一个医疗保险收费和管理系统的设计与实现
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摘要
随着医疗保险改革的不断深入,医保覆盖面的逐步扩大,参保人员迅速增加,医保收费系统如何响应大批量客户并发结算成为一个热点问题。同时医保基金的支出也随之快速增长,因此对医保消费的管理越来越受到各地医保经办机构的重视。但目前国内对于医疗保险基金的管理,主要依靠常规的报表统计功能,缺乏一套系统化的医保基金控制管理系统。
本文在研究了基于三层体系结构的苏州工业园区医疗保险收费系统1.0版的基础上,设计与实现收费和管理软件2.0版本。针对1.0版本大批量用户并发划卡时,系统的结算组件无法响应的问题,在2.0版本中引入Tuxedo中间件平台,使用消息队列异步通信和两阶段提交机制保证大量并发请求的响应,并设计医院前置机数据同步机制,当医院和医保中心网络中断时,不影响参保人员划卡结算。同时,为了合理控制大病统筹基金的支出,本文在研究了数据挖掘的相关理论的基础上,通过分析已有医保大病报销记录的历史数据,采用了Pro-Apriori关联分析算法找出病种与使用的药品和诊疗项目之间的联系,建立了病种、药品、诊疗项目关联库。使用关联库和k-means聚类分析算法,对每个医院上年住院病案进行分析,并使用分析结果对医院信用等级进行评分,分成好、中、差三个等级,建立医院信用等级库。最后,本文提出了改进实时划卡结算流程,对信用等级中和差的医院在使用与病种无关的药品和诊疗项目时,先不予以报销。
本文设计与实现的医保收费和管理系统2.0版本目前已在苏州工业园区上线运行,取得良好的效果:大批量用户并发划卡时系统结算正常,同时新增的管理方法能合理地控制大病统筹基金的支出,是医保管理系统的一个新尝试,为同类系统的设计和发展提供了理论借鉴和实现方法。
With further reformation on medical insurance system, the coverage of medical insurance system is becoming wider and wider. The number of members who are subscribed to this insurance system quickly increased. It became a hot topic on how can a medical insurance charging system respond to big numbers of concurrent settlements directed from client-ends. In the meantime, the expenditure of Medical Insurance Fund grows fast. As a result, the management of medical insurance is being emphasized by related organizations in many cities. However, the management of Medical Insurance Fund still relies on statistics provided by regular forms and reports. There’s an absence of a systematic Medical Insurance Fund management and control system.
The following thesis discussed the design and implementation of version 2.0 of Suzhou Industrial Park Medical Insurance Charging and Management System, which is based on a three-layer structure of the version 1.0. By introducing the Tuxedo middleware platform, using message queue asynchronous communication and two-stage submit scheme to ensure response to large amount of concurrent requests, the version 2.0 tackles the problem of settlement module fail to response to big amount of concurrent transactions in version 1.0. A scheme of data synchronizing of hospital front end processor is designed to assure in the occasion of network disconnection between hospital and medical insurance center, the settlement transaction of medical insurance members won’t be affected.
In the meantime, to reasonably control the expenditure on major illness fund, based on study on data mining related theory, after analysis on history data of medical insurance reimbursement on major illness claim, Pro-Apriori related algorithm was used to find out correlations between illness type, medicine and treatment used, and built a correlated database on illness type, medicine and treatment. Using correlation database and K-means algorithm to analyze every hospital’s inpatient cases in the previous year, and use the analysis result to rate hospital’s credibility. Divide them into good, middle and bad respectively and build the hospital credibility database. In the end, the thesis provided an improved settlement transaction procedure, and system will not respond to claims from hospitals with middle or low credibility, in the cases that they try to use medicines or treatments which are irrelevant to illness identified.
The Medical Insurance Charging and Management 2.0 Version discussed and implemented in this thesis is now operating in Suzhou Industrial Park. The result is satisfactory, the system maintained normal operation when facing concurrent transactions from big number of users. In the meantime, new management approach added to the system can reasonably control expenditure from major illness fund, which is a new experiment in medical insurance management, and provided not only theory reference but also detail implementation to design and development on similar system.
