predetermined medical fee, it is clarified how much the calculation opportunity is missed, and the insurance medical institution The medical fee can be analyzed so that an appropriate medical fee claim can be realized.

In addition, even if the appropriate medical fee cannot be grasped from the electronic receipt data, only one of the data can be obtained based on both the DPC data and the electronic receipt data, which are created for completely different purposes. It becomes possible to provide a medical fee analysis device that analyzes medical fees that cannot be achieved by the medical service.

In the above aspect, the first calculation unit determines that the predetermined medical fee can be calculated when at least a part of the plurality of requirements for determining whether or not the predetermined medical fee can be calculated is satisfied. The number of times that can be calculated may be calculated.

According to this aspect, the number of times a predetermined medical fee can be calculated, assuming that the conditions for which it is difficult to confirm whether or not the medical fees are met are satisfied among the plurality of requirements for determining whether or not the medical fees can be calculated. The maximum value of can be calculated.

In the above aspect, the first calculation unit satisfies at least a part of a plurality of requirements for determining whether or not a predetermined medical fee can be calculated, and satisfies a requirement that the predetermined medical fee cannot be calculated. If not, it may be determined that the predetermined medical fee can be calculated, and the number of times that the calculation is possible may be calculated.

According to this aspect, it is difficult to confirm whether or not the predetermined medical fee meets the requirements for determining whether or not the medical fee can be calculated on the premise that the requirement is not satisfied. The maximum number of times a predetermined medical fee can be calculated can be calculated on the assumption that the above requirements are met.

In the above aspect, a display unit that displays the calculation ratio by one or a plurality of types of graphs may be further provided.

According to this aspect, the magnitude of the calculation ratio can be visually recognized, and the magnitude of the calculation ratio can be grasped more intuitively.

In the above aspect, the display unit may display the calculation ratio in a predetermined period by a pie chart.

In the above aspect, the display unit may divide the predetermined period into a plurality of subperiods and display the time change of the calculation ratio for each of the plurality of subperiods.

According to this aspect, the time change of the calculation rate can be visually recognized, and the time change of the calculation rate can be analyzed so that the insurance medical institution can realize an appropriate medical fee billing.

In the above aspect, the display unit may divide the predetermined period into a plurality of sub-periods and display the time change of the calculation ratio for each of the plurality of sub-periods by a stacked bar graph.

In the above aspect, the third calculation unit that calculates the standard statistical value for the predetermined medical fee based on the public information about the medical fee, and the statistical value for the predetermined medical fee based on the data derived from the extracted medical information. A fourth calculation unit for calculation and a display unit for displaying the reference statistical value and the statistical value in a comparable manner may be further provided.

According to this aspect, the standard statistical value for the predetermined medical fee calculated for other insurance medical institutions is compared with the statistical value for the predetermined medical fee calculated for the insurance medical institution to be analyzed, and the analysis target is used. Medical fees can be analyzed so that the insured medical institution can realize a proper medical fee claim.

In the above aspect, the third calculation unit may calculate the reference statistical value based on the data of the number of beds classified by the medical institution among the public information.

According to this aspect, the standard statistical value regarding the predetermined medical fee calculated for the same institution as the insurance medical institution whose bed number classification is the analysis target among other insurance medical institutions, and the insurance medical institution to be analyzed are calculated. It is possible to analyze the medical treatment fee so that the insurance medical institution to be analyzed can realize an appropriate medical treatment fee claim by comparing with the statistical value regarding the predetermined medical treatment fee.

In the above aspect, the first calculation unit is data extracted from a data set including electronic receipt data about a predetermined insured person, which is acquired based on information associating the predetermined electronic receipt data with the predetermined DPC data. And the number of times that can be calculated may be calculated based on the data extracted from the data set including the DPC data.

According to this aspect, since the information associating the predetermined electronic receipt data with the predetermined DPC data is used, in addition to the electronic receipt data for the predetermined insured person, the data based on the DPC data for the same insured person. Based on, it becomes possible to calculate the number of times that can be calculated.

The medical fee analysis method according to another aspect of the present invention is to acquire data derived from medical information for a predetermined period from a data set derived from medical information including both electronic receipt data and DPC data held by a medical institution. And, from the data derived from medical information for a predetermined period, data derived from medical information related to a predetermined medical fee is extracted, and a plurality of insured persons corresponding to the data derived from the extracted medical information are subjected to a predetermined period. This includes calculating the number of times a predetermined medical fee can be calculated and dividing the number of times a predetermined medical fee has been calculated by the number of times the predetermined medical fee can be calculated to calculate the calculation ratio.

The “medical institution” in the present invention refers to a facility that provides medical care, and specifically, a hospital, a clinic, a nursing care facility for the elderly, a pharmacy that performs dispensing, or other facility that provides medical care (home-based specialized facility, etc.). ) Is shown.

The "medical treatment fee" in the present invention indicates a "medical treatment fee", a "dental treatment fee" or a "dispensing fee", and preferably a "medical treatment fee" or a "dispensing fee".

According to this aspect, by calculating the ratio of the number of times actually calculated to the number of times that can be calculated for a predetermined medical fee, it is clarified how much the calculation opportunity is missed, and the insurance medical institution The medical fee can be analyzed so that an appropriate medical fee claim can be realized.

In addition, even if the appropriate medical fee cannot be grasped from the electronic receipt data, only one of the data can be obtained based on both the DPC data and the electronic receipt data, which are created for completely different purposes. It becomes possible to provide a medical fee analysis method for analyzing medical fees that cannot be achieved by the medical service.

