目的: 探究面向异地恶性肿瘤患者的全流程智能化门特管理系统的实施现状。方法: 以广东省广州市某肿瘤医院为例,该院医生端应用电子申请单并嵌入AI智能体,实现申请单半自动生成;患者端复核门特时通过微信小程序核验人脸并校验参保信息;门特审核时应用AI辅助人工决策,提升审核效率及准确度;门特结算逻辑嵌入后台,自动精准结算;同时引入门特动态退出机制。结果: 目前,广东全省患者可在该院一站式认定门特待遇,门特认定人次呈倍数级增长,累计认定量约10万,2025年异地业务占比达到72.6%。AI辅助人工审核上线后,80.1%的业务可在1小时内办结,认定时长最短缩至5分钟内。结论: 全流程智能化的门特管理系统可显著提升门特审核效率并保障医保基金规范使用,适合推广至其他医疗机构或门慢/门特病种。

Objective: This study investigates the implementation status of intelligent whole-process management system for cross-regional malignant tumor patients with outpatient special diseases. Methods: The study takes a tumor hospital in Guangzhou City as an example. On the physician side, electronic application forms integrated with AI agents were adopted to facilitate semi-automatic generation of application forms. For patient verification, a WeChat mini-program employing facial recognition and basic medical insurance data validation was deployed. The introduction of AI-assisted decision support has improved the efficiency and accuracy of the approval process. Furthermore, automated and precise claim processing was achieved by embedding the settlement logic into the backend system, alongside the implementation of a dynamic eligibility exit mechanism. Results: The one-stop eligibility certification of outpatient special disease is available at the hospital for patients throughout Guangdong Province at present, yielding a multiplicative rise in certified cases and a cumulative certification count of approximately 100000. By 2025, non-local patient services represented 72.6%. The introduction of AI-assisted review led to 80.1% of cases being processed within one hour, alongside a reduction of the minimal approval time to less than five minutes. Conclusion: The fully intelligent management system of outpatient special disease markedly improves approval efficiency while ensuring the proper use of medical insurance funds. These outcomes position it as a promising candidate for implementation across diverse healthcare institutions and outpatient special or chronic disease programs.