Medical insurance, medical treatment and finance integrated collaborative management system

Abstract

The invention relates to the technical field of medical management, in particular to a medical insurance, medical treatment and finance integrated collaborative management system which comprises a data integration module, a DRG intelligent management module, a medical service management module and a finance and operation management module. The DRG intelligent management module is used for grouping the patients according to the illness state data of the patients in combination with a DRG grouping rule and generating unique codes; the DRG intelligent management module is also used for acquiring a doctor's advice issued by the doctor in real time, calculating treatment cost, hospital cost and income according to the doctor's advice issued by the doctor, and associating the treatment cost with the code of the patient; the DRG intelligent management module is also used for obtaining the treatment cost of the patient according to the code of the patient when the patient is discharged from the hospital, and calculating the medical insurance payment amount and the self-payment amount of the patient in combination with the medical insurance policy and the medical insurance settlement rule. The system is complete in logic, and can effectively improve the financial management capability of hospitals.

Description

Technical Field

[0001] The present invention relates to the technical field of medical management, and particularly to an integrated collaborative management system for medical insurance, medical treatment, and finance. Background Art

[0002] In the field of healthcare, the collaboration among medical insurance, medical treatment, and financial management has always been one of the core challenges in hospital operation. With the deepening of medical reform, especially the popularization of the DRG (Diagnosis Related Groups) payment method, the traditional management mode can no longer meet the needs of refined operation of modern hospitals.

[0003] In the existing medical systems, charges are made according to various medical orders issued by doctors. Although the income and expenditure can be accurately calculated, the per-item payment mode in the existing technology is prone to induce over-medical treatment. Hospitals may provide unnecessary medications, examinations, and treatments to increase income, which increases the burden on patients and the medical insurance fund.

[0004] In summary, how to solve the problem that the per-item payment mode in the existing technology is prone to induce over-medical treatment and increase the burden on patients and the medical insurance fund has become a difficult problem that urgently needs to be solved in the current field. Therefore, it is necessary to propose a more reasonable integrated collaborative management system for medical insurance, medical treatment, and finance. Summary of the Invention

[0005] To solve the above problems, the present invention provides an integrated collaborative management system for medical insurance, medical treatment, and finance. By optimizing and adjusting the per-item payment mode in the existing technology, patients are reasonably grouped according to the DRG grouping rules to generate a unique code, thereby optimizing the payment mode, improving the accuracy of hospital income and expenditure, reducing the risk of over-medical treatment, enhancing the management effect of the hospital, and reducing the burden on patients and the medical insurance fund.

[0006] To achieve the above object, the technical solution of the present invention is as follows: An integrated collaborative management system for medical insurance, medical treatment, and finance, comprising a data integration module, a DRG intelligent management module, a medical service management module, and a finance and operation management module.

[0007] The data integration module is used for data docking with the medical insurance system, the hospital information system, and the hospital finance system; obtaining the medical insurance policies, DRG grouping rules, and medical insurance settlement rules in the medical insurance system; obtaining the patient's condition data in the hospital information system; obtaining the hospital's income, expenditure, and costs in the hospital finance system; and transmitting the medical insurance policies, DRG grouping rules, medical insurance settlement rules, condition data, and the hospital's income, expenditure, and costs to the DRG intelligent management module.

[0008] The DRG intelligent management module is used to group patients according to the patient's condition data in combination with the DRG grouping rules and generate a unique code; the DRG intelligent management module is also used to obtain the doctor's orders in real time, calculate the treatment cost, hospital cost and income according to the doctor's orders, and associate the treatment cost with the patient's code; the DRG intelligent management module is also used to obtain the patient's treatment cost according to the patient's code when the patient is discharged, and calculate the medical insurance payment amount and the patient's out-of-pocket amount in combination with the medical insurance policy and the medical insurance settlement rules.

[0009] The medical business management module is used to record the doctor's orders and the nurse's care situation to form a diagnosis and treatment record and a nursing record; according to the diagnosis and treatment record and the nursing record, in combination with the patient's condition data, analyze the rationality of the use of drugs, consumables and equipment, obtain the analysis result, and form an assessment report according to the analysis result.

