Information processing device, information processing method, and program

Abstract

To provide an information processing device, method and program that more accurately calculate medical expenses for each disease as to the disease described in a receipt.SOLUTION: An information processing device includes: a receipt information acquisition unit that acquires a plurality of pieces of receipt information relative to a specific patient, and prepared in a time sequence; an assignment identification unit that identifies an assignment of a medical practise or a medicine associated with the receipt information relative to diseases included in the receipt information; and a medical expenses calculation unit that on the basis of a score of the medical practise or medicine assigned to the disease. The assignment identification unit is configured to: distinguish a preferential disease of the disease included in second receipt information prepared after first receipt information on the basis of information on the disease included in the first receipt information of the plurality of pieces of receipt information; and identify the assignment of the medical practise or medicine relative to the disease included in the second receipt information, using a combination of the preferential disease, and the medical practise or medicine associated with the second receipt information.SELECTED DRAWING: Figure 1

Description

Technical Field

[0001] The present invention relates to an information processing apparatus, an information processing method, and a program for allocating medical expenses.

Background Art

[0002] Conventionally, a technique for calculating medical expenses for injuries and illnesses described in a receipt using the descriptions of medical procedures and pharmaceuticals described in the receipt has been known (Patent Document 1). A receipt is a bill of particulars created separately for each outpatient and inpatient for each patient at the end of each month by a medical institution that has provided insured medical treatment to an insurer based on a medical fee point table or the like. A plurality of injury and illness names may be described in the receipt. For this reason, in Patent Document 1, for medical procedures and pharmaceuticals provided for a plurality of injury and illness names described in the receipt, a technique for identifying which injury or illness they correspond to using the information on pharmaceuticals and medical procedures described in the same receipt has been proposed. By such a technique, it is possible to calculate medical expenses for an injury or illness (allocate medical expenses to an injury or illness) from the medical expenses described in association with a medical procedure or a pharmaceutical. Further, if a database in which the medical records of all subscribers are accumulated in chronological order for each insurer is used, it becomes possible to statistically analyze medical expenses from various viewpoints such as insured persons, medical institutions, and injuries and illnesses.

Prior Art Documents

Patent Documents

[0003]

Patent Document 1

Summary of the Invention

Problems to be Solved by the Invention

[0004] Incidentally, medical treatment and the provision of medications to patients are often ongoing, and several treatments and medications may be provided after follow-up observations. Therefore, by considering the chronological relationship of information in medical claims, it is expected that the accuracy of identifying treatments and medications for multiple illnesses and injuries listed on the claims, as well as the calculation of medical expenses, will improve.

[0005] Patent Document 1 proposes a technique that uses information on pharmaceuticals and medical procedures listed on the same medical claim, as well as various master data for tracing the relationship between medical procedures and pharmaceuticals for disease names, but it did not consider using information from other medical claims that are in a chronological relationship.

[0006] This invention has been made in view of the above problems, and its purpose is to realize a technology that can calculate medical expenses for each illness or injury with greater accuracy based on the illness or injury described in the medical claim form. [Means for solving the problem]

[0007] To solve this problem, for example, the program of the present invention has the following configuration. That is, A computer program for causing a computer to function as one of the means of an information processing device, wherein the information processing device is A means for acquiring multiple claims information for a specific patient, which are created in chronological order, A means of identifying the medical treatment or drug allocation associated with the illness or injury included in the medical claim information, It has a calculation means for calculating the medical expenses for an injury or injury based on the points for medical treatment or pharmaceuticals assigned to that injury or injury, The aforementioned identification means includes information on illness or injury contained in the first medical claim information among the plurality of medical claim information. and the disease information included in the second receipt information generated after the first receipt information. Based on the previous Record number 2. Identify the priority illness or injury among the illness or injury included in the claim information, and link the priority illness or injury to the second claim information. First Combinations of medical treatment or pharmaceuticals After identifying the priority illness or injury, the combination of the illness or injury and the medical treatment or medicine included in the first medical treatment or medicine is to be included.The method is characterized by identifying the medical treatment or allocation of pharmaceuticals for the illness or injury included in the second medical claim information. [Effects of the Invention]

[0008] According to the present invention, it becomes possible to calculate medical expenses for each illness or injury listed on a medical claim form with greater accuracy. [Brief explanation of the drawing]

[0009] [Figure 1] Block diagram showing an example of the functional configuration of an information processing server as an example of an information processing device according to an embodiment of the present invention. [Figure 2] A schematic diagram illustrating an example of a medical claim form (e.g., a medical fee statement). [Figure 3A] A diagram illustrating the time-series structure of medical claim forms. [Figure 3B] A diagram illustrating an example of how to calculate medical expenses when medical treatment is assigned to an illness or injury. [Figure 4A] Figure (1) illustrates an example of the operation of the medical expense calculation process according to the present invention. [Figure 4B] Figure (2) illustrates an example of the operation of the medical expense calculation process according to the present invention. [Figure 4C] This figure illustrates an example of applying previous medical claim information to newly diagnosed illnesses or injuries in the medical expense calculation process according to the present invention. [Figure 4D] This diagram illustrates an example of applying previously submitted medical claim information to previously assigned illnesses and injuries in the medical expense calculation process according to the present invention. [Figure 5] This diagram illustrates an example of the medical expense calculation process according to the present invention, including the addition of pharmaceuticals. [Figure 6A] A flowchart (t=1) showing a series of operations for the medical expense calculation process according to the present invention. [Figure 6B] A flowchart (t=2) illustrating a series of operations for the medical expense calculation process according to the present invention. [Figure 7] A diagram showing an example of data used to determine the relationship between illness / injury and pharmaceuticals. [Figure 8] A diagram showing an example of data used to determine the relationship between illness / injury and medical treatment.

