Clinical path monitoring method and system based on DRG / DIP payment mode

Abstract

The invention discloses a clinical pathway monitoring method and system based on a DRG / DIP payment mode, and the method comprises the steps: determining the disease type of a target patient, and formulating a medical insurance version clinical pathway form for the target patient based on the disease type; determining a diagnosis and treatment item coefficient of each clinical pathway in the medical insurance version clinical pathway form through the historical treatment data, and optimizing the medical insurance version clinical pathway form according to the diagnosis and treatment item coefficients; obtaining related diagnosis and treatment opinions of professional doctors for the optimized medical insurance version clinical pathway form, and determining a final implementation clinical pathway according to the related diagnosis and treatment opinions; and acquiring a path progress monitoring index, a path quality monitoring index and a path cost monitoring index of the final implementation clinical path, and monitoring the medical process of the target patient according to the path progress monitoring index, the path quality monitoring index and the path cost monitoring index. Medical insurance cost index and clinical path management double-index system monitoring is created, hospitals are assisted in controlling unreasonable increase of medical cost, and medical quality is guaranteed.

Description

Technical Field

[0001] The present invention relates to the technical field of medical quality management, and particularly to a clinical pathway monitoring method based on the DRG / DIP payment model. Background Art

[0002] At present, with the in-depth promotion of the reform of China's medical security system, the diagnosis-related group (DRG) and the disease-based payment (DIP) payment models have become the mainstream methods of medical insurance payment. The implementation of these two payment models has posed new challenges to the clinical pathway management of hospitals. The clinical pathway monitoring methods under the traditional item-based payment model can no longer meet the refined management requirements in the prepayment environment1. There are technical bottlenecks in the clinical pathway management under the current DRG / DIP payment model. The existing clinical pathway monitoring systems lack a two-dimensional dynamic evaluation mechanism for medical quality and cost consumption, and it is difficult to achieve the organic unity of "cost control" and "quality improvement". This has reduced the medical quality and treatment efficiency, caused unnecessary medical consumption for patients, and reduced the patient experience. Summary of the Invention

[0003] In view of the problems shown above, the present invention provides a clinical pathway monitoring method and system based on the DRG / DIP payment model to solve the problems that the existing clinical pathway monitoring systems lack a two-dimensional dynamic evaluation mechanism for medical quality and cost consumption, are difficult to achieve the organic unity of "cost control" and "quality improvement", reduce medical quality and treatment efficiency, cause unnecessary medical consumption for patients, and reduce the patient experience mentioned in the background art.

[0004] A clinical pathway monitoring method based on the DRG / DIP payment model includes the following steps:

[0005] Determine the disease type of the target patient, and formulate a medical insurance version clinical pathway form for the target patient based on the disease type;

[0006] Determine the treatment item coefficients of each clinical pathway in the medical insurance version clinical pathway form through historical treatment data, and optimize the medical insurance version clinical pathway form according to the treatment item coefficients;

[0007] Obtain the relevant treatment opinions of professional physicians on the optimized medical insurance version clinical pathway form, and determine the finally implemented clinical pathway according to the relevant treatment opinions;

[0008] Obtain the path progress monitoring indicators, path quality monitoring indicators, and path cost monitoring indicators of the finally implemented clinical pathway, and monitor the medical process of the target patient according to the path progress monitoring indicators, path quality monitoring indicators, and path cost monitoring indicators.

[0009] Preferably, the step of determining the disease type of the target patient and formulating a medical insurance version clinical pathway form for the target patient based on the disease type includes:

[0010] Obtain the medical record report of the target patient, determine the type of disease of the target patient according to the medical record report, and determine the clinical disease treatment method based on the type of disease;

[0011] Determine the treatment resources corresponding to the clinical disease treatment method, determine the diagnosis-related department group based on the treatment resources, and determine multiple clinical pathways for diseases according to the diagnosis-related department group;

[0012] Obtain the DRG payment standard for each clinical pathway of the disease, and formulate the medical insurance version clinical pathway form for the target patient according to the DRG payment standard.

[0013] Preferably, determining the treatment item coefficients of each clinical pathway in the medical insurance version clinical pathway form through historical treatment data, and optimizing the medical insurance version clinical pathway form according to the treatment item coefficients, includes:

[0014] Determine multiple treatment items according to the medical insurance version clinical pathway form, obtain the cost structure of each treatment item, and define multiple cost units according to the cost structure;

[0015] Collect the historical treatment data of each treatment item, and determine the historical treatment cost data of each treatment item according to the historical treatment data;

[0016] Conduct frequency statistics on multiple cost units through the historical treatment cost data, and determine the treatment item coefficients of each clinical pathway in the medical insurance version clinical pathway form according to the statistical results;

[0017] Select the first treatment items greater than or equal to the preset threshold as the mandatory treatment items according to the treatment item coefficients of the clinical pathway, and regard the second treatment items less than the preset threshold as non-mandatory treatment items, and optimize the medical insurance version clinical pathway form according to the classification result.

[0018] Preferably, obtaining the relevant treatment opinions of professional physicians on the optimized medical insurance version clinical pathway form, and determining the finally implemented clinical pathway according to the relevant treatment opinions, includes:

[0019] Upload the optimized medical insurance version clinical pathway form to the professional physician terminal and obtain relevant treatment opinions from the terminal;

[0020] Determine the mandatory medical items and non-mandatory medical items according to the relevant treatment opinions, and respectively obtain the cost control rules for the mandatory medical items and non-mandatory medical items;

[0021] Determine multiple combined medical items in each price range according to the cost control rules, and obtain the expected effect prospects of physicians for each combined medical item;

[0022] Select the target combined medical items according to the expected effect prospect, and determine the final implemented clinical pathway according to the target combined medical items.