[0010] The finance and operation management module is used to generate financial statements according to the hospital's income, expenditure and cost; form medical insurance settlement data and hospital financial data according to the medical insurance payment amount and the patient's out-of-pocket amount, and reconcile the treatment cost, medical insurance settlement data and hospital financial data; if the sum of the medical insurance payment amount and the patient's out-of-pocket amount is inconsistent with the patient's treatment cost, the finance and operation management module will generate a financial anomaly report.

[0011] Furthermore, the DRG intelligent management module is also used to estimate the patient's treatment cost according to the patient's grouping and condition data, and estimate the medical insurance payment amount and the patient's out-of-pocket amount in the treatment cost in combination with the medical insurance policy and the medical insurance settlement rules.

[0012] Furthermore, the DRG intelligent management module is also used to transmit the doctor's orders to the patient's mobile phone in real time for the patient to adjust and confirm.

[0013] Furthermore, the DRG intelligent management module is also used to construct a doctor's order judgment model using a deep learning model; the doctor's order judgment model is used to judge whether the doctor's orders conform to the patient's condition according to the doctor's orders in combination with the patient's condition data; if not, an abnormal doctor's order prompt will be sent to the doctor's computer and the patient's mobile phone.

[0014] Furthermore, the finance and operation management module is also used to obtain the usage situation of drugs, consumables and equipment according to the diagnosis and treatment record and the nursing record, and set the maximum threshold and the minimum threshold of the usage frequency; if the usage frequency of drugs, consumables and equipment exceeds the maximum threshold, it is judged as overuse; if the usage frequency of drugs, consumables and equipment is lower than the minimum threshold, it is judged as over-purchasing; generate a usage suggestion report according to the usage situation of drugs, consumables and equipment.

[0015] Furthermore, based on the DRG grouping rules, several groups are divided with each patient as a member. The DRG intelligent management module is also used to calculate the average income of each group according to the income of each group in the hospital financial system, and set the range value of the treatment cost for each group; if the treatment cost of a patient exceeds the range value, the DRG intelligent management module will send a cost anomaly prompt to the doctor's computer and the patient's mobile phone.

[0016] Furthermore, the condition data includes the patient's basic information and case type.

[0017] Furthermore, the doctor's orders include drug prescriptions, examination items, and treatment items.

[0018] Furthermore, the assessment report includes drug type assessment, drug dosage assessment, consumable type assessment, consumable quantity assessment, equipment type assessment, and equipment usage frequency assessment.

[0019] Furthermore, the DRG intelligent management module is also used to send the treatment cost details to the patient's mobile phone after the patient pays the treatment cost.

[0020] Adopting the above solution has the following beneficial effects:

[0021] 1. Through the design of the data integration module of the present invention, the data of the medical insurance system, the hospital information system, and the hospital financial system are integrated. When a patient is admitted to the hospital for consultation, the DRG intelligent management module will group the patient according to the patient's condition data and the DRG grouping rules and generate a unique code, so that all kinds of data of the patient are associated with this code afterwards, ensuring the accuracy of subsequent treatment, cost accumulation, and cost settlement, thus ensuring the consistency between the medical process and the hospital financial system and laying a foundation for the consistency of the medical process, the medical insurance system, and the hospital financial system.

[0022] 2. In the existing medical systems, the charges are made according to the various doctor's orders issued by the doctor. Although the income and expenditure can be accurately calculated, the item-based payment model in the prior art is prone to over-medical treatment. The hospital may provide unnecessary drugs, examinations, and treatments to increase income, increasing the burden on patients and the medical insurance fund; in the present invention, the DRG intelligent management module can obtain the doctor's orders issued by the doctor in real time, calculate the treatment cost, hospital cost, and income according to the doctor's orders issued; enabling doctors and patients to appropriately adjust the treatment plan according to the treatment cost, combined with the patient's economic status and physical condition; reducing the risk of over-medical treatment; and the hospital can also clearly understand the financial income and expenditure during the treatment process.

[0023] 3. In the present invention, the DRG intelligent management module can obtain the treatment cost of a patient according to the patient's code when the patient is discharged, so as to ensure the correspondence among the patient, the code, and the treatment cost, thereby avoiding situations such as wrong payment and missed payment by the patient; and in combination with medical insurance policies and medical insurance settlement rules, automatically calculate the medical insurance payment amount and the amount to be paid by the patient, without manual calculation, improving the convenience and accuracy of payment.

