基于临床决策中台的医保智能审核平台构建与应用研究  

Research on the construction and application of a medical insurance intelligent audit platform based on a clinical decision center

作　　者：马欣妍 宋飞飞 郑林 张燕[1] 李强[1] MA Xinyan;SONG Feifei;ZHENG Lin;ZHANG Yan;LI Qiang(Tsinghua Changgung Hospital,School of Clinical Medicine,Tsinghua University,Beijing 102218,China)

机构地区：[1]清华大学附属北京清华长庚医院,清华大学临床医学院,北京102218

出　　处：《中国数字医学》2023年第9期74-78,共5页China Digital Medicine

基　　金：北京市属医院科研培育计划项目-数据驱动下基于临床路径的DRG费用管理系统研究(PG2022018)。

摘　　要：目的:全面实时监控医保相关诊疗行为,规避违规事件,提升医院医保管理水平。方法:以某三级综合医院医保业务流程为样本,结合中台知识,抽象出逻辑触发机制、应用结果反馈、策略维护、数据监测等交互模型,集成医保智能审核规则库、临床医学知识库、医药标准对照库,构建基于临床决策中台的医保智能审核体系,并通过平台上线前后的医保数据,分析平台的实施成效。结果:系统已在该医院55个临床科室应用,系统上线后,月医保拒付率平均下降87%,违规事件均可事中监控、事后追责,有效提升了医院医保基金监管的质量和效率。结论:该平台改善了医院医疗数据整合及运用效率不佳、监控平台智能化程度受限、临床应用一体化程度较低等影响医保审核平台应用效果的各类问题。本研究提出的方案达到了设计目标,能灵活且高效地应用于临床系统复杂多变的场景。Objective To comprehensively monitor medical insurance-related diagnosis and treatment behaviors in real time,circumvent violation events,and improve hospital medical insurance management.Methods We took the medical insurance business process of a tertiary general hospital as a sample,combined the knowledge of the middle platform,abstracted the interaction model of logical trigger mechanism,applied interaction models such as result feedback,strategy maintenance,data monitoring,etc.,integrated the medical insurance intelligent audit rule base,clinical medical knowledge base,and medicine standard control base,built a medical insurance intelligent audit system based on the clinical decision middle platform,and analyzed the implementation effectiveness of the platform through the medical insurance data before and after the platform was launched.Results The system has been applied in 55 clinical departments of the hospital.After the system went online,the monthly medical insurance rejection rate decreased by 87%on average,and all violations could be monitored in the middle of the event and pursued afterwards,which effectively improved the quality and efficiency of the hospital's medical insurance fund supervision.Conclusion The platform improved various problems that affect the effectiveness of the application of the medical insurance audit platform,such as poor efficiency in the integration and use of hospital medical data,limited intelligence of the monitoring platform,and low integration of clinical applications.The solution proposed in this study achieved the design goals and can be flexibly and efficiently applied to the complex and changing scenarios of clinical systems.

关 键 词：医保基金 智能审核 中台 临床决策支持 知识库集成 

分 类 号：R137[医药卫生—劳动卫生] R319[医药卫生—公共卫生与预防医学]