医保与医院信息管理系统接口软件的探讨

1、医保与医院信息管理系统接口软件的探讨摘要厦门医疗保险信息管理系统是以城域网为主十的大型计算机管理系统，已正 常运转了两年。作为医疗保险定点医疗机构上网的有51所，其中，全部三级医 院和大部分二级医院已开发应用信息系统。因此，医保系统与医院系统的接口问 题必须得到解决。接口软件必须达到3个要求：医疗消费数据的唯一性、医保系 统的安全性、高效快速的性能。医保系统与医院系统的接口采用3种方案：无缝、 数据扫描、数据包交换。通过这3种方案，较好地解决了接口问题。关键词：医疗保险；医院信息系统厦门职工医疗保险信息管理系统（以下简称医保系统）于1997年7月1日正 式启动运行，到目前已正常运转了两年，状况

2、良好。作为厦门市医疗保险定点医 疗机构上网的医院、门诊部和厂矿企业卫生所有51所，联网计算机已达到200 台，每天与医疗机构发生交易量2万多笔，并且系统正在按计划继续扩大规模。医院信息管理系统（以下简称医院系统）是现代化医院必不可少的基础设施 与技术支撑环境，随着信息社会的到来，医院管理信息化正成为整个医疗行业的 发展趋势。我市全部三级医院和大部分二级医院已开发应用医院信息管理系统， 不仅提高了医院的综合管理水平，而且为患者提供良好的服务环境；并在实际工 作中产生良好的经济效益和社会效益。在全国全面实行医疗保险制度的今天，如 何将相对独立的医保系统和医院系统有机的结合在一起，使之既符合医疗保险

3、的 需求，又适合医院的实际情况，是摆在我国医保和医院管理者面前的实际问题。 我们认为解决这一问题，不单单是软件开发人员的事，更是管理者必须提高全局 意识，全盘统筹规划协调，下大决心解决的重大问题。一、厦门市医保系统简介厦门医保系统是一套以IC卡为载体，以城域网为主十，以现代化通讯方式 为网络联通手段，以客户机服务器模式为系统结构的大型计算机管理系统。服务 器采用两台DEC Alpha4000小型机，一台主服务器，一台辅服务器，采用集群技 术，两台小型机共享一个磁盘阵列，阵列采用Raid0、1、5技术。小型机安装 Digital UNIX,ORACIE7.3.2。整个网络采用TCP/IP协议作为

4、网络互连协议。 DECHUB900作为中心交换机完成中心局域网的设备连接。远程网经中心路由器通 过64Kbps的DDN专线与医院端路由器相连。另外是利用普通电话网以拨号方式 进入中心与服务器相连。它既作为大型医院的备用线路，也作为小型医院主要上 网方式。系统的IC卡不仅起到身份标识作用，还记载有大量信息，包括个人基 本情况和个人消费情况。二、厦门市医院信息管理系统现状目前，厦门市医疗机构的医院信息管理系统，既有采用以客户机/服务器模 式、大型数据库（如ORACLE、SQLSERVER）等当今最新计算机技术，也有在DOS平 台采用NETWARE，FOXPRO开发的小型数据库管理系统。厦门市现有4

5、所三级医院和5所二级医院已经开发应用了医院挂号划价收费 管理系统，还有大部分医院尚未开发应用。已开发应用的医疗机构，其系统是由 多所软件公司开发，各系统在开发平台和开发工具等诸多方面不统一。以上这些， 反映了厦门市医疗机构在应用医院信息管理系统的工作上，在应用层次上有差 异，在相应层次上的应用水平也很不一致，这种应用发展的不平衡状况，直接影 响医保系统与现有医院系统的结合，也同时加大了医保系统与医院系统开发的工 作难度和工作量。三、厦门医保系统与医院系统的接口分析厦门市医保系统提供医院前台收费软件，通过该收费软件将医保病人的消费 数据实时传送到医保中心的主机系统存储，这些消费记录既作为医保病人

