심사평가 정보수집체계 개편 로드맵 개발

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Review system has been reformed focusing on connecting medical validity and quality of care and the need to improve data collection system is gaining more and more attention. The Health Insurance Review and Assessment Service (HIRA) has collected health outcome for value measurement using health insurance claim data and additional survey, but it required to build a system that can assure diversity and efficiency in the type and process of data collection. As such, HIRA has established and operated HIRA e-Image and e-Form System in order to reduce providers’ burden for data submission and streamline review and assessment process.
The main objective of this study is to propose a road map for review and assessment data collection system revision. More specifically, i) to review efficient data collection system by researching data collection and utilization cases from Korea and abroad, ii) to set up a direction for data collection in consideration of review and assessment system reform, and iii) to propose a step-by-step road map to improve data collection system.
To conduct review and assessment service,‘specific-statements’of health insurance claim statement need to be utilized in the short term, and a data submission system for review and assessment needs to be implemented in the long term. In order to expand HIRA e-Image and e-Form System, four mid and long-term strategies and nine sub-tasks were presented.
First, it is necessary to decide clear objectives and utilization of data collection and define standardization template in order to switch to HIRA e-Image and e-Form System. In other words, standardization of list of collected data should precede to enhance predictability of providers and data accuracy.
Second, data connection system between HIRA e-Image and e-Form System and providers’ EMR needs to be developed and data key-in principles need to be systematized. If HIRA developed and distributed a standardized data connection system or guideline, the system building period could be shortened. Also, clear principles for data key-in method should be presented to enhance data reliability. The guideline for EMR data will improve providers' understanding of data key-in, and narrow down gaps in data input.
Third, legal and institutional basis should be prepared for data collection to encourage utilization of HIRA e-Image and e-Form System. System expansion mechanism and data reliability validation method are also required. To expand HIRA e-Image and e-Form System, it is essential to secure not only non-financial support like development and distribution of standardized EMR connection system, but also financial support to aid data connection system development cost. And data reliability should be checked before collection process.
Forth, data collected through HIRA e-Image and e-Form System are important clinical data, such as test results and health outcome. Therefore, the value of collected data needs to be maximized through secondary utilization. A collaboration system should be discussed and reviewed to connect the HIRA e-Image and e-Form System with other healthcare information projects.
Alternative Title
Road map development for review and assessment data collection system revision
Table Of Contents
요 약 ⅰ
제1장 서론 ····································································································· 1
1. 연구 배경 ········································································································ 1
2. 연구 목적 ········································································································ 2
3. 연구 내용 및 방법 ·························································································· 3

제2장 국내 정보 수집 시스템 현황 ······························································· 5
1. 건강보험심사평가원 ························································································ 5
가. 진료비청구포털시스템 ·············································································· 5
나. e-평가시스템 ··························································································· 6
다. 심사평가정보 제출 시스템 ···································································· 8
라. 진료의뢰․회송 중계시스템 ····································································· 11
2. 한국보건의료정보원 ······················································································ 16
가. 전자의무기록시스템 인증제 ·································································· 16
나. 전자의무기록 표준화 지원사업 ····························································· 18
3. 한국사회보장정보원 ······················································································ 20

제3장 국외 정보 수집 및 활용 현황 ····························································· 25
1. 미국 ··············································································································· 25
2. 영국 ··············································································································· 38
3. 대만 ············································································································· 42

제4장 심사평가정보 수집과 활용 ································································· 47
1. 심사평가 정보 수집과 활용 ········································································· 47
가. 적정성 평가 ··························································································· 47
나. 진료비 심사 ··························································································· 51
다. 의료질평가지원금 ················································································· 60
라. 신포괄수가 지불제도 시범사업 ····························································· 64
마. 난임 시술 의료기관 평가 ······································································ 68
바. 조건부 선별급여 항목(의료기술) 재평가 ·············································· 70
2. 진료비청구 소프트웨어 업체 인터뷰 결과 ·················································· 71

제5장 정보수집체계 개편 로드맵 ··································································· 73
1. 정보수집체계 개편 방향 ··············································································· 73
가. 수집 방법 ······························································································· 73
나. 수집 정보 ······························································································· 74
2. 정보수집체계 개편을 위한 과제 ·································································· 75
가. 근거기반 수집 정보 목록 개발 ····························································· 76
나. 시스템 개발 지원과 정보 입력 체계화 ················································ 77
다. 정보 수집과 질 관리 체계 구축 ··························································· 77
라. 시스템과 수집 정보 활용 확대 ····························································· 79

참고 문헌 ······································································································· 81
ABSTRACT ··································································································· 85
부 록 ············································································································ 87
김소희 et al. (202012). 심사평가 정보수집체계 개편 로드맵 개발.
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