In the medical treatment fee analysis program according to another aspect of the present invention, the calculation unit provided in the medical treatment fee analysis device is held by a medical institution from a data set derived from medical treatment information including both electronic receipt data and DPC data. An acquisition unit that acquires data derived from medical information for a predetermined period, an extraction unit that extracts data derived from medical information related to a predetermined medical fee among data derived from medical information for a predetermined period, and data derived from the extracted medical information. For the corresponding multiple insured persons, the first calculation unit that calculates the number of times that the prescribed medical fee can be calculated in a predetermined period, and the number of times that the prescribed medical fee is calculated are divided by the number that can be calculated. Then, it functions as a second calculation unit that calculates the calculation ratio.

According to this aspect, by calculating the ratio of the number of times actually calculated to the number of times that can be calculated for a predetermined medical fee, it is clarified how much the calculation opportunity is missed, and the insurance medical institution The medical fee can be analyzed so that an appropriate medical fee claim can be realized.

In addition, even if the appropriate medical fee cannot be grasped only from the electronic receipt data or the DPC data, one of them can be obtained based on both the DPC data and the electronic receipt data created for completely different purposes. It will be possible to provide a medical treatment method analysis program that analyzes medical treatment fees that cannot be achieved from data alone.

According to the present invention, there is provided a medical fee analysis device, a medical fee analysis method, and a medical fee analysis program that analyze medical fees so that an insurance medical institution can realize proper medical practice and proper medical fee billing. be able to.

It is a figure which shows the network structure of the medical treatment fee analysis system which concerns on embodiment of this invention. It is a figure which shows the functional block of the medical treatment fee analyzer which concerns on this embodiment. It is a figure which shows the physical structure of the medical treatment fee analyzer which concerns on this embodiment. It is a figure which shows an example of the data to be analyzed of the medical fee reimbursement analyzer which concerns on this embodiment. It is a figure which shows the circle graph of the calculation ratio calculated by the medical treatment fee analyzer which concerns on this embodiment. It is a figure which shows the number of times actually calculated and the number of times not calculated among the number of times that the medical fee can be calculated by the medical fee analyzer which concerns on this embodiment. It is a figure which shows the stacking bar graph of the calculation ratio calculated by the medical fee reimbursement analyzer which concerns on this embodiment. It is a flowchart of the calculation ratio calculation process executed by the medical treatment fee analyzer which concerns on this embodiment. It is a flowchart of the calculateable number of times calculation processing executed by the medical fee reimbursement analysis apparatus which concerns on this embodiment. It is a figure which shows the standard statistical value calculated by the medical treatment fee analyzer which concerns on this embodiment, and the statistical value calculated about the insurance medical institution which is the analysis target. It is a flowchart of the statistical value calculation process executed by the medical treatment fee analyzer which concerns on this embodiment. It is a figure which shows the network composition of the medical fee analysis system which concerns on 2nd Embodiment. It is a flowchart of the calculation ratio calculation process executed by the medical fee reimbursement analyzer which concerns on 2nd Embodiment.

Embodiments of the present invention will be described with reference to the accompanying drawings. In each figure, those having the same reference numerals have the same or similar configurations.

[First Embodiment]
FIG. 1 is a diagram showing a network configuration of the medical treatment fee analysis system 100 according to the embodiment of the present invention. The medical fee analysis system 100 includes a medical fee analysis device 10, a medical institution terminal 20, a medical fee open data DB1, and an electronic receipt database DB2. The medical fee analyzer 10, the medical institution terminal 20, and the medical fee open data DB 1 are communicably connected to each other via a communication network N such as the Internet. The electronic receipt database DB2 is communicably connected to the medical institution terminal 20 via an intranet or the like.

The medical treatment fee analyzer 10 acquires an electronic receipt or DPC recorded at a predetermined insurance medical institution from the medical institution terminal 20, and analyzes the medical treatment fee so that the insurance medical institution can realize an appropriate medical fee claim. To do. The medical fee reimbursement analyzer 10 may be composed of a general-purpose computer.

The medical institution terminal 20 is a terminal provided in the medical institution to be analyzed by the medical fee reimbursement analyzer 10, and may be composed of a general-purpose computer. The electronic receipt database DB2 is a database related to electronic receipts recorded at a predetermined insurance medical institution, and is connected to the medical institution terminal 20. In the present embodiment, the case where the electronic receipt is analyzed by the medical fee reimbursement analyzer 10 will be described, but the medical fee reimbursement analyzer 10 may analyze the DPC.

The medical fee open data DB1 is a database of public information regarding medical fees. The medical fee open data DB1 may be, for example, statistics by social medical treatment practice.

FIG. 2 is a diagram showing a functional block of the medical fee reimbursement analyzer 10 according to the present embodiment. The medical fee analysis device 10 includes an acquisition unit 11, an extraction unit 12, a first calculation unit 13, a second calculation unit 14, a third calculation unit 15, a fourth calculation unit 16, and a display unit 10f.

The acquisition unit 11 acquires data derived from medical information for a predetermined period from a data set derived from medical information held by a medical institution. Here, the data set derived from the medical information may include at least one of the electronic receipt data and the DPC data. The data set derived from medical information may include at least one of electronic receipt data and DPC data held by the medical institution to be analyzed. In the present embodiment, a case where the data set derived from the medical information is electronic receipt data will be described. A data set derived from medical information is a data set containing at least information representing a data recording date and a calculated medical fee.

