Data processing: financial – business practice – management – or co – Automated electrical financial or business practice or... – Health care management
Reexamination Certificate
1999-11-10
2002-03-12
Rimell, Sam (Department: 2163)
Data processing: financial, business practice, management, or co
Automated electrical financial or business practice or...
Health care management
C705S001100, C705S002000, C705S500000
Reexamination Certificate
active
06356873
ABSTRACT:
BACKGROUND OF THE INVENTION
1. Field of the Invention
The present invention generally relates to a computer implemented and/or assisted process for controlling drug or health care spending and/or use while improving or maintaining the quality of care in a patient population. More particularly, the present invention relates to a computer implemented and/or assisted process for ensuring and/or designing appropriate patient care, through the selection and/or collection of extensive information on a patient's use of medication(s), medical history, and/or satisfaction, as well as the involvement of both the patient and physician in the decision-making process. The patient may optionally be, for example, using multiple medications for treatment of multiple diseases in the computer implemented and/or assisted process.
2. Background of the Related Art
Health care costs currently represent a significant portion of the United States Gross National Product, and continue to rise at an exceptional pace. A significant portion of these increased costs represents an inability to appropriately coordinate or target the appropriate medications and/or treatment for individual patients. Accordingly, we have determined that many people are deprived of access to services which can coordinate the most needed medical care and information.
Coupled with the inability to prescribe the appropriate medication and/or treatment, many people delay in obtaining, or are prevented from seeking, medical attention because of cost, time constraints, or inconvenience. If the public had universal, unrestricted and easy access to medical information, many diseases could be prevented. Similarly, the early detection and treatment of numerous diseases could keep many patients from reaching the advanced stages of illness. These advanced stages of illness are a significant part of the costs attributed to our nation's health care system. It is obvious that the United States, and the world is facing health-related issues of enormous proportions.
One prior attempt at a solution to the health care problem is called Ask-A-Nurse, wherein a group of nurses provide health information by telephone around-the-clock. A person with a medical problem calls an 800 number and describes the problem to the nurse. The nurse uses a computer for general or diagnostic information on the ailment or complaint mentioned by the caller. The nurse may then refer the caller to a doctor from a computerized referral list for a contracting hospital or group of hospitals. Client hospitals contract with Ask-A-Nurse to provide patient referrals. A managed care option called Personal Health Advisor is similar and adds the capability for the caller to hear prerecorded messages on health topics 24 hours a day.
Several problems exist with these prior medical advice systems. First, these systems have high costs associated with having a nurse answer each telephone call. Second, the caller may have to belong to a participating health plan to utilize the service. Third, and significantly, this system is designed to respond to reactive problems determined by the caller, and therefore, provides no ability to eliminate the possibility of such a condition occurring in the first instance. Fourth, these medical advice systems generally do not possess the requisite in-depth knowledge to provide meaningful guidance in any specific area, e.g., drug use.
Another prior health system provides a computerized service that answers health care questions and advises people in their homes. A health maintenance organization (HMO) may provide this service to its members in a particular geographic area. To get advice at home, an HMO member connects a toaster-sized box to a telephone and calls a toll-free 800 number. Using a keyboard that is part of the box, the user answers questions displayed on a screen of the box relating to the user's symptoms. Depending on the answers, the user might be told to try a home remedy, be called by a nurse or doctor, or be given an appointment to be examined. This system is also designed to respond to reactive problems determined by the caller, and therefore, provides no ability to eliminate the possibility of such a condition occurring in the first instance.
At the other end of the spectrum, are various attempts at analyzing retroactively using hindsight, the appropriateness of the delivered medical care for quality and cost. For example, U.S. Pat. No. 5,544,044 to Leatherman, incorporated herein by reference, relates to a software-based medical information system performs a method of analyzing health care claims records for an enrolled population (e.g., HMO, Medicaid) to assess and report on quality of care based on conformance to nationally recognized medical practice guidelines or quality indicators.
FIGS. 1
a
-
1
d
are flow charts illustrating this software-based medical information system that analyzes health care claims records to assess and report on quality of care.
The process is typically performed at the request of a customer that is a health maintenance organization, indemnity insurer (e.g., Blue Cross), a large, self-insured employer group or a government program (e.g., Medicaid). At the start
1
, the first step
3
is to obtain the customer specific parameters, such as what time period the customer wishes to analyze or whether the customer wants to have some data broken down by particular providers or other grouping variables. The next step
4
is to update the system options and parameters using the customer specifications. Thereafter, the system obtains and loads
5
the customer data, usually consisting of the customer's already-computerized health care claims data for a specified period, together with enrollment data and health care provider data.
The enrollment data is extracted
7
so as to identify the enrollees served by the customer that meet a predefined enrollment criterion. The resulting enrollment data
9
contains one record per enrollee. Next, the relevant claims data are extracted
11
from the complete customer data base and are configured through linkages to produce the necessary health records. The claims data will include claims records for medical professional services
12
(outpatient records), claims records for hospital services
13
(inpatient records) and claims records for pharmacy purchases
14
(pharmacy records).
If the customer desires, provider-specific data is also extracted
16
from the customer data, permitting the later analysis to be broken down by the particular provider of services or products, which may be a particular doctor, clinic or hospital. The resulting files are merged
19
to produce uncorrected master files
21
. Duplicate claims are excluded
23
and claims that have been reversed through the claims adjudication process. This produces a master file
25
of health care claims records.
Step
29
involves the application of the definitions for the health care condition to identify the population having that condition, followed by an analysis of the claims records for that population (a subset of the master files
25
) under the defined quality care criteria. The result of the analysis in step
29
is a report that includes: charts and graphs
31
reporting statistically observed quality of care data in the population defined as having the health care condition of interest; a written analysis reporting, from a care quality viewpoint, statistical results considered worthy of highlighting
33
,
35
; and a report containing recommendations for actions to improve health care quality
37
,
39
.
Analysis for multiple health care conditions takes place iteratively through the software at step
41
, and the process just described, comprising steps
29
,
31
,
33
, and
37
and producing charts and graphs
31
and reports
35
,
39
is repeated, using the next health care condition definition to identify the population having that condition, followed by an analysis of the claims records for that population under the defined quality care criteria for that next condition. Af
Angaran David
Clotz Michael
Kenreigh Charlotte
Teagarden J. Russel
Donner Irah H.
Hale and Dorr LLP
Merck-Medco Managed Care, LLC
Rimell Sam
Robinson-Boyce Akiba
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