JP6053446B2 - Electronic Receipt Data Processing Method for Aggregation Analysis of Disease Status, Medical Expenses, etc. - Google Patents

Description

The present invention relates to a method for processing electronic receipt data for more effectively and effectively summing up and analyzing disease status, medical expenses, etc. using the receipt data that has been digitized by the Ministry of Health, Labor and Welfare since 2006 About.

The “receipt” is referred to as a “medical care (dispensing) remuneration statement”, and is a medical cost statement that a medical institution charges an insurer (such as a municipality or a health insurance association) for medical treatment received by a patient. The receipt includes the patient's name, insurer number, disease name, injections, treatment, surgery, examination, diagnosis, rehabilitation and prescription drugs given in the month of medical care. Create with.

Electronic receipt data created by a medical institution is sent to the Social Insurance Medical Fee Payment Fund or the National Health Insurance Association, and is organized by the payment fund or National Health Insurance Association before being insured (each health insurance association or municipality). To be sent to.

Of the insurers (each health insurance association and municipality), especially in the case of health insurance associations such as large corporations, the electronic receipt data sent from the payment fund can be used for various requests from companies participating in the association. The results are aggregated and analyzed, and the results are provided. However, we will not provide any content related to personal information.

The union-affiliated company requires the above-mentioned receipt data to be aggregated and analyzed as material for judging whether the health business (health promotion measures, disease prevention measures, etc.) implemented by each health insurance association is being implemented effectively. However, the reason for this is that the cost for implementing the above health service uses a part of the premium paid by the union member company and the insured, and the cost-effectiveness is the association that pays the premium. This is because it is a big problem for participating companies and insured persons.

On the other hand, in order to grasp the incidence of disease and the rate of patients, the total number of denominator populations, that is, the insured persons and dependents of each health insurance association, is required, but only electronic receipt data is used. Therefore, it is not possible to grasp the “rate” simply because the population is unknown.

Japanese Patent Publication No. 2002-366648 Japanese Patent Publication No. 2005-346690 Japanese Patent Publication No. 2004-318348

In order to ascertain the exact disease incidence and patient rate, information on insured persons and dependents obtained from health insurance associations, etc., for those who do not have receipt data, that is, those who are not in hospital There is a need to create a file as an unexamined person.

The present invention is an electronic receipt data processing method for collecting and analyzing illness status, medical expenses, etc. using electronic receipt data, based on the above-mentioned present situation, and all insured obtained from a specific health insurance association, etc. The information of the person and the dependent is compared with the electronic receipt data, and an unexamined person master is created for the insured person and the dependent who do not exist in the electronic reception data.

The present invention is an electronic receipt data processing method for collecting and analyzing illness status, medical expenses, etc. using electronic receipt data, based on the above-mentioned present situation, and all insured obtained from a specific health insurance association, etc. The information of the person and the dependent and the electronic receipt data are compared, and based on the electronic receipt data, the wound disease-specific decomposition master 1 decomposed for each disease, the wound disease-specific decomposition master 2 to which the wound disease code is assigned, the name processing. The wound disease and disease classification master 3 and the wound and disease classification master 4 to which the address information is assigned are created , and the undiagnosed patient master is created for the insured and dependent who are not present in the electronic receipt data. 1 to 4 and the unexamined person master are combined to create a wound disease-specific decomposition master .

By tallying and analyzing based on this accurate data, it can be a basic material for accurately determining whether or not various health services carried out by the health insurance association have really been effective.

Furthermore, because it is possible to plan, formulate, implement, and measure the effects of health services based on accurate medical cost tabulation / analysis results, ultimately the social loss (long-term (Such as loss of productivity due to absence from work or retirement) and the prevention of potential patients from developing seriously, it is possible to reduce and control overall medical expenses.

Flow for sending electronic receipt data Overview of injury and disease analysis system data Flow of creating a disability master by wound Flow for creating generic drug comparison master An example of actual receipt data (medicine) Example of actual receipt data (drug) Example of ICD10 injury code

Examples of the present invention will be described in detail below. As shown in FIG. 1, electronic receipt data created by various medical institutions is transmitted to a payment fund or the National Health Insurance Union through an Internet line or the like.

The payment fund and the National Health Insurance Association classify this electronic receipt data for each insurer and send it to each health insurance association and municipality.

Currently, depending on the medical institution, there is a person who sends a receipt to a payment institution not in the form of electronic data but in a paper medium. In that case, only necessary information is manually punched into the payment fund and converted into electronic data.