The extraction unit 12 extracts data derived from medical information related to a predetermined medical fee from the data derived from medical information for a predetermined period. The extraction unit 12 may narrow down the data derived from medical information by a designated period and a designated medical fee item, and extract the data derived from medical information.

The first calculation unit 13 calculates the number of times that a predetermined medical fee can be calculated for a plurality of insured persons corresponding to the data derived from the extracted medical information in a predetermined period. Whether or not the medical fee can be calculated is determined based on the medical fee calculation requirements announced by the Ministry of Health, Labor and Welfare.

The first calculation unit 13 determines that the predetermined medical fee can be calculated and can calculate it when at least a part of the plurality of requirements for determining whether or not the predetermined medical fee can be calculated is satisfied. The number of times may be calculated. The medical fee calculation requirements may include requirements for which it is difficult to determine whether or not the medical fees are met only from data derived from medical information. Even in such a case, according to the first calculation unit 13, it is assumed that the requirements that are difficult to confirm whether or not they are satisfied are satisfied among the plurality of requirements for determining whether or not the calculation is possible. Then, the maximum value of the number of times that a predetermined medical fee can be calculated can be calculated.

The first calculation unit 13 satisfies at least a part of a plurality of requirements for determining whether or not a predetermined medical fee can be calculated, and the predetermined medical fee does not satisfy the uncalcifiable requirement. , It may be determined that the predetermined medical fee can be calculated, and the number of times that the calculation is possible may be calculated. The medical fee calculation requirements may include requirements that must not be met. Even in such a case, according to the first calculation unit 13, a plurality of determinations for determining whether or not the medical treatment fee can be calculated on the premise that the predetermined medical fee does not meet the requirement that the calculation is impossible. It is possible to calculate the maximum value of the number of times that a predetermined medical fee can be calculated, assuming that the requirements that are difficult to confirm whether or not they are satisfied are satisfied.

The second calculation unit 14 calculates the calculation ratio by dividing the number of times a predetermined medical fee has been calculated by the number of times that can be calculated. When the number of times that the predetermined medical fee can be calculated, which is calculated by the first calculation unit 13, is represented by N and the number of times when the predetermined medical fee is calculated is represented by n, the second calculation unit 14 expresses R = n. The calculation ratio R is calculated by / N.

According to the medical fee reimbursement analyzer 10 according to the present embodiment, it is possible to determine how much calculation opportunity is missed by calculating the ratio of the actually calculated number of times to the calculable number of times for the predetermined medical fee. Clearly, medical fees can be analyzed so that insurance medical institutions can realize proper medical fee claims.

The third calculation unit 15 calculates a standard statistical value regarding a predetermined medical fee based on public information regarding the medical fee. The third calculation unit 15 may calculate a reference statistical value regarding the number of times a predetermined medical fee is calculated based on the medical fee open data DB1.

The fourth calculation unit 16 calculates a statistical value regarding a predetermined medical treatment fee based on the data derived from the medical treatment information extracted by the extraction unit 12. The fourth calculation unit 16 may calculate a statistical value regarding the number of times a predetermined medical fee is calculated recorded at the medical institution to be analyzed.

The display unit 10f displays the reference statistical value and the statistical value in a comparable manner. As a result, the standard statistical values for the prescribed medical fees calculated for other insurance medical institutions are compared with the statistical values for the prescribed medical fees calculated for the insurance medical institutions to be analyzed, and the insurance medical treatment targeted for analysis is compared. The medical fees can be analyzed so that the institution can realize a proper medical fee claim. The display unit 10f may display a graph of the calculation ratio, or may display the calculation ratio together with the reference statistical value and the statistical value, as will be described in detail later.

In addition, the third calculation unit 15 may calculate the reference statistical value based on the data of the number of beds classified by the medical institution in the public information. As a result, the standard statistical values for the prescribed medical fees calculated for the same insurance medical institution whose bed number classification is the analysis target among other insurance medical institutions, and the prescribed medical treatment calculated for the insurance medical institution to be analyzed. The medical fees can be analyzed so that the insurance medical institution to be analyzed can realize an appropriate medical fee claim by comparing with the statistical values related to the fees.

FIG. 3 is a diagram showing a physical configuration of the medical fee reimbursement analyzer 10 according to the present embodiment. The medical fee analyzer 10 communicates with a CPU (Central Processing Unit) 10a corresponding to a calculation unit, a RAM (Random Access Memory) 10b corresponding to a storage unit, and a ROM (Read only Memory) 10c corresponding to a storage unit. It has a unit 10d, an input unit 10e, and a display unit 10f. Each of these configurations is connected to each other via a bus so that data can be transmitted and received. In this example, the case where the medical treatment fee analysis device 10 is composed of one computer will be described, but the medical treatment fee analysis device 10 may be realized by combining a plurality of computers. Further, the configuration shown in FIG. 3 is an example, and the medical fee reimbursement analyzer 10 may have configurations other than these, or may not have a part of these configurations.

The CPU 10a is a control unit that controls execution of a program stored in the RAM 10b or ROM 10c, calculates data, and processes data. The CPU 10a is a calculation unit that executes a program (medical fee analysis program) for calculating a predetermined medical fee calculation ratio based on a data set derived from medical information related to the insurance medical institution to be analyzed. The CPU 10a receives various data from the input unit 10e and the communication unit 10d, displays the calculation result of the data on the display unit 10f, and stores the data in the RAM 10b.

