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附件：
贵州省
新型农村合作医疗信息管理系统
应用软件需求
农村卫生管理处 贵州省卫生厅 信 息中心
二〇〇七年七月
目 录
1
2
3 项目背景............................................................................................................ - 3 - 新农合信息化建设现状.................................................................................... - 4 - 建设目标............................................................................................................ - 5 -
3.1 总体目标 ................................................................................................. - 5 -
3.2 具体目标 ................................................................................................. - 6 - 4 业务描述............................................................................................................ - 6 -
4.1 新型农村合作医疗业务组织机构与关系 ............................................. - 6 -
4.2 业务流程 ................................................................................................. - 7 - 5 需求分析............................................................................................................ - 8 -
5.1 数据交换平台需求 ................................................................................. - 9 -
5.2 核心数据库信息需求 ............................................................................. - 9 -
5.3 核心数据库容量 ................................................................................... - 10 -
5.4 应用软件系统需求及方案设计 ........................................................... - 10 -
5.4.1
5.4.2
5.4.3 基础数据收集管理需求.................................................................... - 10 - 应用架构............................................................................................ - 11 - 数据流走向........................................................................................ - 11 -
5.5 业务功能需求 ....................................................................................... - 11 - 6 业务应用方案描述................................................................................... - 14 -
6.1 决策辅助系统 ....................................................................................... - 14 -
6.1.1
6.1.2
6.1.3 统计报告子系统................................................................................ - 15 - 基金监控子系统................................................................................ - 16 - 综合查询分析子系统........................................................................ - 17 -
6.2 业务管理系统 ....................................................................................... - 18 -
6.2.1
6.2.2
6.2.2.1
6.2.2.2
- 1 - 用户及权限划分 ............................................................................ - 18 - 系统功能 ........................................................................................ - 19 - 配置维护..................................................................................... - 19 - 权限管理..................................................................................... - 20 -
6.2.2.3
6.2.2.4
6.2.2.5
6.2.2.6
6.2.2.7
6.2.2.8
6.2.2.9
6.2.2.10
6.2.2.11 参合管理..................................................................................... - 20 - 基金管理..................................................................................... - 21 - 补偿管理..................................................................................... - 21 - 转诊管理..................................................................................... - 22 - 体检补偿管理............................................................................. - 22 - 补偿模式管理............................................................................. - 22 - 会计财务业务处理..................................................................... - 23 - 数据管理..................................................................................... - 23 - 定点医疗机构前端补偿管理..................................................... - 23 -
6.3 数据交换管理平台 ............................................................................... - 23 -
6.3.1
6.3.2
6.3.3 跨统筹区域参合人员基本信息交换................................................ - 23 - 与定点医疗机构的数据交换............................................................ - 23 - 与财务软件的数据交换.................................................................... - 24 -
6.4 门户网站系统 ....................................................................................... - 24 -
6.4.1
6.4.2
6.4.3
6.4.4
6.4.5
6.4.6
6.4.7
6.4.8 首页.................................................................................................... - 24 - 工作动态............................................................................................ - 24 - 政策法规............................................................................................ - 25 - 网上公告............................................................................................ - 25 - 市县工作动态.................................................................................... - 25 - 办事指南............................................................................................ - 25 - 管理频道............................................................................................ - 25 - 其它功能............................................................................................ - 25 -
- 2 -
1 项目背景
按照国家卫生部和贵州省人民政府的总体部署和安排，自2003年启动新型农村合作医疗试点工作以来，截至2006年年底，我省有34个试点县已经推行了新型农村合作医疗，参合农民人数达918.81万人，参合率为72.32%，已有523.9万人次获得新型农村合作医疗补偿(含住院、门诊)，报销总额达到22229.53万元。新型农村合作医疗制度的实施取得了明显成效。一是合作医疗制度框架和运行机制已基本形成，初步建立了较为有效的管理监督机制，特别是资金的封闭运行管理和信息公开、公示制度，为加强基金管理和群众监督发挥了较好的作用。二是参加合作医疗的农民对卫生服务的利用水平明显提高，就医经济负担得到减轻，参加合作医疗的农民住院次均补偿375.21元，占次均住院总费用的39.26％。三是合作医疗制度运行比较平稳，得到农民的广泛认可。
2007年，我省新型农村合作医疗全面覆盖所有县市。参合农民达2600万人，新型农村合作医疗覆盖地域广,参加农民人数多,管理环节涉及省、市、县各级政府、财政、卫生、各级各类医疗卫生机构及农民个人等各个方面，监督管理要求高、范围广，工作量巨大，必须充分利用现代科技手段和信息技术解决传统手工管理的种种弊端，逐步建立起具有统一规范和标准，适合我省实际的新型农村合作医疗网络系统，更好地为广大农民和各级政府及部门提供快捷、准确、全面的信息，为农村合作医疗管理决策提供服务。
卫生部、国家发改委和财政部等七部委联合下发的《关于加快推进新型农村合作医疗试点工作的通知》（卫农卫发[2006]13号）明确提出：“要加快合作医疗信息化建设，逐步实现网上审核报销、监管和信息传输，加强规范管理”。《卫生部关于新型农村合作医疗信息系- 3 -
统建设的指导意见》（以下简称“指导意见”）(卫农卫发[2006]453号)对建立健全新型农村合作医疗信息系统作了总体规划和部署，要求立足于规范管理、提高效率和农民方便受益，在2—3年内建立起与新农合制度发展相适应，与建设中的国家卫生信息系统相衔接、较为完备和高效的新农合信息系统，在各级新农合管理部门、经办机构、定点医疗机构以及其他部门之间建立计算机网络联接，实现新农合业务管理的数字化、信息化和科学化，提高新农合工作效率和服务水平的建设目标。
为了贯彻和落实“指导意见”中提出的统一规划，以省为单位统一新农合软件、数据标准及数据接口，力争在2007年底省级新农合信息平台投入运行的要求，提出以下我省新型农村合作医疗信息化管理整体解决方案。
2 新农合信息化建设现状
我省新型农村合作医疗信息化从2005年开始起步，信息化建设初期以县为单位，实现了在线审核等多种业务处理功能，经过1年多的建设，各级卫生部门在信息系统建设方面进行了积极的探索，在制定规划标准、设备配臵、网络建设、应用软件开发、人员培训等方面奠定了一定的基础，积累了经验：
1、 制定了相关标准：卫生部《新型农村合作医疗信息系统基本规范》（卫办农卫发[2005]108号，以下简称《规范》），从平台建设、功能规范、基本数据规范和数据代码规范等诸多方面对新农合信息化建设制定了技术规范。今年，卫生部又出台了“指导意见”，对构建全国新农合信息系统的建设目标、建设原则、总体架构、实施进度安排和保障措施等方面作了进一步的部署安排，明确了信息系统建 - 4 -
新型农村合作医疗信息系统用户手册
目 录
第一章
第二章
2.1
2.2
2.3
2.4 序言 ........................................................................................................................................ 6 首次安装须知 ........................................................................................................................ 7 系统的主要功能 ....................................................................................................................... 7 硬件环境 ................................................................................................................................... 7 操作平台推荐 ........................................................................................................................... 8 IE浏览器设置 .......................................................................................................................... 8
IE基本设置 ....................................................................................................................... 8
IE常见问题 ..................................................................................................................... 12 2.4.1 2.4.2
