U.S. patent application number 11/103111 was filed with the patent office on 2005-08-25 for method and system for consolidating and distributing information.
Invention is credited to Johnson, Janice.
Application Number | 20050187797 11/103111 |
Document ID | / |
Family ID | 25503579 |
Filed Date | 2005-08-25 |
United States Patent
Application |
20050187797 |
Kind Code |
A1 |
Johnson, Janice |
August 25, 2005 |
Method and system for consolidating and distributing
information
Abstract
A method and system are provided for consolidating and
distributing information. Implementation of system functionalities
for both restricted local and unrestricted system-wide uses are
permitted. Open standards for hardware, software and firmware
components and standardized medical codes, definitions and formats
are supported. The preferred embodiment of the invention provides
an integrated health care system. The invention can also be used to
allow secure access to Social Security, annuity, retirement
account, and benefit information, allowing individuals a unified
view of their benefit and payment status. A centralized host
maintains, consolidates, and redistributes information generated at
all networked locations. Information is electronically transferred
among the system components to link an individual's local records
to those stored remotely. The individual information device,
centralized host computer, and any other computers or networks
linked to the system can therefore be automatically updated. An
individual information device stores a service recipient's
insurance information, a emergency records and critical health care
histories. This information is accessed by the system for use in
managing any aspect of the service recipient's health care.
Portable terminals can be used to access the system. A portable
terminal can also be used independently from the system to perform
health care functions. Unrestricted system-wide, or restricted
local uses are supported. Insurance coverage for services and
treatments can be determined and the information transmitted
directly from the carrier(s) to the service recipient and service
provider(s). Supported features include service authorization,
messaging, diagnostic services, coverage determination, billing,
and electronic payment.
Inventors: |
Johnson, Janice; (Mill
Valley, CA) |
Correspondence
Address: |
GLENN PATENT GROUP
3475 EDISON WAY, SUITE L
MENLO PARK
CA
94025
US
|
Family ID: |
25503579 |
Appl. No.: |
11/103111 |
Filed: |
April 11, 2005 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
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11103111 |
Apr 11, 2005 |
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08960755 |
Oct 29, 1997 |
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6915265 |
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Current U.S.
Class: |
705/3 |
Current CPC
Class: |
G16H 80/00 20180101;
G06Q 10/10 20130101; G06Q 40/02 20130101; G16H 40/67 20180101; G06Q
40/08 20130101; G16H 50/20 20180101; G16H 10/65 20180101; G16H
70/40 20180101; G16H 10/60 20180101; G16H 20/10 20180101 |
Class at
Publication: |
705/003 |
International
Class: |
G06F 017/60 |
Claims
1. An integrated health care system, comprising: at least one
central host computer system for maintaining, consolidating, and
distributing information generated by any component of said system;
at least one of a remote, single provider, or networked provider
terminal in communication with said central host computer; at least
one individual information device for accessing said system; and a
common data dictionary; wherein said service recipient's health
care data records are stored on any of said central host computer,
said terminal, or said individual information device; wherein said
central host computer, said terminal, and said portable individual
information device are electronically linked as a network, to
permit information distribution to various locations on said
network, and wherein said common data dictionary facilitates said
information distribution among said various locations by
standardizing system database elements; and wherein open standards
are used for hardware, software, and firmware components of said
system.
2. The system of claim 1, wherein said portable individual
information device stores any of an individual service recipient's
insurance information, emergency records, and health care
history.
3. The system of claim 1, wherein said remote, single provider, or
networked provider terminal comprises any of: a medical insurer
module; a health plan sponsor module; a health care service
provider module; a health care research module; and a service
support module.
4. The system of claim 3, wherein said medical insurer module
supports any of plan definition, open enrollment marketing
features, automated authorization of benefits, automated referrals,
and service payment accounting.
5. The system of claim 3, wherein said health plan sponsor module
supports any of open enrollment processes, maintaining benefit plan
information, and coordinating distribution and deactivation of
individual information devices.
6. The system of claim 3, wherein said health care service provider
module supports any of maintaining service recipient records,
diagnostic and treatment support, service payment management,
accounting services, and maintaining service provider records,
including licensing information, staffing affiliations,
organizational ownership information, tax identification
information, curriculum vitae of licensed practitioners, and well
as information regarding disciplinary actions.
7. The system of claim 3, wherein said health care research module
supports the collection of data on said system for research and
analysis of health care issues.
8. The system of claim 3, wherein said service support module
supports any of service parameter maintenance, product support,
customer requests, and system maintenance.
9. The system of claim 1, further comprising an integrated
statistical analysis software package linked to said system for
providing statistical analysis of said information stored in said
system.
10. The system of claim 1, further comprising a billing module for
calculating billing information for a service provided to said
service recipient.
11. The system of claim 1, further comprising an insurance benefits
module for calculating available insurance benefits for a service
provided to said service recipient.
12. The system of claim 1, further comprising a payment module for
electronically transferring funds to pay a bill for services
provided to said service recipient.
13. The system of claim 1, further comprising an authorization
module for authorizing service recipient treatment.
14. The system of claim 1, wherein said centralized host computer
system is one of a computer, or a network of linked computers
having at least one central server.
15. The system of claim 1, wherein said individual information
device is any of an integrated circuit card, a magnetic storage
card, or a portable integrated circuit or microchip-based
device.
16. The system of claim 15, further comprising a card reader,
linked to said remote, single provider, or networked provider
terminal, for accessing information stored on said individual
information device, and for transmitting information among said
individual information device and any of said components of said
system.
17. The system of claim 1, wherein said remote, single provider, or
networked provider terminal is one of a portable computer, personal
information device, personal computer, or server computer.
18. The system of claim 17, wherein said remote, single provider,
or networked provider terminal is operable to communicate with said
entire system or any portion of said system, or is operable
independently from said system.
19. The system of claim 1, further comprising a messaging module
for providing messaging services to a component of said system.
20. The system of claim 1, wherein said system is implemented using
any of the Internet, or a local area network.
21. The system of claim 1, wherein said system provides access to
any of Social Security, annuity, retirement account, and benefit
information.
22. The system of claim 1, wherein said common data dictionary
comprises: field definitions; and acceptable codes or values
organized in acceptable values tables to provide a uniform
healthcare vocabulary; wherein said codes ensure data integrity
throughout a data value chain and ensure the data's universal
consistency.
23. The system of claim 22, said data dictionary further
comprising: edit rules; format rules; identification of a field's
data owner, wherein the owner has ultimate authority for issuing
updates and revisions to the field; and references to diagnostic,
procedural, pharmaceutical and personal information codes for use
in processing changes to databases and in construction of research
requests to identify potential incompatibilities and problems;
wherein a database accesses data dictionary codes when responding
to a query so that information retrieved in response to a query is
limited to those cases containing no potential incompatibilities or
problems.
24. An integrated health care system, implemented using any of the
Internet or a local area network, the system comprising: at least
one central host computer system for maintaining, consolidating,
and distributing information generated by any component of said
system; at least one of a remote, single provider, or networked
provider terminal in communication with said central host computer;
a portable terminal in communication with said central host
computer, wherein said portable terminal is operable to communicate
with said entire system or any portion of said system, or is
operable independently from said system; at least one portable
integrated circuit card for accessing said system, wherein said
portable individual information device stores any of an individual
service recipient's insurance information, emergency records, and
health care history; a card reader, linked to said remote, single
provider, or networked provider terminal, for accessing information
stored on said individual information device, and for transmitting
information among said individual information device and any of
said components of said system; a messaging module for providing
messaging services to a component of said system; and a common data
dictionary; wherein said service recipient's health care data
records are stored on any of said central host computer, said
terminal, or said portable individual information device; wherein
said central host computer, said terminal, and said portable
individual information device are electronically linked as a
network, to permit information distribution to various locations on
said network, and wherein said common data dictionary facilitates
said information distribution among said various locations by
standardizing system database elements; wherein open standards are
used for hardware, software, and firmware components of said
system.
25. The system of claim 24, wherein said remote, single provider,
or networked provider terminal comprises any of: a medical insurer
module for supporting any of plan definition, open enrollment
marketing features, automated authorization of benefits, automated
referrals, and service payment accounting; a health plan sponsor
module, said health plan sponsor module supporting any of open
enrollment processes, maintaining benefit plan information, and
coordinating distribution and deactivation of individual
information devices; a health care service provider module, said
health care service provider module supports any of maintaining
service recipient records, diagnostic and treatment support,
service payment management, accounting services, and maintaining
service provider records, including licensing information, staffing
affiliations, organizational ownership information, tax
identification information, curriculum vitae of licensed
practitioners, and well as information regarding disciplinary
actions; a health care research module, said health care research
module supporting the collection of data on said system for
research and analysis of health care issues; and a service support
module, said service support module supporting any of service
parameter maintenance, product support, customer requests, and
system maintenance.
26. The system of claim 24, further comprising an integrated
statistical analysis software package linked to said system for
providing statistical analysis of said information stored in said
system.
27. The system of claim 24, further comprising a billing module for
calculating billing information for a service provided to said
service recipient.