[0023] Preferably, obtaining the path progress monitoring index, path quality monitoring index and path cost monitoring index of the finally implemented clinical pathway, and monitoring the medical process of the target patient according to the path progress monitoring index, path quality monitoring index and path cost monitoring index, includes:

[0024] Determine the enrollment rate reference index, completion rate reference index and cost reference index of the finally implemented clinical pathway;

[0025] Obtain the path progress monitoring index, path quality monitoring index and path cost monitoring index of the finally implemented clinical pathway according to the enrollment rate reference index, completion rate reference index and cost reference index;

[0026] Determine the monitoring object and monitoring process according to the path progress monitoring index, path quality monitoring index and path cost monitoring index;

[0027] Monitor the data of the monitoring object according to the monitoring process to realize the monitoring work of the medical process of the target patient.

[0028] Preferably, determining the treatment resources corresponding to the clinical disease treatment method, determining the diagnosis-related groups based on the treatment resources, and determining the clinical pathways of multiple disease types according to the diagnosis-related groups, includes:

[0029] Decompose the clinical disease treatment method to determine the corresponding drug resources, equipment resources, human resources and space resources required;

[0030] Statistically count the drug resources, equipment resources, human resources and space resources as treatment resources, and determine multiple resource types of the treatment resources;

[0031] Match the diagnosis-related groups according to the resource types, and determine the leading group and collaborative group in the diagnosis-related groups and the collaborative working mechanism between the two;

[0032] Determine the diagnosis process parameters and treatment process parameters according to the leading group and collaborative group and the collaborative working mechanism between the two, and determine the clinical pathways of multiple disease types according to the diagnosis process parameters, treatment process parameters and rehabilitation indicators.

[0033] Preferably, determining multiple diagnosis and treatment items according to the clinical pathway form of the medical insurance version, obtaining the cost structure of each diagnosis and treatment item, and defining multiple cost units according to the cost structure, includes:

[0034] Decompose the clinical pathway form of the medical insurance version into multiple diagnosis and treatment items according to the time axis, and determine the item attributes of each medical item, where the item attributes include: mandatory items and optional items;

[0035] Determine each necessary diagnosis and treatment item according to the project attributes, obtain the fee details of the necessary diagnosis and treatment items, and determine the direct medical expense details and indirect medical expense details according to the fee details;

[0036] Determine the cost structure of each necessary diagnosis and treatment item based on the direct medical expense details and indirect medical expense details;

[0037] Determine multiple definition dimensions according to the cost structure, and define multiple cost units of the necessary diagnosis and treatment items through multiple positioning dimensions. The definition dimensions include: cost type, cost nature, and cost stage.

[0038] Preferably, after obtaining the medical insurance version of the clinical pathway form, it further includes:

[0039] Obtain the historical treatment information of the target patient based on the disease type, determine the medical data of the target patient according to the historical treatment information, and determine the medical global concept for the target patient according to the medical data;

[0040] Determine the diagnosis and treatment decision-making factors for the target patient according to the medical global concept, and determine the medical field based on the diagnosis and treatment decision-making factors;

[0041] Obtain the clinical rules of the medical field, determine multiple diagnosis and treatment reference features for the target patient according to the clinical rules, and determine the key included information elements of the medical insurance version of the clinical pathway form according to the diagnosis and treatment reference features through a preset medical knowledge model;

[0042] Obtain the mapping indicators of the key included information elements, and determine the key diagnosis and treatment items and the non-included diagnosis and treatment items in the medical insurance version of the clinical pathway form according to the mapping indicators;

[0043] Determine the medical association parameters between the non-included diagnosis and treatment items and the key diagnosis and treatment items, and determine the co-progression bundling of the non-included diagnosis and treatment items and the key diagnosis and treatment items according to the medical association parameters;

[0044] Determine the diagnosis and treatment items to be added to the medical insurance version of the clinical pathway form according to the co-progression bundling, and obtain the target diagnosis and treatment stage where the diagnosis and treatment items to be added are located;

[0045] Obtain the stage target of the target diagnosis and treatment stage, determine the core diagnosis and treatment item group according to the stage target, and confirm whether the diagnosis and treatment items to be added are included in the core diagnosis and treatment items;

[0046] If so, add the diagnosis and treatment items to be added to the medical insurance version of the clinical pathway form to generate a new medical insurance version of the clinical pathway form. If not, confirm that there is no need to add the diagnosis and treatment items to be added;

[0047] Generate an initial diagnosis and treatment node sequence according to the new medical insurance version of the clinical pathway form through a preset comprehensive diagnosis and treatment information model;

[0048] Generate a dynamic adjustment mechanism based on the initial diagnosis and treatment node sequence and the reservation strategies of each diagnosis and treatment item, and adjust the brand-new medical insurance version of the clinical pathway form in real time through the dynamic adjustment mechanism.