Best Mode for Carrying Out the Invention

[0010] Hereinafter, embodiments will be described in detail with reference to the accompanying drawings. Note that the following embodiments do not limit the invention according to the claims, and not all combinations of the features described in the embodiments are essential to the invention. Two or more of the plurality of features described in the embodiments may be arbitrarily combined. Also, the same or similar configurations are assigned the same reference numerals, and duplicate descriptions are omitted.

[0011] (Configuration of Information Processing Server) An example of the functional configuration of the information processing server 100 will be described with reference to FIG. 1. Note that each of the functional blocks to be described may be integrated or separated, and the functions to be described may be realized by other blocks. Also, what is described as hardware may be realized by software, and vice versa.

[0012] The communication unit 101 includes a communication circuit that communicates with various devices via a network. The communication unit 101 receives, for example, receipt information from information processing devices of various medical institutions. The power supply unit 102 includes a power supply that provides power necessary for the operation of the information processing server 100.

[0013] The storage unit 103 includes a nonvolatile storage medium such as a hard disk or a semiconductor memory, and includes various programs executed by the control unit 104 of the information processing server 100, various data used by the control unit 104, and a DB. The various programs include a program for executing the medical expense calculation process according to the present embodiment, as well as an operating system, a framework, a library, and the like. The various data include, for example, setting values of the information processing server 100. The DB includes tables used for the medical expense calculation process such as a drug master, a drug table, an indication disease name link table, an indication disease name information file, etc., to be described later, and time-series receipt information.

[0014] The control unit 104 includes a central processing unit (CPU) 110 and RAM 111. The control unit 104 controls the operation of various parts within the control unit 104 and the operation of various parts of the information processing server 100 by loading and executing programs stored in the memory unit 103 into the RAM 111. The control unit 104 also performs the medical expense calculation process described later.

[0015] The claims information acquisition unit 112 acquires multiple claims information for a specific patient, created in chronological order, from the storage unit 103.

[0016] Here, we will explain what a medical claim form (Rezept) is. A medical claim form (Rezept) is a detailed billing statement that medical institutions and pharmacies that have provided insured medical services prepare monthly for each patient, separately for outpatient and inpatient care, based on the medical fee schedule, and submit to the insurer (health insurance association, national health insurance association, seamen's insurance, mutual aid association, national health insurance, etc.). In the case of medical and dental services, it may be called a medical fee statement, and in the case of pharmacies, it may be called a dispensing fee statement. A medical claim form details what diagnoses, tests were performed, treatments were given, and how much medication was prescribed for the patient.

[0017] Figure 2 schematically shows an example of a medical claim form (in this case, a medical fee statement). Claim form 200 has various fields, such as Date of Treatment 201, Insurance Details 202, Patient 203, Medical Institution 204, Illness / Injury 205, Points 206, Remarks 207, and Claim 208. The Date of Treatment 201 field records the date of treatment. The Insurance Details 202 field records, for example, the patient's insurer number. The Patient 203 field records, for example, the patient's name and date of birth. The Medical Institution 204 field records, for example, the name of the medical institution, address, number of beds, and medical department. The Illness / Injury 205 field records the patient's illness / injury. Multiple illness / injury names may be listed. Other information, such as the start date of treatment, is also recorded. Furthermore, in column 206, the details and quantities of medical procedures and medications are recorded according to the medical fee schedule for each designated category (initial consultation, follow-up consultation, medication, injection, treatment, surgery / anesthesia, examination, diagnostic imaging, hospitalization, etc.). In column 207, the detailed content and quantities of medical procedures and medications are recorded. In column 208, the total points for the medical procedures received by the patient at the medical institution are recorded.

[0018] For example, as shown in Figure 3A, when patient 300 visits a medical institution, the medical institution 310 or dispensing pharmacy that provided medical services or medications creates a claim form. The information contained in the claim form may be transmitted and received as digital claim form information 320. As mentioned above, since claim forms are created monthly, the accumulated claim form information constitutes a time series. The example shown in Figure 3 schematically shows an example where claim form information is structured chronologically for each medical institution, but it can be categorized and chronologically organized in more detail. In the information processing server 100, the claim form information is categorized and chronologically organized, for example, by patient, by medical institution, by medical department, by type of claim (in the case of medical claims, for example, medical inpatient claims, medical outpatient claims, DPC claims), or by dispensing claim. Note that the claim forms chronologically organized are not limited to Figure 3 or this example, but may be categorized by at least one of the following: patient, medical institution, medical department, or type of claim. For example, the claim information is sequentially transmitted from the medical institution 310 to the information processing server 100 and stored in the information processing server 100. In this embodiment, for convenience, the case in which the information processing server 100 receives claim information from each medical institution 310 is described as an example, as shown in Figure 3A. However, the information processing server 100 may be configured to first receive the claim information received from the medical institution by the insurer's information processing device from the insurer's information processing device.

[0019] The allocation identification unit 113 identifies the allocation of medical procedures or pharmaceuticals associated with the illness or injury included in the medical claim information during the medical expense calculation process described later. The allocation of illness or injury to medical procedures or pharmaceuticals will be described later.

[0020] The medical expense calculation unit 114 calculates the medical expenses for an illness or injury based on the points for medical procedures and pharmaceuticals assigned to the illness or injury by the assignment identification unit 113 in the medical expense calculation process described later. An example of medical expense calculation will be explained with reference to Figure 3B. In the example in Figure 3B, the medical procedures included in the claim are assigned to the illness or injury. In this example, only medical procedures are given as an example, but medical expenses can be calculated in the same way when medical procedures and pharmaceuticals are assigned to an illness or injury, or when only pharmaceuticals are assigned to an illness or injury.