本文在研究了基于三层体系结构的苏州工业园区医疗保险收费系统1.0版的基础上,设计与实现收费和管理软件2.0版本。针对1.0版本大批量用户并发划卡时,系统的结算组件无法响应的问题,在2.0版本中引入Tuxedo中间件平台,使用消息队列异步通信和两阶段提交机制保证大量并发请求的响应,并设计医院前置机数据同步机制,当医院和医保中心网络中断时,不影响参保人员划卡结算。同时,为了合理控制大病统筹基金的支出,本文在研究了数据挖掘的相关理论的基础上,通过分析已有医保大病报销记录的历史数据,采用了Pro-Apriori关联分析算法找出病种与使用的药品和诊疗项目之间的联系,建立了病种、药品、诊疗项目关联库。使用关联库和k-means聚类分析算法,对每个医院上年住院病案进行分析,并使用分析结果对医院信用等级进行评分,分成好、中、差三个等级,建立医院信用等级库。最后,本文提出了改进实时划卡结算流程,对信用等级中和差的医院在使用与病种无关的药品和诊疗项目时,先不予以报销。
本文设计与实现的医保收费和管理系统2.0版本目前已在苏州工业园区上线运行,取得良好的效果:大批量用户并发划卡时系统结算正常,同时新增的管理方法能合理地控制大病统筹基金的支出,是医保管理系统的一个新尝试,为同类系统的设计和发展提供了理论借鉴和实现方法。
With further reformation on medical insurance system, the coverage of medical insurance system is becoming wider and wider. The number of members who are subscribed to this insurance system quickly increased. It became a hot topic on how can a medical insurance charging system respond to big numbers of concurrent settlements directed from client-ends. In the meantime, the expenditure of Medical Insurance Fund grows fast. As a result, the management of medical insurance is being emphasized by related organizations in many cities. However, the management of Medical Insurance Fund still relies on statistics provided by regular forms and reports. There’s an absence of a systematic Medical Insurance Fund management and control system.
The following thesis discussed the design and implementation of version 2.0 of Suzhou Industrial Park Medical Insurance Charging and Management System, which is based on a three-layer structure of the version 1.0. By introducing the Tuxedo middleware platform, using message queue asynchronous communication and two-stage submit scheme to ensure response to large amount of concurrent requests, the version 2.0 tackles the problem of settlement module fail to response to big amount of concurrent transactions in version 1.0. A scheme of data synchronizing of hospital front end processor is designed to assure in the occasion of network disconnection between hospital and medical insurance center, the settlement transaction of medical insurance members won’t be affected.
In the meantime, to reasonably control the expenditure on major illness fund, based on study on data mining related theory, after analysis on history data of medical insurance reimbursement on major illness claim, Pro-Apriori related algorithm was used to find out correlations between illness type, medicine and treatment used, and built a correlated database on illness type, medicine and treatment. Using correlation database and K-means algorithm to analyze every hospital’s inpatient cases in the previous year, and use the analysis result to rate hospital’s credibility. Divide them into good, middle and bad respectively and build the hospital credibility database. In the end, the thesis provided an improved settlement transaction procedure, and system will not respond to claims from hospitals with middle or low credibility, in the cases that they try to use medicines or treatments which are irrelevant to illness identified.
The Medical Insurance Charging and Management 2.0 Version discussed and implemented in this thesis is now operating in Suzhou Industrial Park. The result is satisfactory, the system maintained normal operation when facing concurrent transactions from big number of users. In the meantime, new management approach added to the system can reasonably control expenditure from major illness fund, which is a new experiment in medical insurance management, and provided not only theory reference but also detail implementation to design and development on similar system.
引文
[1]王伟俊.三层架构在上海医疗保险计算机结算系统中的应用[J].计算机应用与软件, 2005, (01):143-144页.