[0049] Preferably, after determining the clinical pathways of multiple diseases according to the diagnosis-related groups, it further includes:

[0050] Determine the resource types corresponding to each disease clinical pathway, determine the medical resource usage level according to the resource types, and determine the medical resource occupancy cost index of each disease clinical pathway based on the medical resource usage level;

[0051] Obtain the single-operation frequency and multi-operation cooperation frequency of each disease clinical pathway, and determine the operation complexity index of each disease clinical pathway based on the single-operation frequency and multi-operation cooperation frequency;

[0052] Obtain the human resource allocation parameters of each disease clinical pathway, and determine the human cost index of each disease clinical pathway according to the human resource allocation parameters and the cooperation operation process parameters;

[0053] Calculate the recommended adaptability of each disease clinical pathway based on the human cost index, operation complexity index and medical resource occupancy cost index of each disease clinical pathway;

[0054] Screen out the first disease clinical pathways that are greater than or equal to the preset threshold based on the recommended adaptability of each disease clinical pathway, and remove the second disease clinical pathways that are less than the preset threshold;

[0055] Use the first disease clinical pathway as the reference clinical pathway for the medical insurance version of the clinical pathway form for the target patient.

[0056] A clinical pathway monitoring system based on the DRG / DIP payment model, the system includes:

[0057] A formulation module, used to determine the disease type of the target patient, and formulate the medical insurance version of the clinical pathway form for the target patient based on the disease type;

[0058] An optimization module, used to determine the diagnosis and treatment item coefficients of each clinical pathway in the medical insurance version of the clinical pathway form through historical treatment data, and optimize the medical insurance version of the clinical pathway form according to the diagnosis and treatment item coefficients;

[0059] A determination module, used to obtain the relevant diagnosis and treatment opinions of professional physicians on the optimized medical insurance version of the clinical pathway form, and determine the finally implemented clinical pathway according to the relevant diagnosis and treatment opinions;

[0060] The monitoring module is used to obtain the path progress monitoring indicators, path quality monitoring indicators, and path cost monitoring indicators for the final implementation of the clinical path, and monitor the medical process of the target patient based on the path progress monitoring indicators, path quality monitoring indicators, and path cost monitoring indicators.

[0061] Other features and advantages of the present invention will be described in the following specification, and partly will be obvious from the specification, or will be understood by implementing the present invention. The objectives and other advantages of the present invention can be achieved and obtained by the structures specifically pointed out in the written specification and the accompanying drawings.

[0062] The technical solution of the present invention will be further described in detail below through the accompanying drawings and embodiments. Description of the Drawings

[0063] The drawings are used to provide a further understanding of the present invention, and constitute a part of the specification. Together with the embodiments of the present invention, they are used to explain the present invention and do not constitute a limitation to the present invention.

[0064] Figure 1 It is a working flowchart of a clinical path monitoring method based on the DRG / DIP payment model provided by the present invention;

[0065] Figure 2 It is another working flowchart of a clinical path monitoring method based on the DRG / DIP payment model provided by the present invention;

[0066] Figure 3 It is yet another working flowchart of a clinical path monitoring method based on the DRG / DIP payment model provided by the present invention;

[0067] Figure 4 It is a schematic structural diagram of a clinical path monitoring system based on the DRG / DIP payment model provided by the present invention. Detailed Embodiments

[0068] Here, the exemplary embodiments will be described in detail, and their examples are shown in the drawings. When the following description refers to the drawings, unless otherwise indicated, the same numbers in different drawings represent the same or similar elements. The implementation manners described in the following exemplary embodiments do not represent all implementation manners consistent with the present disclosure. On the contrary, they are merely examples of devices and methods consistent with some aspects of the present disclosure as detailed in the appended claims.

[0069] At present, with the in-depth promotion of the reform of China's medical security system, the payment models of Diagnosis Related Groups (DRG) and Diagnosis-Intervention Packet (DIP) have become the mainstream ways of medical insurance payment. The implementation of these two payment models has posed new challenges to the clinical pathway management in hospitals. The clinical pathway monitoring methods under the traditional item-based payment model can no longer meet the refined management requirements in the prepayment environment1. There are the following technical bottlenecks in the clinical pathway management under the current DRG / DIP payment model. The existing clinical pathway monitoring system lacks a two-dimensional dynamic evaluation mechanism for medical quality and cost consumption, and it is difficult to achieve the organic unity of "cost control" and "quality improvement". To solve the above problems, this embodiment discloses a clinical pathway monitoring method based on the DRG / DIP payment model.

[0070] A clinical pathway monitoring method based on the DRG / DIP payment model, as Figure 1 shown, includes the following steps:

[0071] Step S101: Determine the disease type of the target patient, and formulate a medical insurance version clinical pathway form for the target patient based on the disease type;

[0072] Step S102: Determine the diagnosis and treatment item coefficients of each clinical pathway in the medical insurance version clinical pathway form through historical treatment data, and optimize the medical insurance version clinical pathway form according to the diagnosis and treatment item coefficients;

[0073] Step S103: Obtain the relevant diagnosis and treatment opinions of professional physicians on the optimized medical insurance version clinical pathway form, and determine the finally implemented clinical pathway according to the relevant diagnosis and treatment opinions;

[0074] Step S104: Obtain the path progress monitoring indicators, path quality monitoring indicators and path cost monitoring indicators of the finally implemented clinical pathway, and monitor the medical process of the target patient according to the path progress monitoring indicators, path quality monitoring indicators and path cost monitoring indicators.