[0021] In the example in Figure 3B(a), the conditions included in a medical claim, namely sleep disorders and anxiety disorders, are assigned the following fees: "re-examination fee, additional fee for detailed statement issuance system, additional fee for outpatient management, nasal airflow" and "re-examination fee, additional fee for detailed statement issuance system, additional fee for outpatient management," respectively. In some cases, a medical procedure, such as "nasal airflow," may be assigned to a single condition, while in other cases, such as "re-examination fee," the same medical procedure may be assigned to multiple conditions.

[0022] Figure 3B(b) shows the medical costs (and points) for each medical procedure. In this example, for instance, the follow-up consultation fee is 730 yen (73 points), and the nasal airflow assessment fee is 3000 yen (300 points). The medical cost for sleep disorders is the sum of the cost of the nasal airflow assessment and the allocated costs of the follow-up consultation fee, the additional fee for issuing detailed statements, and the additional fee for outpatient management. The allocation of medical costs is calculated, for example, by dividing the medical cost of the medical procedure by the number of assigned illnesses or injuries. That is, the medical cost for sleep disorders is 3000 + (730 + 10 + 520) / 2 = 3630 yen. Similarly, the medical cost for anxiety disorders is (730 + 10 + 520) / 2 = 630 yen. Note that the method of calculating medical costs is not limited to the method shown in Figure 3B, and other calculation methods may be used. For example, in the example shown in Figure 3, the medical expenses for sleep disorders and anxiety disorders are calculated by allocating half (730 / 2) of the medical expenses for the follow-up consultation fee. However, the medical expenses for each illness or injury may be calculated by multiplying each medical procedure by a coefficient calculated for that specific illness or injury, or by a predetermined coefficient for each medical procedure. For example, the medical expenses for anxiety disorders are calculated as 730 × α + 10 × β + 520 × γ, where α, β, and γ are coefficients calculated for each anxiety disorder, including the follow-up consultation fee, the additional fee for issuing detailed statements, and the additional fee for outpatient management. The method of calculating these coefficients is arbitrary, but they may be calculated probabilistically, for example, based on the number of occurrences of medical procedures for illnesses or injuries in all or part of the collected claims information.

[0023] The dispensing data processing unit 115 links the information from the dispensing claim to medical claims (inpatient, outpatient, and DPC) that include medical services such as prescription fees. Medical services such as prescription fees are, for example, those in which the first four digits of the medical fee schedule classification number are listed as "F400". The dispensing data processing unit 115 links the information from the dispensing claim and the medical claims based on the correspondence between information that identifies the medical institution (e.g., unique ID, medical institution ID) and dates (e.g., prescription date on the dispensing claim, medical service date on the medical claims, etc.). The dispensing data processing unit 115 filters the combinations of drugs included in the dispensing claim and diseases in the medical claims (those with medical services such as prescription fees) using the indication master and selects practical combinations between diseases and drugs. Filtering using the indication master will be described later. The dispensing data processing unit 115 stores in the storage unit 103 the illnesses and injuries of the medical claims (those with prescription fee information) associated with the drugs in the dispensing claims, obtained as a result of filtering by the indication master, in an identifiable state (for example, by setting a flag). In this way, when performing medical expense calculation processing based on the information in the medical claims, the drugs in the dispensing claims can be taken into consideration.

[0024] The claims data recording unit 116 stores the claims information received by the communication unit 101 in the storage unit 103. As described above, the claims information is categorized by patient, medical institution, medical department, type of claims (for example, in the case of medical claims, medical inpatient claims, medical outpatient claims, DPC claims), or dispensing claims, and is organized chronologically. In addition, various tables to be stored in the storage unit 103 are generated in response to commands from the administrator of the information processing server 100, and the information of the generated tables is stored in the storage unit 103.

[0025] (Example of medical expense calculation process) Next, an example of the medical expense calculation process performed by the allocation identification unit 113 and the medical expense calculation unit 114 will be explained with reference to Figures 4A to 4D.

[0026] Figure 4A shows the processing of the claim information to be processed when the time of the claim information to be processed is t=1 (the first claim) among the claim information that constitutes the time series. The claim information 401 shown in Figure 4A includes illness A, illness B, and illness C. In addition, medical treatment A, medical treatment B, and medical treatment C are associated with the claim information 401.

[0027] Filtering will be discussed later, but in the example shown in Figure 4A, medical procedure A is a medical procedure that is not classified as an examination or surgery according to the medical fee schedule classification number. Therefore, medical procedure A is a medical procedure that is not related to the implementation of the indication master. On the other hand, medical procedures B and C are medical procedures that can be selected by filtering using the indication master. However, medical procedure B is a medical procedure for which there is no combination indicated in the indication master in relation to illnesses A to C, while medical procedure C is a medical procedure for which there is a combination indicated in the indication master in relation to illness C.

[0028] The assignment identification unit 113 first generates a combination 402 of anticipated illnesses and medical procedures by combining all medical procedures A to C with illness A, illness B, and illness C, respectively. The assignment identification unit 113 then applies filtering using the indication master to the obtained combinations 402 to select the combinations indicated by the indication master from among the obtained combinations 402. Here, the indication master indicates a set of practical, predetermined combinations of illnesses and medical procedures (or pharmaceuticals) that may be included in the claims information. In other words, by applying filtering using the indication master, it is possible to extract practical combinations of illnesses and medical procedures (or pharmaceuticals) from the anticipated combinations 402 of anticipated illnesses and medical procedures. In this embodiment, filtering using the indication master is applied to medical procedures that are classified as examinations or surgeries according to the medical fee schedule classification number.

[0029] In the example in Figure 4A, medical procedure A is selected for all illnesses A-C, regardless of whether the indication master is performed. Medical procedure B does not have any combinations with illnesses A-C that are shown in the indication master. Therefore, medical procedure B is not included in the actual combination 404. On the other hand, medical procedure C is selected as an actual combination 404 because a combination exists with illness C that is shown in the indication master.