6、的消费 数据记录，也是医保中心与医院进行财务结算的重要依据。医院收费系统通过IC卡读卡器读出个人IC卡号等信息数据送往医保系统确 认，医保系统返回个人基本信息，医院收费系统据此进行挂号、住院登记及收费； 医院收费系统需将收费明细项目金额传送给医保系统，医保系统根据医保政策及 病人的基本信息，计算出3段付费金额，即个人帐户支付金额、个人现金支付金 额及统筹基金支付金额，并将其返回给医院收费系统，医院收费系统据此打印发 票并写入IC卡。由于厦门市医疗机构的医院信息管理系统应用水平发展的不平衡，我们在医 保最初的应用前台收费系统并未包含划价收费功能，其划价收费由各所医院按照 现行办法运行。这样，已有

7、划价收费系统的医院就必然地要求为医保前台收费软 件与医院现有划价收费软件提供一个高效快速的接口。四、厦门医保系统与医院系统的接口要求厦门市医保系统是一个全新的应用系统，其高平台、先进的实时性、更高的 安全性，使得所设计的与医院管理系统的接口软件必须达到以下几个具体要求。医疗消费数据的唯一性：医保患者的医疗消费数据要求一致，这是医保系统与 医院系统接口的最基本要求。医院的收费划价管理系统将个人处方划价结果数据 除登记在医院管理系统，还必需按照医保中心的要求登记在医保中心的主机系统 中，这就要求在两个相对独立的系统中，医保病人的消费记录保持一致，都来自 医院的收费划价系统，确保数据的唯一性。医保系

8、统的安全性：医保中心系统的主机存放几十万参保人员的基本档 案、个人帐户和统筹基金、个人和单位帐目等多方面数据，关系到几十万参保人 员的切身利益，其数据要求高度安全。因此，医保系统不能完全对医院系统开放。 任何医院管理系统要求与医保系统连接，其接口方案必须经医保中心审核，在保 证医保系统安全的前提下，做好接口工作。高效快速的性能：医院系统与医保系统连接，其接口软件要求高效快速， 对现有系统的速度影响减到最低程度，以缩短操作时间及病人等待时间。五、厦门医保系统与医院系统的接口方案目前，厦门市医保系统与医院系统的接口采用以下3种实施方案。无缝接口：计划开发医院信息管理系统的医疗机构，在设计功能等各方

9、面 达到医院要求的前提下，选择开发医保系统的软件公司。由该软件公司开发的医 院系统在保证医保系统安全的前提下，可直接访问医保系统主机，实现无缝接口， 即医保系统与医院系统的一体化。此种方式最为理想，既符合医保需求，又适应 医院的实际情况；既保证了安全性，又实现高效快速。厦门市已有2所三级医院、 2所二级医院选用此方案，减少了中间环节，大大节省了投资，并已达到较理想 的效果。数据扫描接口：将医院具有划价功能的收费软件产生的结果传送到医保系 统要求输入划价结果的窗口中，并要求对应的收费栏目数据统一，有关医院已开 发了屏幕或键盘缓冲区数据扫描和接收功能，很好地解决了接口问题，其主要特 点是在一台机上

10、同时运行两套软件，医保系统处于收费状态时由医院收费划价系 统发送划价结果，医保系统正确接收到数据后可依序操作，这样，在不修改医保 系统收费模块的前提下实现两个系统的数据接口，既保证了医保系统的安全，也 共享了医院的信息资源。数据包交换接口：采用数据包交换方案，即医保系统把相关信息存储在一 个数据包中供医院划价系统读取，医院划价系统处理完的收费信息也存储在一个 数据包中供医保系统使用，以数据包交换的方式实现数据接口。厦门市医保系统经过两年的探索和实践，通过制定相关的管理措施，密切与 医疗机构协作，以尽力保护医院现有管理系统投资为原则，较好地解决了医保系 统与医院系统的接口问题。然而，随着医疗保险