[2]黄昕,耿胜华.基于Tuxedo中间件的多层体系结构研究[J].计算机工程与应用, 2006, (01):94-95,102页.
[3]陈刚,傅瑜光.基于CICS的交易控制平台的研究与设计[J].计算机应用与软件, 2007, (24):79-82页.
[4]余亚.基于三层架构的医疗保险系统IC卡模块的分析与设计[D].哈尔滨理工大学, 2006:113页.
[5]张良燕,龚卫华,黄德才. OLAM技术在医疗保险系统中的应用研究[J].浙江工业大学学报, 2007,(05):535-539页.
[6]罗涛,张正.基于Tuxedo中间件的分布式业务系统的实现[J].计算机工程与应用, 2005,(21):104-106页.
[7]邹新国.医疗保险管理信息系统的分析与设计[D].山东大学, 2007:246页.
[8]李晓虹,尚晋.一种改进的新Apriori算法[J]计算机科学, 2007,(04):196-198页.
[9]周义建,王轶.基于Apriori数据挖掘优化方法研究[J].计算机与数字工程, 2008, (02):20-22页.
[10]张建萍,刘希玉.基于聚类分析的K-means算法研究及应用[J].计算机应用研究, 2007,(05):166-168页.
[11]钟其兵,陈波.中间件技术及其应用研究[J].微机发展, 2005, (06):72-74,77页.
[12]李欣,秦永杰.基于BEA TUXEDO的邮政绿卡系统的开发[J].现代计算机(专业版), 2006,(06):37-40页..
[13]魏昕炜.交易中间件TUXEDO在医保医院联网系统中的应用[D].湖南大学, 2005:217-218页.
[14] Abraham Silberschatz,Henry E Korth.数据库系统概念[M].北京:机械工业出版社, 2007:185-189页.
[15]赵伯山. Oracle 9i中文版实用培训教程[M].北京:清华大学出版社,2005:3-7页.
[16] Oracle数据库简介. http://www.pconline.com.cn/pcjob/oracle/jc/214792.html.
[17]张海藩.软件工程导论(第四版)[M].北京:清华大学出版社, 2003年11月:43-48页.
[18]贾宗宣,龚晓峰.基于CVS的软件项目管理的研究[J].微计算机信息, 2006, (06):22-224页.
[19]赵丽,赵春江,吴华瑞. CVS在小城镇电子政务系统中的应用[J].计算机工程与设计, 2008,(05):1067-1068,1290页.
[20]陈小勇,尹刚.软件测试模型分析与研究[J].现代计算机(专业版), 2008,(05):88-90页.
[21]杨朝红,宫云战.基于模型的软件测试[J].北京化工大学学报(自然科学版), 2007,(1):85-88页.
[22]施寅生,邓世伟.软件安全性测试方法与工具[J].计算机工程与设计, 2008,(01):27-30页.
[23]徐兵.电子商务CA认证系统方案研究[J].微计算机信息, 2006,(18):192-193页.
[24]李尚勇.基于.NET架构的动态权限管理的设计与实现[J].电脑开发与应用, 2006, (07):31-32,35页.
[25]李国民,张磊. PowerBuilder7编程基础[M].北京:清华大学出版社, 2006:23-26页.
[26] Simon J.A. Herbert. PowerBuilder7.0实用全书[M].北京:电子工业出版社,2007:163-168页.
[27]柯海丰,吴明晖,应晶.基于中间件的领域软件开发方法[J].计算机应用研究, 2007, (08):54-56页..
[28]王海亮,王海凤.Oracle9i Pro*C/C++编程指南[M].北京:中国水利水电出版社, 2004:263-265页
[29]刘兆丽,魏仕民.数字签名研究的现状与发展[J].电脑知识与技术, 2008,(12):36-38页.
