Sear A M
Department of Health Policy and Management, University of South Florida, Tampa 33612.
J Med Syst. 1988 Oct;12(5):275-83. doi: 10.1007/BF00996578.
The eligibility requirements for AFDC Medicaid are so extensive and complicated that most health care providers do not attempt to ascertain whether or not a particular patient is eligible for the program, even when no other source of payment is available. This results in lost revenue for health service providers nationwide amounting to hundreds of millions of dollars per year. Computer technology, in the form of expert systems, offers an opportunity to rationalize the Medicaid eligibility determination process and to do real-time assessments of patient eligibility. This article presents an expert system called MEDELEX (MEdicaid ELigibility EXpert) for determining Medicaid eligibility. The program (when run on an 8 MHz MS-DOS microcomputer with at least 640 KB of RAM) requires about 20 min for data entry and 5 sec for the actual eligibility determination. The expert system was written in Prolog and has been designed in such a way that it can be readily modified to take into account the state-to-state variability in eligibility requirements for AFDC Medicaid.
对“抚养未成年子女家庭援助计划”医疗补助的资格要求极为宽泛且复杂，以至于即便没有其他支付来源，大多数医疗服务提供者也不会去试图确定某个特定患者是否符合该计划的资格。这导致全国范围内的医疗服务提供者每年损失数亿美元的收入。以专家系统形式存在的计算机技术为使医疗补助资格判定过程合理化以及对患者资格进行实时评估提供了契机。本文介绍了一个名为MEDELEX（医疗补助资格专家系统）的用于判定医疗补助资格的专家系统。该程序（在一台8兆赫兹、至少有640千字节随机存取存储器的MS - DOS微型计算机上运行时）数据录入大约需要20分钟，实际资格判定需要5秒钟。这个专家系统是用Prolog编写的，其设计方式使得它能够很容易地根据不同州“抚养未成年子女家庭援助计划”医疗补助资格要求的差异进行修改。
