建構診斷關係群決策支援系統－－以某區域教學醫院為例

Develop of Diagnosis Related Group Decision Support System--The Case of a Regional Teaching Hospital in Taiwan

衛生署於2001 年7 月1 日正式實施醫院總額支付制度（Global Budget System） ，希望藉由前瞻性支付制度（Prospective Payment System） 改善醫療 資源浪費的問題。為確保醫療費用的支出合理，又避免降低醫療服務品質， 因此提出幾個支付基準來約束醫療院所，其中健保局將於明年度擴大實施診 斷關係群DRGs （Diagnosis Related Groups） 來做為醫院住院服務項目的支付 標準'而診斷關侍、群又以1CD-9-CM （Intemational Classification of Diseases 9th Revision Clinical Modification ）為基礎，因此疾病分類與DRG 碼編碼的正確性 在醫療給付中扮演相當重要的角色。 疾病分類的正確性、時效性與醫院申報收入息息相扣，但因台灣各醫院 疾病分類人員並非僅從事編碼工作，加上疾病分類原則相當繁瑣，造成DRG 編碼品質受到影響，光靠疾病分類人員的經驗判斷進行人為決策，易造成編 碼錯誤風險的存在。因此急需利用一套決策系統輔助申報人員進行編碼工 作。 在健保局即將全面採行DRG 的給付制度下，本院自行發展一套決策支援 系統輔助疾病分類人員快速的編審DRGs 、提高疾病分類的品質、判斷主要診 斷資訊，以資訊輔助代替人為決策的不確定風險，不僅協助減少疾病分類人 員工作壓力，也協助提升編碼品質與時效。本系統利用健保局所提供的第3 版 DRG 分類、DRG 編碼流程園、權重來作為判請DRG 的依據，以此來建立診斷 關係群的最適化編碼。

Prospective payment system has been promoted in Taiwan for improving health care utilization management, such as Global Budget System and DRG (Diagnosis Related Group) are intended to curb the health expenditure and carry out the quality assurance. To integrate ICD-9-CM (International Classification of Diseases 9th Revision Clinical Modification) codes and generate a optimal DRG code are important tasks in hospital. accuracy ICD code is related to hospital revenue. However, code name or coded depending on human decision. To classify disease may not accuracy, because coding rule is complicate, and taxonomist in Taiwan hospital cannot engage in classify disease. Our research is to develop a decision support system to integrating the optimal DRG code generation, hopefully to assure the DRG coding accuracy. It is expected to improve medical disease taxonomist solve several problems, such as increasing coding accuracy, decreasing coding time spending. Our decision support system is developed to base on DRG classification 3rd editions and DRG coding guideline from Bureau of National Health Insurance. We accord DRG coding guideline to create a calculation of DRG weights to assign the optimal DRG code.