我国基层医疗诊断编码实施现况与优化策略

Implementation Status and Optimization Strategy of Primary Care Diagnostic Coding in China

随着基层医药卫生体制改革的不断深化,基层卫生信息标准化建设愈发被重视。基层医疗诊断编码作为基层卫生信息化建设的重要环节,在提高基层医疗管理效率、促进基层医疗质量控制、有效收集基层医疗数据等方面都起着至关重要的作用。但我国长期以来沿用综合性医院使用的疾病分类作为基层医疗诊断编码使用,不仅导致基层医疗诊断不规范、无法统计的混乱状态,更可能造成基层医疗收集、记录、分析的数据出现缺失和误差。本文通过梳理国内外基层医疗诊断编码发展的历史沿革,指出当前我国基层医疗诊断编码所面临的5个主要问题:各方对基层医疗诊断编码的重视程度不足、缺乏统一的基层医疗诊断编码导致我国基层医疗功能与质量发展受限、我国基层医疗诊断编码与何种国际基层分类匹配存在分歧、基层医疗诊断编码本土化面临的诸多挑战及我国缺乏评价与优化基层医疗诊断编码的人才与工具。并在此基础上,结合国外基层医疗诊断编码的发展过程,提出我国各方应重视基层医疗诊断编码的发展,在进一步推动基层医疗信息建设与国际接轨的同时,基于目前试行的国际疾病分类编码(ICD)-11与基层医疗保健国际分类(ICPC)-3分类尽快制定全国统一的基层医疗诊断编码标准,并通过建立健全的基层医疗诊断编码人才培养体系,为我国基层医疗诊断编码的进一步实施和优化提供保障。

With the continuous deepening of the reform of the primary care and health system,the standardization of primary health information has received more and more attention.As an important part of the construction of primary health information,primary care diagnostic coding plays an important role in improving the efficiency of primary care management,promoting the quality control of primary care,and effectively collecting primary care data.However,China has used the disease classification of general hospitals as the primary care diagnostic code for a long time,which not only leads to the chaotic state of non-standard and non-standardized primary care diagnosis,but also causes loss and error in the data collection,record and analysis in primary care.By summarizing the historical development of primary care diagnostic coding at home and abroad,this paper points out five main problems faced by China's primary care diagnostic coding:the lack of attention to primary care diagnostic coding,the lack of unified primary care diagnostic coding leads to the limited development of primary care function and quality in China,the disagreements about which international primary care classifications match the primary care diagnostic codes in China,the various challenges faced by the localization of primary care diagnostic coding,and the lack of talents and tools to evaluate and optimize primary care diagnostic coding in China.On this basis,combined with the development process of foreign primary care diagnostic coding,it is proposed that all parties in China should pay attention to the development of primary care diagnostic coding.While further promoting the construction of primary care information in line with international standards,the national unified primary care diagnostic coding standard should be formulated based on the current trial ICD-11 and ICPC-3 classification as soon as possible,and the sound training system for primary care diagnostic coding talents should be established to further implement and optimize primary care diagnostic coding in China.