[0024] 4. In the present invention, the finance and operation management module can check the medical insurance settlement data and the hospital finance data according to the patient's code, so as to ensure the consistency between the hospital finance system and the medical insurance system; and further achieve the consistency among the medical process, the medical insurance system, and the hospital finance system, improving the coordination and management ability of the medical process, the medical insurance system, and the hospital finance system in the medical system.

[0025] Additional aspects and advantages of the present invention will be given in part in the following description, become apparent in part from the following description, or be learned through the practice of the present invention. BRIEF DESCRIPTION OF THE DRAWINGS

[0026] Figure 1 It is a schematic structural diagram of the medical insurance, medical treatment, and finance integrated collaborative management system of the present invention. DETAILED DESCRIPTION OF THE EMBODIMENTS

[0027] The following will be further detailed through specific embodiments:

[0028] Embodiment:

[0029] As shown in the appended Figure 1 figures: A medical insurance, medical treatment, and finance integrated collaborative management system includes a data integration module for integrating data, a DRG intelligent management module for grouping and managing patients, a medical service management module for managing medical services, and a finance and operation management module for managing finance; all modules are signal-connected to each other and are also signal-connected to the doctor's computer, the nurse's computer, and the user's mobile phone.

[0030] The specific functions of each module are as follows:

[0031] The data integration module is used to perform data docking with the medical insurance system, the hospital information system, and the hospital finance system; obtain medical insurance policies, DRG grouping rules, and medical insurance settlement rules in the medical insurance system; obtain the patient's condition data in the hospital information system; obtain the hospital's income, expenditure, and cost in the hospital finance system; and transmit the medical insurance policies, DRG grouping rules, medical insurance settlement rules, condition data, and the hospital's income, expenditure, and cost to the DRG intelligent management module.

[0032] The DRG intelligent management module is used to group patients according to their disease condition data and generate a unique code in combination with the DRG grouping rules; the DRG intelligent management module will send the code to the patient's mobile phone in the form of a text message. The specific DRG grouping rules are as follows: Cases within the same group should have similar diagnoses and treatment methods; cases within the same group should be similar in terms of medical resource consumption (such as drugs, consumables, examination items, treatment items, and length of hospital stay, etc.). The disease condition data includes the patient's basic information and case type.

[0033] For example, patient A's main diagnosis is "acute appendicitis", the main operation is "appendectomy", and there are no complications; patient B's main diagnosis is "acute appendicitis", the main operation is "appendectomy", and there is a slight infection; patient C's main diagnosis is "acute gastroenteritis", the main operation is "drug treatment", and there are no complications; then patient A and patient B are grouped into one group, and patient C is grouped into another group.

[0034] The DRG intelligent management module is signal-connected to the remote control terminals of the operators (such as mobile phones, computers, and tablets, etc.), and the operators can customize the grouping rules and coding rules. In this embodiment, the coding rule is as follows: the first letter of the case name + admission date + the order of admission on the same day; taking the above patient A as an example, assuming that patient A is admitted to the hospital on June 6, 2020, and is the 7th patient in this group, then the code of patient A is: JXLWY2020667, and the code will be sent to patient A's mobile phone in the form of a text message.

[0035] The DRG intelligent management module is also used to obtain the doctor's orders in real time, calculate the treatment cost, hospital cost, and income according to the doctor's orders, and associate the treatment cost with the patient's code; the DRG intelligent management module is also used to obtain the patient's treatment cost according to the patient's code when the patient is discharged, and calculate the medical insurance payment amount and the patient's out-of-pocket amount in combination with the medical insurance policy and medical insurance settlement rules. The doctor's orders include drug prescriptions, examination items, and treatment items. The DRG intelligent management module is also used to send the treatment cost details to the patient's mobile phone after the patient pays the treatment cost.

[0036] Taking the above patient A as an example, assuming that patient A is discharged cured, patient A only needs to provide the code to the settlement personnel, and the settlement personnel input the code into the DRG intelligent management module, and the DRG intelligent management module can output the treatment cost of patient A according to the code, and at the same time send the treatment cost details to patient A's mobile phone.

[0037] The medical service management module is used to record the doctor's orders and the nurse's care situation, forming diagnosis and treatment records and nursing records; according to the diagnosis and treatment records and nursing records, combined with the patient's condition data, analyze the rationality of the use of drugs, consumables and equipment, obtain the analysis results, and form an assessment report according to the analysis results. The assessment report includes drug type assessment, drug dosage assessment, consumable type assessment, consumable quantity assessment, equipment type assessment and equipment usage frequency assessment.