11、业务、计算机技术、通信技术及 医疗信息技术的迅猛发展，有些起点低、技术落后的医院系统已暴露出严重缺陷， 既不能满足医保的需要，又阻碍医院系统的进一步发展，势将被逐步淘汰。以地 （市）为统筹单位，其所在地（市）各个定点医疗机构，应在医保管理部门和卫生 主管部门的共同努力下，逐步建立起一套与医保系统融为一体的、统一的医院信 息系统，走向规范化、标准化；既减少重复开发和重复投资，又可降低软件和硬 件的开发成本和开发周期；既可以与国家“金卫工程”连接，又可以使医院之间 联网而共享信息资源。总之，顺利解决医保系统与医院系统接口问题，必将有益 于正在全国各地开展的医疗保险工作。我院是铁道部唯一指定的医疗保

12、险制度（以下简称医保）试点医院，1997年 我们研制了适应医保制度的医院信息管理系统，运行一年多来，性能稳定。一、医保方案我们采用“三通道”的医保方案，即分为个人帐户、隔离带、统筹金3个收 费段。个人交纳的年收入的1%与单位交纳的人均年收入的8%的40%一起入到个 人帐户，门诊和住院交费超出个人帐户后进入隔离带，隔离带用完后即进入统筹 金，由单位和个人分担不同的比例。现已发医疗保险IC卡89 900张，其中在职 职工卡69 829张、退休职工卡18 979张，离休职工卡1 092张，基本实现了 职工持卡看病，不必再垫付医药费。二、网络环境服务器采用IBM PC Server 315操作系统为W

13、indows NT，并采用双机热 备份，与Raid 5磁盘阵列相连，以确保数据的安全性和可靠性。服务器硬盘容 量为2GB，24小时运行。客户端采用IBM 300GL，操作系统为Windows95。数据库系统选择了 Informix Dynamic 7.22,充分利用其稳定性、可靠性、可伸缩性和先进性。采用以太网，通信协议为TCP/IPO医院以DDN专线经Cisco2511路由器与医保与中心进行数据交换。计算机配备：住院处配备3台工作机，负责门诊、急诊挂号与办理住院手 续；负责患者医药费用查询。收费处配备8台工作机，其中4台负责医嘱录入， 4台负责门诊、急诊收费与办理出院结算手续。中药房配备1台

14、工作机，西药房 配备2台工作机，负责处方的确认与发药。计算机室配备2台服务器，1台网管 机。药库、财务科、院长办公室各配备1台工作机。三、系统功能本系统包括10个子系统。挂号子系统：包括挂号作业、挂号查询、挂号结帐、挂号统计。门急诊收费子系统：包括录方划价计费、退方处理、处方查询、结账、费 用统计、门诊医疗费结算清单、路外医疗费结算清单。住院管理子系统：包括入院登记、医嘱管理、预交金管理、床位管理、转 科处理、病案首页、出院结算、统计。药房管理子系统：包括初始化录入、初始化盘存、药房出药、损耗登记、 药房发药、处方查询、入药情况、出药情况和初始化情况查询，剩余量查询，盘 存查询。药库管理子系统

15、：包括出入库操作、出入库校验、出入库查询、药典维护、 药库盘点、药房缺药查询、药库计划等。院长查询子系统：门急诊挂号信息、住院信息、药库药房信息、综合信息。财物管理子系统：汇总信息、日常事物（收款员交帐与交账查询等）、常用 财务报表（各科室路内收入一览表、医疗统筹金清算表、住院医疗费结算清单等）。字典维护子系统：包括科室编码字典维护、录入员与医师信息字典维护、 处置优惠与处置编码字典维护、病床信息字典维护、药典维护、门诊急诊与专家 挂号字典维护、系统功能维护。数据传输子系统：与医保中心进行数据传输。患者费用查询子系统：IC卡金额查询、住院部出院费用查询、住院部在 院费用查询、门诊费用查询。四、

16、系统特点标准化：遵从国家有关医保政策的标准和规范，标准的数据库结构与数据 字典，统一的数据交换格式。开放性：本系统从系统软硬平台到应用程序均采用开放结构，对今后系统 升级和对应用软件的二次开发提供了充分的保证。高效性：医院客户端以IC卡为个人信息载体，电子划价为基础，实现高 速收费，减少病人就诊排队的等待时间。安全性：系统采用了 IC卡、读卡机及数据库存3部分连锁加密，IC卡分 卡加密及DES数据加密算法，极大的保证了数据的安全性。灵活性：医保方案有一个逐渐完善的过程，为了增加系统的灵活性，该系 统设计中采用了软件参数相分离的方式，不同的医保方案、不同政策优惠比例系 数及金额的界定，只需通过在

