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研究生:林祥忠
研究生(外文):Hsiang-Chung Lin
論文名稱:健保特定醫療事前審查作業數位化之研究
論文名稱(外文):Research on Digitizing the Pre-examination Operation of the Health Insurance for Specific Medical Care Services
指導教授:陳澤生陳澤生引用關係
指導教授(外文):Tse-Sheng Chen
學位類別:碩士
校院名稱:國立成功大學
系所名稱:工程科學系專班
學門:工程學門
學類:綜合工程學類
論文種類:學術論文
論文出版年:2002
畢業學年度:90
語文別:中文
論文頁數:78
中文關鍵詞:健保醫療事前審查審查無片化無紙化作業醫療資訊交換標準
外文關鍵詞:DICOMPACSMedical Service Pre-examinationHL7
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  依全民健康保險法第四十一條第三款之規定,保險對象如有經保險人事前審查非屬醫療必需之診療服務及藥品,不予保險給付。又全民健康保險醫事服務機構醫療服務審查辦法第二十條之規定,對於高危險、昂貴或易浮濫使用之醫療服務、特殊材料及藥品等,保險人應就主管機關核定後公告之項目辦理事前審查。中央健康保險局需依法辦理特定醫療服務事前審查業務。

  目前事前審查作業係採用書面申請及人工處理方式作業。申請事前審查時,除了書面申請表之外,尚需檢附相關檢查報告及診斷文件等用來佐證申請項目為治療病情需要之附件。若檢附的附件中有X光攝影、電腦斷層(CT)掃瞄及磁振造影(MRI)等放射檢查影像軟片時,則會產生洗片成本較高、佔用空間較多及環境污染等問題。並且人工作業也有耗費人力較多與流程時間較長等缺點。這些花費成本高、佔用空間多、人工作業流程太長、較費人力及污染環境等問題與缺點,均有待改善。

  本研究的主要目的就是為了解決上述醫療服務品質、整體作業效率、空間與製作成本及環境保護等問題。首先,提出一套創新採用HL7及DICOM國際資訊交換標準的電子化作業方案。接著,建立數位化事前審查作業系統及簡化標準作業流程,並推動試行實施。最後,進行系統探討與作業評估,期能提供做為健保局及醫療院所相關作業未來發展與改進的參考。依據評估結果顯示,此項新的作業流程可縮短作業時程及節省洗片費用、郵資與人力。
  According to Article 41 of the National Health Insurance Act, no insurance benefits shall be payable to the beneficiaries if the treatment and drug are not medically necessary according to the pre-examination by the Insurer. In addition, according to Article 20 of the Medical Service Examination Act of National Health Insurance Medical Service Institutes, the Insurer should make an application for pre-examination of highly-dangerous, expensive and easily-abused medical service, special materials and medicines which are already ratified and proclaimed by the competent authority.

  The pre-examination and many administractive transactions are currently carried out manully on paper. When applying for the pre-examination, besides the application forms, related examination reports and diagnosis papers which can prove the need of the items in treating the illness should also be attached. However, if the attached documents include radiographs such as Computed Radiography Images, Computed Tomography Images and Magnetic Resonance Images, problems like heavy expenses, high space consumption and environmental pollution will arise. Besides, manual process also gives rise to problems of high human resources consumption and long processing time. These problems and defects should all be improved.

  The main purpose of this research is to solve the above-mentioned problems such as the quality of medical service, the efficiency of the overall process, cost, space and also the protection of the environment. First, a new completely electronic message exchange approach which adopts the medical information exchange standard of HL7 and DICOM is proposed. Second, a digitized pre-examination operating system and a simplified standardization working process are set up and a trial-out is promoted. Last, several potential issues are discussed and the availability and economics of the process are evaluated in the hope of providing the Bureau of National Health Insurance and Medical Institutes with references for future development and improvement. According to the evaluation ,use of this new working process can reduce processing time and cost spent on film printing,postage and human resources.
考試合格證明 Ⅰ
中文摘要 Ⅱ
英文摘要 Ⅲ
誌謝 Ⅴ
目錄 Ⅵ
表目錄 Ⅸ
圖目錄 Ⅹ
中英文縮寫對照表 XI

第一章 緒 論 1
  1.1 研究背景 1
  1.2 研究動機 2
  1.3 現況分析 3
    1.3.1 國際醫療資訊交換標準發展現況 3
    1.3.2 本研究所面臨問題現況 5
  1.4 研究目的與方法 6

第二章 文獻回顧 8
  2.1 醫療作業資訊交換標準 8
    2.1.1 醫療作業資訊交換標準化的需求 8
    2.1.2 HL7的訊息結構 10
    2.1.3 HL7的訊息傳輸及回覆模式 13
  2.2 醫療影像資訊交換標準 15
    2.2.1 DICOM的資訊模型簡介 15
    2.2.2 DICOM的資料元素結構 17
    2.2.3 DICOM資訊物件定義 19
    2.2.4 唯一性識別碼(Unique Identifier,UID) 22
    2.2.5 DICOM的通訊模型 24
    2.2.6 DICOM的訊息服務元素(DIMSE) 26
    2.2.7 DICOM媒體儲存格式及服務 31
  2.3醫療資訊標準之整合 33

第三章 研究結果 35
  3.1 系統架構 35
  3.2 作業流程 36
  3.3 系統功能 37
  3.4 申請事前審查案件媒體格式 41
  3.5 HL7訊息格式 44
  3.6 事前審查申請案件資料與HL7訊息欄位對照 52
  3.7 事件訊息範例 56
  3.8 試辦計畫之推動現況 57

第四章 討論與評估 58
  4.1 數位化作業與原來作業之比較 58
    4.1.1 原人工及書面作業方式的六項缺點 58
    4.1.2 數位化作業方式的六項優點 59
  4.2 HL7訊息認知差異性分析與解決方案 60
  4.3 醫療資訊交換標準推廣使用的二大瓶頸 62
  4.4 系統整合面臨之問題與解決方案 64
    4.4.1 系統作業功能符合HL7與DICOM標準一致性問題 64
    4.4.2 HIS與PACS的整合暨系統建置參考方案 65
  4.5 醫療院所參考作業流程 66
  4.6 可行性評估 67
  4.7 效益評估 68

第五章 結論與未來發展方向 69
  5.1 研究結論 69
  5.2 未來發展方向 69

參考文獻 71
附錄1 76
附錄2 77
自述 78
參 考 文 獻
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