[0030] Next, the assignment identification unit 113 identifies the previous claim information (405). The previous claim information includes diseases and injuries included in combination 404 that include medical procedures selected by the indication master (assigned diseases and injuries 406), medical procedures combined with each disease and injury in combination 404, and medical procedures that are not assigned in combination 404 (unassigned medical procedures 407). Furthermore, the previous claim information may include the identification number of the claim that was processed and information on all medical procedures associated with the claim.

[0031] Furthermore, the allocation identification unit 113 assigns an unassigned medical procedure (medical procedure B in the example of Figure 4A) to each illness or injury included in the existing combination 404 (408). In this way, the medical expenses for medical procedures that could not be explicitly assigned to a particular illness or injury can be allocated to each illness or injury. Subsequently, the medical expense calculation unit 114 calculates the medical expenses for each illness or injury based on the combination to which the unassigned medical procedures have been assigned, using the process described above in Figure 3B.

[0032] (Medical expense calculation process for claim information at time t=2) Next, referring to Figure 4B, we will explain the processing when the time of the claim information to be processed is t=2 (the next claim) among the claim information that constitutes the time series. In the example shown in Figure 4B, claim information 411 includes illness A, illness C, and illness D. Claim information 411 is associated with medical procedures A, B, and D. Medical procedures A and B are the same as those described above in Figure 4A. That is, medical procedure A is a medical procedure that is selected regardless of the implementation of the indication master, and medical procedure B is a medical procedure for which there is no combination indicated in the indication master in relation to illnesses A, C, and D. Medical procedure D is a medical procedure for which there is a combination indicated in the indication master in relation to illness C. In addition, illness C is an illness that has been assigned as described above in Figure 4A and is included in claim information 411 (previously assigned illness 412). Disease D is a new disease (newly identified disease 413) included in claim information 411 but not in claim information 401. Disease C, which is already assigned, and disease D, which is newly identified, are identified as priority diseases that are treated with priority over other diseases (for example, disease A). On the other hand, disease A is a non-priority disease among the diseases included in claim information 411.

[0033] The allocation identification unit 113 first filters for priority illnesses (illnesses C and D), and then combines medical procedures that were not assigned to any illness in the filtering in (1) for illnesses that are not priority (illness A), and then filters the combination using the indication master.

[0034] First, (1) will be explained in detail. The assignment identification unit 113 generates combinations 414 of medical procedures for newly identified and previously assigned diseases by combining medical procedures A, B, and D for diseases C and D. The assignment identification unit 113 then applies filtering based on the indication master and previous claim information to the combinations 414 (415). At this time, the assignment identification unit 113 applies different filtering processes to the medical procedures for newly identified diseases (e.g., disease D) and the medical procedures for previously assigned diseases (e.g., disease C). The assignment identification unit 113 applies filtering based on the indication master to the combination of medical procedures for newly identified diseases. In the example shown in Figure 4B, medical procedure D does not remain because there is no combination indicated in the indication master in relation to disease D. Medical procedure A remains regardless of the application of the indication master. Therefore, only medical procedure A is selected by filtering for newly identified disease D.

[0035] On the other hand, for combinations of medical procedures for disease C, which is a previously assigned disease, filtering using the previous claim information and filtering using the indication master are applied to the corresponding medical procedures. In filtering using the previous claim information, disease procedures that are not covered by the indication master and medical procedures that are not covered by the indication master in the previous claim information are selected (retained). That is, medical procedure A, which is combined with disease C, matches medical procedure A for disease C in the previous claim information, so it remains after filtering. Also, medical procedure D is subject to processing by the indication master and corresponds to a combination indicated by the indication master, so it remains after filtering. In this way, medical procedures A and D are combined with disease C, and medical procedure A is combined with disease D (416).

[0036] Thus, in this embodiment, newly identified illnesses and injuries and previously assigned illnesses are given priority. This allows illnesses that were assigned medical procedures in the previous claim or newly added in the current claim information to be treated as high-priority illnesses, and medical procedures can be appropriately assigned to these illnesses. Furthermore, medical procedures that are not subject to the indication master (medical procedure A) include, for example, medical procedures such as follow-up consultation fees and outpatient management surcharges, and these medical procedures can be exclusively assigned to high-priority illnesses (illness C, etc.) where it is considered that medical procedures were actually performed. In other words, by assigning medical procedure A to less important illnesses A, it becomes possible to prevent the dispersion of medical expenses and to calculate medical expenses more accurately. In this embodiment, the case where the claim information for t=1 and the claim information following the claim information for t=1 (i.e., t=2) are used will be explained as an example. However, this embodiment is not limited to claim information adjacent in time series. The processing according to this embodiment may be applied, for example, to the claim information for t=1 and claim information within a predetermined period after t=1 (e.g., t=3). Furthermore, this embodiment is not limited to cases where only two claim information entries in time series are used, but can also be applied when three or more claim information entries are used. For example, previous claim information may be generated from the claim information for t=1 and the claim information for t=2, and diseases that overlap between either of the previous claim information entries and the claim information for t=3, or diseases in the claim information for t=3 that do not overlap with any of the previous claim information entries, may be identified (as previously assigned diseases or newly identified diseases). Even in this way, specific illnesses and injuries can be given priority in chronological claims information (as newly reported illnesses or previously assigned illnesses and injuries).

[0037] Next, (2) will be explained. The assignment identification unit 113 then combines a medical procedure that was not assigned to any of the illnesses in the filtering in (1) with an illness that is not a priority illness (illness A). In the example in Figure 4B, medical procedure B is combined with illness A. The assignment identification unit 113 then filters the combination using the indication master. In the example shown in Figure 4B, medical procedure B is not a combination indicated in the indication master with respect to illness A, so at this stage, medical procedure B is not assigned to illness A.