[30]李强.访问控制列表(ACL)在网络安全设计中的应用[J].计算机与网络, 2004,(07):60-61页
[31]张孝. PostgreSQL中基于ACL的数据访问控制技术[J].计算机应用与软件, 2007,(09):68-71页.
[32]沈海波,洪帆.访问控制模型研究综述[J].计算机应用研究, 2005,(06):9-11页.
[33]郭磊,吴春旭.BEA TUXEDO在移动计费系统中的应用[J].计算机系统应用, 2006, (04):91-93页.
[34]杨敏,丁月华.中间件Tuxedo在高速公路收费系统中的应用[J].微机发展, 2005, (15):148-151页.
[35]吴春明,杨国正.银行自助设备综合前置系统设计和实现[J].计算机应用与软件, 2005,(05):124-126页.
[36]顼庆坤,刘彦伟.医疗保险管理信息系统中的数据传输设计[J].计算机与网络, 2002,(13):56-57页.
[37]文春勇,赵建民.基于关联规则挖掘的算法研究与应用[J].计算机时代, 2008,(07): 126-128页.
[38]马建庆,钟亦平,张世永.基于兴趣度的关联规则挖掘算法[J].计算机工程, 2006,(17):121-122,149页.
[39]刘星沙,谭利球,熊拥军.关联规则挖掘算法及其应用研究[J].计算机工程与科学, 2007,(01):83-85,108页.
[40]梁瑜.基于Apriori算法的知识点内部关联的研究与实现[J].电脑与电信, 2008,(06):46-49页.
[41]彭仪普,熊拥军.关联规则挖掘AprioriTid算法优化研究[J].计算机工程, 2006,(05):55-57页.
[42]梁志荣.数据挖掘中聚类分析的技术方法[J].电脑开发与应用, 2007,(06):37-39页.
[43]胡庆林,叶念渝,朱明富.数据挖掘中聚类算法的综述[J].计算机与数字工程, 2007,(02):17-20页.
[44]杨尚森,李玉海.数据挖掘中聚类分析算法性能探析[J].计算机与数字工程, 2007,(11):6-8页.
[45]王守强,朱大铭,史士英.基于最小聚类划分的K-means聚类(1+ε)近似算法[J].计算机研究与发展, 2008,(01):97-99页.
[46]赵伟,张姝.改进K-means的空间聚类算法[J].计算机应用研究, 2008,(07):146-147页.
[47]王文香,左春,张正.保险业决策支持系统的数据仓库的设计与实现[J].计算机系统应用, 2006, (07):9-12页.
[2]黄昕,耿胜华.基于Tuxedo中间件的多层体系结构研究[J].计算机工程与应用, 2006, (01):94-95,102页.
[3]陈刚,傅瑜光.基于CICS的交易控制平台的研究与设计[J].计算机应用与软件, 2007, (24):79-82页.
[4]余亚.基于三层架构的医疗保险系统IC卡模块的分析与设计[D].哈尔滨理工大学, 2006:113页.
[5]张良燕,龚卫华,黄德才. OLAM技术在医疗保险系统中的应用研究[J].浙江工业大学学报, 2007,(05):535-539页.
[6]罗涛,张正.基于Tuxedo中间件的分布式业务系统的实现[J].计算机工程与应用, 2005,(21):104-106页.
[7]邹新国.医疗保险管理信息系统的分析与设计[D].山东大学, 2007:246页.
[8]李晓虹,尚晋.一种改进的新Apriori算法[J]计算机科学, 2007,(04):196-198页.
[9]周义建,王轶.基于Apriori数据挖掘优化方法研究[J].计算机与数字工程, 2008, (02):20-22页.
[10]张建萍,刘希玉.基于聚类分析的K-means算法研究及应用[J].计算机应用研究, 2007,(05):166-168页.
[11]钟其兵,陈波.中间件技术及其应用研究[J].微机发展, 2005, (06):72-74,77页.
[12]李欣,秦永杰.基于BEA TUXEDO的邮政绿卡系统的开发[J].现代计算机(专业版), 2006,(06):37-40页..