[0075] The working principle of the above technical solution is: Determine the disease type of the target patient, and formulate a medical insurance version clinical pathway form for the target patient based on the disease type; Determine the diagnosis and treatment item coefficients of each clinical pathway in the medical insurance version clinical pathway form through historical treatment data, and optimize the medical insurance version clinical pathway form according to the diagnosis and treatment item coefficients; Obtain the relevant diagnosis and treatment opinions of professional physicians on the optimized medical insurance version clinical pathway form, and determine the finally implemented clinical pathway according to the relevant diagnosis and treatment opinions; Obtain the path progress monitoring indicators, path quality monitoring indicators and path cost monitoring indicators of the finally implemented clinical pathway, and monitor the medical process of the target patient according to the path progress monitoring indicators, path quality monitoring indicators and path cost monitoring indicators.

[0076] The beneficial effects of the above technical solution are as follows: By determining the treatment item coefficients of each clinical pathway, an objective and reasonable evaluation of the applicability of treatment items is carried out, and then the clinical pathway form of the medical insurance version is optimized and finally reviewed by experts to determine the final implementation of the clinical pathway. This not only creates a dual-index system monitoring of medical insurance cost indicators and clinical pathway management, assists the hospital in controlling the unreasonable growth of medical expenses, but also ensures medical quality, improves the diagnosis and treatment efficiency and the patient experience. It solves the problem mentioned in the existing technology that the existing clinical pathway monitoring system lacks a two-dimensional dynamic evaluation mechanism for medical quality and cost consumption, making it difficult to achieve the organic unity of "cost control" and "quality improvement", reducing medical quality and diagnosis and treatment efficiency, causing unnecessary medical consumption for patients, and reducing the patient experience.

[0077] In one embodiment, determining the disease type of the target patient and formulating a clinical pathway form of the medical insurance version for the target patient based on the disease type includes:

[0078] Obtain the medical record report of the target patient, determine the disease type of the target patient according to the medical record report, and determine the clinical disease treatment method based on the disease type;

[0079] Determine the treatment resources corresponding to the clinical disease treatment method, determine the diagnosis-related group based on the treatment resources, and determine multiple disease clinical pathways according to the diagnosis-related group;

[0080] Obtain the DRG payment standard for each disease clinical pathway, and formulate a clinical pathway form of the medical insurance version for the target patient according to the DRG payment standard.

[0081] The beneficial effects of the above technical solution are as follows: Determining the clinical disease treatment method and the corresponding treatment resources according to the medical record report of the target patient can ensure that the patient receives the most targeted treatment and improve the treatment effect. Further, determining multiple disease clinical pathways and DRG payment standards according to the treatment resources and formulating a clinical pathway form of the medical insurance version for the target patient can optimize the allocation of medical resources and reduce the treatment cost.

[0082] In one embodiment, determining the treatment item coefficients of each clinical pathway in the clinical pathway form of the medical insurance version through historical treatment data and optimizing the clinical pathway form of the medical insurance version according to the treatment item coefficients includes:

[0083] Determine multiple treatment items according to the clinical pathway form of the medical insurance version, obtain the cost structure of each treatment item, and define multiple cost units according to the cost structure;

[0084] Collect the historical treatment data of each treatment item, and determine the historical treatment cost data of each treatment item according to the historical treatment data;

[0085] Perform frequency statistics on multiple cost units based on the historical data of medical treatment costs, and determine the treatment item coefficients of each clinical pathway in the clinical pathway form of the medical insurance version according to the statistical results;

[0086] Screen out the first treatment items greater than or equal to the preset threshold based on the treatment item coefficients of the clinical pathway and use them as mandatory treatment items, and use the second treatment items less than the preset threshold as non-mandatory treatment items. Optimize the clinical pathway form of the medical insurance version according to the classification results.

[0087] The beneficial effects of the above technical solution are as follows: Determine multiple treatment items and historical treatment data according to the clinical pathway form of the medical insurance version, determine the historical data of the treatment costs of each treatment item based on the historical treatment data, and perform frequency statistics on multiple cost units to determine mandatory treatment items and non-mandatory treatment items, which can accurately identify necessary items. For non-mandatory treatment items, according to their usage frequency and cost situation, reasonably plan their usage scope and conditions to avoid waste of resources. Further, optimizing the clinical pathway form of the medical insurance version can better adapt to the reform of the DRG / DIP payment method, and reasonably control the cost ratio by adjusting the disease cost structure.

[0088] In one embodiment, as Figure 2 shown, obtaining the relevant treatment opinions of professional physicians on the optimized clinical pathway form of the medical insurance version, and determining the finally implemented clinical pathway according to the relevant treatment opinions includes:

[0089] Step S201: Upload the optimized clinical pathway form of the medical insurance version to the professional physician terminal and obtain relevant treatment opinions from the terminal;

[0090] Step S202: Determine the mandatory medical items and non-mandatory medical items according to the relevant treatment opinions, and obtain the cost control rules for the mandatory medical items and non-mandatory medical items respectively;

[0091] Step S203: Determine multiple combined medical items in each price range according to the cost control rules, and obtain the expected effect prospects of the physician for each combined medical item;

[0092] Step S204: Select the target combined medical items according to the expected effect prospects, and determine the finally implemented clinical pathway according to the target combined medical items.

[0093] The beneficial effects of the above technical solution are as follows: By determining the medical items that must be executed and those that do not have to be executed according to the diagnosis and treatment opinions, as well as their respective cost control rules, multiple combined medical items and the expected effect prospects in each price range can be determined, which can reduce unreasonable diagnosis and treatment behaviors caused by economic interests, improve the medical quality and the medical experience. Further, by determining the final implemented clinical pathway based on the target combined medical items, the diagnosis and treatment opinions can be transformed into standardized medical processes, reducing the inconsistency of diagnosis and treatment caused by individual differences, ensuring the standardization and consistency of medical services, and improving the treatment safety of patients.