28. The system of claim 24, further comprising an insurance
benefits module for calculating available insurance benefits for a
service provided to said service recipient.
29. The system of claim 24, further comprising a payment module for
electronically transferring funds to pay a bill for services
provided to said service recipient.
30. The system of claim 24, further comprising an authorization
module for authorizing service recipient treatment.
31. The system of claim 24, wherein said centralized host computer
system is one of a computer, or a network of linked computers
having at least one central server.
32. The system of claim 24, wherein said system provides access to
any of Social Security, annuity, retirement account, and benefit
information.
33. The system of claim 24, wherein said common data dictionary
comprises: field definitions; and acceptable codes or values
organized in acceptable values tables to provide a uniform
healthcare vocabulary; wherein said codes ensure data integrity
throughout a data value chain and ensure the data's universal
consistency.
34. The system of claim 33, wherein said data dictionary further
comprises: edit rules; format rules; identification of a field's
data owner, wherein the owner has ultimate authority for issuing
updates and revisions to the field; and references to diagnostic,
procedural, pharmaceutical and personal information codes for use
in processing changes to databases and in construction of research
requests to identify potential incompatibilities and problems;
wherein a database accesses data dictionary codes when responding
to a query so that information retrieved in response to a query is
limited to those cases containing no potential incompatibilities or
problems.
35. A method for consolidating information in an integrated health
care system implemented using any of the Internet or a local area
network, the method comprising the steps of: maintaining,
consolidating, and distributing information generated by any
component of said system with at least one central host computer
system for; providing at least one of a remote, single provider, or
networked provider terminal in communication with said central host
computer; providing a common data dictionary; providing a portable
terminal in communication with said central host computer, wherein
said portable terminal is operable to communicate with said entire
system or any portion of said system, or is operable independently
from said system; providing at least one portable integrated
circuit card for accessing said system, wherein said portable
individual information device stores any of an individual service
recipient's insurance information, emergency records, and health
care history; linking a card reader to said remote, single
provider, or networked provider terminal, for accessing information
stored on said individual information device, and for transmitting
information among said individual information device and any of
said components of said system; providing messaging services to a
component of said system; wherein said service recipient's health
care data records are stored on any of said central host computer,
said terminal, or said portable individual information device;
wherein said central host computer, said terminal, and said
portable individual information device are electronically linked as
a network, to permit information distribution to various locations
on said network, and wherein said common data dictionary
facilitates said information distribution among said various
locations by standardizing system database elements; wherein open
standards are used for hardware, software, and firmware components
of said system.
36. The method of claim 35, further comprising the step of
providing access to any of Social Security, annuity, retirement
account, and benefit information.
37. The method of claim 37, wherein said common data dictionary
comprises: field definitions; and acceptable codes or values
organized in acceptable values tables to provide a uniform
healthcare vocabulary; wherein said codes ensure data integrity
throughout a data value chain and ensure the data's universal
consistency.
38. The method of claim 37, wherein said data dictionary further
comprises: edit rules; format rules; identification of a field's
data owner, wherein the owner has ultimate authority for issuing
updates and revisions to the field; and references to diagnostic,
procedural, pharmaceutical and personal information codes for use
in processing changes to databases and in construction of research
requests to identify potential incompatibilities and problems;
wherein a database accesses data dictionary codes when responding
to a query so that information retrieved in response to a query is
limited to those cases containing no potential incompatibilities or
problems.
Description
CROSS REFERENCE TO RELATED APPLICATION
[0001] This application is a continuation of U.S. patent
application Ser. No. 08/960,755, filed 29 Oct. 1997.
BACKGROUND OF THE INVENTION
[0002] 1. Technical Field
[0003] The invention relates to information processing. More
particularly, the invention relates to a method and system for
consolidating and distributing health care records.
[0004] 2. Description of the Prior Art
[0005] Providing effective management and organization for the
health care system is a continuing need. Many attempts have been
made to improve communication, for example, among insurers, health
care providers, health plan sponsors, and patients. However, the
health care system is still subject to significant problems in
accurate record maintenance, access to information, and
communication among various organizations and agencies.
[0006] Pritchard, Medical Insurance Verification and Processing
System, U.S. Pat. No. 4,491,725 (1 Jan. 1985) discloses a system
for verifying and determining a patient's background medical and
insurance coverage. However, Pritchard does not integrate other
essential participants in the modern health care system. For
example, a user cannot locate and schedule appointments with health
care specialists, or research treatment options using the system
disclosed in Pritchard.
[0007] Each user of an integrated health care system may maintain
records and computer operations that are not to be distributed to
the other users of the system. Such information as personnel
records and internal disciplinary records are typically
confidential. However, it can be desirable for the user to also be
able to access these records as a part of the integrated health
care system. For example, the user may wish to compare the
treatment requirements of a patient with the discipline records of
a health care practitioner to determine if it is appropriate to
assign a case to a particular practitioner. It is therefore
desirable that the integrated health care system permit both
restricted local and unrestricted system-wide uses. However, the
Pritchard system does not disclose the structure or functionalities
for providing both such local and system-wide uses in the same
system.
[0008] Cummings, All Care Health Management System, U.S. Pat. No.
5,301,105 (5 Apr. 1994), describes a system for integrating the
participants in a health care system. The Cummings system is
designed for use by those directly involved in an individual
patient's health care program. Such users include the patient,
health care provider, bank or other financial institution,
insurance company, utilization reviewer and employer. However, the
Cummings system is not designed for use by other participants in
the health care system, such as medical researchers, and public
agencies. Furthermore, Cummings does not disclose support for
health care data reporting standards. Thus, the various users of
the Cummings system will need to convert the non-standardized
information retrieved from the system for use in other health care
reporting applications.
[0009] Additionally, Cummings does not support auxiliary
functionalities that are often essential to providing total health
care for a patient. For example, Cummings does not disclose support
for such functionalities as Social Security, annuity, retirement
account, and other benefit information.
[0010] The rapid transmission of data to the appropriate sources is
frequently of critical importance in providing health care.
Portable input devices, such as personal digital assistants, are
increasingly being used for creating, maintaining, and transmitting
data records. However, neither Cummings nor Pritchard discusses the
use of such portable input devices.
[0011] It would therefore be an advantage to provide a method and
system for integrating the various participants in a health care
system that permits both restricted local and unrestricted
system-wide uses. It would be a further advantage if such method
and system supported auxiliary functionalities related to providing
total health care. It would be yet another advantage if the method
and system supported the use of portable data input devices to
rapidly create, maintain, and transmit data records.
SUMMARY OF THE INVENTION
[0012] The invention provides a method and system for consolidating
and distributing information. Flexible configuration and access
options provide an array of options to best meet the needs of the
service provider's personal workstyle and required volume of
information. The system permits implementation of system
functionalities for both restricted local and unrestricted
system-wide uses. Open standards for hardware, software and
firmware components and standardized medical codes, definitions and
formats are supported.
[0013] The preferred embodiment of the invention provides an
integrated health care system, managing all facets of modern health
care, including individual service recipient care, public health,
and health care policy. The invention is used to consolidate health
care records, for example for diagnostic and research purposes, and
to permit immediate access to time critical health care
information. However, alternative embodiments of the invention can
be used to capture, store, and process other types of information.
For example, the invention can also be used to allow secure access
to Social Security, annuity, retirement account, and benefit
information, allowing individuals a unified view of their benefit
and payment status.
[0014] The invention provides centralized record collection and
facilitates the transfer of information among the different system
components by electronically linking an individual's local records
to those stored remotely, such as on the computer systems of
insurance companies, health care service providers, health plan
sponsors, medical researchers, and service support. A complete
record of individual care is thereby provided.
[0015] Such links between the individual service recipient's
records and other information systems permit the immediate transfer
of results and information among specialist service providers and
sites, libraries of scientific literature and bibliographic
information, institutional databases and registries, researchers,
and records of family members. Insurance coverage for services and
treatments can be determined and the information transmitted
directly from the carrier(s) to the service recipient and service
provider(s).
[0016] In the system, an individual service recipient is provided
an individual information device that stores the service
recipient's insurance information, as well as emergency records and
critical health care histories. In the preferred embodiment, this
individual information device is an integrated circuit (Smart)
card. However, the information device may include any appropriate
means for storing and/or encoding information, such as magnetic
storage cards or any other types of portable integrated circuit or
microchip-based devices.
[0017] A service provider accesses the information on the
individual information device, for example, by swiping the card
through a card reader linked to a remote terminal or to a single or
networked provider terminal. Such terminals include portable
computers and personal information devices, or any desktop computer
or networked computer.
[0018] In one embodiment of the invention, the invention is
implemented using a local area network (LAN) or intranet. In this
embodiment, information is transmitted from, for example, the
portable personal device, to the LAN or intranet Server. This
information may then be accessed by any workstations on the
internal network and can be transmitted from the LAN or intranet
Server to the host computer.
[0019] In the preferred embodiment of the invention, the terminal
is a portable device. This portable device can optionally be used
to communicate with the entire system, any portion of the system,
or independently from the system. Restricted local and unrestricted
system-wide uses can therefore be implemented.