2.5
2.6
第三章
3.1
3.2 如何访问本系统 ..................................................................................................................... 15 如何获得登陆帐号 ................................................................................................................. 16 使用本系统 .......................................................................................................................... 16 功能介绍 ................................................................................................................................. 16 登陆系统 ................................................................................................................................. 17
3.3 系统管理 ..................................................................................................................................... 30
3.3.1用户管理 ............................................................................................................................... 30
3.3.2 角色管理 .............................................................................................................................. 30
3.3.3 组织机构 .............................................................................................................................. 31
3.3.4 行政区划管理 ...................................................................................................................... 34
3.4 档案管理 ..................................................................................................................................... 36
3.4.1 业务说明 .............................................................................................................................. 36
3.4.2 档案登记 .............................................................................................................................. 37
3.4.2.1新家庭登记 ..................................................................................................................... 38
3.4.2.2 查看变更日志 ................................................................................................................ 39
3.4.3 档案变更 .............................................................................................................................. 40
3.4.4迁址 ....................................................................................................................................... 40
3.4.5 拆户 ...................................................................................................................................... 41
3.5 基金管理 ..................................................................................................................................... 44
3.5.1 基金缴纳 .............................................................................................................................. 44
3.5.2 基金缴纳审核 ...................................................................................................................... 45
3.5.3 账户修改 .............................................................................................................................. 46
3.5.4 基金收入 .............................................................................................................................. 47
3.6 报表管理 ..................................................................................................................................... 49
3.6.1 参合分析 .............................................................................................................................. 49
3.6.1.1 注册登记表 .................................................................................................................... 49
3.6.1.2 参合人员表 .................................................................................................................... 51
3.6.1.3 参合年龄查询 ................................................................................................................ 52
3.6.1.4 特殊人员统计 ................................................................................................................ 54
3.6.1.5 参合档案汇总 ................................................................................................................ 55
3.6.1.6 下年度参合档案汇总 .................................................................................................... 56
3.6.2 补偿报表 .............................................................................................................................. 57
3.6.2.1 补偿审批表 .................................................................................................................... 57
3.6.2.2 门诊补助明细 ................................................................................................................ 58
3.6.2.3 门诊报销登记表 ............................................................................................................ 58
3.6.2.4 住院补助详细 ................................................................................................................ 59
3.6.3.5住院报销登记表 ............................................................................................................. 60
3.6.2.6各医疗机构报账统计 ..................................................................................................... 61
3.6.3 统计报表 .............................................................................................................................. 62
3.6.3.1 补偿进度表 .................................................................................................................... 62
3.6.3.2 医疗基金使用情况月表 ................................................................................................ 63
3.6.3.3 就医机构统计表 ............................................................................................................ 64
3.6.3.4 基金费用统计表 ............................................................................................................ 64
3.6.3.5全县补助综合统计表 ..................................................................................................... 65
3.6.4卫统报表 ............................................................................................................................... 66
3.6.4.1卫统53-1表 ................................................................................................................... 66
3.6.4.2卫统53-2表 ................................................................................................................... 66
3.6.4.3卫统53-3表 ................................................................................................................... 67
3.6.5.1门诊公示 ......................................................................................................................... 68
3.6.5.2 慢性病公示 .................................................................................................................... 69
3.6.5.3 住院公示 ........................................................................................................................ 70
3.6.5.4 住院公示（按医院） .................................................................................................... 70
3.6.6 地区报表 .............................................................................................................................. 71
3.6.6.1县外就医住院费用结算汇总表 ..................................................................................... 72
3.6.6.2 定点医疗机构费用审核结算汇总表-县级 .................................................................. 72
3.6.6.3 特殊人员费用统计表 .................................................................................................... 73
3.6.6.4 定点医疗机构医疗费用审核结算汇总单（三）-乡级 .............................................. 74
3.6.6.5 新型农村合作医疗参合情况登记表 ............................................................................ 75