The RAM 10b is a storage unit capable of rewriting data, and may be composed of, for example, a semiconductor storage element. The RAM 10b may store a program executed by the CPU 10a, data derived from medical information related to an insurance medical institution to be analyzed, and the like. It should be noted that these are examples, and data other than these may be stored in the RAM 10b, or a part of these may not be stored.

The ROM 10c is a storage unit capable of reading data, and may be composed of, for example, a semiconductor storage element. The ROM 10c may store, for example, a medical fee analysis program or data that is not rewritten.

The communication unit 10d is an interface for connecting the medical fee reimbursement analyzer 10 to another device. The communication unit 10d may be connected to a communication network N such as the Internet.

The input unit 10e receives data input from the user, and may include, for example, a keyboard and a touch panel.

The display unit 10f visually displays the calculation result by the CPU 10a, and may be configured by, for example, an LCD (Liquid Crystal Display). The display unit 10f may display a graph showing the calculation ratio or a graph showing the statistical value.

The medical fee analysis program may be stored in a storage medium readable by a computer such as RAM 10b or ROM 10c and provided, or may be provided via a communication network connected by the communication unit 10d. In the medical treatment fee analysis device 10, the CPU 10a executes the medical treatment fee analysis program to realize various operations described with reference to FIG. It should be noted that these physical configurations are examples and do not necessarily have to be independent configurations. For example, the medical fee reimbursement analyzer 10 may include an LSI (Large-Scale Integration) in which the CPU 10a and the RAM 10b or ROM 10c are integrated.

FIG. 4 is a diagram showing an example of data to be analyzed by the medical fee reimbursement analyzer 10 according to the present embodiment. In this example, the number of cases for which the "epilepsy guidance fee" has been calculated and the number of cases for which the "epilepsy guidance fee" has not been calculated are shown for the patients who visited the insurance medical institution to be analyzed and were diagnosed with epilepsy.

In the data of this example, the number of outpatients diagnosed with epilepsy is "32,355 (3,416)", of which the number of outpatients for which the "epilepsy guidance fee" is calculated is "28,189". Cases (2,477 people) ". In the case of this example, the "epilepsy guidance fee" is the prescribed medical fee, and the number of outpatients for which the "epilepsy guidance fee" is to be calculated can be calculated by the first calculation unit 13. The number of times.

Of the number of outpatients for which the "epilepsy guidance fee" is calculated, the number of cases for which the "epilepsy guidance fee" was actually calculated was "9,551 (834 people)", and the number without calculation was "18, 638 cases (2,079 people) ". The second calculation unit 14 divides the number of times the "epilepsy guidance fee" is calculated (9,551 cases) by the number of times (28189 cases) that can be calculated, and calculates the calculation ratio as 33.9%.

FIG. 5 is a diagram showing a pie chart of the calculation ratio calculated by the medical fee reimbursement analyzer 10 according to the present embodiment. In the figure, the calculation ratio calculated based on the data of the “epilepsy guidance fee” shown in FIG. 4 is shown by a pie chart.

According to FIG. 5, the calculation ratio P1 of the “epilepsy guidance fee” is 33.9%, and the number of cases is 9,551. On the other hand, the ratio P2 for which the "epilepsy guidance fee" was not calculated was 66.1%, and the number of cases was 18,638.

The display unit 10f may display the calculation ratio regarding the predetermined medical fee by one or a plurality of types of graphs, and may display the calculation ratio in the predetermined period by a pie chart as in this example. By displaying the calculation ratio in a graph, the magnitude of the calculation ratio can be visually recognized, and the magnitude of the calculation ratio can be grasped more intuitively.

FIG. 6 is a diagram showing the number of times the medical fee is calculated by the medical fee analyzer 10 according to the present embodiment and the number of times the medical fee is not calculated. In the figure, the number of calculations calculated based on the data of the “epilepsy guidance fee” shown in FIG. 4 is shown by the stacked bar graph G1.

In FIG. 6, from April 2017 to September 2018, the number of times the “epilepsy guidance fee” was calculated and the number of times the “epilepsy guidance fee” was not calculated are shown by a stacked bar graph G1. In the stacked bar graph G1, the number of times the "epilepsy guidance fee" was calculated is shown at the bottom of the graph, and the number of times the "epilepsy guidance fee" was not calculated is shown at the top of the graph. For example, in April 2018, the number of times the "epilepsy guidance fee" was calculated was 29, and the number of times the "epilepsy guidance fee" was not calculated was 74 times.

FIG. 7 is a diagram showing a stacked bar graph G2 of the calculation ratio calculated by the medical fee reimbursement analyzer 10 according to the present embodiment. In the figure, the calculation ratio calculated based on the data of the “epilepsy guidance fee” shown in FIG. 4 is shown by the stacked bar graph G2.

In FIG. 7, from April 2017 to September 2018, the ratio of the “epilepsy guidance fee” calculated and the ratio of the “epilepsy guidance fee” not calculated are shown by the stacked bar graph G2. In the stacked bar graph G2, the ratio at which the "epilepsy guidance fee" was calculated is shown at the bottom of the graph, and the ratio at which the "epilepsy guidance fee" was not calculated is shown at the top of the graph. For example, in April 2018, the percentage of "epilepsy guidance fees" calculated was 28.2%, and the number of times the "epilepsy guidance fees" were not calculated was 71.8%.