[0020] A centralized host processing system is used to maintain,
consolidate and redistribute information generated at all access
endpoints, such as from the individual information device, with
stored information and from any computer or other processing and
storage device on the centralized network. The centralized host
processing system can be, for example, a computer network, or a
plurality of such linked networks having a central server. The
consolidated information is then distributed to various locations
on the network, for example, in response to a query.
[0021] Service information, formatted service recipient records,
and potential diagnostic codes are transmitted across the network
between the remote or provider terminal and the host computer(s).
The individual information device, centralized host computer, and
any other computers or networks linked to the system can therefore
be automatically updated.
[0022] Services can be authorized through access to the central
host(s), which can also calculate the costs of the services, as
well as the amount of available insurance coverage. The invention
can be used to generate billing information and to electronically
transfer funds from sources such as insurance carriers, bank
accounts, and credit card accounts.
[0023] Each Insurance carrier can be electronically billed for the
amount charged to that carrier. The Insurance carrier can then pay
the bill by electronically transferring funds to the service
provider's account at a specified payment interval. Payment
histories can be also be electronically transferred from the
Insurance carrier to the service provider on the network. The
charges to the service recipient can also be calculated and
transmitted to the service recipient.
[0024] In the preferred embodiment of the invention, an on-line
diagnostic service is provided, such as a software application or
an on-line diagnostician. Additionally, the system can be
integrated with statistical analysis software packages, for
example, to monitor patterns in national health care, or to plot
the distribution of cases of an infectious disease.
[0025] The invention supports messaging and scheduling services,
including electronic mail (e-mail), voice mail, and paging.
Appointment records and administrative information can also be
distributed through the system.
[0026] Service historical records stored on the system can be
accessed by researchers for full data analysis. The invention
supports research requests for analysis of any of the elements of
the system, such as for analyzing legal compliance or disease
management. Such historical records can be stripped of identifying
information before being distributed to researchers.
[0027] The invention promotes marketing and enrollment efforts for
new and current plans. Changes, for example, in plan memberships,
benefits, personal information, or health care information can be
automatically transmitted to the various participants in the
system.
[0028] The invention permits participants to search records for
health care providers and organizations. Such records can include
licensing information, staffing affiliations, organizational
ownership information, tax identification information, curriculum
vitae of licensed practitioners, as well as information regarding
disciplinary actions. Service recipients can access and review the
contents of their health care record and perform searches of
research databases, for example, regarding treatment options, and
toward development of a care contact network.
BRIEF DESCRIPTION OF THE DRAWINGS
[0029] FIG. 1 is a diagram of the system for consolidating and
distributing information, according to the invention;
[0030] FIG. 2 is a diagram of the components of the system for
consolidating and distributing information, according to the
invention;
[0031] FIG. 3 is a context diagram of the system for consolidating
and distributing information, according to the preferred embodiment
of the invention;
[0032] FIG. 4 is a flow diagram of the medical insurer/benefit
provider processes, according to the preferred embodiment of the
invention;
[0033] FIG. 5 is a flow diagram of the Health/Benefit plan sponsor
processes, according to the preferred embodiment of the
invention;
[0034] FIG. 6 is a flow diagram of the individual service
recipients processes, according to the preferred embodiment of the
invention;
[0035] FIG. 7 is a flow diagram of the health care service provider
processes, according to the preferred embodiment of the
invention;
[0036] FIG. 8 is a flow diagram of the Medical Research processes
according to the preferred embodiment of the invention; and
[0037] FIG. 9 is a flow diagram of the service support processes,
according to the preferred embodiment of the invention.
DETAILED DESCRIPTION OF THE INVENTION
[0038] The invention provides a method and system for consolidating
and distributing information. Flexible configuration and access
options provide an array of options to best meet the needs of the
service provider's personal workstyle and required volume of
information. The system permits implementation of system
functionalities for both restricted local and unrestricted
system-wide uses. Open standards for hardware, software and
firmware components and standardized medical codes, definitions and
formats are supported.
[0039] The invention creates an infrastructure for health care and
benefits management resulting in:
[0040] (1) support of service recipient care and improvement of
quality;
[0041] (2) enhancement of the productivity of health care
professionals and reduction of administrative costs associated with
health care delivery and financing;
[0042] (3) support of clinical and health services research;
[0043] (4) accommodation of future developments in health care
technology, policy, management and finance; and
[0044] (5) ensuring service recipient data confidentiality.
[0045] The preferred embodiment of the invention provides an
integrated health care system, managing all facets of modern health
care, including individual service recipient care, public health,
and health care policy. The invention is used to consolidate health
care records, for example for diagnostic and research purposes, and
to permit immediate access to time critical health care
information. However, alternative embodiments of the invention can
be used to capture, store, and process other types of information.
For example, the invention can also be used to allow secure access
to Social Security, annuity, retirement account, and benefit
information, allowing individuals a unified view of their benefit
and payment status.
[0046] The invention provides centralized record collection and
facilitates the transfer of information among the different system
components by electronically linking an individual's local records
to those stored remotely, such as on the computer systems of
insurance companies, health care service providers, health plan
sponsors, medical researchers, and service support. A complete
record of individual care is thereby provided.
[0047] Such links between the individual service recipient's
records and other information systems permit the immediate transfer
of results and information among specialist service providers and
sites, libraries of scientific literature and bibliographic
information, institutional databases and registries, researchers,
and records of family members. Insurance coverage for services and
treatments can be determined and the information transmitted
directly from the carrier(s) to the service recipient and service
provider(s).
[0048] Services can be authorized through access to the central
host(s), which can also calculate the costs of the services, as
well as the amount of available insurance coverage. The invention
can be used to generate billing information and to electronically
transfer funds from sources such as insurance carriers, bank
accounts, and credit card accounts.
[0049] Links may also be provided to decision support systems, such
as diagnosticians, thereby increasing the treatment information
available to service providers. Additionally, the system may be
integrated with statistical analysis software packages, for
example, to monitor patterns in national health care, or to plot
the distribution of cases of an infectious disease.
[0050] The invention therefore provides the data and processes
necessary to improve current and future health care services and
promote disease management, while reducing administrative costs and
simplifying payment processing for health care providers and health
care customers.
[0051] In this application, the term "function" refers to a
business related procedure that can be performed in one or more
steps, or "processes". These steps can be manual, automated, or
both. Processes often cross departmental and organizational
boundaries. Re-design or re-engineering such processes can often
improve management operation and functions, resulting in
significant time and cost savings. Components are subsets of a
functional process. Additionally, in this application, "user
groups" are the users of certain system functions.
[0052] FIG. 1 is a diagram of the system for consolidating and
distributing information, according to the invention. In the system
10, a participating individual is provided with an individual
information device 12. In the preferred embodiment, this individual
information device is an integrated circuit (Smart) card. However,
the information device may include any appropriate means for
storing and/or encoding information, such as magnetic storage cards
or any other types of portable integrated circuit or
microchip-based devices.
[0053] A centralized host processing system 14 is used to maintain,
consolidate and redistribute information generated at all access
endpoints, such as from the individual information device (not
shown), with stored information and from any computer 16, 18 or
other processing and storage device on the centralized network. The
centralized host processing system can be, for example, a computer
network, or a plurality of such linked networks having a central
server. The consolidated information is then distributed to various
locations 22, 24, 26, 28 on the network, for example, in response
to a query.
[0054] FIG. 2 is a diagram of the components of the system for
consolidating and distributing information, according to a
preferred embodiment of the invention. An individual is given an
individual information device 12 that stores the individual's
insurance information, as well as emergency records and critical
health care histories. This information may be encrypted.
[0055] A service provider accesses the information on the
individual information device, for example, of a health care
service recipient. When the individual information device is a
smart card, the information is accessed by swiping the card through
a card reader linked to a remote terminal 30 or a single or
networked provider terminal. Such remote terminals include portable
computers and personal information devices and provider terminals
can include any computing device operating in either a stand-alone
mode or connected to other computing devices through a local area
network, intranet, wide area network or any other interconnected
mode.
[0056] In the preferred embodiment of the invention, the terminal
is a portable device. This portable device can be optionally be
used to communicate with the entire system, any portion of the
system, or independently from the system. For example, a personal
digital assistant can be used by a physician to access a patient's
medical records stored on a central host. The personal digital
assistant can also be used on access confidential information
stored in a database that is not connected to the network, such as
files stored in the physicians personal computer. In addition, the
personal digital assistant can be used independently from the
system, such as to maintain work and appointment schedules, or to
store personal notes.
[0057] Service recipient information is transmitted from the remote
terminal or provider terminal across the network to the host
computer(s) 14. Information such as detailed histories and records
stored on the host computer are accessed and downloaded to the
service provider's computing device 32 or to a high volume
configuration such as a localized server or host 36. The individual
information device may then be updated by new information in the
information downloaded from the host computer 14.
[0058] Formatted service recipient record and potential diagnostic
codes may be downloaded from a network server, or the host computer
to a portable personal device or terminal for use by a health care
practitioner, for example, during an appointment with the service
recipient. Information gathered by the practitioner may also be
uploaded to the server, host computer, or individual information
device. Thus, for example, the service recipient will be provided
with an updated electronic record of new procedures and medications
prescribed by the health care practitioner and the service
recipient information on the central host computer will also be
updated to reflect the changes.