[0038] Furthermore, the assignment identification unit 113 stores the currently identified combination of illness and medical treatment in the storage unit 103 as previous information, similar to the case where t=1. The assignment identification unit 113 also assigns the unassigned medical treatment included in the claim information 411 to all illnesses. Through the above processing, the assignment of medical treatment to the illnesses included in the claim information is identified. Subsequently, the medical expense calculation unit 114 calculates the medical expenses for illnesses A, C, and D.

[0039] (Example of applying previous claim information to newly diagnosed illnesses / injuries) Next, referring to Figure 4C, we will explain an example of processing when different claim information 421 is entered at time t=2 compared to the case in Figure 4B. The example in Figure 4C shows a case in which a new medical procedure E is included in the claim information 421, to which the indication master is not applied, compared to the case in Figure 4B.

[0040] The processing steps are the same as those described with reference to Figure 4B, but the results differ when filtering is applied to the combination of medical procedures 424 for newly identified illnesses, etc., using the previous claim information. Specifically, after combining illness C, which is the previously assigned illness 422, and illness E, which is the newly identified illness 423, medical procedures A, B, and E are applied, and then the newly identified illness is filtered using the indication master. At this time, medical procedures A and E, which are not subject to filtering by the indication master, remain.

[0041] On the other hand, for disease C, which is already assigned, filtering based on the previous claim information and filtering based on the indication master are applied. As a result, medical procedure E, which is new at t=2, does not exist in the previous claim information and therefore does not remain in the filtered combinations. In other words, the result of filtering based on the indication master and the previous claim information is the combination shown in 426 of Figure 4C.

[0042] In other words, in this medical expense calculation process, when a medical procedure that does not apply to the indication master (a medical procedure not classified as an examination or surgery according to the medical fee schedule classification number) newly appears in the claim being processed, that medical procedure can be assigned only to newly identified illnesses or injuries. That is, by performing filtering based on the previous claim information on previously assigned illnesses or injuries, it becomes possible to avoid assigning such medical procedures to previously assigned illnesses or injuries and to calculate medical expenses appropriately.

[0043] The allocation identification unit 113 then performs the processing described above in Figure 4B. For example, the allocation identification unit 113 performs selection processing for other illnesses (e.g., illness A that is not a priority), identification of previous claim information, and allocation of unassigned medical procedures (427). The medical expense calculation unit 114 calculates the medical expenses allocated to each illness (428).

[0044] (Example of applying previous claim information to previously assigned illnesses / injuries) Furthermore, referring to Figure 4D, we will explain an example of processing when different claim information 431 is entered at time t=2 compared to the cases in Figures 4B and 4C. The example in Figure 4D shows a case where medical procedure F, to which the indication master does not apply, is included in the claim information 431. Medical procedure F is assumed to be included in the previous claim information. Furthermore, the claim information does not include newly identified illnesses or injuries. In the example in Figure 4D, in the previous claim information, illness A includes medical procedure A, and illness F includes both medical procedure A and medical procedure F.

[0045] The processing steps are the same as those described with reference to Figure 4B. In the example shown in Figure 4D, illness A and illness F become previously assigned illnesses 432 and 433. Therefore, the assignment identification unit 113 combines medical procedures A, B, and F with illness A and illness F, respectively. For this combination of medical procedures 434 for previously assigned illnesses, the assignment identification unit 113 applies filtering based on the previous claim information. In this example, there are no medical procedures to which filtering by the indication master should be applied, so this step is omitted.

[0046] When filtering is applied to the combination of medical procedures 434 using the previous claim information, medical procedure F is not assigned to illness A, which does not include medical procedure F in the previous claim information. On the other hand, medical procedure F is assigned to illness F, which does include medical procedure F in the previous claim information (436). The assignment identification unit 113 then identifies the previous claim information and assigns unassigned medical procedures (437), and the medical expense calculation unit 114 calculates the medical expenses assigned to each illness (438). In this way, filtering using the previous claim information allows medical procedures to be assigned only to illnesses for which medical procedures have actually been performed in the past, enabling accurate allocation of medical expenses. Furthermore, as is clear from the above example, in the medical expense calculation process according to this embodiment, the combination of illness and medical procedure selected for the claim information at t=2 can be made different depending on the content of the previous claim information. Therefore, even if the claim information at t=2 is the same, if the content of the previous claim information (i.e., past treatment history) is different, the assigned illness will be different. Thus, the medical expense calculation process according to this embodiment can reflect medical procedures related to past treatments, such as new medical procedures or follow-up examinations.

[0047] (Allocation of medicines for illnesses and injuries) The above explanation used the example of a case where only medical treatment is linked to the claim information. However, in addition to medical treatment, pharmaceuticals can also be linked to the claim. The assignment of pharmaceuticals to illnesses can be done in the same way as the assignment of medical treatment, except when additional processing specific to pharmaceuticals is required, as will be described later. For this reason, the assignment of pharmaceuticals to illnesses will be briefly explained using the case where time t=2 as an example.

[0048] Figure 5 shows an example of medical expense calculation processing when a drug is linked to a medical claim. In the example shown in Figure 5, medical claim information 511 includes illness A, illness C, and illness D. Medical claim information 511 is also linked to medical procedure A, medical procedure B, and drug Y. Medical procedure A and medical procedure B are the same as those described above in Figure 4A. That is, medical procedure A is a medical procedure that is selected regardless of the implementation of the indication master, and medical procedure B is a medical procedure for which there is no combination indicated in the indication master in relation to illness A, C, and D. Drug Y is a medical procedure for which there is a combination indicated in the indication master in relation to illness C. Illness C is an illness that has been assigned as described above in Figure 4A and is included in medical claim information 511 (previously assigned illness 512). Illness D is a new illness (newly identified illness 513) included in medical claim information 511 that was not included in the previous medical claim information. Disease A is a disease that is not a priority among the diseases included in claim information 511.