[0094] In one embodiment, as Figure 3 shown, obtaining the path progress monitoring indicators, path quality monitoring indicators, and path cost monitoring indicators of the finally implemented clinical pathway and monitoring the medical process of the target patient according to the path progress monitoring indicators, path quality monitoring indicators, and path cost monitoring indicators includes:

[0095] Step S301, determining the enrollment rate reference indicator, completion rate reference indicator, and cost reference indicator of the finally implemented clinical pathway;

[0096] Step S302, obtaining the path progress monitoring indicators, path quality monitoring indicators, and path cost monitoring indicators of the finally implemented clinical pathway according to the enrollment rate reference indicator, completion rate reference indicator, and cost reference indicator;

[0097] Step S303, determining the monitoring object and monitoring process according to the path progress monitoring indicators, path quality monitoring indicators, and path cost monitoring indicators;

[0098] Step S304, performing data monitoring on the monitoring object according to the monitoring process to implement the monitoring work of the medical process of the target patient.

[0099] The beneficial effects of the above technical solution are as follows: By obtaining multiple indicators of the path progress based on multiple indicators of the finally implemented clinical pathway, the monitoring object and monitoring process can be determined, enabling real-time monitoring of the treatment process, improving the authenticity of the medical process, and avoiding the problem of being unable to trace the source in case of medical disputes.

[0100] In one embodiment, determining the treatment resources corresponding to the clinical disease treatment method, determining the diagnosis-related groups based on the treatment resources, and determining multiple disease clinical pathways according to the diagnosis-related groups includes:

[0101] Decomposing the clinical disease treatment method to determine the corresponding drug resources, equipment resources, human resources, and space resources required;

[0102] Counting the drug resources, equipment resources, human resources, and space resources as treatment resources and determining multiple resource types of the treatment resources;

[0103] Match the diagnosis-related department groups according to the resource type, determine the leading department group and the collaborative department group in the diagnosis-related department groups and the collaborative working mechanism between the two;

[0104] Determine the diagnosis process parameters and treatment process parameters according to the leading department group and the collaborative department group and the collaborative working mechanism between the two, and determine the clinical pathways for multiple disease types according to the diagnosis process parameters, treatment process parameters and rehabilitation indicators.

[0105] The beneficial effects of the above technical solution are as follows: Decompose the clinical disease treatment method to determine its corresponding treatment resources, and match the diagnosis-related department groups according to the treatment resources, so that patients can be more accurately assigned to the most suitable departments and treatment teams, avoiding resource waste. Further, determine the collaborative working mechanism between the leading department group and the collaborative department group in the diagnosis-related department groups, so as to determine the diagnosis process parameters, treatment process parameters and clinical pathways for multiple disease types, which can standardize medical behaviors, reduce treatment inconsistencies caused by individual differences, and improve the safety of patients.

[0106] In one embodiment, determine multiple diagnosis and treatment items according to the clinical pathway form of medical insurance, obtain the cost structure of each diagnosis and treatment item, and define multiple cost units according to the cost structure, including:

[0107] Decompose the clinical pathway form of medical insurance into multiple diagnosis and treatment items according to the time axis, and determine the item attributes of each medical item, where the item attributes include: mandatory items and optional items;

[0108] Determine each necessary diagnosis and treatment item according to the item attributes, obtain the charge details of the necessary diagnosis and treatment items, and determine the direct medical expense details and indirect medical expense details according to the charge details;

[0109] Determine the cost structure of each necessary diagnosis and treatment item based on the direct medical expense details and indirect medical expense details;

[0110] Determine multiple definition dimensions according to the cost structure, and define multiple cost units of the necessary diagnosis and treatment items through multiple positioning dimensions, where the definition dimensions include: cost type, cost nature and cost stage.

[0111] The beneficial effects of the above technical solution are as follows: Determine each necessary diagnosis and treatment item and related charge details according to the item attributes of each medical item, determine the cost structure and multiple definition dimensions according to the charge details, which can more accurately determine the cost composition and avoid unnecessary problems caused by not understanding the payment process. Further, define multiple cost units of the necessary diagnosis and treatment items through multiple positioning dimensions, and reasonable cost unit definition can prevent patients from bearing high medical expenses due to unnecessary examinations and treatments, ensuring that patients pay reasonable fees while obtaining high-quality medical services.

[0112] In one embodiment, after obtaining the medical insurance version of the clinical pathway form, it further includes:

[0113] Obtain the historical treatment information of the target patient based on the disease type, determine the medical data of the target patient according to the historical treatment information, and determine the medical global concept for the target patient according to the medical data;

[0114] Determine the diagnosis and treatment decision-making factors for the target patient according to the medical global concept, and determine the medical field based on the diagnosis and treatment decision-making factors;

[0115] Obtain the clinical rules in the medical field, determine multiple diagnosis and treatment reference features for the target patient according to the clinical rules, and determine the key included information elements of the medical insurance version of the clinical pathway form according to the diagnosis and treatment reference features through a preset medical knowledge model;

[0116] Obtain the mapping indicators of the key included information elements, and determine the key diagnosis and treatment items and the non-included diagnosis and treatment items in the medical insurance version of the clinical pathway form according to the mapping indicators;

[0117] Determine the medical association parameters between the non-included diagnosis and treatment items and the key diagnosis and treatment items, and determine the co-progression bundling between the non-included diagnosis and treatment items and the key diagnosis and treatment items according to the medical association parameters;