3.7数据查询 ...................................................................................................................................... 76
3.7.1医疗机构综合信息表 ........................................................................................................... 76
3.7.2工作量统计 ........................................................................................................................... 77
3.8证卡管理 ...................................................................................................................................... 78
3.8.1证卡制作 ............................................................................................................................... 78
3.8.2证卡挂失 ............................................................................................................................... 80
3.8.3 证卡补办 .............................................................................................................................. 80
3.8.4证卡维护 ............................................................................................................................... 81
3.8.5医疗卡（慢性病） ............................................................................................................... 83
3.8.6 打印设置 .............................................................................................................................. 84
3.9 门诊管理 ..................................................................................................................................... 88
3.9.1门诊补偿 ............................................................................................................................... 88
3.9.3门诊冲正 ............................................................................................................................... 95
3.9.4 门诊结算 .............................................................................................................................. 96
3.9.5门诊审核（门诊初审） ....................................................................................................... 98
3.9.6门诊终审 ............................................................................................................................. 100
3.10辅助功能 .................................................................................................................................. 103
3.10.1站内短消息 ....................................................................................................................... 103
3.10.2系统公告 ........................................................................................................................... 106
3.10.3客户反馈 ........................................................................................................................... 108
3.11住院管理 .................................................................................................................................. 113
3.11.1住院登记............................................................................................................................ 113
3.11.2住院补偿............................................................................................................................ 117
3.11.3转诊管理............................................................................................................................ 123
3.11.4住院冲正............................................................................................................................ 124
3.11.5住院审核（住院初审）.................................................................................................... 126
3.11.6住院终审............................................................................................................................ 129
3.11.7 住院结算........................................................................................................................... 131
第四章
4.1
4.2
4.3
4.4
4.5
4.6
4.7
4.8
4.9
4.10
4.11 方案管理 ............................................................................................................................ 135 概念描述 ............................................................................................................................... 135 方案配置的整体流程 ........................................................................................................... 136 计算项是什么 ....................................................................................................................... 137 怎么配置计算项 ................................................................................................................... 137 起付线是什么 ....................................................................................................................... 139 怎么配置起付线 ................................................................................................................... 139 封顶线是什么 ....................................................................................................................... 140 怎么配置封顶线 ................................................................................................................... 140 什么是优惠项 ....................................................................................................................... 141 怎么配置优惠项 ................................................................................................................ 141 怎么配置方案 .................................................................................................................... 143
4.11.1
4.11.2
4.11.3
4.11.4【新农合管理系统】
4.12 方案登记 ..................................................................................................................... 143 方案配置 ..................................................................................................................... 144 方案复制 ..................................................................................................................... 145 方案作废 ..................................................................................................................... 145 怎么测试方案 .................................................................................................................... 145
4.12.1
4.12.2
4.13
4.14 单方案测试 ................................................................................................................. 145 方案整体测试 ............................................................................................................. 146 怎么发布方案 .................................................................................................................... 147 方案配置示例 .................................................................................................................... 148
4.14.1 方案描述 ..................................................................................................................... 148
新型农村合作医疗管理信息系统
URCCM（V3.0）
操 作 手 册
目 录
一、系统登录 ··································································································· 5 二、系统功能列表 ···························································································· 6 三、常见功能描述与说明 ················································································· 8
1、功能按钮说明： ······································································································································ 8 2、数据合法性检验： ·································································································································· 8
四、详细功能描述 ···························································································· 9