[0059] Appointment records and administrative information may also
be distributed through the system. Thus, a health care practitioner
may view the day's scheduled appointments, receive health care
records for each service recipient, record relevant information
from each appointment, and receive memos from, for example, an
Insurance carrier or a hospital using the portable personal device
or provider terminal.
[0060] In one embodiment of the invention, the invention is
implemented using a local area network (LAN) or intranet 42. In
this embodiment, information is transmitted from, for example, the
portable personal device 12, to a computer 34 that is connected to
the LAN or intranet server 36. This information may then be
accessed by any workstations or other computers 41 on the internal
network and can be transmitted from the LAN or intranet server to
the host computer 14.
[0061] In the preferred embodiment of the invention, an on-line
diagnostic service is provided. In one embodiment, this service is
a software application. This application allows a service provider
or service recipient to identify symptoms and search for potential
diagnoses, procedures, medications or pharmaceuticals, support
groups, specialists and other care options, pertinent research,
on-line video, audio and other multimedia options. The software
application also provides communication access features to
individuals and organizations.
[0062] In an alternative embodiment, the diagnostic service is an
on-line diagnostician. For example, the practitioner can submit
information and questions through the network to an on-call
physician. The physician can then respond immediately with a
diagnosis, treatment recommendations, or a request for further
information. Alternatively, the information can be stored in a
dedicated database for later diagnosis by a diagnostician, or in a
general database for review and suggestions from any practitioner
who uses the invention.
[0063] Following treatment, the service provider transmits
diagnostic and procedure codes to the system. Insurance coverage
for the services provided is then calculated. This calculation may
be performed at any appropriate device on the network, including a
remote terminal, portable personal device, service provider's
computer, network server, or host computer. If the service
recipient has multiple insurance carriers, or if insurance
deductibles apply to the services provided, the service provider's
records are updated with the appropriate billing parties and amount
chargeable to each.
[0064] Each insurance carrier can be electronically billed for the
amount charged to that carrier. The insurance carrier can then pay
the bill by electronically transferring funds to the service
provider's account at a specified payment interval. Payment
histories can be also be electronically transferred from the
Insurance carrier to the service provider.
[0065] The charges to the service recipient can also be calculated
by the system and transmitted to the service recipient through the
remote terminal, provider terminal, or portable personal device.
Thus, the service recipient can be advised of the total charges,
amount of insurance charges, and the amount for which the service
recipient is liable prior to authorizing any treatment.
[0066] In the preferred embodiment of the invention, administrative
information transfers are transmitted to the centralized host
system during non-peak times. Thus, invoices, appointment lists,
messages, and payment records may be transmitted, for example, at
night. Batch transfers are preferably used in appropriate instances
for high-volume, non-critical information transfers to reduce
bandwidth overhead and network contention. However, on-line access
approaching twenty-four hour, seven days per week is available for
service recipient record access and updates. Emergency and critical
information transfers are thereby supported.
[0067] The invention facilitates information retrieval and analysis
for research. Service recipient historical records stored on the
system can be accessed by researchers for full data analysis. Such
historical records can be stripped of identifying information
before being distributed to researchers.
[0068] Research requests can be sent to the system, and run, for
example, during non-peak processing times to minimize system
resource contention. Data can then be returned to the requesting
party through the party's communication link. The invention
supports research requests for analysis of any of the elements of
the system, such as for analyzing legal compliance or disease
management.
[0069] In the preferred embodiment, data can be stored in a
relational database. Keys such as subscriber identification number,
insurer identification number, prognosis, and treatment codes can
be used to index this relational database. In the preferred
embodiment, the service recipient record data is chronologically
indexed to create a continuous history of the service recipient's
health care.
[0070] The contents of a service recipient's record can include,
for example:
[0071] (1) uniform core data elements;
[0072] (2) standardized coding systems and formats;
[0073] (3) common data dictionary; and
[0074] (4) information on outcomes of care and functional
status.
[0075] The core data elements are a set of information fields
defined in accordance with federal and international standard
setting organizations. These include standard codes for diagnoses,
procedures, medications and other elements of health care, standard
identifier information for service providers and insurers, and
standard data formats for maintaining and transmitting record
information. All data elements and their coded values and textual
descriptions are maintained in a common data dictionary, which is
one of a shared set of platform services used by all system
components during processing. (See, for example, FIG. 9).
[0076] Records for each service recipient served by the system are
stored in a Subscriber/Medical history database. All personal and
health care records are included in this centralized database.
These records include standard codes for all plans/benefits for
which the service recipient is a participant. These codes are used
to link to a Plan/Benefit database to access detailed records of a
service recipient's coverage.
[0077] The service provider standard codes, defined under the
Plan/Benefit database record, are used to link to detailed
information maintained in a service provider database. In this way,
standardized codes are used to access records throughout the
system. These records can therefore be maintained at a single
location, improving access and eliminating error-prone multiple
entries.
[0078] Service records within the service recipient's
Subscriber/medical history record are preferably stored in
chronological order. These records can contain multiple fields
relating to the episode, care, outcome of care, and functional
status. The personal information device of the service recipient
can hold either a selected subset of the full service recipient
record or the full record. In the preferred embodiment of the
invention, the available storage parameters are used by the system
to define a critical subset of the service recipient record to be
stored on the card.
[0079] In the preferred embodiment of the invention, a
standardized, patient-oriented health care record with display of
service recipient identification and emergency information followed
by sequential episodes of care is used as a default format for
service provider and service recipient access. This default format
can be displayed as a screen display or graphical user interface
(GUI). A customized screen display can also be provided to meet the
specific needs of a system user. This GUI can present the
standardized health care record for the service recipient as it is
downloaded from the individual information device or from the total
record stored in the Subscriber/Medical history database. This
standardized health care record can include:
[0080] (1) A structured, systematically collected database of
service recipient health care records constructed at the point of
service and collected during the service process;
[0081] (2) An easily reviewed and updated problem list using
standard diagnostic codes. Definitions can be updated and new
diagnostic, procedural and medication codes created and stored in
the central records;
[0082] (3) Records of clinical formulations and plans for care and
follow-up can be stored in the central host databases for use, for
example, by all research organizations and agencies in assessing
care components.
[0083] In addition, intelligence built into the system includes
decision support, clinician reminders, and customizable "alarm"
systems as explained below, in detail, in Al
Medications/procedures. Multiple standard reporting formats, such
as hard copy reports, and billing and payment reports, are also
available to all clients on a daily, weekly, monthly and annual
basis.
[0084] In the preferred embodiment of the invention, all central
host databases use a standardized common data dictionary to ensure
standardization of all system database elements. The common data
dictionary can store field definitions, acceptable codes or values,
edit rules, format rules, data owner showing who has ultimate
authority to issue updates and revisions to the field. The data
dictionary fields can also contain references to other diagnostic,
procedural, pharmaceutical and personal information codes to
identify potential incompatibilities or problems.
[0085] This data dictionary can be used in the processing of
changes to the databases and in the construction of research
requests. In addition, a database, such as the
Medications/Procedures database can access the data dictionary
codes when responding to a query. The data dictionary can then be
used to limit the information retrieved in response to the query to
those cases containing no potential incompatibilities or problems.
In this way, the information stored in the data dictionary can be
used to enable other functional capabilities of the system.
[0086] The lists of standardized codes for all prognoses,
medications and treatments are centrally controlled. Full cross
element edits are included to flag potentially invalid or incorrect
entries. The values in the data dictionary can be used to construct
a customized edit of a service recipient record. The use of such
common data dictionary, standardized coding schemes, and uniform
data sets promotes complete, reliable analyses of care and disease
patterns.
[0087] This invention employs the use of open standards promulgated
by standards organizations. Such open standards include the open
standards defined for hardware, software and firmware components.
For example, use of the open standard for integrated circuit cards
can significantly reduce the cost of card production, and increase
the availability of compatible components, such as card readers.
Additionally, use of the open standard can enable the card to carry
other value-added consumer information regarding additional
services, products, organizations and corporation.
[0088] Customized GUI formats implementing such standard elements
can be configured to follow the standards of different specialties,
for example, as defined by the American Medical Association or
other specialist and international organizations. Technology
support standards from unified representation, such as those
developed by the National Institute of Standards and Technology and
the International Standards Organization's (ISO) Open Systems
Interconnect (OSI) model can also be implemented.
[0089] A standardized vocabulary developed from unified
representation, such as the Systematized Nomenclature of Medicine,
the Read Clinical Classification in Great Britain, the ASTM
Standard Guide for Nosologic Standards and Guides for Construction
of New Biomedical Nomenclature and the National Library of
Medicine's UMLS project, can be used with the invention. The
preferred embodiment of the invention also supports the use of
standardized formats for health care data interchange from unified
representation, such as HL7 (Health Layer 7), an American National
Standards Institute (ANSI) accredited standards organization, ANSI
X12 electronic data interchange formats for health care information
communication (published by the Data Interchange Standards
Association, also known as DISA), National Provider Identifier and
PAYERID (initiatives of the US Health Care Financing Administration
for identification standardization for service providers and health
care payers, respectively), Institute of Electrical and Electronics
Engineers (IEEE), Medix, standards for transfer of clinical data
from the American Society for Testing and Materials, and the
American College of Radiologists/National Electrical Manufacturers
Association standards for image transfer.