[13]魏昕炜.交易中间件TUXEDO在医保医院联网系统中的应用[D].湖南大学, 2005:217-218页.
[14] Abraham Silberschatz,Henry E Korth.数据库系统概念[M].北京:机械工业出版社, 2007:185-189页.
[15]赵伯山. Oracle 9i中文版实用培训教程[M].北京:清华大学出版社,2005:3-7页.
[16] Oracle数据库简介. http://www.pconline.com.cn/pcjob/oracle/jc/214792.html.
[17]张海藩.软件工程导论(第四版)[M].北京:清华大学出版社, 2003年11月:43-48页.
[18]贾宗宣,龚晓峰.基于CVS的软件项目管理的研究[J].微计算机信息, 2006, (06):22-224页.
[19]赵丽,赵春江,吴华瑞. CVS在小城镇电子政务系统中的应用[J].计算机工程与设计, 2008,(05):1067-1068,1290页.
[20]陈小勇,尹刚.软件测试模型分析与研究[J].现代计算机(专业版), 2008,(05):88-90页.
[21]杨朝红,宫云战.基于模型的软件测试[J].北京化工大学学报(自然科学版), 2007,(1):85-88页.
[22]施寅生,邓世伟.软件安全性测试方法与工具[J].计算机工程与设计, 2008,(01):27-30页.
[23]徐兵.电子商务CA认证系统方案研究[J].微计算机信息, 2006,(18):192-193页.
[24]李尚勇.基于.NET架构的动态权限管理的设计与实现[J].电脑开发与应用, 2006, (07):31-32,35页.
[25]李国民,张磊. PowerBuilder7编程基础[M].北京:清华大学出版社, 2006:23-26页.
[26] Simon J.A. Herbert. PowerBuilder7.0实用全书[M].北京:电子工业出版社,2007:163-168页.
[27]柯海丰,吴明晖,应晶.基于中间件的领域软件开发方法[J].计算机应用研究, 2007, (08):54-56页..
[28]王海亮,王海凤.Oracle9i Pro*C/C++编程指南[M].北京:中国水利水电出版社, 2004:263-265页
[29]刘兆丽,魏仕民.数字签名研究的现状与发展[J].电脑知识与技术, 2008,(12):36-38页.
[30]李强.访问控制列表(ACL)在网络安全设计中的应用[J].计算机与网络, 2004,(07):60-61页
[31]张孝. PostgreSQL中基于ACL的数据访问控制技术[J].计算机应用与软件, 2007,(09):68-71页.
[32]沈海波,洪帆.访问控制模型研究综述[J].计算机应用研究, 2005,(06):9-11页.
[33]郭磊,吴春旭.BEA TUXEDO在移动计费系统中的应用[J].计算机系统应用, 2006, (04):91-93页.
[34]杨敏,丁月华.中间件Tuxedo在高速公路收费系统中的应用[J].微机发展, 2005, (15):148-151页.
[35]吴春明,杨国正.银行自助设备综合前置系统设计和实现[J].计算机应用与软件, 2005,(05):124-126页.
[36]顼庆坤,刘彦伟.医疗保险管理信息系统中的数据传输设计[J].计算机与网络, 2002,(13):56-57页.
[37]文春勇,赵建民.基于关联规则挖掘的算法研究与应用[J].计算机时代, 2008,(07): 126-128页.
[38]马建庆,钟亦平,张世永.基于兴趣度的关联规则挖掘算法[J].计算机工程, 2006,(17):121-122,149页.
[39]刘星沙,谭利球,熊拥军.关联规则挖掘算法及其应用研究[J].计算机工程与科学, 2007,(01):83-85,108页.
[40]梁瑜.基于Apriori算法的知识点内部关联的研究与实现[J].电脑与电信, 2008,(06):46-49页.
[41]彭仪普,熊拥军.关联规则挖掘AprioriTid算法优化研究[J].计算机工程, 2006,(05):55-57页.
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