In this way, the display unit 10f may divide the predetermined period into a plurality of subperiods and display the time change of the calculation ratio for each of the plurality of subperiods. In the case of this example, the predetermined period is from April 2017 to September 2018, and the partial period is one month. However, how to select a predetermined period or a partial period is arbitrary. The display unit 10f may divide the predetermined period into a plurality of subperiods, and display the time change of the calculation ratio for each of the plurality of subperiods by a stacked bar graph. By displaying the time change of the calculation rate in a graph in this way, the time change of the calculation rate can be visually recognized, and the calculation rate can be calculated so that the insurance medical institution can realize an appropriate medical fee billing. It is possible to analyze changes over time.

FIG. 8 is a flowchart of the calculation ratio calculation process executed by the medical fee reimbursement analyzer 10 according to the present embodiment. First, the medical fee reimbursement analyzer 10 acquires an electronic receipt for a predetermined period from the electronic receipt database DB2 of the medical institution (S10). The medical fee reimbursement analyzer 10 may acquire DPC data of a medical institution, and the same applies hereinafter.

The medical fee reimbursement analyzer 10 extracts an electronic receipt related to a predetermined medical fee (S11), and determines the number of times that a predetermined medical fee can be calculated for a plurality of insured persons corresponding to the extracted electronic receipt in a predetermined period. Calculate (S12). The process of calculating the number of times a predetermined medical fee can be calculated in a predetermined period will be described in detail with reference to the following figure.

After that, the medical fee reimbursement analyzer 10 calculates the calculation ratio by dividing the number of times the predetermined medical fee has been calculated by the number of times that can be calculated (S13). Then, the medical fee reimbursement analyzer 10 displays the calculation ratio by one or a plurality of types of graphs (S14).

FIG. 9 is a flowchart of the calculateable number of times calculation process executed by the medical fee reimbursement analyzer 10 according to the present embodiment. In the figure, the details of the process S12 of FIG. 8 are shown, and an example of calculating the number of times that the “epilepsy guidance fee” can be calculated is shown. The calculation requirements for the "epilepsy guidance fee" are the following four. (1) At an insurance medical institution advocating pediatrics, neurology, neurology, psychiatry, neurosurgery or psychotherapy, we provide necessary guidance for medical treatment to epilepsy patients or their families other than inpatients based on the treatment plan. In that case, it can be calculated only once a month. (2) The first epilepsy guidance fee can be calculated after one month has passed from the day of the first medical examination when the initial medical examination fee was calculated or the day of discharge from the insurance medical institution. (3) It cannot be calculated for patients who have calculated the specific disease medical treatment management fee, pediatric medical treatment guidance fee, and pediatric malignant tumor patient guidance management fee. (4) It cannot be calculated for patients who receive guidance management related to each category of home care guidance management fee.

The medical fee reimbursement analyzer 10 determines whether or not one month has passed from the day of the first medical examination or the day of discharge (S121). If one month has passed from the day of the first medical examination or the day of discharge (S121: YES), the medical fee analyzer 10 calculates the specific disease medical treatment management fee, the pediatric medical treatment guidance fee, or the pediatric malignant tumor patient guidance management fee. Is determined (S122). The requirement of calculating the specific disease medical treatment management fee, the pediatric medical treatment guidance fee, or the pediatric malignant tumor patient guidance management fee corresponds to the requirement that the prescribed medical treatment fee cannot be calculated.

When the specific disease medical treatment management fee, the pediatric medical treatment guidance fee, or the pediatric malignant tumor patient guidance management fee is not calculated (S122: NO), the medical fee analyzer 10 performs guidance management related to each category of the home medical treatment guidance management fee. It is determined whether or not it has been received (S123). The requirement of receiving guidance management for each category of home medical treatment guidance management fee corresponds to the requirement that the prescribed medical treatment fee cannot be calculated.

When not receiving guidance management related to each category of home medical treatment guidance management fee (S123: NO), the medical treatment fee analyzer 10 calculates the number of times a predetermined medical treatment fee (in this example, epilepsy guidance fee) can be calculated. Add (S124). Then, when the medical fee reimbursement analyzer 10 has not determined all medical treatment opportunities (S125: NO), the processes S121 to S124 are executed again. On the other hand, when all the medical treatment opportunities are determined (S125: YES), the calculation process of the number of times that the predetermined medical treatment fee can be calculated is completed.

FIG. 10 is a diagram showing a reference statistical value calculated by the medical fee reimbursement analyzer 10 according to the present embodiment and a statistical value calculated for an insurance medical institution to be analyzed. The figure shows a bar graph G3 showing standard statistical values calculated based on data on medical institutions having 100 to 199 beds and statistical values on medical institutions to be analyzed among the public information. The bar graph G3 is displayed on the display unit 10f of the medical fee reimbursement analyzer 10. Of the public information, the number of beds of the medical institution used for analysis may be selected so as to be about the same as the number of beds of the medical institution to be analyzed.

The standard statistical value shown in this example is a value obtained by dividing the total number of calculations for each medical treatment item by the number of initial / return visits. Similarly, the statistical value for the medical institution to be analyzed is the value obtained by dividing the total number of calculations for each medical treatment item by the number of initial / return visits. In the bar graph G3, the standard statistical value calculated based on the public information is shown at the upper part of each medical treatment item, and the statistical value regarding the medical institution to be analyzed is shown at the lower part.

