DRGs支付制度下病案智能化编码现状与完善策略

Current Situation and Improvement Strategy of Intelligent Coding of Medical Records Under the Payment System of DRGs

目的:在DRGs支付制度下,为实现智能化辅助编码工具的改进和推广提供参考。方法:调研市场上病案智能化辅助编码的主流产品技术、应用现状。结果:首先我国已有产品基本满足DRGs支付制度下对智能化编码的功能需求,但由于缺乏结构化、标准化的病案数据,产品核心功能实现基础相对薄弱;其次由于单一产品的影响力有限,其应用范围十分促狭;最后,我国编码审查以内部为主,缺少DRGs制度相匹配的审查监管制度。结论:建议通过加强多方数据共享机制建设、运用人工智能等技术提高数据质量、颁布专门的法律法规保障、构建完善的费用、编码及数据质量审查监管机制等措施推广和完善智能辅助编码的应用。

Objective:Under the DRGs payment system,it provides a reference for the improvement and promotion of intelligent auxiliary coding tools.Methods:Investigate the current state of technology,application of intelligent auxiliary coding of electronic medical records.Results:Firstly,the existing products in China basically meet the functional requirements for intelligent coding under the DRGs payment system,but due to the lack of structured,and standardized medical record data,the foundation of the product's core functions is relatively weak.Secondly,because of the limited influence of a single product,its scope of application is very limited.Finally,China's code review is mainly internal and lacks a review and supervision system that matches the DRGs system.Conclusion:It is recommended to promote and improve the application of intelligent auxiliary coding through measures such as strengthening the construction of multi-party data sharing mechanisms,using artificial intelligence technology to improve data quality,promulgating special legal and regulatory guarantees,constructing comprehensive fees,encoding and data quality review and supervision mechanisms.