医疗保险信息监控系统建设目标和要素

Goal and Elements in the Construction of Medical Insurance Information Monitoring System

截至2013年底,社会保障卡实际持卡人数已达到5.4亿人,覆盖334个地市,统筹地区内医疗保险即时结算基本实现,绝大多数省份正在积极推进省内异地就医服务。2012年,人社部进一步组织开发了医疗服务监控系统,并在18个地区试点,2013年扩展到45个重点联系城市。信息化为十几年来医疗保险管理提供了强大平台。利用信息系统手段开展医疗服务监控,必须有五要素:数据、系统、规则、知识、人员。在医疗服务监控系统建设中,要合理划分事前事中事后的关系,医疗服务监控系统与结算系统的关系,起步阶段先抓住最突出的问题进行重点监控、逐步完善。

By the end of 2013, the social security card holders have reached the number of 540 million, which covered the people of 334 cities. The goal of immediate settlement of the medical insurance in the urban areas has almost achieved, and most of the provinces are actively promoting the inner provincial medical settlement. In 2012, the Ministry of Human Resources and Social Security developed the monitoring system of medical service, and the pilot studies have been carried out in the 18 areas, and then expanded to 45 cities in 2013. Information technology has promoted the medical insurance management over a decade. To monitor medical service by means of information technology, five elements must be considered： data, system, rules, knowledge, personnel. To construct the monitoring system of medical service by information technology, we must distinguish the relationship of prior control, on spot control and afterwards control, the relationship of monitoring system and settlement system, and must catch the key problem in the initial stage and improve it step by step.