[0118] Determine the diagnosis and treatment items to be added to the medical insurance version of the clinical pathway form according to the co-progression bundling, and obtain the target diagnosis and treatment stage where the diagnosis and treatment items to be added are located;

[0119] Obtain the stage objectives of the target diagnosis and treatment stage, determine the core diagnosis and treatment project group according to the stage objectives, and confirm whether the diagnosis and treatment items to be added are included in the core diagnosis and treatment items;

[0120] If so, add the diagnosis and treatment items to be added to the medical insurance version of the clinical pathway form to generate a new medical insurance version of the clinical pathway form. If not, confirm that there is no need to add the diagnosis and treatment items to be added;

[0121] Generate an initial diagnosis and treatment node sequence according to the new medical insurance version of the clinical pathway form through a preset comprehensive diagnosis and treatment information model;

[0122] Generate a dynamic adjustment mechanism according to the initial diagnosis and treatment node sequence and the appointment strategies of each diagnosis and treatment item, and perform real-time adjustment on the new medical insurance version of the clinical pathway form through the dynamic adjustment mechanism.

[0123] The beneficial effects of the above technical solution are as follows: By making real-time adjustments to the brand-new medical insurance version of the clinical pathway form, the order of the medical treatment items in the brand-new medical insurance version of the clinical pathway form can be adjusted according to the real-time diagnosis and treatment resource allocation situation, so that medical staff can quickly perform relevant medical treatment work, improving work efficiency. Further, by evaluating the associated bundled items of the medical treatment items in the obtained medical insurance version of the clinical pathway form according to the medical treatment goals, it can ensure that the whole process of medical treatment to achieve the medical treatment goals is in place without omission, improving the medical treatment efficiency and stability.

[0124] In one embodiment, after determining the clinical pathways of multiple disease types according to the diagnosis-related groups, it further includes:

[0125] Determine the resource type corresponding to each disease type's clinical pathway, determine the medical resource usage level according to the resource type, and determine the medical resource occupancy cost index of each disease type's clinical pathway based on the medical resource usage level;

[0126] Obtain the single-operation frequency and multi-operation collaborative frequency of each disease type's clinical pathway, and determine the operation complexity index of each disease type's clinical pathway based on the single-operation frequency and multi-operation collaborative frequency;

[0127] Obtain the human resource allocation parameters of each disease type's clinical pathway, and determine the human cost index of each disease type's clinical pathway according to the human resource allocation parameters and the collaborative operation process parameters;

[0128] Calculate the recommended adaptability of each disease type's clinical pathway based on the human cost index, operation complexity index, and medical resource occupancy cost index of each disease type's clinical pathway:

[0129]

[0130] Among them, F i represents the recommended adaptability of the i-th disease type's clinical pathway, A i represents the human cost index of the i-th disease type's clinical pathway, μ1 represents the first weight, with a value of 0.3, B i represents the operation complexity index of the i-th disease type's clinical pathway, μ2 represents the second weight, with a value of 0.3, C i represents the medical resource occupancy cost index of the i-th disease type's clinical pathway, μ3 represents the third weight, with a value of 0.4, ln represents the natural logarithm, d i represents the diagnosis and treatment adaptability factor of the i-th disease type's clinical pathway to the target patient's disease type, h i represents the medical positive effect threshold of the i-th disease type's clinical pathway, S i represents the medical negative effect threshold of the i-th disease type's clinical pathway;

[0131] The first clinical pathways for each disease type with a recommendation fitness greater than or equal to a preset threshold are screened out based on the recommendation fitness of the clinical pathways for each disease type, and the second clinical pathways for each disease type with a fitness less than the preset threshold are removed;

[0132] The first clinical pathways for each disease type are used as the reference clinical pathways for the medical insurance version of the clinical pathway form for the target patient.

[0133] The beneficial effects of the above technical solution are as follows: By calculating the recommendation fitness of the clinical pathways for each disease type, the multi-faceted cost evaluation of the clinical pathways for each disease type can be carried out from multiple perspectives, which not only ensures the fitness of the screened clinical pathways but also improves the medical quality. Further, the occurrence of useless consumption by patients is avoided, and the patient experience is improved.

[0134] In one embodiment, this embodiment also discloses a clinical pathway monitoring system based on the DRG / DIP payment model, as Figure 4 shown. The system includes:

[0135] A formulation module 401, configured to determine the disease type of the target patient and formulate a medical insurance version of the clinical pathway form for the target patient based on the disease type;

[0136] An optimization module 402, configured to determine the treatment item coefficients of each clinical pathway in the medical insurance version of the clinical pathway form through historical treatment data, and optimize the medical insurance version of the clinical pathway form according to the treatment item coefficients;

[0137] A determination module 403, configured to obtain relevant treatment opinions of professional physicians on the optimized medical insurance version of the clinical pathway form, and determine the finally implemented clinical pathway according to the relevant treatment opinions;

[0138] A monitoring module 404, configured to obtain the path progress monitoring indicators, path quality monitoring indicators, and path cost monitoring indicators of the finally implemented clinical pathway, and monitor the medical process of the target patient according to the path progress monitoring indicators, path quality monitoring indicators, and path cost monitoring indicators.

[0139] The working principle and beneficial effects of the above technical solution have been described in the method embodiment and will not be elaborated here.

[0140] Those skilled in the art should understand that the first and second in the present invention refer to different application stages.