[0090] The system software is designed as a distributed model with
software modules stored at either their point of use or point of
access. The central host(s) preferably maintains the central
databases, data dictionaries, centralized communication functions
for informational updating, routing and messaging, centralized
servicing including database maintenance, remote systems
management, customer servicing, funds transfer processing, data
warehouse querying, statistical analysis processing, exception
processing, record and processing overrides, and service billing
and accounting applications.
[0091] For service providers, a server can store subsets of the
central databases, applications for performing batched update
functions, and software modules for accessing functionalities of
other system components. This model allows localized sharing of
data among service providers operating within a single
administrative setting, for example, within a hospital or clinic,
without the delays and additional costs of continual central host
accesses. Restricted local and unrestricted system-wide uses can
therefore be implemented.
[0092] In a single terminal embodiment of the invention, the
terminal (for example, the provider terminal, or a personal digital
assistant) can store subsets of the central databases, applications
for performing batched update functions, and software modules for
accessing functionalities of other system components. In addition,
the terminal stores the applications required to access and
transfer information to and from the individual information
device.
[0093] For the other functional users of the system, the
applications for performing the various users' processes can reside
on the users' local computers or localized server configuration.
Alternatively, any subset of the software applications, such as
communications and security software only, can be stored on the
user's computer, while additional applications are accessed from
the central host/server. In all cases, records for all databases
are accessed and stored at the central host.
[0094] The invention provides security for restricting access to
the system to an authorized user. The types of security supported
by the invention include password protection, encryption, and
identification authentication. This security is provided by a
security module within the user's computer or individual
information device and used in conjunction with passwords.
Information regarding such security attributes and procedures can
be stored in a security management shared platform service for use
by all system processes and components.
[0095] The invention can be used in conjunction with data storage,
backup, and restore mechanisms to safeguard records in the event of
system failures. These system management features are included
within the Applications/Management shared platform services and are
used by all central host databases. Personal or networked computers
used by various system users can be customized to provide remote or
local data backup, archive and restore capabilities. Additionally,
data can be fully restored from the files of the central
host(s).
[0096] FIG. 3 is a context diagram of the system for consolidating
and distributing information, according to the preferred embodiment
of the invention. This diagram shows the primary functional areas
of the system and identifies the users of each functional area. The
system 50 links together functional areas such as Medical
Insurers/Benefits Providers 52, Health/Benefit plan sponsors 54,
individual service recipients 56, health care service providers 58,
Medical Research 60 and service support 62.
[0097] Medical Insurers/Benefit Providers 52 include:
[0098] (1) benefit managers;
[0099] (2) federal, state and private insurers;
[0100] (3) business health care coalitions;
[0101] (4) employers who self-insure or manage their own benefits
packages; and
[0102] (5) annuity and retirement account management
organizations.
[0103] Processes supported by the invention include plan
definitions. In such plan definitions, an insurer defines a new
plan or changes an existing plan, including coverage options,
geographic coverage, lifetime treatment limits, support features,
procedures and medications covered, service providers and/or
categories of services provided, limitations on groups or
individuals applying for coverage, automated authorization of
benefits, service recipient automated referrals, service payment
accounting with payment service network integration, providing
communication in the event exception processing is required, and
reporting and statistical analysis. Changes in plan definitions can
be automatically communicated to current service providers and plan
sponsors. Plan definitions can also include open enrollment
marketing features. Such open enrollment marketing features can
include features supporting simplified design of an on-line plan
summary for accessing the plan definition information within the
central host database and for responding to plan sponsor requests
for contact, and update methods for adding, deleting and changing
service recipient plan participation records.
[0104] All health care program providers are identified within, and
electronically linked to, the system and are therefore provided
with up-to-date information. Thus, problems associated with service
provider status are avoided. For example, the service recipient or
referring service provider is informed when a provider ends its
affiliation with a care plan and can therefore select another,
affiliated provider.
[0105] The invention also can reduce the costs of publishing and
distributing directories of caregiver information. New medical
insurer/benefit provider defined plans are communicated to
providers and to plan customers automatically by the central host
as the plans are implemented, changed or discontinued. Thus, all
customers and suppliers of an affected plan are aware of changes in
plan coverage.
[0106] Health/Benefit plan sponsors 54 include:
[0107] (1) health and benefit plan management staff; and
[0108] (2) human resource department staff.
[0109] The processes supported by the invention include support of
open enrollment, in which the medical insurer/benefit provider
creates a record within the Plan/Benefit database specifying plan
parameters (detailed information on plan coverage) which are
accessible to plan sponsors, service recipients and service
providers through features of the full system. These processes
allow plan sponsors to search for new applicable plans, and allow
service providers to investigate new service relationships.
[0110] Changes to existing plans, are automatically communicated to
plan sponsors and service providers with current plan
relationships, by the central host. When changes are made to
existing plans, the Medical Insurer/Benefit Provider can request,
during the queuing of the update file to the central host, that
current service providers and plan sponsors be notified by an
electronic message of the changes to the plan. This is described
below, in detail.
[0111] Individual service recipients 56 include health care and
benefit consumers such as:
[0112] (1) service recipients; and
[0113] (2) service recipient family members.
[0114] Processes supported by the invention include updating
records and messaging. Such messaging services can include
electronic mail (e-mail), voice mail, and paging. Service
recipients can review the contents of their health care record and
its associated payment history, identify errors and omissions
therein, and include treatment plan preferences.
[0115] The invention permits service recipients to search the
Artificial Intelligence (AI) Medications/Procedures database
regarding treatment options and medications and procedures
information, and search the Subscriber/medical history database
toward development of a care contact network. The invention also
supports health plan enrollment and use by providing features
allowing service recipients to review plan coverage parameters and
service provider networks affiliated with health plans offered by
their plan sponsor. Communication to all members of a service
recipient's health care network are supported by the system.
[0116] Medical service providers 58 include:
[0117] (1) alliances, associations, networks and systems of
providers;
[0118] (2) ambulance services;
[0119] (3) ambulatory surgery centers;
[0120] (4) donor banks including those for blood, tissue and
organs;
[0121] (5) health maintenance organizations;
[0122] (6) home care agencies;
[0123] (7) hospices;
[0124] (8) hospitals;
[0125] (9) nursing homes;
[0126] (10) preferred provider organizations;
[0127] (11) physician offices;
[0128] (12) psychiatric facilities;
[0129] (13) public health departments;
[0130] (14) substance abuse programs;
[0131] (15) dental service providers;
[0132] (16) pharmacies;
[0133] (17) testing facilities; and
[0134] (18) therapeutic care providers.
[0135] Functions supported by the invention include accessing
service recipient histories and updating service recipient records.
Services can be authorized through access to the central host(s).
The central host can also calculate, and attach to all pertinent
records, the amount of payment required from each of multiple
parties, health care history updates (including payment
calculations and authorization of services, automated referrals
with communication linkages, etc.), AI medications/procedures
available for diagnostic and treatment support, and research
requests. In addition, the system manages and services payments and
record keeping, including automated invoicing for un-reimbursed
service recipient accounts.
[0136] Medical Research 60 include:
[0137] (1) allied health professional schools and programs;
[0138] (2) medical schools;
[0139] (3) nursing schools;
[0140] (4) public health schools;
[0141] (5) accreditation organizations;
[0142] (6) institutional licensure agencies;
[0143] (7) professional licensure agencies;
[0144] (8) disease registries;
[0145] (9) federal, state and local government policy-makers;
[0146] (10) agencies investigating legal compliance;
[0147] (11) lawyers;
[0148] (12) health care researchers and clinical investigators;
[0149] (13) health care technology developers and
manufacturers;
[0150] (14) health data organizations;
[0151] (15) health sciences journalists editors;
[0152] (16) research centers;
[0153] (17) medicare peer review organizations;
[0154] (18) quality assurance companies;
[0155] (19) risk management companies;
[0156] (20) utilization review and management companies; and
[0157] (21) service providers and service recipients.
[0158] The needs of the users of this functional area are supported
by links to informational databases, statistical reporting
applications, and software features for collecting data and
constructing customized databases. The use of standardized codes
permits the users to readily retrieve information necessary for the
long-term analysis of treatment methods and outcome of care.
[0159] Service support 62 includes the agencies and staff for
updating and maintaining the system, including:
[0160] (1) service parameter maintenance;
[0161] (2) product support;
[0162] (3) customer requests; and
[0163] (4) system maintenance.
[0164] The processes supported by this functional area of the
invention include those for performing system maintenance,
security, customer service and billing functions and for
international, federal or state authorized agencies to
automatically update centralized information. Designated agencies
such as the Agency for Health Care Policy and Research and
authorized organizations such as state licensing review boards can
be provided with secure access to the system for updating and
maintaining records. Additionally, the system is continually
updated to include current health care standards, as well as
information regarding all users of the invention.