For example, according to the data D1 regarding the “drug information provision fee”, the standard statistical value calculated based on the public information is 10.20, and the statistical value regarding the medical institution to be analyzed is 1.76. That is, it can be read that the medical institution to be analyzed can only charge about 17% of the "drug information provision fee" compared to other medical institutions. In this way, the standard statistical value for the predetermined medical fee calculated for other insurance medical institutions is compared with the statistical value for the predetermined medical fee calculated for the insurance medical institution to be analyzed, and the analysis target is used. The medical fees can be analyzed so that the insurance medical institution can realize a proper medical fee claim.

FIG. 11 is a flowchart of the statistical value calculation process executed by the medical fee reimbursement analyzer 10 according to the present embodiment. First, the medical fee reimbursement analyzer 10 extracts data of the number of beds to which the medical institution belongs from the medical fee open data (medical fee open data DB1) (S20).

The medical treatment fee analyzer 10 calculates a reference statistical value regarding a predetermined medical treatment fee based on the extracted data (S21). Then, the medical treatment fee analyzer 10 calculates a statistical value regarding a predetermined medical treatment fee based on the extracted electronic receipt (S22).

Finally, the medical fee reimbursement analyzer 10 displays the reference statistical value and the statistical value in a comparable manner (S23).

[Second Embodiment]
Hereinafter, a second embodiment of the present invention will be described. Elements having the same or similar functions or configurations are designated by the same or similar reference numerals, overlapping parts will be omitted or simplified, and different parts will be mainly described.

FIG. 12 is a diagram showing a network configuration of the medical treatment fee analysis system 100A according to the second embodiment of the present invention. The medical fee analysis system 100A includes a medical fee analyzer 10A, a medical institution terminal 20A, a medical fee open data DB1, an electronic receipt database DB2, a DPC database DB3, and an integrated database DB4. The electronic receipt database DB2, the DPC database DB3, and the integrated database DB4 are communicably connected to each other by the medical institution terminal 20 and an intranet or the like.

The medical fee reimbursement analyzer 10A acquires electronic receipt data, DPC data, and integrated data recorded at a predetermined insurance medical institution from the medical institution terminal 20A so that the insurance medical institution can realize an appropriate medical fee claim. Analyze medical fees.

The electronic medical record data stored in the electronic medical record database DB2 is configured according to a predetermined format, and as the common medical record information, for example, 2 bytes of "record identification information", 6 bytes or less of "receipt number" information, and 4 bytes. Includes "receipt type" information, 5-byte "medical treatment date" information, 40-byte or less "name" information, and 20-byte or less "medical record number, etc." information. Here, the medical record number, the patient ID number, etc. are recorded in the "medical record number, etc.", and the recording is arbitrary.

The DPC data stored in the DPC database DB3 is configured according to a format different from the electronic receipt data, and contains information different from the electronic receipt data. However, the DPC data may include the same information as the electronic receipt data. Specifically, the DPC data includes patient-specific anonymization information and facility information. Patient-specific anonymization information includes medical record information, certain case questionnaires other than medical insurance medical treatment, daily anonymization information from medical records, and medical fee billing information. The medical record information is information related to data attributes, such as a data identification number, hospitalization / discharge information such as hospitalization date, discharge date, schedule / emergency medical information, etc., and diagnostic information such as main injury / illness name and hospitalization trigger. The surgical information such as the name of the injury or illness includes the surgical name, the date of the operation, the type of anesthesia, etc., and the medical information includes information such as the height, weight, and smoking index of the patient. The patient-specific anonymization information does not include information that can identify a specific individual, such as a name, a symbol and a number of an insured person's card, and the like.

As described above, the electronic receipt data and the DPC data are two types of data sets derived from medical information created by the same medical institution for different purposes for the same patient. In addition, both data have different data formats and capacities. Furthermore, both data include only information contained in both (for example, information on injury / illness name), information contained only in electronic receipt data (for example, medical information based on volume method, information on patient's name, etc.), and DPC data. There is information that includes (eg, information about the date of discharge, outcome at discharge, etc.).

The integrated database DB4 acquires information relating the electronic receipt data and the DPC data regarding the same patient. For example, the integrated database DB4 records table information for associating information on the "medical record number, etc." of the electronic receipt data with the "data identification number" information of the DPC data for the same patient.

When creating the DPC data, the "data identification number" information of the DPC data may be configured to be created based on the information included in the electronic receipt data. That is, the electronic receipt data includes the first identification information, the DPC data includes the second identification information, and the second identification information constitutes each data so as to be generated based on the first identification information. You may. As described above, when the DPC data to be anonymized, which has a completely different purpose from the electronic receipt data, is generated, the second identification information is generated based on the first identification information, thereby relating to the same patient. It is possible to reliably acquire the electronic receipt data and the DPC data.

The functional blocks of the medical fee reimbursement analyzer 10A are the acquisition unit, the extraction unit, the first calculation unit, the second calculation unit, the third calculation unit, the fourth calculation unit, and the display unit, similarly to the functional blocks of the medical treatment fee analysis device 10. To be equipped. In the following, parts that exhibit different functions will be described, and parts that exhibit similar functions will be omitted or simplified.

The acquisition unit acquires DPC data from the DPC database DB3 and electronic receipt data from the electronic receipt database DB2, respectively. In addition, the table information that associates the DPC data with the electronic receipt data is acquired from the integrated database DB4. However, when the second identification information included in the DPC data is generated based on the first identification information included in the electronic receipt data based on a predetermined logic, the acquisition unit uses such logic. As a result, it is not necessary to acquire the information relating both data.