[0141] Other embodiments of the present disclosure will be readily apparent to those skilled in the art in view of the specification and practice of the disclosure herein. This application is intended to cover any variations, uses, or adaptations of the present disclosure that follow the general principles of the present disclosure and include known common general knowledge or conventional technical means in the technical field not disclosed herein. The specification and examples are only illustrative, and the true scope and spirit of the present disclosure are pointed out by the following claims.

[0142] It should be understood that the present disclosure is not limited to the exact structures described above and shown in the drawings, and various modifications and changes can be made without departing from its scope. The scope of the present disclosure is only limited by the appended claims.

Claims

1. A clinical pathway monitoring method under the DRG / DIP payment model, characterized in that, It includes the following steps: Determine the type of disease of the target patient, and formulate a clinical pathway form for the medical insurance version for the target patient based on the type of disease; Determine the treatment item coefficients of each clinical pathway in the clinical pathway form for the medical insurance version through historical treatment data, and optimize the clinical pathway form for the medical insurance version according to the treatment item coefficients; Obtain the relevant treatment opinions of professional physicians on the optimized clinical pathway form for the medical insurance version, and determine the finally implemented clinical pathway according to the relevant treatment opinions; Obtain the path progress monitoring indicators, path quality monitoring indicators, and path cost monitoring indicators of the finally implemented clinical pathway, and monitor the medical process of the target patient according to the path progress monitoring indicators, path quality monitoring indicators, and path cost monitoring indicators.

2. The clinical pathway monitoring method based on the DRG / DIP payment model according to claim 1, wherein The determination of the type of disease of the target patient and the formulation of a clinical pathway form for the medical insurance version for the target patient based on the type of disease include: Obtain the medical record report of the target patient, determine the type of disease of the target patient according to the medical record report, and determine the treatment method for clinical symptoms based on the type of disease; Determine the treatment resources corresponding to the treatment method for clinical symptoms, determine the diagnosis-related department group based on the treatment resources, and determine multiple clinical pathways for disease types according to the diagnosis-related department group; Obtain the DRG payment standard for each clinical pathway for disease types, and formulate a clinical pathway form for the medical insurance version for the target patient according to the DRG payment standard.

3. The clinical pathway monitoring method based on the DRG / DIP payment model according to claim 1, wherein The determination of the treatment item coefficients of each clinical pathway in the clinical pathway form for the medical insurance version through historical treatment data and the optimization of the clinical pathway form for the medical insurance version according to the treatment item coefficients include: Determine multiple treatment items according to the clinical pathway form for the medical insurance version, obtain the cost structure of each treatment item, and define multiple cost units according to the cost structure; Collect the historical treatment data of each treatment item, and determine the historical treatment cost data of each treatment item according to the historical treatment data; Conduct frequency statistics on multiple cost units through the historical treatment cost data, and determine the treatment item coefficients of each clinical pathway in the clinical pathway form for the medical insurance version according to the statistical results; Screen out the first treatment items that are greater than or equal to the preset threshold according to the treatment item coefficients of the clinical pathway and use them as mandatory treatment items, and use the second treatment items that are less than the preset threshold as non-mandatory treatment items, and optimize the clinical pathway form for the medical insurance version according to the classification results.

4. The clinical pathway monitoring method based on the DRG / DIP payment model according to claim 1, wherein The obtaining of the relevant treatment opinions of professional physicians on the optimized clinical pathway form for the medical insurance version and the determination of the finally implemented clinical pathway according to the relevant treatment opinions include: Upload the optimized clinical pathway form for the medical insurance version to the professional physician terminal and obtain relevant treatment opinions from the terminal; Determine the mandatory medical items and non-mandatory medical items according to the relevant treatment opinions, and obtain the cost control rules for the mandatory medical items and non-mandatory medical items respectively; Determine multiple combined medical items in each price range according to the cost control rules, and obtain the expected effect prospects of the physicians for each combined medical item; Select the target combined medical item according to the expected effect prospects, and determine the finally implemented clinical pathway according to the target combined medical item.

5. The clinical pathway monitoring method based on the DRG / DIP payment model according to claim 1, wherein, Obtaining the path progress monitoring indicators, path quality monitoring indicators, and path cost monitoring indicators for the finally implemented clinical path, and monitoring the medical process of the target patient according to the path progress monitoring indicators, path quality monitoring indicators, and path cost monitoring indicators, including: Determining the enrollment rate reference indicator, completion rate reference indicator, and cost reference indicator for the finally implemented clinical path; Obtaining the path progress monitoring indicators, path quality monitoring indicators, and path cost monitoring indicators for the finally implemented clinical path according to the enrollment rate reference indicator, completion rate reference indicator, and cost reference indicator; Determining the monitoring object and monitoring process according to the path progress monitoring indicators, path quality monitoring indicators, and path cost monitoring indicators; Performing data monitoring on the monitoring object according to the monitoring process to implement the monitoring work of the medical process of the target patient.

6. The clinical pathway monitoring method based on the DRG / DIP payment model according to claim 2, wherein Determining the treatment resources corresponding to the clinical disease treatment method, determining the diagnosis-related groups based on the treatment resources, and determining multiple disease clinical paths according to the diagnosis-related groups, including: Decomposing the clinical disease treatment method to determine the corresponding drug resources, equipment resources, human resources, and space resources required; Counting the drug resources, equipment resources, human resources, and space resources as treatment resources, and determining multiple resource types of the treatment resources; Matching the diagnosis-related groups according to the resource types, determining the leading group and collaborative group in the diagnosis-related groups and the collaborative working mechanism between the two; Determining the diagnosis process parameters and treatment process parameters according to the leading group, collaborative group, and the collaborative working mechanism between the two, and determining multiple disease clinical paths according to the diagnosis process parameters, treatment process parameters, and rehabilitation indicators.