[0049] The assignment identification unit 113 first filters for priority illnesses (illnesses C and D) (515), and then combines medical procedures that were not assigned to any illness in the filtering in (1) for illnesses that are not priority (illness A), and performs filtering on the combination using the indication master (516).

[0050] First, the allocation identification unit 113 generates combinations 514 of medical procedures 514 for newly identified and previously assigned illnesses by combining medical procedures A, B, and drug Y for illnesses C and D. Then, the allocation identification unit 113 applies filtering based on the indication master and previous claim information to the combinations 514 (515). At this time, the allocation identification unit 113 applies filtering based on the indication master to the combination of medical procedures for newly identified illnesses (for example, illness D). In the example shown in Figure 5, drug Y does not remain because there is no combination indicated in the indication master in relation to illness D. Also, medical procedure A remains regardless of the application of the indication master. Therefore, only medical procedure A is selected by filtering for newly identified illness D.

[0051] On the other hand, for combinations of medical procedures for disease C, which is already assigned, filtering using the previous claim information and filtering using the indication master are applied to the corresponding medical procedures. Drug Y is filtered using the indication master and assigned to disease C. In this way, medical procedure A and drug Y are combined for disease C, and medical procedure A is combined for disease D (516).

[0052] Furthermore, drug filtering may be performed using drug-specific processing. For example, first, filtering of disease-disease and drug combinations is performed using the indication master or previous claim information, prior to filtering of disease-disease and medical procedure combinations. Then, for the remaining disease-disease and drug combinations after filtering, diseases that are combined with drugs related to anesthesia (e.g., ATC subclassification N01) are identified (e.g., an anesthesia flag is set). Next, when filtering disease-disease and medical procedure combinations, for diseases with the anesthesia flag set, the indication disease name of the combined medical procedure is considered to be "during anesthesia," and filtering using the indication master is applied. In this way, medical procedures and drugs can be assigned more appropriately to diseases that require anesthesia during examinations. This process of considering the indication disease name of a medical procedure as "during anesthesia" may be applied not only when t=2 but also when t=1.

[0053] Next, the assignment unit 113 combines a medical procedure (medical procedure B) that was not assigned to any of the diseases in the above filtering with a disease that is not a priority disease (disease A). Furthermore, the assignment unit 113 filters the combination using the indication master (517). As described above in Figure 4B, at this stage, medical procedure B is not assigned to disease A. Furthermore, the assignment unit 113 stores the previous claim information in the storage unit 103. The assignment unit 113 also assigns the unassigned medical procedures included in the claim information 511 to all diseases. After that, the medical expense calculation unit 114 calculates the medical expenses for diseases A, C, and D.

[0054] (A series of actions related to the calculation of medical expenses) Next, the series of operations of the medical expense calculation process according to this embodiment will be described with reference to the flowcharts shown in Figures 6A and 6B. The medical expense calculation process is performed by the control unit 104 executing the program stored in the storage unit 103. For convenience, the following explanation will describe the case in which medical treatment and pharmaceuticals are combined for an illness or injury, but it is sufficient to combine at least one of medical treatment or pharmaceuticals with the illness or injury.

[0055] In S601, the claims information acquisition unit 112 sequentially acquires claims information that has been pre-stored in the storage unit 103 in a time-series format.

[0056] In S602, the control unit 104 determines whether the acquired claim information is the first (t=1) claim information. If the claim information to be processed is the first claim information, the control unit 104 proceeds to S603; otherwise, it proceeds to S620 as shown in Figure 6B.

[0057] In S603, the control unit 104 determines whether there is only one illness or injury included in the claim information. If there is only one illness or injury, the process proceeds to S610. On the other hand, if there is more than one illness or injury included in the claim information, the process proceeds to S604. In S610, the assignment identification unit 113 assigns all medical procedures and pharmaceuticals to the single illness or injury and proceeds to S609.

[0058] In S604, the dispensing data processing unit 115 performs the dispensing claim linking process. As described above, the dispensing data processing unit 115 links the information of the dispensing claim to medical claims (inpatient medical care, outpatient medical care, DPC) that include medical services such as prescription fees. The dispensing data processing unit 115 links the information of the dispensing claim with the information of the medical claims and performs filtering using the indication master for the combination of drugs included in the dispensing claim and diseases in the medical claims (those that include medical services such as prescription fees). The dispensing data processing unit 115 makes it possible to refer to the diseases in the medical claims (those that include prescription fees) that are associated with the drugs in the dispensing claim, as obtained as a result of filtering using the indication master.

[0059] In S605-S609, the allocation identification unit 113 or the medical expense calculation unit 114 performs the process of calculating medical expenses for the illness in the claim form when t=1, referring to Figure 4A as described above. That is, the allocation identification unit 113 combines medical procedures and pharmaceuticals for each illness included in the claim form information (S605). The allocation identification unit 113 applies the indication master to the combination of medical procedures and pharmaceuticals for the illness to select a practical combination of illness and medical procedures or pharmaceuticals (S606).

[0060] Here, an example of the process for obtaining the relationship between diseases and pharmaceuticals in the indication master when applying the indication master will be explained with reference to Figure 7. First, the assignment identification unit 113 extracts the pharmaceutical code from the receipt and identifies the ATC subclassification that corresponds to the pharmaceutical code in the receipt from the corresponding pharmaceutical code in the pharmaceutical master 700. Next, it identifies the corresponding efficacy code from the corresponding ATC subclassification in the pharmaceutical table 701. Then, it obtains the corresponding ICD subclassification from the corresponding efficacy code in the indication disease name link table 702 and compares it with the disease name (ICD10 subclassification) included in the receipt. The pharmaceutical master 700 is a table that contains records such as pharmaceutical code, ATC subclassification, and ATC subclassification name. The pharmaceutical table 701 is a table that contains the pharmaceutical name, efficacy code, and ATC subclassification. Furthermore, the indication disease name link table 702 is a table that contains the efficacy code, target efficacy name, and ICD. In this way, one or more disease names (ICD10 subclassifications) associated with a specific pharmaceutical can be identified.