The extraction unit extracts electronic receipt data and DPC data related to a predetermined medical fee from the data derived from the medical information for a predetermined period. Since the electronic receipt data and the DPC data include information on the name of injury or illness as common information, it is possible to extract information on the same medical fee (for example, information on a predetermined medical fee item).

The first calculation unit calculates the number of times that a predetermined medical fee can be calculated for a plurality of insured persons corresponding to the extracted electronic receipt data and DPC data in a predetermined period.

Specifically, the first calculation unit sets the first identification information and the first identification information about the same patient based on the information or logic that associates the electronic receipt data and the DPC data about the same patient stored in the integrated database DB4. 2 It becomes possible to acquire identification information. Therefore, the first calculation unit can specify the electronic receipt data and the DPC data regarding the same patient and the same medical fee, and can acquire the information necessary for the medical fee calculation requirement from the electronic receipt data and the DPC data. become.

Here, the inventors of the present application have noted that the electronic receipt data may not include the information necessary for the medical fee calculation requirements.

For example, the above-mentioned calculation requirements for the "epilepsy guidance fee" include "(2) Is the first epilepsy guidance fee 1 from the day of the first medical examination when the initial medical examination fee was calculated or the day of discharge from the insurance medical institution? It includes "after the day when the month has passed". However, the information indicating "the date of discharge from the insurance medical institution" is not included in the electronic receipt data. For this reason, the above calculation requirements cannot be correctly determined from the electronic receipt data, which may lead to an erroneous determination that the "epilepsy guidance fee" should be calculated even though it should not be calculated. .. Similarly, depending on the calculation requirements, it may lead to a misjudgment that the calculation should not be performed even though it should be calculated.

Therefore, as a result of trial and error, the inventors of the present application have noticed that the DPC data often contains information that is not included in the electronic receipt data.

For example, in the determination of the calculation requirement (2) of the "epilepsy guidance fee", the first calculation department acquires information on the "first medical examination date" (medical treatment start date) from the data included in the electronic receipt data and "discharges the hospital". Information on "day" is acquired from the data included in the DPC data, and the satisfaction of the calculation requirement (2) is determined. Therefore, the first calculation unit can accurately calculate the number of times that a predetermined medical fee can be calculated.

When the first calculation unit includes information common to the DPC data and the electronic receipt data (for example, information regarding the date of medical practice), the first calculation unit may collate the information acquired from both. With this configuration, it is possible to reduce the possibility of confusing information on different medical fees.

Similar to the first calculation unit 13, the first calculation unit can calculate the predetermined medical treatment fee when at least a part of the plurality of requirements for determining whether or not the predetermined medical treatment fee can be calculated is satisfied. The number of times that can be calculated may be calculated. With this configuration, the maximum value of the number of times a predetermined medical fee can be calculated can be calculated. Further, the first calculation unit determines that the predetermined medical fee can be calculated when all of the plurality of requirements for determining whether or not the predetermined medical fee can be calculated are satisfied, and the calculation is always performed. The possible number of times may be calculated. In this way, by calculating the maximum number of times that can be calculated and the number of times that can be calculated without fail and displaying them on the display unit, it is possible to analyze medical fees with high accuracy.

The second calculation unit, the third calculation unit, the fourth calculation unit, and the display unit exhibit the same functions as the second calculation unit 14, the third calculation unit 15, the fourth calculation unit 16, and the display unit 10f, respectively. , The description is omitted.

Further, since the physical configuration of the medical fee reimbursement analyzer 10A is the same as the physical configuration of the medical fee reimbursement analyzer 10, the description thereof will be omitted.

Further, a computer program (medical fee analysis program) for calculating the calculation ratio of a predetermined medical fee for executing the above-mentioned arithmetic processing is stored in an information recording medium such as a semiconductor memory and executed by a processor such as a CPU. Will be done.

FIG. 13 is a flowchart of the calculation ratio calculation process executed by the medical fee reimbursement analyzer 10A according to the present embodiment. First, the medical fee reimbursement analyzer 10A acquires an electronic receipt for a predetermined period from the electronic receipt database DB2 of the medical institution (step S20), and acquires DPC data from the DPC database DB3 (step S21).

The medical treatment fee analyzer 10A extracts electronic receipt data related to a predetermined medical treatment fee (step S22), and extracts electronic receipt data related to the same medical treatment fee (step S23).

Next, the information for associating the predetermined electronic receipt data with the predetermined DPC data is acquired from the integrated database DB4 (step S24).

The medical fee reimbursement analyzer 10A identifies electronic receipt data and DPC data for the same insured person based on this information (step S25). The medical fee reimbursement analyzer 10A identifies the electronic receipt data and the DPC data related to the same insured person based on the logic for associating the predetermined electronic receipt data with the predetermined DPC data without executing step S24. , The data necessary for calculating the number of times that can be calculated may be acquired. In that case, by including the first identification information in the electronic receipt data and including the second identification information generated based on the first identification information in the DPC data, information on the same medical fee for the same patient can be obtained. It becomes possible to do.

Since steps S26 to S28 are the same as steps S12 to S14, the description thereof will be omitted. However, the display unit directly or indirectly determines the maximum number of times that a predetermined medical fee such as "epilepsy guidance fee" can be calculated, the number of times that can be reliably calculated, and the number of times that is not calculated. Information to be indicated (including information indicating a ratio regarding the maximum number of times) may be displayed.

As described above, according to the medical treatment fee analyzer 10A and the medical treatment fee analysis method executed by the medical treatment fee analysis device 10A, it is possible to analyze the medical treatment fee that cannot be achieved only from one of the data.

