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基于前置审方系统的互联网医院处方、外配处方合理用药及医保基金管控体系构建与应用
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| 篇名： | 基于前置审方系统的互联网医院处方、外配处方合理用药及医保基金管控体系构建与应用 |
| TITLE： | Construction and application of a system for rational drug use for prescriptions from internet hospitals and external prescriptions and medical insurance fund control based on a pre-review prescription system |
| 摘要： | 目的 通过升级前置审方系统功能实现互联网医院处方与外配处方的前置审核以及药品（包含院内及外配药品）支付方式的审核，在保障患者用药安全的同时管控医保支出风险。方法整合互联网医院处方与外配处方数据接口，实现对互联网医院处方与外配处方的实时合理用药干预；增设支付方式智能审核项目，实现药品医保支付方式的精准干预。通过比较2025年1－4月（系统升级前）和2025年5－8月（系统升级后）互联网医院处方和外配处方的点评合格率及疑似违规药品金额，进行系统升级后的效果评价。结果前置审方系统升级后，互联网医院处方和外配处方的合格率提升了3.5%[95%置信区间（CI）为0.3%～6.7%，P＝0.037]；疑似药品违规金额下降至升级前的52.9%（95%CI为31.6%～88.5%，P＝0.026），同时平均每个月环比下降29.5%（95%CI为12.2%～43.4%，P＝0.012）。此外，新增的支付方式智能审核项目促进了我院超说明书用药管理，系统升级后共收到79份有效超说明书用药备案申请并归档。结论前置审方系统的升级有效提升了互联网医院处方与外配处方的点评合格率及药品医保支付准确性，并强化了超说明书用药监管，实现了临床合理性与医保合规性的双重保障。 |
| ABSTRACT： | OBJECTIVE To ensure the safety of patients’ drug use and control the risk of medical insurance expenditure by upgrading the pre-prescription review system to conduct pre-review on prescriptions from internet hospitals and external prescriptions， as well as to review the payment methods of drugs （including in-hospital and external drug dispensing）. METHODS The data interfaces of prescriptions from internet hospitals and external prescriptions were integrated to achieve real-time rational drug use intervention. Additionally， an intelligent review project for payment method was added to precisely intervene in the medical insurance payment methods of drugs. The effect of the system upgrade was evaluated by comparing the qualification rates of prescriptions from internet hospitals and external prescriptions and the suspected amounts of drug violations from January to April 2025 （before the system upgrade） and May to August 2025 （after the system upgrade）. RESULTS After the upgrade of the pre-prescription review system， the qualification rates of prescriptions from internet hospitals and external prescriptions increased by 3.5% [95% confidence interval （CI）＝0.3%-6.7%， P ＝0.037 ] ； the suspected amounts of drug violations decreased to 52.9% of the pre-upgrade level （95%CI＝31.6%-88.5%， P ＝0.026）， and the average monthly sequential decrease was 29.5% （95%CI＝12.2%-43.4%， P ＝0.012）. Moreover， the addition of the intelligent review project for payment methods promoted the management of off-label drug use in our hospital. After the upgrade， a total of 79 filling valid applications for off-label drug use were received and archived. CONCLUSIONS The upgrade of the pre-prescription review system effectively improves the review qualification rates of prescriptions from internet hospitals and external prescriptions and the accuracy of medical insurance payment for drugs， and strengthens the supervision of off-label drug use， achieving dual guarantees of clinical rationality and medical insurance compliance. |
| 期刊： | 2026年第37卷第05期 |
| 作者： | 葛意；王晓兰；韩俊萍；吕波；管玉；许峰；施爱明 |
| AUTHORS： | GE Yi，WANG Xiaolan，HAN Junping，LYU Bo，GUAN Yu，XU Feng，SHI Aiming |
| 关键字： | 前置审方；医保基金；超说明书用药；智能审核；院内处方；外配处方；互联网医院 |
| KEYWORDS： | pre-prescription review； medical insurance |
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