The electronic receipt data is composed of about 256 items, but there are about 60 items of data in which only necessary information is manually input by the payment fund. In this embodiment, electronic receipt data consisting of about 256 items is referred to as receipt code information, and data in which only necessary information is manually entered with a payment fund is referred to as unique text information. However, when referred to as electronic receipt data, Data that combines electronic code information and unique text information is also intended.

In this embodiment, the information processing company obtains the power code information, unique text information, insured information, dependent information, and other information necessary for analysis from each health insurance association, Assume a business model that provides analytical processing services.

As shown in FIG. 2, the information processing company performs various tabulations and analyzes using the electronic receipt data, so that the four masters of the medical / dispensing receipt connection master, the wound disease-specific decomposition master, the replacement injury disease master, and the generic drug comparison master. Create

Before creating each master, a wound name / patient name master, a medicine master, a medical practice master, a generic medicine master, a medical practice / medicine / wound related master, and weighting data for matching with the receipt data are created.

In the following, the process of creating the four masters of the medical / dispensing receipt connection master, the wound disease-specific decomposition master, the replacement wound disease master, and the generic drug comparison master will be described with reference to FIGS.

Information processing companies read and process the power code information, unique text information, insured person information, dependent information, establishment information, and other data required for analysis obtained from each health insurance association. .

1. Medical / Dispensing Concatenated Combined Calculation Processing First, a medical receipt and a medicine receipt prescribed at that time are consecutively calculated from the receipt power code information and the unique text information. Usually, the medical treatment, treatment and examination received by the doctor are separate from the drug reception, but in this process, they are linked and combined as data of a specific individual. This combined data is referred to as “medical / dispensing receipt connection master”.

For example, if the medical cost in October 2012 of Mr. Taro Patent of the Health Insurance Association of Patent Co., Ltd. is 100 points and the drug cost is 50 points, the data is created as 150 points after the connection.

2. Processing by the PDM method Next, using the PDM (Proportional Disease Magnet) method, the weighted data for the scores and days for each receipt is referred to, and the “degradation master for each disease and disease is decomposed for every injury and disease listed in the receipt. 1 ”is created. In addition, the PDM method is a classification method that proportionally distributes the scores and days of receipts devised by Mr. Junji Okamoto (National Institute of Health Sciences) by giving a certain “weight” to all the names of wounds and diseases described therein. .

At present, the general process for counting and analyzing receipts is to count and analyze only the names of the wounds and diseases listed at the top, even if multiple wounds are listed. I can't figure it out. In this embodiment, in order to collect and analyze all injuries and diseases listed in the receipt, the points are distributed using the PDM method.

For example, Taro Patent Taro of the above-mentioned Patent Co., Ltd. Health Insurance Association has a medical cost of 100 points in October 2012, 50 points of dispensing, a total of 150 points, including 70 points for diabetes treatment and 50 points for hypertension treatment by PDM decomposition. Create data for 30 gout treatments.

3. Injury and disease replacement process Next, from the medical practice and prescription drug data, it is judged whether the name of the injury and disease is correctly described correctly. create.

5 and 6 are examples of actual receipts. In the receipt shown in FIG. 5, the name of the wound is described as “suspected epidemic cold” by the doctor who performed the examination. In addition, in the receipt shown in FIG. 6, the prescribed medicine is Tamiflu (registered trademark of Roche), so it can be estimated that the correct name of the disease is “influenza”.

In this way, in this example, even if an injured disease name by a doctor is described, it can be replaced with an accurate disease name depending on the test item or prescribed medicine, and as a result, a correct analysis should be performed. Is possible. In the process of replacing the name of the disease with an appropriate name, the optimal name is automatically selected by the program, or an inappropriate display is given by the program. You may make it input.

4). Next, a process related to the code assigned to the name of the wound will be described with reference to FIG. In medical institutions in Japan, a wound name code (seven-digit wound code) determined in Japan is assigned, and a specific number is assigned to each wound name as shown in FIG. For example, even in the same influenza category, type A, type B, etc. are disjoint, and symptom and disease name cannot be grouped only by this code number.

In contrast, the ICD10 wound code, which is an international code, has the same main code in the same influenza category, so these can be grouped together and easily compared with international infectious disease names. It becomes. For this reason, in this embodiment, a process of assigning an IDC10 wound code to the wound name code (7-digit wound code) is performed. The data to which the IDC10 injury / illness code is assigned is referred to as “injury / disease-specific decomposition master 2”.

5. Nayoro process Next, from the insurance card qualification information, the Nayoro process is performed so that each receipt can be aggregated and analyzed as the same person.