[0061] Furthermore, the process for obtaining the relationship between the disease in the indication master and the medical procedures related to the examination will be explained with reference to Figure 8. In the indication disease name information file 800 shown in Figure 8, the medical fee schedule classification code and the ICD10 subclassification are associated. Therefore, the assignment identification unit 113 can identify the ICD10 subclassification from the medical fee schedule classification code.

[0062] Furthermore, the allocation identification unit 113 can obtain the relationship between the disease in the indication master and the medical procedures related to the examination using the table 801 which shows the medical procedures for surgery as shown in Figure 8. Since the table 801 also associates the medical fee schedule classification code with the ICD10 subclassification, the allocation identification unit 113 can identify the ICD10 subclassification from the medical fee schedule classification code.

[0063] Returning to the explanation of Figure 6A, the allocation identification unit 113 stores the previous claim information obtained through the processing in S606 in the storage unit 103 (S607), and allocates the unassigned medical procedures and unassigned pharmaceuticals to all illnesses and injuries (S608). Finally, the medical expense calculation unit 114 calculates the medical expenses for each illness or injury using the medical expenses (points) of the medical procedures and pharmaceuticals assigned to each illness or injury (S609). Here, if there is only one illness or injury, the allocation identification unit 113 stores the result obtained through the processing in S610 as the previous claim information in the storage unit 103, and the medical expense calculation unit 114 calculates the medical expenses for that illness or injury (S609).

[0064] In S611, the control unit 104 determines whether the claim information to be processed is the final claim. If it is not the final claim, it returns to S602 to process the next claim.

[0065] Referring to Figure 6B, the processing for the following claim information (t=2) will be explained. In S620, the control unit 104 determines whether there is only one illness or injury included in the claim information. If there is only one illness or injury, the processing proceeds to S630. On the other hand, if there is more than one illness or injury included in the claim information, the processing proceeds to S621. In S630, the assignment identification unit 113 assigns all medical procedures and pharmaceuticals to one illness or injury and proceeds to S629.

[0066] In S621, the dispensing data processing unit 115 performs the dispensing claim linking process in the same manner as in S604.

[0067] In S622-S628, the allocation identification unit 113 or the medical expense calculation unit 114 performs the process of calculating medical expenses for the illness in the claim for t=2, as described above, with reference to Figure 4B (~Figures 4D and 5). Specifically, the allocation identification unit 113 identifies priority illnesses (newly identified illnesses, previously assigned illnesses) included in the claim information and combines medical procedures and pharmaceuticals for the identified illnesses (S622). The allocation identification unit 113 applies filtering based on the indication master and previous claim information to the combinations of medical procedures and pharmaceuticals for priority illnesses (S623) to select practical combinations or previously used combinations of illnesses and medical procedures or pharmaceuticals (S624). Furthermore, the allocation identification unit 113 applies the indication master to the combinations of medical procedures and pharmaceuticals for non-priority illnesses to select practical combinations of non-priority illnesses and medical procedures or pharmaceuticals (S625). Furthermore, the allocation identification unit 113 stores the previous claim information obtained through the processing in S625 in the storage unit 103 (S626), and allocates the unassigned medical procedures and unassigned pharmaceuticals to all illnesses and injuries (S627). Finally, the medical expense calculation unit 114 calculates the medical expenses for each illness or injury using the medical expenses (points) of the medical procedures and pharmaceuticals assigned to each illness or injury (S628). Here, if there is only one illness or injury, the allocation identification unit 113 stores the result obtained through the processing in S630 as the previous claim information in the storage unit 103, and the medical expense calculation unit 114 calculates the medical expenses for that illness or injury (S628).

[0068] The control unit 104 determines whether the claim to be processed is the final claim. If the claim to be processed is not the final claim, it returns to S601 to process the next claim information. On the other hand, if the claim to be processed is the final claim, it terminates this medical expense calculation process.

[0069] As explained above, in this embodiment, information from medical claims organized in chronological order is used to identify the assignment of medical procedures and pharmaceuticals associated with the medical claims for the illnesses and injuries included in the medical claims. At this time, based on the information about illnesses and injuries included in the medical claims information at t=1, priority illnesses and injuries (newly diagnosed illnesses and illnesses or previously assigned illnesses) included in medical claims information after t=1 (for example, t=2) are identified. Then, using the combination of priority illnesses and medical procedures or pharmaceuticals associated with the medical claims information at t=2, the assignment of medical procedures or pharmaceuticals for the illnesses and injuries included in the medical claims information at t=2 is identified. In this way, new illnesses and injuries, and illnesses for which medical procedures have actually been performed in the past, can be assigned preferentially to those with a high degree of certainty. In other words, it becomes possible to calculate the medical expenses for each illness and injury with greater accuracy for those listed in the medical claims.

[0070] The invention is not limited to the embodiments described above, and various modifications and changes are possible within the scope of the gist of the invention. [Explanation of symbols]

[0071] 100... Information processing server, 103... Storage unit, 104... Control unit, 112... Receipt information acquisition unit, 113... Allocation identification unit, 114... Medical expense calculation unit

Claims

1. A computer program for causing a computer to function as one of the means of an information processing device, wherein the information processing device is A means for acquiring multiple claims information for a specific patient, which are created in chronological order, A means of identifying the medical treatment or drug allocation associated with the illness or injury included in the medical claim information, It has a calculation means for calculating the medical expenses for an injury or injury based on the points for medical treatment or pharmaceuticals assigned to that injury or injury, The program is characterized in that the identifying means identifies a preferred disease among the diseases included in the second receipt information based on the disease information included in the first receipt information among the plurality of receipt information and the disease information included in the second receipt information generated after the first receipt information, identifies a combination of the preferred disease and a first medical procedure or drug associated with the second receipt information, and then identifies the assignment of a medical procedure or drug to the disease included in the second receipt information so as to include a combination of the preferred disease and a medical procedure or drug included in the first medical procedure or drug.