The embodiments described above are for facilitating the understanding of the present invention, and are not for limiting and interpreting the present invention. Each element included in the embodiment and its arrangement, material, condition, shape, size, etc. are not limited to those exemplified, and can be changed as appropriate. In addition, the configurations shown in different embodiments can be partially replaced or combined. For example, the display unit 10f of the medical fee reimbursement analyzer 10 may be configured to display the same information as the display unit of the medical fee reimbursement analyzer 10A.

10, 10A ... Medical fee analyzer, 10a ... CPU, 10b ... RAM, 10c ... ROM, 10d ... Communication unit, 10e ... Input unit, 10f ... Display unit, 11 ... Acquisition unit, 12 ... Extraction unit, 13 ... First Calculation unit, 14 ... 2nd calculation unit, 15 ... 3rd calculation unit, 16 ... 4th calculation unit, 20 ... Medical institution terminal, 100, 100A ... Medical fee analysis system, DB1 ... Medical fee open data, DB2 ... Electronic receipt Database, DB3 ... DPC database, DB4 ... Integrated database

Claims (13)

An acquisition department that acquires data derived from medical information for a predetermined period from a data set derived from medical information including both electronic receipt data and DPC data held by a medical institution.
An extraction unit that extracts data derived from medical information related to a predetermined medical fee from the data derived from medical information for a predetermined period, and an extraction unit.
For a plurality of insured persons corresponding to the extracted data derived from the medical treatment information, a first calculation unit for calculating the number of times that the predetermined medical treatment fee can be calculated in the predetermined period, and
The second calculation unit that calculates the calculation ratio by dividing the number of times the predetermined medical fee is calculated by the number of times that the calculation is possible, and
Medical fee analyzer equipped with. The first calculation unit determines that the predetermined medical fee can be calculated when at least a part of the plurality of requirements for determining whether or not the predetermined medical fee can be calculated is satisfied. Calculate the number of times that can be calculated,
The medical fee reimbursement analyzer according to claim 1. The first calculation unit satisfies at least a part of a plurality of requirements for determining whether or not the predetermined medical fee can be calculated, and does not satisfy the requirement that the predetermined medical fee cannot be calculated. In this case, it is determined that the predetermined medical fee can be calculated, and the number of times the calculation is possible is calculated.
The medical fee reimbursement analyzer according to claim 2. A display unit for displaying the calculation ratio by one or a plurality of types of graphs is further provided.
The medical fee reimbursement analyzer according to any one of claims 1 to 3. The display unit displays the calculation ratio in the predetermined period by a pie chart.
The medical fee reimbursement analyzer according to claim 4. The display unit divides the predetermined period into a plurality of subperiods, and displays the time change of the calculation ratio for each of the plurality of subperiods.
The medical fee reimbursement analyzer according to claim 4 or 5. The display unit divides the predetermined period into a plurality of subperiods, and displays the time change of the calculation ratio for each of the plurality of subperiods by a stacked bar graph.
The medical fee reimbursement analyzer according to claim 6. The third calculation unit that calculates the standard statistical value for the predetermined medical treatment fee based on the public information about the medical treatment fee, and
A fourth calculation unit that calculates statistical values related to the predetermined medical treatment fee based on the extracted data derived from the medical treatment information.
A display unit for displaying the reference statistical value and the statistical value in a comparable manner is further provided.
The medical fee reimbursement analyzer according to any one of claims 1 to 7. The third calculation unit calculates the reference statistical value based on the data of the number of beds classified by the medical institution in the public information.
The medical fee reimbursement analyzer according to claim 8. The first calculation unit is extracted from a data set including the electronic receipt data for the predetermined insured person, which is acquired based on the information associating the predetermined electronic receipt data with the predetermined DPC data. It is configured to calculate the number of times the calculation is possible based on the data and the data extracted from the data set including the DPC data.
The medical fee reimbursement analyzer according to claim 1. The electronic receipt data includes the first identification information.
The DPC data includes a second identification information generated based on the first identification information.
The first calculation unit extracts from the data extracted from the electronic receipt data and the DPC data including the second identification information generated based on the predetermined first identification information included in the electronic receipt data. It is configured to calculate the number of times the calculation is possible based on the obtained data.
The medical fee reimbursement analyzer according to claim 1. To acquire data derived from medical information for a predetermined period from a data set derived from medical information including both electronic receipt data and DPC data held by a medical institution.
Extracting the data derived from the medical information related to the predetermined medical fee from the data derived from the medical information for the predetermined period, and
For a plurality of insured persons corresponding to the extracted data derived from the medical treatment information, the number of times that the predetermined medical treatment fee can be calculated in the predetermined period is calculated.
By dividing the number of times the prescribed medical fee has been calculated by the number of times the calculation is possible, the calculation ratio can be calculated.
Medical fee analysis method including. The calculation unit provided in the medical fee analyzer
An acquisition department that acquires data derived from medical information for a predetermined period from a data set derived from medical information including both electronic receipt data and DPC data held by a medical institution.
An extraction unit that extracts data derived from medical information related to a predetermined medical fee from the data derived from medical information for a predetermined period.
For a plurality of insured persons corresponding to the extracted data derived from the medical treatment information, the first calculation unit that calculates the number of times that the predetermined medical treatment fee can be calculated in the predetermined period, and the predetermined medical treatment fee are calculated. A medical fee analysis program that functions as a second calculation unit that calculates the calculation ratio by dividing the number of times that has been calculated by the number of times that can be calculated.

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