17、数据字典中灵活配置参数即可实现，而无须修改程 序。五、应用体会系统的应用强化了门诊挂号、诊疗、划价收费管理，住院病人根据医嘱自动 结帐，堵塞了人为造成的收费漏洞，增加了医院的合理收入，提高了医院的经济 管理水平。加强了药品价格管理，由于收费处与药存相连，保证了药品价格的及 时调整。我院多年来一直未能解决就医不挂号问题，现在患者不挂号，IC卡就 不能用，就不能取药或处置，因此患者也行成了首先自动挂号的习惯，为医院带 来了经济收益。系统设置了催款程序，促使病人尽快续交费用，控制了欠费现象。 患者办理住院手续时，将IC卡留在收费处，避免了病人不结帐就出院溜走的现 象。系统可为管理者提供准确信息。通过

18、“院长查询子系统”可以看到有关部门 的运行情况，并且可以对不同时期的指标作对比。我院自1999年开始实行成本 核算，从计算机系统可及时准确地调出各医疗、医技科室的工作量，计算出各科 的收入情况。计算机网络为患者提供了监督条件。住院处设有查询机，患者可对 各项费用进行查询，提高了患者对医院的信任度。4月22日，金卫医保信息管理（中国）有限公司在上海宣告成立,做为中国首家 专业从事医疗保险信息管理及医疗保险服务外包的技术先进型企业，金卫医保抢 滩上海，并在世博会开幕前夕揭牌，意味着从是日起，在境外投保的来华人士，可 以在中国的医院使用医疗保险就医。金卫医保系由在香港上市的金卫医疗集团与美国著名的政

19、府医保管理公司 SynerMed和EHS组建的合资公司，公司注册资本金五千万美元。金卫医疗拥有金 卫医保70%权益。集团主席兼金卫医保董事局主席甘源在媒体交流时表示，做为有效连接国内 外医疗保险公司、医院和投保人三方的桥梁和纽带，金卫医保公司的成立不仅填 补了国内相关行业发展的空白，满足大量来华工作和旅游的境外人士日益增长的 医疗服务和医疗保障的需求，亦能为促进中国旅游医疗事业的发展创造基本条 件。金卫医保执行董事兼CEO经建中介绍，身为国内第一家医疗保险第三方服务 机构，目前已有30多家大型跨国商业保险公司与金卫医保签约。公司的运行，将 带来多赢局面：首先，外籍人士来华就医更为方便、有了更多

20、选择。因有效解决了支付问题, 将为旅游医疗创造一个最必要的条件；其次，国外几十个保险公司与金卫医保合作，可以建议投保人在中国医院就 医，实现像在本国一样，用保险卡支付，这样便为医院带来赚取利润的机会；第三,对保险公司降低成本、规避风险可起到很好的作用。经建中表示，这项业务的合作医院，目前主选大的城市，即外国人居住、工作、 旅游较多的城市大三甲医院，其VIP、特需区、国际部是主要合作对象。在上海, 这样的点有60个左右。他透露，依托金卫医疗集团在中国广泛的医院网络资源、美方合作伙伴多年 服务管理美国政府医疗保险（Medicare）的经验和自建的智能化专有网络系统和 软件平台，金卫医保能够为海内外

21、医疗保险公司和其他相关机构提供专业化、可 定制、精准的后台服务;协助保险公司降低经营风险和运营成本，支持其实现产品 创新；同时亦能推动医疗保险产业与医疗临床服务的有机结合，并带动商业补充 医疗保险的健康发展。他着重指出，作为一家创新的、独立第三方医保外包服务企业,金卫医保的成 立，符合当前国内外医疗保险行业将后台业务外包日渐加速的趋势。Medical insurance and hospital information management system interface software ofInvestigateABSTRACTXiamens medical insurance inf

22、ormation management system, a large-scale computer management system with city network as its mainstay, has been functioning normally for 2 years. 51 of the medical institutions designated for medical insurance have joined the network. Among them, all of the first-grade and most of the second-grade