2. The program according to claim 1, characterized in that the identifying means identifies new illnesses and injuries included in the second claim information that are not included in the first claim information as preferred illnesses and injuries, and identifies the assignment of medical treatments or pharmaceuticals to the illnesses and injuries included in the second claim information so as to include combinations of the new illnesses and injuries with the medical treatments or pharmaceuticals included in the first medical treatment or pharmaceuticals.

3. The program according to claim 1 or 2, characterized in that the identifying means identifies a previously listed predetermined illness or injury included in the first claim information to which a medical procedure or medicine linked to the first claim information has been pre-assigned as the preferred illness or injury, and identifies the assignment of a medical procedure or medicine to the illness or injury included in the second claim information to include a combination of the previously listed predetermined illness or injury and a medical procedure or medicine included in the first medical procedure or medicine.

4. The program according to any one of claims 1 to 3, characterized in that the identifying means further identifies illnesses that are not the preferred illnesses among the illnesses included in the second claim information, and identifies the assignment of medical procedures or pharmaceuticals to illnesses included in the second claim information such that it includes combinations of medical procedures or pharmaceuticals included in the first medical procedure or pharmaceutical that are not assigned to the preferred illnesses, and illnesses that are not the preferred illnesses.

5. The aforementioned specified illness or injury is an illness or injury that relates to a combination of illness or injury included in the first claim information and a medical procedure or drug associated with the first claim information, selected as a combination indicated by the indication master, and includes the same illness or injury as the illness or injury included in the second claim information. The program according to claim 3, characterized in that the aforementioned indication master is a practical, predetermined combination of illness or injury and medical treatment or pharmaceutical product that may be included in the medical claim information.

6. The identification means, when identifying the assignment of medical treatment or pharmaceuticals for the illness or injury included in the second claim information, selects a combination indicated by the indication master from among the combinations of the illness or injury identified as the priority illness or injury and the medical treatment or pharmaceuticals associated with the second claim information, The program according to any one of claims 1 to 4, characterized in that the aforementioned indication master is a practical, predetermined combination of illness or injury and medical treatment or pharmaceutical product that may be included in the claims information.

7. The program according to claim 6, characterized in that, among the combinations of the disease identified as a priority disease and the medical procedure or drug associated with the second receipt information, the program selects a combination of the disease identified as a priority disease and the medical procedure that is selected regardless of the selection by the indication master, in addition to the combinations indicated by the indication master.

8. The program according to claim 7, characterized in that the medical procedure selected regardless of the selection by the indication master is a medical procedure that is not classified as an examination or surgery according to the medical fee schedule classification number.

9. The program according to claim 7 or 8, characterized in that the identifying means identifies a previously recorded predetermined injury or injury included in the first receipt information, among the injuries or injuries included in the second receipt information, to which a medical procedure or drug associated with the first receipt information has been pre-assigned, and from among the combinations of the previously recorded predetermined injury or injury and the medical procedure or drug associated with the second receipt information, selects a combination of the previously recorded predetermined injury or injury and the predetermined medical procedure and a combination indicated by the indication master.

10. The program according to any one of claims 1 to 9, further comprising a linking means for linking illnesses and injuries included in claim information that contains descriptions of medical procedures defined as prescription fees, etc., according to the classification number of the medical fee schedule, with pharmaceuticals included in the claim information of a dispensing claim.

11. The program according to any one of claims 1 to 10, characterized in that the plurality of claims information are stored in a storage means in the time series in which they were created, for at least one of the patient, medical institution, medical department, and type of claims.

12. An information processing method in which each step is performed by an information processing device, A process for acquiring multiple claims information for a specific patient, which are created in chronological order, A process to identify the medical treatment or drug allocation associated with the illness or injury included in the medical claim information, It includes a calculation process for calculating the medical expenses for an injury or injury based on the points allocated to the medical treatment or pharmaceuticals for that injury or injury, An information processing method comprising the above-mentioned specific step, in which, based on the disease information contained in the first claim information among the plurality of claim information and the disease information contained in the second claim information generated after the first claim information, a preferred disease among the diseases contained in the second claim information is identified, a combination of the preferred disease and a first medical procedure or pharmaceutical product associated with the second claim information is identified, and an assignment of a medical procedure or pharmaceutical product to the disease contained in the second claim information is identified so as to include the combination of the preferred disease and a medical procedure or pharmaceutical product contained in the first medical procedure or pharmaceutical product.

13. A means for acquiring multiple claims information for a specific patient, which are created in chronological order, A means of identifying the medical treatment or drug allocation associated with the illness or injury included in the medical claim information, It has a calculation means for calculating the medical expenses for an injury or injury based on the points for medical treatment or pharmaceuticals assigned to that injury or injury, The identification means is characterized by identifying a preferred disease among the diseases included in the second receipt information based on the disease information included in the first receipt information among the plurality of receipt information and the disease information included in the second receipt information generated after the first receipt information, identifying a combination of the preferred disease and a first medical procedure or pharmaceutical product associated with the second receipt information, and then identifying the assignment of a medical procedure or pharmaceutical product to the disease included in the second receipt information so as to include a combination of the preferred disease and a medical procedure or pharmaceutical product included in the first medical procedure or pharmaceutical product.

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