[0165] Licensing and other regulatory information is preferably
stored in a service provider record within the service provider
database. This information is available to all authorized users of
the system and can be updated or used for research requests by
regulatory agencies. Security levels are defined within the
Security management component of the shared platform of
services.
[0166] As an example, records for service provider organizations
within the service provider database can contain licensing
information, staffing affiliations, organizational ownership
information and tax identification information required to monitor
legal compliance. The service provider records can include the
curriculum vitae of a licensed practitioner, as well as information
regarding any disciplinary actions against a licensed practitioner
or service provider.
[0167] The medical insurer/benefit provider (see FIG. 3, element
52) functional area supports all aspects of service recipient care
reimbursement. FIG. 4 is a flow diagram of the medical
insurer/benefit provider processes, according to the preferred
embodiment of the invention. Plan Definition processes 100 are
available to update medical/benefit plans stored in the
Plan/Benefit database 102, located at the central host(s).
[0168] The medical insurer/benefit provider accesses the central
host(s), and provides required security responses to download
current insurer records for the specified plan(s) from the
Plan/Benefit and service provider 104 databases. Software
applications, preferably operable on the medical insurer/benefit
provider's computer, is used to add, update or delete records
to/from the databases. Such updates include the review, deletion,
and revision of existing plans, as well as the creation of new
plans through the setting of new plan parameters. Plan parameters
include the identification of procedures, pharmaceuticals, service
providers and other care plan components covered by the
medical/benefit plan, and the determination of payment and
reimbursement ceilings and out-of-network service coverages.
[0169] The date on which a change is to occur can be included in
the records. Batched update features and copy capabilities for
current record information is available to simplify changes to
records. The medical insurer/benefit provider computer can access
the central host(s) and download an updated file, with any other
information regarding implementation dates/times, automated
notifications of changes, and whether service recipient records are
to be updated with plan changes.
[0170] Open enrollment processes 106 are available to support
marketing and enrollment efforts for new and current plans by
supplying on-line information for access by, and/or automated
distribution to, Health/Benefit plan sponsors and their respective
service recipients. The medical insurer/benefit provider accesses
the central host(s), to download current medical insurer/benefit
provider records for the specified plan(s) from the Plan/Benefit
and service provider databases.
[0171] The medical insurer/benefit provider then can construct or
change the plan marketing information. When all changes have been
completed, edited and audited, the updated file is downloaded to
the central host(s).
[0172] Health/Benefit plan information is available to potential
customers, for example, through non-solicited searches by other
service providers, plan sponsors, and service recipients for other
available plans. Potential Health/Benefit plan sponsors or service
recipients can review the information and communicate with the
medical insurer/benefit provider's marketing and sales staff.
Potential service providers can also apply for inclusion in a plan
by communicating with the medical insurer/benefit provider.
[0173] When a plan sponsor elects to participate in a new plan, to
change plan record information, or to drop participation in a plan,
the medical insurer/benefit provider updates the Plan/Benefit
database with plan sponsor information. In addition, the medical
insurer/benefit provider can update the subscriber/medical history
database when new subscribers/service recipients are enrolled or
changes are needed to a subscriber/service recipient's record.
[0174] The medical insurer/benefit provider accesses the current
Plan/Benefit records from the Plan/Benefit database stored on the
central host(s), and/or subscriber/medical history records from the
subscriber/medical history database for the specified plan sponsor
group(s). These records can then be reviewed, modified, or deleted,
as desired.
[0175] In the preferred embodiment of this invention, a field
indicator on the subscriber/service recipient record can be used to
request a new or replacement individual information device.
[0176] Automated authorization of benefits 108 is also provided by
the invention. When authorizations for services are submitted by a
service provider during the Update Medical History process, a
record containing service recipient identification and plan
information, service provider identification, and procedure and/or
medication codes is transmitted to the central host(s). The central
host tags the request with a unique authorization request number,
verifies the service recipient plan information from the
subscriber/medical history database, and verifies status of the
service provider.
[0177] The request is then compared to plan coverage information
parameters for the affected plan(s) from the Plan/Benefit database.
If multiple payers are involved, payment amounts are calculated for
all affected parties. An authorization record is created in the
provider service history/Payment database and in the
subscriber/medical history database.
[0178] The applicable approval codes and payment amounts are added
to the service provider authorization record. The authorization
record can contain standard formats and codes of international
standard setting organizations, such as 837 Health Care claim
Process in X12 from the Data Interchange Standards Organization.
When a request for authorization is declined, due to parameters of
the plan, the central host(s) transmits an on-line decline message
to the medical insurer/benefit provider and the service provider. A
manual review procedure for handling exceptions, appeals and
questions can then be initiated.
[0179] Patient automated referrals 110 identifies specialist
service providers, hospitals, and clinics participating in a
Health/Benefit plan, as defined in the service provider database
104. If, during the Update Medical History process, the service
provider wishes to refer a service recipient to a specialist
service provider, hospital, clinic or other referral organization,
a referral request is transmitted, along with service recipient
plan information, from the service provider computer to the central
host(s).
[0180] The central host(s) uses these codes to construct a search
of the service provider database. Search results are returned to
the requesting service provider for display in a selectable GUI on
the service provider computer. The service provider can then select
the record for the desired referral provider.
[0181] The service provider database search can be limited to
in-plan providers. Alternatively, the service provider can perform
a geographic or affiliation search, or can identify a specific
targeted referral provider. The service provider can then perform a
service authorization, as defined above.
[0182] Authorization approval is returned from the central host to
the service provider computer. A message requesting an appointment
for the service recipient, including the phone number to call for
scheduling can be automatically constructed and transmitted to the
referral service provider.
[0183] The preferred embodiment of the invention provides
accounting services 112 to users. Such accounting services include
the transmittal of invoices from a provider service history/payment
database 114 to the medical insurer/benefit provider. Payments of
these invoices may be made electronically, with funds transferred
directly from the medical insurer/benefit provider's account to
that of the service provider.
[0184] The medical insurer/benefit provider can identify specific
accounts from which a payment is to be made, and can record the
date of the payment and information regarding its transfer. A
payment history can also be generated and stored in the provider
service history/Payment database 114. Such payment history can then
be appended to the service recipient's medical history.
[0185] The medical insurer/benefit provider accesses the central
host(s) to retrieve unpaid provider service history records for the
specified plan(s) from the provider service history database. If
desired, current plan and provider information can be retrieved
from the Plan/benefit and service provider databases.
[0186] Software applications operable on the medical
insurer/benefit provider's computer are used to approve records for
payment. Account information from the service provider database can
be used to define the electronic funds transfer parameters. Records
can be batched into folders for operational handling purposes, and
electronic and printed audit reports can be generated. The payment
record can contain standard formats and codes of international
standard setting organizations (such as 837 Health Care claim
Process in X12 from the Data Interchange Standards
Organization).
[0187] If exception items are identified, an exception handling
message can be constructed and prepared for routing, using the
parameters of the service provider record, including communication
addresses. An updated file is transmitted to the appropriate
database(s) on the central host(s).
[0188] The invention supports reporting and statistical analysis
processes 116 for information stored in the subscriber/medical
history, plan/benefit, service provider, and provider service
history/payment databases 114. Such processes include providing
reporting and statistical information for service provider
monitoring, and providing service data for benefit
calculations.
[0189] Organizational summaries can be generated for use in
developing practice guidelines. Practice guidelines are
systematically developed statements for assisting practitioner and
patient decisions regarding appropriate health care for specific
clinical conditions. Organizational summaries can also be generated
for use in outcomes management. Outcomes management is the
assessment of ultimate results of efforts to prevent, diagnose, and
treat various health problems.
[0190] A statistical analysis of the cost and outcomes of care
information can readily be performed to assist a service provider
in budgeting decisions. Full service recipient care information can
also be electronically provided for use in adjudicating of claims
and making coverage decisions. The medical insurer/benefit provider
accesses the Research Request database 162 on the central host(s)
to download data dictionary information for the central host
databases, including the subscriber/medical history 122,
Plan/Benefit 102, service provider 104 and provider service history
114 databases. This information can be stored on the medical
insurer/benefit provider's computer, as desired.
[0191] The medical insurer/benefit provider can then use software
operable on the provider's computer to construct a data query.
Desired data fields are selected from the data dictionary of the
central databases, ensuring from the rules in the data dictionary
that appropriate authority is available for access to the data.
Security rules limit access to certain fields, and requests for
non-authorized data are returned from central host processing with
a security restriction message.
[0192] Data queries can be specified as one-time only or can be
requested on an ongoing, time-specific basis for continuing
research efforts. When all data queries have been completed, the
request file is transmitted to the central host(s) and the data
search is performed. The search results, or an error message, is
then returned to the medical insurer/benefit provider.
[0193] The Health/Benefit plan sponsor (see FIG. 3, element 54)
functional area of the invention supports Health/Benefit plan
management staff and human resource department staff. FIG. 5 is a
flow diagram of the Health/Benefit plan sponsor processes,
according to the preferred embodiment of the invention.
