Decision Support System for Medical Care Quality Assessment Based on Health Records Analysis in Russia

摘要

The paper presents developed decision system, oriented for healthcare providers. The system allows healthcare providers to detect and decrease nonconformities in health records and forecast the sum of insurance payments taking into account nonconformities. The components are ISO13606, fuzzy logic and case-based reasoning concept. The result of system implementation allowed to 10% increase insurance payments for healthcare provider. Medical care process in Russia was unified [1] and medical standards were implemented. Standard describes the necessary medical services and drug prescriptions for groups of diagnoses. Medical services contain coefficients, which determine the probability of application. This fact identifies medical standard as reference document with uncertainty and makes fuzzy logic [2] as a relevant tool to work with them. Medical organizations (MO) have to provide their activity with standards. Insurance companies (IC) makes evaluation for MO's medical care by inspecting health records. On the result of evaluation, IC makes an invoice document that contains data of insurance payment for a medical service. However, this evaluation can be based not only on standards, but also on medical expert's personal experience. Expert produces a document, which presents all nonconformities. This document evaluates the quality of medical care specifies the sum of insurance payments for the analyzed treatment case. Medical care quality assessment based on health records evaluation by expert. Expert can evaluate using medical standards (explicit knowledge) and personal experience (implicit knowledge). In the Russian practice, the use of implicit knowledge is more common. We propose a concept of a decision support system for medical aid quality management, which allows healthcare providers to detect and reduce medical nonconformities in health records taking into account uncertainty and forecast the sum of insurance payments.