23、hospitals have made use of the information management system. Thus the problem of interfacing of softwares for medical insurance and hospital information management systems and the hospital administration system must be solved. Interface softwares must meet 3 requirements: uniqueness of medical cons

24、umption data, security of medical insurance information management system and high efficiency and speed. The issue has been fairly well solved through the adoption of 3 measures: seamless structure, data scanning and packet exchange.Key Words: Medical insurance; Hospital information systemXiamen, me

25、dical insurance information management system (hereinafter referred to as medical insurance system) on July 1, 1997 officially started operation to normal operation now for two years, in good condition. Xiamen City, as designated medical institutions, medical insurance, access hospitals, health clin

26、ics and industrial enterprises of all 51, the computer network has reached 200 per day trading volume occurred with the medical institutions more than 20,000 pen, and the system is planned to expand the scale of .Hospital Information Management System (hereinafter referred to as the hospital system)

27、 is essential for modern hospital infrastructure and technical support environment, with the advent of the information society, the hospital management information is becoming the development trend of the entire medical industry. All three city hospitals and two hospitals have been development and a

28、pplication of most of the hospital information management system not only improves the level of integrated management of the hospital, but also provide good services for the patient environment; and in actual work to produce good economic and social benefits. The full implementation of the national

29、health insurance system, how will independent medical insurance system and hospital system combines organic, enabling it to meet the demand for health insurance, but also the actual situation for the hospital, is placed in our medical insurance and hospital management practical problems in front. We

30、 believe that to solve this problem, not just software developers, but also a need to improve the overall awareness of managers, co-ordinate the overall planning and coordination, be determined to solve the major problem.First, Introduction Xiamen Medicare.Xiamen health insurance system is a set of

31、IC cards as the carrier, metro backbone, with modern means of communications for the network Unicom to client-server model for the system structure of large computer management system. Server with two DEC Alpha4000 minicomputer, a main server, a secondary server, using clustering technology, two sma

32、ll machines to share a disk array, array with Raid0, 1,5 technology. Minicomputer installs Digital UNIX, ORACIE7.3.2. Entire network using TCP / IP protocol as a network interconnection agreement. DECHUB900 completed as a central switching center LAN device. The center of the remote network router v

33、ia the DDN 64Kbps line client router connected to the hospital. Another is the use of ordinary telephone network to dial into the center and the server is connected. Its back-line as a large hospital, but also as the main access way for small hospitals. IC card system not only plays the role of iden

34、tity, but also records a large amount of information, including basic personal circumstances and personal consumption.Second, Xiamen City Hospital Information Management System Status.At present, Xiamen City, the hospital medical information management system, both adopt a client / server model, a l

35、arge database (such as ORACLE, SQLSERVER) so todays latest computer technology, also used in the DOS platform, NETWARE, FOXPRO database management system developed by a small .Xiamen available in 4 hospitals and five secondary hospitals have been designated development and application of the price c

36、harged by registered hospital management system, as well as most hospitals have not yet developed applications. Development and application of medical institutions has been their system is more than software developed by the various system platforms and development tools in the development of many a

37、spects such as non-uniform. These reflect the Xiamen Municipal Hospital medical institutions in the application of information management systems work, there are differences in the application level, application level in the corresponding levels are inconsistent, the imbalance in the development of

38、this application, directly affect the health insurance system integration with existing hospital systems, health insurance system also increased the work of the hospital system development difficulty and workload.Third, Xiamen medical insurance system and hospital system interface analysis. Xiamen M

39、unicipal Hospital medical insurance system charges the software front, the adoption of the Medicare patients and charging software will transmit real-time consumption data to the Insurance Center of host system memory, which records both as a health insurance consumer consumption of data records of

40、patients, healthcare centers and hospitals is also a financial settlement an important basis.Hospital payment system through the IC card reader to read out personal information such as data sent to the IC card number to confirm medical insurance system, medical insurance system back to basic persona

41、l information, payment system whereby hospitals were registered, hospital registration and fees; hospital billing systems to charge the amount of detail the project to send medical insurance system, medical insurance system, medical insurance policy and under the patients basic information, pay the

