Data processing: financial – business practice – management – or co – Automated electrical financial or business practice or... – Health care management
Reexamination Certificate
1998-12-30
2002-05-07
Chilcot, Richard (Department: 2761)
Data processing: financial, business practice, management, or co
Automated electrical financial or business practice or...
Health care management
C705S003000
Reexamination Certificate
active
06385589
ABSTRACT:
BACKGROUND OF THE INVENTION
1. Field of the Invention
The present invention relates to software and hardware systems for proactively monitoring and managing the health care of a population of member patients. More particularly, the present invention relates to a proactive system in which medical data are periodically gathered and, based on medical data indicating a risk situation, Coordination Specialists are notified and provided with information enabling them to take specific actions to avoid unintended health care utilization and/or health care process failures.
2. Description of the Related Art
Conventional systems for providing health care services operate mainly in response to existing health problems. For example, in such reactive systems, a patient experiencing health problems must initially schedule an appointment with a physician for evaluation of the problems. During the appointment, the physician evaluates the patient, the patient is treated by the physician or is referred to a specialist physician for treatment, and the patient is prescribed medicine or other types of follow-up care/treatment.
Accordingly, the effectiveness of conventional reactive systems in their ability to maintain patient health depends heavily upon patient responsibility. For example, conventional systems require a patient to determine when to seek medical help, to determine where to go for help (physician's office, outpatient clinic, hospital, emergency room, etc.), to understand his condition and his role in treatments), to comply with prescribed treatment, and to manage multiple conditions and corresponding treatments simultaneously. In a case that any of these functions is poorly performed, the health of the patient is jeopardized and additional health care expenditures are likely to be necessary.
Conventional systems also require several physicians or other care providers to care for a particular patient. In some of these systems, for example, a primary care physician focuses on diagnosis and development of a treatment plan, a specialist physician focuses on a particular specialty area, a surgeon performs needed surgeries, and a home health care provider delivers home-based treatment and support. However, conventional systems often fail to cooperatively execute each of the above health care processes, most often due to a lack of communication among the various care providers.
As a result of the foregoing, conventional health care systems are susceptible to several types of process failures. These failures often lead to lower quality of care and higher health care costs. In one type of process failure, a patient fails to fulfill his responsibilities in managing his condition or executing his health care regimen. Specifically, a patient with hypertension may not properly manage his condition by lowering his sodium intake, or a patient with dementia and no caregiver support may be unable to properly manage multiple prescribed medications.
Another type of process failure occurs when health care is not consistently delivered to patients with progressive chronic conditions. For example, a patient with heart problems who is taking blood-thinning agents may fail to undergo required periodic lab tests due to either patient non-compliance or neglect on the part of the primary care physician. In another example, a patient with diabetes, at risk for deteriorating vision, may fail to attend annual eye examinations.
Communication failures are another type of process failure and occur between various care providers. In one instance, due to a lack of communication with a patient's primary care physician, a hospital-based physician may prescribe care for an elderly patient that is in conflict with the primary care physician's treatment plan and understanding of the patient. In another instance, a specialist may perform lab tests identical to those previously performed by a primary care physician because he is unaware of the previous tests or because he does not have access to the results of the previous tests.
Failures in task execution may occur even if communication between various providers is successful. For example, even though instructions are issued to provide a wheelchair to the home of a discharged patient, those instructions may not be carried out, or may be carried out several days too late. In either case, the health of the patient is jeopardized.
Improper utilization of health care resources is another common type of process failure. For example, a patient with a chronic condition and poor understanding of the health care system may use the emergency room for health care services when other options would be more appropriate and much less costly. In another example, improper utilization of resources also may occur when a patient ignores serious symptoms of disease and, as a result, fails to seek care. In this latter case, the health of the patient is endangered and the potential costs of future care for that patient may increase substantially.
Finally, conventional health care systems are effective only if providers follow accepted standards of care, whether in prescribing medicine, rehabilation, or other treatment. If such standards are not followed, patient health is jeopardized even if all other aspects of the system function properly.
As a result of the prevalence of process failures in conventional health care delivery systems, health care providers, health maintenance organizations (HMOs), and medical insurance companies are attempting to create and enforce strict protocols to deal with health problems once they occur, and to perform limited preventive care for certain individuals. However, these conventional protocols have not adequately improved the health of individuals subject to the protocols, nor have they sufficiently reduced health care costs.
SUMMARY OF THE INVENTION
In order to address the foregoing problems, the present Applicants have discovered that certain combinations of patient characteristics and medical events concerning a patient indicate that the patient is at risk of incurring medical costs due to an avoidable process failure of the health care system. Such combinations are hereinafter referred to as “risk situations”. Moreover, Applicants have invented a system which detects risk situations and allows care providers to proactively address avoidable process failures that correspond to the risk situations.
Advantageously, the present invention allows proactive intervention in cases where the cost of preventing a process failure is less than the cost incurred if the failure occurs, as reduced by the probability of the failure occurring without the intervention. Accordingly, the present invention provides a flexible and proactive system to improve the health of a population of member patients and to lower the costs of caring for the population. The system also provides proactive intervention in cases where the above cost-benefit relationship is not satisfied, but where intervention is nonetheless desired, such as to meet a regulatory requirement.
More specifically, a system for managing health care of a member population according to the present invention preferably includes periodic monitoring of a member population for member characteristics and/or medical events, identification of opportunities to assist members in managing their health and in navigating through the health care system based on combinations of member characteristics and/or medical events, and identification, based on combinations of member characteristics and medical events, of opportunities to assist physicians and other care providers in properly delivering health care services.
A system according to the invention also preferably includes proactive, cost-effective, and coordinated patient interventions to address the identified opportunities, as well as-proactive interventions with physicians and providers to assist them in managing care and in coordinating the activities of various care providers.
FIG. 1
is a representative block diagram of a system according to the present invent
McAlearney Ann
Melkus Timothy
Trusheim Mark
Yager J. Michael
Chilcot Richard
Fitzpatrick ,Cella, Harper & Scinto
Harle J
Pharmacia Corporation
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