【1】、系统控制台 ········································································································································· 9 【1.1】系统年度初始化 ····················································································································· 9 【1.2】系统用户管理 ······················································································································· 10 【1.3】用户组权限管理 ··················································································································· 11 【1.4】系统日志管理 ······················································································································· 12 【1.5】补偿公式设置 ······················································································································· 13 【2】、基础信息设置 ·································································································································· 14 【2.1】类别及险种信息设置 ··········································································································· 14 【2.2】药品及诊疗项目维护 ··········································································································· 16 【2.3】定点医疗服务机构维护 ······································································································· 17 【2.4】常见疾病信息维护 ··············································································································· 18 【3】、参合档案管理 ·································································································································· 19 【3.1】乡镇信息维护 ······················································································································· 19 【3.2】行政村信息维护 ··················································································································· 20 【3.3】户及人员信息维护 ··············································································································· 21 【3.4】合作医疗证（卡）管理 ······································································································· 24 【3.4.1】合作医疗证（卡）处理 ································································································ 24 【3.4.2】合作医疗证（卡）处理统计 ························································································ 27 【3.5】家庭合疗帐户设置 ··············································································································· 27 【3.5.1】单户家庭帐户划拨 ········································································································ 27 【3.5.2】全村家庭帐户划拨 ········································································································ 28 【3.5.3】全镇家庭帐户划拨 ········································································································ 29 【3.6】家庭合疗帐户查询 ··············································································································· 30 【3.7】参合人员花名册打印 ··········································································································· 31 【4】、基金缴纳管理 ·································································································································· 32 【4.1】缴纳参保资金 ······················································································································· 32
【4.2】其他收入登记 ······················································································································· 33 【4.3】缴款信息统计 ······················································································································· 34 【4.4】滚动筹资统计表 ··················································································································· 35 【5】、转院治疗管理 ·································································································································· 35 【5.1】转诊单据管理 ······················································································································· 35 【5.2】转诊单据统计 ······················································································································· 36 【6】、结算支付管理 ·································································································································· 37 【6.1】费用信息登记 ······················································································································· 37 【6.1.1】门诊费用信息登记 ········································································································ 37 【6.1.2】住院费用信息登记 ········································································································ 38 【6.2】费用信息编辑 ······················································································································· 39 【6.3】费用信息审核 ······················································································································· 40 【6.3.1】门诊费用信息审核 ········································································································ 40 【6.3.2】住院费用信息审核 ········································································································ 41 【6.4】门诊补偿结算单 ··················································································································· 42 【6.5】住院信息统计 ······················································································································· 42 【7】、统计分析管理 ·································································································································· 43 【7.1】按地区统计合作医疗参合情况 ··························································································· 43 【7.2】参合人员费用信息查询 ······································································································· 44 【7.3】受益家庭及人员统计分析 ··································································································· 46 【7.4】本年度未享受合作医疗补偿人员名单 ··············································································· 47 【7.5】医疗机构与合管办费用结算统计 ······················································································· 47 【7.5】合作医疗费用按补偿方式统计 ··························································································· 50 【7.6】合作医疗费用补偿统计分析 ······························································································· 51 【7.6.1】地区合作医疗补偿统计分析 ························································································ 51 【7.6.2】医院合作医疗补偿统计分析 ························································································ 52 【7.6.3】医院类别合作医疗补偿统计分析 ················································································ 54 【7.7】合作医疗病人发生费用统计 ······························································································· 56 【7.7.1】以镇为单位统计 ············································································································ 56 【7.7.2】以村为单位统计 ············································································································ 56
五：辅助功能描述 ·························································································· 58
【1】、锁定系统 ··········································································································································· 58 【2】、关闭所有窗口 ·································································································································· 58 【3】、登录用户 ··········································································································································· 58 【4】、计算器 ····················································
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