[0038] For example, if the drug prescribed by the doctor is Drug A and Drug A has no therapeutic effect on all the case types of the patient, it is judged that the drug prescribed by the doctor is abnormal, an assessment report is generated, and the hospital is reminded to evaluate the doctor's ability.

[0039] The finance and operation management module is used to generate financial statements according to the hospital's income, expenditure and cost; form medical insurance settlement data and hospital financial data according to the medical insurance payment amount and the patient's out-of-pocket amount, and reconcile the treatment cost, medical insurance settlement data and hospital financial data; if the sum of the medical insurance payment amount and the patient's out-of-pocket amount is inconsistent with the patient's treatment cost, the finance and operation management module will generate a financial anomaly report, reminding the hospital to further reconcile the treatment cost, medical insurance payment amount and the patient's out-of-pocket amount.

[0040] The DRG intelligent management module is also used to estimate the patient's treatment cost according to the patient's grouping and condition data, and combine the medical insurance policy and medical insurance settlement rules to estimate the medical insurance payment amount and the patient's out-of-pocket amount in the treatment cost. The DRG intelligent management module is also used to transmit the doctor's orders to the patient's mobile phone in real time for the patient to adjust and confirm, improving the transparency of the doctor's orders, protecting the rights and interests of doctors and patients, and at the same time reducing the risk of over-medical treatment.

[0041] The DRG intelligent management module is also used to construct a doctor's order judgment model using a deep learning model; the doctor's order judgment model is used to judge whether the doctor's order conforms to the patient's condition according to the doctor's order and the patient's condition data; if not, an abnormal doctor's order prompt is sent to the doctor's computer and the patient's mobile phone.

[0042] The finance and operation management module is also used to obtain the usage situation of drugs, consumables and equipment according to the diagnosis and treatment records and nursing records, and set the maximum threshold and minimum threshold of the usage frequency; if the usage frequency of drugs, consumables and equipment exceeds the maximum threshold, it is judged as overuse; if the usage frequency of drugs, consumables and equipment is lower than the minimum threshold, it is judged that there is an over-purchasing problem with drugs, consumables and equipment; according to the usage situation of drugs, consumables and equipment, a usage suggestion report is generated.

[0043] For example, 20 units of a certain device were purchased. Within one year, each unit was used only 7 times on average, while the minimum threshold for the usage frequency of this device is at least 15 times per unit per year. Then, the usage frequency of this device is much lower than the minimum threshold, and the DRG intelligent management module determines that this device is over-purchased and generates a usage suggestion report: suggesting reducing the quantity of devices and returning, renting, or reselling the excess devices.

[0044] Based on the DRG grouping rules, with each patient as a member divided into several groups, the DRG intelligent management module is also used to calculate the average income of each group according to the income of each group in the hospital financial system, and set the range value of the treatment cost for each group. If the treatment cost of a patient exceeds the range value, the DRG intelligent management module will send a cost anomaly prompt to the doctor's computer and the patient's mobile phone.

[0045] For example, the average single hospitalization cost of a certain group in the hospital financial system is 3000 yuan. The operator can set the treatment cost of this group to be between 2800 - 3200 yuan according to the average single hospitalization cost of 3000 yuan for this group. If the treatment cost of a certain patient in this group is 4200 yuan, far exceeding the set range value, the DRG intelligent management module will immediately send a cost anomaly prompt to the doctor's computer and the patient's mobile phone, reminding the doctor and the patient to check the doctor's orders and determine whether adjustment is needed.

[0046] Obviously, the above embodiments are merely examples given for clear illustration and not limitations on the implementation manners. For those of ordinary skill in the art, other different forms of changes or alterations can be made based on the above description. It is not necessary and impossible to enumerate all the implementation manners here. And the obvious changes or alterations derived therefrom still fall within the protection scope of this invention.