In the totaling / analysis processing using the conventional receipt, when a certain individual goes to the hospital for 3 months, it is processed as 3 outpatients. That is, although the actual patient = sick person is one, the total result is processed so that it is determined that three patients have occurred.

For example, if the number of members of the Patent Co., Ltd. Health Insurance Association, which has 2500 members, was the only one who visited the hospital in 2011, Taro Patent was the only one to visit in May, June, and August. The patient incidence in 2011 was treated as 3/2500, but since it is actually only Taro Taro, it needs to be treated as 1/2500.

In the present embodiment, in order to prevent aggregation / analysis that does not match the actual situation, the true number of patients is known by the name processing. The data subjected to the name processing is referred to as “wound-and-disease-specific decomposition master 3”.

6). Granting of municipal code The patient's address information does not exist in the receipt created by each medical institution, but in this embodiment, the municipality is based on the information of the insured and dependents obtained from the health insurance association, etc. Is extracted and added to the receipt data. If the address of the insured person or dependent cannot be specified, the location data of the medical institution is given. The data to which the address information is assigned is referred to as “wound / sickness-specific decomposition master 4”.

The purpose of this additional processing is to make it possible to analyze, for example, where an infectious disease such as influenza first occurred and where it spread. As in the past, when only the receipt data was used, it was impossible to count and analyze by address, and it was impossible to know the location of the infectious disease and the expansion range in time series. According to this, these can also be aggregated and analyzed.

The above aggregation / analysis methods can be used for infectious disease prevention measures on a nationwide scale, beyond the scope of each health insurance association and individual company, if receipt data for health insurance associations nationwide can be obtained. It becomes possible.

In general, receipt data is collected and analyzed one to two months after the actual medical practice, so it is impossible to grasp the spread of infection in real time, but by accumulating past data, It can be used effectively as a basis for future predictions.

7). Unexamined person data creation process To understand the incidence of illnesses and the rate of patients, a denominator population is required, but the electronic receipt data alone does not know this population, so it understands the "rate". Can not do it.

In the present embodiment, a file as an unexamined person is created for those who do not have receipt data, that is, those who do not go to hospital, from information on the insured and dependents obtained from the health insurance association or the like.

The file of the unexamined person has exactly the same items as the receipt data, and is a file in which the disease name, examination name, and drug name are “empty”.

The total number of people who have this empty file and those who have electronic receipt data is the total number of insured persons and dependents who join the health insurance association. It is possible to grasp the “rate”.

If, in the future, an undiagnosed person goes to the hospital because he / she is ill, he / she replaces it with data describing information on medical treatments, treatments and examinations, and prescribed medicines by means of receipt data sent thereafter.

The undiagnosed person master composed of the undiagnosed person file and the wound disease and disease separation masters 1 to 4 are combined to create a final “wound and disease separation master”.

8). The creation of generic drug comparison masters and the price of drugs in medical expenses are also a major social problem. In recent years, generic drugs, so-called generic products, have been recommended.

In this embodiment, a generic drug comparison master consisting of a database of new drugs and generic products is created in advance, so that it is possible to analyze whether or not cheap generic products exist for drugs listed on the electronic receipt. .

The information processing company aggregates each master created as described above for each patient, disease, etc. according to the client's request, and creates form output, analysis result inquiry screen data, and the like.

For example, of course, the aggregation process of the most basic medical expenses by the three elements (number of cases per person, number of days per case, medical expenses per day) is, of course, when using the data of the present invention to calculate and analyze Aggregation / analysis based on accurate disease names that could not be achieved with systems and data, analysis of the occurrence and spread of infectious diseases based on address information, and the incidence and rate of illness on an individual basis. .

Claims (2)

An electronic receipt data processing method for collecting and analyzing disease status and medical expenses using electronic receipt data,
Based on the electronic receipt data, the wound disease-specific decomposition master 1 decomposed for each disease, the wound disease-specific decomposition master 2 to which the wound code is assigned, the wound-related disease-specific decomposition master 3 to which the name processing is performed, and the wound-related decomposition to which the address information is given. Create master 4 and
Compare all insured and dependent information obtained from specific health insurance associations with electronic receipt data,
Create an undiagnosed person master for insured persons and dependents who do not exist in the electronic receipt data ,
Combine the wound disease-specific decomposition masters 1 to 4 and the undiagnosed patient master to create a wound disease-specific decomposition master ,
An electronic receipt data processing method. The undiagnosed patient master, the injury and illness name, the test item, the drug name are all empty,
An electronic receipt data processing method.