[0194] Open Enrollment processes 120 are available to support
changes to currently sponsored benefit plans and to support
requests for the production and distribution of individual
information devices. These changes are implemented through access
to the central host, as described above.
[0195] Modifications can be made, for example, to change benefit
information, such as additions, changes or deletions to auxiliary
reimbursement accounts, insurance, annuity, retirement or workman's
compensation plans, in the Plan/Benefit database. These changes can
be made manually or electronically. Modifications can also be made
to plan participation records in the subscriber/medical history
database.
[0196] Production and distribution of new or replacement individual
information devices can be requested by the medical insurer/benefit
provider. In this way, requests for new devices, for replacement of
existing devices, and for deactivation of devices are transmitted
electronically through the central host(s) from the Health/Benefit
plan sponsor to the authorizing medical insurer/benefit
provider.
[0197] When all changes have been completed, the updated files are
transmitted to the central host(s). The central host can then
distribute these updated files to the various components of the
system.
[0198] Research plans processes 124 are available to permit plan
sponsors to search for available applicable plans within the
Plan/Benefit database. Plan sponsors are also able to review and
compare available plans and to communicate with a medical
insurer/benefit provider to apply for inclusion in a new plan. In
addition, when medical insurer/benefit providers add or update
plans, electronic notification is automatically sent automatically
to affected parties.
[0199] The electronic communication features support exception item
processing and dispute resolution among medical insurers/plan
sponsors, service providers and service recipients. This is
accomplished by allowing the plan sponsor to copy records involved
in the exception or dispute from the subscriber/medical history
database, Plan/Benefit database and/or service provider database
into a message for involved parties. This message can include text
supplied by the plan sponsor.
[0200] The plan sponsor accesses the central host(s) to retrieve
electronic messages or download previously requested files, review
available plans on-line, send electronic messages constructed
on-line or off-line, and/or submit a request for access to
applicable records from the central host databases. This
information can be stored on the plan sponsor's computer for later
use.
[0201] The plan sponsor can then construct a search for applicable
new plans by loading subscriber/medical history records into a
summary criteria data query format GUI. This information is
transmitted to the central host(s) to, for example, create a search
for other applicable plans, review plan information, request
marketing information, or respond to plan and coverage issues.
[0202] Benefit usage management processes 126 allow the
Health/Benefit plan sponsor to access information stored in the
subscriber/medical history 122 and Provider/Service History 114
databases. This information can then be used for management of
medical care reimbursement accounts, workman's compensation or
other auxiliary plans. The Health/Benefit plan sponsor can also use
this information to respond to queries on service participant
benefit selection and usage, service audits and information for tax
and reporting purposes.
[0203] The plan sponsor accesses the central host research request
database to download data dictionary information for central host
databases, including subscriber/medical history 122, Plan/Benefit
102, service provider 104 and provider service history 114. This
information can be stored on the plan sponsor's computer for later
use, for example in constructing data queries. Data queries can be
specified as one-time only or can be requested on an ongoing,
time-specific basis for continuing efforts, such as electronic
transmission of data to reimbursement plans on a regular basis. The
individual service recipients (see FIG. 3, element 56) functional
area of the invention supports service recipients, their families
and dependents. FIG. 6 is a flow diagram of the individual service
recipients processes, according to the preferred embodiment of the
invention.
[0204] A service recipient is provided with an individual
information device which holds identification and critical care
information. In the preferred embodiment of the invention, this
individual information device is an integrated circuit card, also
known as a Smart Card.
[0205] The individual information device stores a summarized health
care history of the service recipient. This summarized history is
available to service providers in the event of a health care
emergency and can be readily updated through the electronic
network. The summarized health care history can include information
regarding chronic health conditions, allergies to medications,
medications currently prescribed, and emergency family
contacts.
[0206] For example, a paramedic providing emergency health care
treatment to the service recipient can use the individual
information device to review the service recipient's diagnostic and
treatment history, emergency contact information, allergy and other
critical information and plan coverage records through the use of a
portable reader device. In addition, a paramedic having access to
the central host can use the host's diagnostic features, in
conjunction with the service recipient record, to aid diagnosis of
a problem and isolate a possible course of emergency treatment.
[0207] The electronic health and personal record eliminates the
need for a service recipient to fill out paper forms at a service
provider office or to try to remember episodes of care and the
affiliated dates. Also, the automated service and authorization
features of the central host(s) eliminates the problems of
selecting referral service providers covered by the service
recipient's plan(s), and identifying payment responsibility for
treatment.
[0208] Further features allow service recipient's access to health
care treatment option information (through access to the AI
Medications/Procedures 144 features) and allow service recipients
to create a care network by communicating with others who currently
or have previously suffered from similar health care diagnoses.
[0209] Updates and messaging processes 130 allow the service
recipient to communicate with health care providers such as
practitioners, insurers, and sponsors. The service recipient can
access the central host to electronically research care options
provided under the service recipient's Health/Benefit plan and
access expert health care databases.
[0210] Electronic messages can be retrieved, previously requested
files downloaded, available plans reviewed on-line, and electronic
messages sent. Requests can be made for access to applicable
records from the central host databases. Plan/Benefit information
can include information about other types of benefit plans,
including reimbursement accounts, insurance, annuity, retirement or
workman's compensation plans.
[0211] The service recipient can use this information to review
plan information, treatment and payment histories, construct
messages to a plan sponsor for replacement of an individual
information device, or ask questions regarding plan options or
usage. The service recipient can also initiate changes in the
recipient's medical history record. Such changes can include
emergency, allergy, contact, identification or treatment preference
option information, notations on functional health status or errors
found in the health care history record during an audit. Messages
can be sent to service providers regarding questions, treatment
options, or requests for appointments. Messages can be sent to
medical insurer/plan sponsors regarding questions, coverage issues,
payment records, dispute resolution, regarding research queries on
diagnostic options or for contact information. For all processes
completed while operating in an off-line mode on the service
recipient's computer, the service recipient repeats the process
described above to connect to the central host(s) and collect and
transmit new messages.
[0212] Health plan enrollment and use 132 processes provide access
to health plan information during open enrollment periods. The
service recipient can periodically access the Plan/Benefit database
102 to review changes to plan parameters such as approved
procedures, pharmaceuticals, providers, payment/reimbursement
ceilings, and out-of-network services coverage parameters.
[0213] For example, information on multiple plans for health plan
enrollment evaluation can be loaded into a comparison form at the
service recipient's computer to provide a feature by feature
comparative analysis of available plans and their respective
treatment options, coverage limits, service providers, etc. This
information can be used to construct messages and requests to
medical insurer/benefit providers, service providers or plan
sponsors for further information, clarification or action. For all
processes completed while operating in an off-line mode on the
service recipient's computer, the service recipient repeats the
process described above to connect to the central host(s) and
collect and transmit new messages.
[0214] In the preferred embodiment of the invention,
medical/benefit plan history records processes 134 are available to
access information pertaining to their care or the care of their
family members which are stored in the central host databases
including the subscriber/medical history 122, Plan/Benefit 102,
service provider 104 and provider service history/Payment 114
databases. The service recipient can therefore review allergies and
emergency information, health plan status, identification, and
emergency contact information, health care history records and
service history/payment records.
[0215] Information from the subscriber/medical history record can
be formatted into a health care history and subscriber information
record. The service recipient can "flip through" these records,
allowing an audit of current services, diagnoses, procedures and
medications, and payment histories. Messaging features are also
supported.
[0216] Using a service recipient features GUI, the service
recipient selects a message option, and identifies a selected plan
sponsor (if there are more than one). The system then constructs a
message form which the service recipient can use, for example, to
request replacement of an individual information device, change
personal records, or ask questions regarding plan options or usage.
This message can be transmitted through the central host(s) during
the service recipient's next on-line session.
[0217] Changes to the service recipient's health care history
record are implemented by selecting an information history change
or addition option to note changes, for example, to emergency,
allergy, contact, identification or treatment preference option
information, notations on functional health status (such as current
condition updates for health monitoring like results of home
testing on a regular basis) or to correct errors found in the
health care history record during an audit. These changes will be
routed to central host(s) database administration during the next
on-line session.
[0218] A construct message option permits the service provider to
communicate, for example, questions, requests for appointments,
queries regarding functional health status and results of
administration of home tests. Information relating to the request
and additional notes and comments can be append to a communication.
A construct search option permits searches of system records.
[0219] An additional formatting option allows the service recipient
to use health care information and payment records to construct
printed reports, including IRS accountings of health care services
and costs during a given tax year, listings for health care
reimbursement plans, or general health care information
records.
[0220] Artificial Intelligence (AI) Medications/Procedures 144
processes allow the service recipient to review results of consumer
queries regarding procedures, medications, and other care
components from a constructed search of the AI
Medications/Procedures Database. This database maintains
information on current treatments and medications, including
company names and cost information. The database may also include
descriptions of diseases and information regarding their causes, as
well as preventative advice or health maintenance information.
[0221] Supported AI medications/procedures processes include
database searching, and messaging. In the preferred embodiment of
this invention, these service recipient features are off-line
processes, thereby reducing contention on the central host
databases. However, an alternate embodiment of the invention
supports direct connection and on-line searches by the service
recipient of the Medications And Procedures database 146, as well
as access to records in the other central host databases.