Claims

1. A medical insurance, medical care, and financial integrated collaborative management system, characterized in that, It includes a data integration module, a DRG intelligent management module, a medical service management module, and a finance and operation management module; The data integration module is used to conduct data docking with the medical insurance system, the hospital information system, and the hospital finance system; obtain the medical insurance policies, DRG grouping rules, and medical insurance settlement rules in the medical insurance system; obtain the patient's condition data in the hospital information system; obtain the hospital's income, expenditure, and costs in the hospital finance system; and transmit the medical insurance policies, DRG grouping rules, medical insurance settlement rules, condition data, and the hospital's income, expenditure, and costs to the DRG intelligent management module; The DRG intelligent management module is used to group patients according to the patient's condition data and generate a unique code in combination with the DRG grouping rules; The DRG intelligent management module is also used to obtain the doctor's orders issued in real time, calculate the treatment costs, hospital costs, and income according to the doctor's orders, and associate the treatment costs with the patient's code; The DRG intelligent management module is also used to obtain the patient's treatment costs according to the patient's code when the patient is discharged, and calculate the medical insurance payment amount and the patient's out-of-pocket amount in combination with the medical insurance policy and the medical insurance settlement rules; The medical service management module is used to record the doctor's orders and the nurse's care situation to form a diagnosis and treatment record and a nursing record; analyze the rationality of the use of drugs, consumables, and equipment according to the diagnosis and treatment record and the nursing record in combination with the patient's condition data, obtain the analysis result, and form an assessment report according to the analysis result; The finance and operation management module is used to generate financial statements according to the hospital's income, expenditure, and costs; form medical insurance settlement data and hospital financial data according to the medical insurance payment amount and the patient's out-of-pocket amount, and reconcile the treatment costs, medical insurance settlement data, and hospital financial data; if the sum of the medical insurance payment amount and the patient's out-of-pocket amount is inconsistent with the patient's treatment costs, the finance and operation management module will generate a financial anomaly report.

2. The integrated collaborative management system for medical insurance, medical care and finance according to claim 1, characterized in that The DRG intelligent management module is also used to estimate the patient's treatment costs according to the patient's grouping and condition data, and estimate the medical insurance payment amount and the patient's out-of-pocket amount in the treatment costs in combination with the medical insurance policy and the medical insurance settlement rules.

3. The integrated collaborative management system for medical insurance, medical care, and finance according to claim 2, wherein The DRG intelligent management module is also used to transmit the doctor's orders issued in real time to the patient's mobile phone for the patient to adjust and confirm.

4. The integrated collaborative management system for medical insurance, medical care and finance according to claim 3, characterized in that, The DRG intelligent management module is also used to construct a doctor's order judgment model using a deep learning model; the doctor's order judgment model is used to judge whether the doctor's orders issued are in line with the patient's condition according to the doctor's orders in combination with the patient's condition data; if not, an abnormal doctor's order prompt will be sent to the doctor's computer and the patient's mobile phone.

5. The integrated and collaborative management system for medical insurance, medical care and finance according to claim 4, characterized in that, The finance and operation management module is also used to obtain the usage situation of drugs, consumables, and equipment according to the diagnosis and treatment record and the nursing record, and set the maximum threshold and minimum threshold of the usage frequency; if the usage frequency of drugs, consumables, and equipment exceeds the maximum threshold, it is judged as overuse; if the usage frequency of drugs, consumables, and equipment is lower than the minimum threshold, it is judged as over-purchasing; generate a usage recommendation report according to the usage situation of drugs, consumables, and equipment.

6. The integrated collaborative management system for medical insurance, medical care and finance according to claim 5, wherein, Based on the DRG grouping rules, several groups are divided with each patient as a member. The DRG intelligent management module is also used to calculate the average income of each group according to the income of each group in the hospital financial system, and set the range value of the treatment cost for each group; if the treatment cost of a patient exceeds the range value, the DRG intelligent management module will send a cost anomaly prompt to the doctor's computer and the patient's mobile phone.

7. The integrated collaborative management system for medical insurance, medical care, and finance according to claim 6, wherein The condition data includes the patient's basic information and case type.

8. The integrated collaborative management system for medical insurance, medical care, and finance according to claim 7, characterized in that, Medical orders include drug prescriptions, examination items, and treatment items.

9. The integrated collaborative management system for medical insurance, medical care and finance according to claim 8, characterized in that, The assessment report includes drug type assessment, drug dosage assessment, consumable type assessment, consumable quantity assessment, equipment type assessment, and equipment usage frequency assessment.

10. The integrated collaborative management system for medical insurance, medical care and finance according to claim 9, characterized in that, The DRG intelligent management module is also used to send the treatment cost details to the patient's mobile phone after the patient pays the treatment cost.

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