42、amount calculated in paragraph 3, that personal account to pay the amount of personal cash payments and co-ordinate fund payments, and return to the hospital charges system, hospital payment system according to print invoices and write IC cards.As medical institutions Xiamen Hospital Information Man

43、agement System application level uneven development, the application of our first front in the Medicare payment system does not include price plan charge function, and its designated price charged by the hospital to run under the existing approach. This has been designated payment system of hospital

44、 price is bound to ask for the health insurance front software fees and hospital charges price of existing software program to provide a rapid and efficient interface.Fourth, Xiamen medical insurance system and hospital system interface requirements. Xiamen is a new medical insurance system, applica

45、tion system, its high platform, the real-time advanced, more secure, so that designed the systems Joe Kou and hospital management software to the following Jigejuti Yao Qiu Da Dao.The uniqueness of health care consumption data: Medicare patients with the same data requirements of medical consumption

46、, which is medical insurance system and hospital system interface of the most basic requirements. Hospital management system will pay price plan prescription plan price personal data except the results registered in the hospital management system, also need to register in accordance with the require

47、ments of Medicare Centre center hosts in the health insurance system, which requires two relatively independent systems, Medicare patients consistent consumer records, all charges from the hospital designated price system to ensure that data is unique.Medicare System Security: Insurance Center syste

48、m host hundreds of thousands of insured deposit the basic records, personal accounts and social pool fund, accounts and other aspects of individuals and units of data related to the hundreds of thousands of insured personal interests of the high security of their data requirements. Therefore, the me

49、dical insurance system on the hospital system can not open. Any hospital management system requirements and medical insurance system is connected, its interface program must be reviewed by the Health Insurance Center, in ensuring the safety of medical insurance system under the premise of good inter

50、face to work.Rapid and efficient performance: the hospital system and medical insurance system is connected, its interface software requires high speed, the speed of impact on existing systems to minimize the extent to shorten the operation time and patient waiting time.Fifth, Xiamen medical insuran

51、ce system and hospital system interface program.At present, Xiamen City medical insurance system and hospital system interface using the following three kinds of implementation.Seamless interface: plans to develop the hospital information management system, medical institutions, and other aspects in

52、 the design of functional requirements to the hospital and the premise, select the health insurance system software development company. Software developed by the hospital system in ensuring the safety of medical insurance system under the premise of direct access to medical insurance system host, s

53、eamless interface, the medical insurance system and hospital system integration. In this way the best, consistent with Medicare requirements, but also to adapt to the actual situation of the hospital; not only guarantee security, but also to achieve fast and efficient. Xiamen has two tertiary hospit

54、als; two hospitals secondary use this program to reduce intermediate links, significant savings in investment, and has reached a more satisfactory results.Data scan interface: the hospital has a designated price it cost software result sent to the medical insurance system for the importation of desi

55、gnated price results window, and asked the corresponding fees and charges section of data unity, the hospital has developed a screen or keyboard buffer data scanning and receive functions, solves the interface problem, the main features on a single machine to run two sets of software at the same tim

56、e, state health insurance system in the fees charged by the hospital system Fazing planning plan price results, medical insurance system correctly received data Key Yi sequence operation, so that no changes in the health insurance system under the premise of charging module to achieve the two system

57、s of data interface, both to ensure the Medicare systems security, also shared the hospitals information resources.Data Packet Interface: The packet exchange program, the Medicare system, the related information is stored in a data package for hospital planning price system to read, the hospital des

58、ignated price system processed the charge information is also stored in a data package for the medical insurance system use to the way packets of data exchange interfaces.Xiamen health insurance system after two years of exploration and practice, through the development of related management measure

59、s, in close collaboration with medical institutions to try to protect the investment of existing hospital management system principles, can solve the health insurance system, the interface with the hospital system. However, as medical insurance, computer technology, communication technology and medi

60、cal information technology, the rapid development of some low starting point, technology behind the hospital system has revealed serious shortcomings as it neither satisfies medical insurance needs nor had the further development of hospital system Zuni is bound to be phased out. To (city) to the in