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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
                                                  Δ


          葛 意 ，王晓兰，韩俊萍，吕 波，管 玉，许 峰，施爱明（苏州大学附属第二医院药学部，江苏 苏州
                ＊
                                                                  #
          215000）

          中图分类号  R952      文献标志码  A      文章编号  1001-0408（2026）05-0584-05
          DOI  10.6039/j.issn.1001-0408.2026.05.06

          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。
          关键词  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

          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
          GE Yi，WANG Xiaolan，HAN Junping，LYU Bo，GUAN Yu，XU Feng，SHI Aiming（Dept.  of  Pharmacy，  the
          Second Affiliated Hospital of Soochow University， Jiangsu Suzhou 215000， China）

          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，
              Δ 基金项目 苏州市药学会-江苏恒瑞医药临床药学科研基金研究
                                                              achieving  dual  guarantees  of  clinical  rationality  and  medical
          项目（No.Syhky202309）；江苏省药学会-“药”研新声药学科研项目
         （No.202495093）                                       insurance compliance.
             ＊ 第一作者 主 管 药 师 。 研 究 方 向 ：临 床 药 学 。 E-mail：      KEYWORDS    pre-prescription  review；  medical  insurance
          1083794439@qq.com
                                                              fund；  off-label  drug  use；  intelligent  review；  in-hospital
              #  通信作者 主 任 药 师 。 研 究 方 向 ：药 事 管 理 。 E-mail：
          sam740411@163.com                                   prescriptions； external prescriptions； internet hospitals


          · 584 ·    China Pharmacy  2026 Vol. 37  No. 5                               中国药房  2026年第37卷第5期
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