7. The clinical pathway monitoring method based on the DRG / DIP payment model according to claim 3, wherein According to the clinical path form of the medical insurance version, determining multiple diagnosis and treatment items, obtaining the cost structure of each diagnosis and treatment item, and defining multiple cost units according to the cost structure, including: Decomposing the clinical path form of the medical insurance version into multiple diagnosis and treatment items according to the time axis, and determining the item attributes of each medical item, where the item attributes include: mandatory items and optional items; Determining each necessary diagnosis and treatment item according to the item attributes, obtaining the charge details of the necessary diagnosis and treatment items, and determining the direct medical expense details and indirect medical expense details according to the charge details; Determining the cost structure of each necessary diagnosis and treatment item based on the direct medical expense details and indirect medical expense details; Determining multiple definition dimensions according to the cost structure, and defining multiple cost units of the necessary diagnosis and treatment items through multiple positioning dimensions, where the definition dimensions include: expense type, expense nature, and expense stage.

8. The clinical pathway monitoring method based on the DRG / DIP payment model according to claim 1, wherein After obtaining the clinical path form of the medical insurance version, it further includes: Obtaining the historical treatment information of the target patient based on the disease type, determining the medical data of the target patient according to the historical treatment information, and determining the medical global concept for the target patient according to the medical data; Determining the diagnosis and treatment decision-making factors for the target patient according to the medical global concept, and determining the medical field based on the diagnosis and treatment decision-making factors; Obtaining the clinical rules of the medical field, determining multiple diagnosis and treatment reference features for the target patient according to the clinical rules, and determining the key inclusion information elements of the clinical path form of the medical insurance version through a preset medical knowledge model according to the diagnosis and treatment reference features; Obtain the mapping indicators of key included information elements, and determine the key diagnosis and treatment items and the non-included diagnosis and treatment items in the medical insurance version of the clinical pathway form according to the mapping indicators; Determine the medical correlation parameters between the non-included diagnosis and treatment items and the key diagnosis and treatment items, and determine the co-progression bundling of the non-included diagnosis and treatment items and the key diagnosis and treatment items according to the medical correlation parameters; Determine the to-be-added diagnosis and treatment items in the medical insurance version of the clinical pathway form according to the co-progression bundling, and obtain the target diagnosis and treatment stage where the to-be-added diagnosis and treatment items are located; Obtain the stage objectives of the target diagnosis and treatment stage, determine the core diagnosis and treatment item group according to the stage objectives, and confirm whether the to-be-added diagnosis and treatment items are included in the core diagnosis and treatment items; If so, add the to-be-added diagnosis and treatment items to the medical insurance version of the clinical pathway form to generate a new medical insurance version of the clinical pathway form, if not, confirm that there is no need to add the to-be-added diagnosis and treatment items; Generate an initial diagnosis and treatment node sequence according to the new medical insurance version of the clinical pathway form through a preset comprehensive diagnosis and treatment information model; Generate a dynamic adjustment mechanism according to the initial diagnosis and treatment node sequence and the appointment strategies of each diagnosis and treatment item, and perform real-time adjustment on the new medical insurance version of the clinical pathway form through the dynamic adjustment mechanism.

9. The clinical pathway monitoring method based on the DRG / DIP payment model according to claim 2, wherein, After determining the clinical pathways of multiple diseases according to the diagnosis-related groups, it further includes: Determine the resource types corresponding to each disease clinical pathway, determine the medical resource usage level according to the resource types, and determine the medical resource occupancy cost index of each disease clinical pathway based on the medical resource usage level; Obtain the single-operation frequency and multi-operation cooperation frequency of each disease clinical pathway, and determine the operation complexity index of each disease clinical pathway based on the single-operation frequency and multi-operation cooperation frequency; Obtain the human resource allocation parameters of each disease clinical pathway, and determine the human cost index of each disease clinical pathway according to the human resource allocation parameters and the cooperation operation process parameters; Calculate the recommended fitness of each disease clinical pathway based on the human cost index, operation complexity index and medical resource occupancy cost index of each disease clinical pathway; Screen out the first disease clinical pathways greater than or equal to the preset threshold based on the recommended fitness of each disease clinical pathway, and remove the second disease clinical pathways less than the preset threshold; Use the first disease clinical pathway as the reference clinical pathway for the medical insurance version of the clinical pathway form for the target patient.

10. A clinical pathway monitoring system based on the DRG / DIP payment model, characterized in that, The system includes: A formulation module for determining the disease type of the target patient and formulating a medical insurance version of the clinical pathway form for the target patient based on the disease type; An optimization module for determining the diagnosis and treatment item coefficients of each clinical pathway in the medical insurance version of the clinical pathway form through historical treatment data, and optimizing the medical insurance version of the clinical pathway form according to the diagnosis and treatment item coefficients; A determination module for obtaining relevant diagnosis and treatment opinions of professional physicians on the optimized medical insurance version of the clinical pathway form, and determining the finally implemented clinical pathway according to the relevant diagnosis and treatment opinions; A monitoring module for obtaining the path progress monitoring indicators, path quality monitoring indicators and path cost monitoring indicators of the finally implemented clinical pathway, and monitoring the medical process of the target patient according to the path progress monitoring indicators, path quality monitoring indicators and path cost monitoring indicators.

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