[0222] Health care service provider processes support private
health care practitioners, service recipient care providers, health
care delivery organizations, hospitals, and emergency health care
services. FIG. 7 is a flow diagram of the medical service provider
processes, according to the preferred embodiment of the
invention.
[0223] Service recipient history processes 140 support the review
of health care history records stored on the service recipient
integrated circuit card and, for a full and detailed record, on the
subscriber/medical history database 122. Portable devices, such as
mobile units can be used to access emergency information stored on
the service recipient individual information device. Such access
can be made either on or off-line.
[0224] The service provider swipes the individual information
device through an attached card reader. If the service provider is
operating in an on-line mode, the service provider accesses the
central host(s), provides required security responses, and
transmits identification parameters from the ICC record, which
identifies the full record on the central host(s)
subscriber/medical history database and downloads the full
record.
[0225] If the service provider specifies a request to download
diagnostic codes, software operable on the service provider's
computer allows the service provider to identify categories for
selection of appropriate detailed diagnostic codes for use during
the consultation. These codes, along with the service recipient
record, can be transmitted to a hand-held or digital personal
assistant device if desired, or can be printed for use during the
examination. Full diagnostic code sets can also be resident on the
service provider's server, downloaded with other batched transfers,
if a larger volume computing configuration is being used by the
service provider.
[0226] Once available, the full service recipient record is loaded
into software operable on the service provider computer, which
formats the record into a desired screen format, which can also be
printed. This format can be of a standard problem-oriented medical
record, time-oriented medical record or any other customized
format, as selected by the service provider. Diagnostic, procedural
and medication codes are shown with their definitions, as available
through the central host(s). These codes can be downloaded at any
time and stored for further off-line usage.
[0227] In addition, all codes for medical plans/benefits can be
shown with full textual code descriptions in the language specified
by the service provider. Service recipient information contains a
detailed health care history including procedures and medications
and dates of both, emergency, allergy, contact and identification
information, insurance information, functional status, treatment
preferences and comments and changes to history as noted by the
patient.
[0228] An on-line help feature can also be provided to facilitate
service provider use of the invention. The on-line help is a file
on the service provider's computer which can walk a caregiver
through the process of accessing and loading information from any
source, whether the ICC record only or steps involved in accessing
the central host(s) subscriber/medical history database and
performing the operations of accessing, downloading and using
diagnostic codes.
[0229] These steps allow the health care service provider (see FIG.
3, element 58) to quickly access a list of current problems, a
trail of clinical logic, the service recipient's health status, and
the most recent information about various treatment options for the
service recipient's condition. The health care provider's rationale
for clinical decisions can also be accessed. In the preferred
embodiment of the invention, routine service recipient care,
organizational operations and decision making processes are
supported. In addition, since all consultation records are stored
in the subscriber's medical history database, health care service
providers can avoid requesting redundant medical tests for a
service recipient.
[0230] In the preferred embodiment of the invention, the service
provider's computer software supports a GUI that simplifies access
and extends use of the information, permitting users to analyze,
transfer, process and compare information using other standard
market software packages which extend the system capabilities. Such
simplified access also allows integration of customized local
features, such as inclusion of text, tables, graphics, video,
animation, and audio display.
[0231] The GUI is configurable to display information related to
the health care service provider's focus. Thus, the GUI can be
configured, for example, to display information related to a
current query or problem, organized by date, or organized by
symptom. In alternative embodiments of the invention, the GUI is
configurable to display any information stored in the
subscriber/medical history database, which can be linked by the
standard system key identifiers to customized capabilities and
features maintained on local storage media or accessed via links to
remote network addresses. As an example, a teaching hospital can
have video display modules, identified by the standard system
diagnostic codes, which allow the service provider to select video
diagnostic help through the standard GUI, allowing the service
provider to view training steps in a recommended procedure.
[0232] The service provider can access the service recipient's
health care history and information regarding any potential
diagnosis. This information can be printed, or displayed on a
computer display, or on the display of a personal portable device.
The time spent by the service provider in preparing written records
and histories can therefore be significantly reduced.
[0233] Using the Update Medical History processes 142, a
practitioner can communicate with health care providers, insurers,
sponsors and service recipients, provide preventative advice and
health maintenance information for service recipient self-care,
review service recipient preferences and generate care plans,
document services provided, assess and manage the risks of various
possible treatments for a service recipient, authorize treatments
and care options, authorize referrals within a Service recipient's
care network, or send messages to other service providers or
organizations.
[0234] Using software operable on the service provider's computer
in an off-line mode, the service provider uses the service
recipient's record from the subscriber/medical history database 122
and the selected diagnostic codes which were accessed and
downloaded to the service provider's computer through the Patient
History process described above.
[0235] Software operable on the service provider's computer
provides customized screen record formatting. The service provider
uses an update record process to update the service recipient
record with information obtained during a current appointment. Test
results can be loaded into the service recipient's record manually
or through an electronic automated interface into the record, such
as through electronic monitoring devices, and other patient care
equipment for adding data, images or other formats into the record.
Because the service recipient's health care history information is
readily updated using the electronic network, a health care service
provider can monitor subsequent service recipient care and the
reporting of any adverse reactions.
[0236] The preferred embodiment of the invention provides links to
administrative, bibliographic, clinical knowledge and research
databases. If the service provider wishes to review on-line
diagnostic information through the AI Medications/Procedures
functions, the service provider uses software operable on the
provider's computer to select a diagnostic assistance feature which
prompts the provider to select symptom codes (as included during
patient examination), test results, etc. and to define procedure
and medication limitations by noting category codes for allergies,
current conditions and medications, or other limiting factors.
[0237] General database searches can also be constructed. These
queries can be constructed on-line or off-line from the central
host(s). To connect to the central host(s), the service provider
uses software operable on the provider's computer to access the
central host(s), provides required security responses, and
transmits the search record to the central host(s). The central
host processes the search and returns the result records to the
service provider, or in the case of video information links, allows
the service provider to view the search results through the
communication connection.
[0238] The service provider can also use the communication
facilities to construct a message to referred specialists for later
response. Using software operable on the provider's computer, the
service provider can select procedural and/or medication codes to
run a conflict search against the service recipient record and, if
no conflict is noted, paste the selected
treatment/procedure/medication/referral codes into the service
recipient record and prepare a request for authorization through
the central host(s). If codes resulting in conflicts are used by
the service provider anyway, that information is appended to the
service recipient record.
[0239] In addition, a service provider can construct a research
request to the Research Request database 162 on the central
host(s). This facility can be used to perform outcomes research on
specific diagnostic codes or to identify a care network containing
other individuals with the same prognosis as one of their service
recipients. Using software operable on the service provider's
computer, screen options in the Update Medical History component
allow the service provider to construct a research request using a
service recipient record, or using individual diagnostic or
treatment codes. This record is then transmitted to the central
host(s) and the result of the search is returned to the service
provider at a later on-line session.
[0240] The service provider uses software operable on their
computer to construct an authorization for services and/or
authorization for referral. This date and time stamped record
contains service recipient identification and plan information,
service provider identification, and procedure and/or medication
codes and referral codes, which are transmitted to the central
host(s). The central host(s) tags the request with a unique
authorization request number, verifies the service recipient plan
information from the subscriber/medical history database, verifies
status of the service provider and reads plan coverage information
for the affected plan(s) from the Plan/Benefit database, calculates
payment amounts for all affected parties if multiple payers are
involved, creates an authorization record in the provider service
history/payment and subscriber/medical history databases, and
returns the numbered service authorization record with approval
codes and payment amount notification to the service provider.
[0241] If a referral has been requested, the central host(s)
identifies service providers available through the service
recipient's plan(s) by identifying providers from the service
provider database, returning a listing of names with address, phone
number, affiliations and other information as an attachment to the
authorization. If a plan available to a service recipient covers
disability, worker's compensation or other support benefits which
apply for the prognosis, this information can also be returned in
the record, if requested by the service provider.
[0242] If a referral was requested, the service provider can select
a service provider from the on-screen returned list, send a message
to the selected referral service provider which includes the
service recipient record, the authorization message and a request
for appointment or any other information. This referral
authorization information can also be printed for action by the
service recipient or a staff member at the service provider's
location and can cover prescriptions for pharmaceuticals and
medications as well as procedures and services.
[0243] Negative results of conflict edits that were ignored by the
service provider is included on any printed output. If no referral
is needed, the authorization is saved in the service provider's
computer for later transmittal to the central host(s) during the
Service Payments and Record keeping processes. When a request for
authorization is declined, due to parameters of the plan, the
central host(s) transmits an on-line decline message to the medical
insurer/benefit provider and the service provider, which can
initiate a manual review procedure to handle exceptions, appeals
and questions.
[0244] When all health care history update activities have been
completed and/or all service recipient payments have been made
(defined in Service Payments and Record keeping 148), the service
provider can use software operable on their computer to update the
service recipient's record on their personal information device. In
the preferred embodiment, the service recipient's integrated
circuit card is updated by swiping it through the service
provider's card reader and downloading the most recent record
information.
[0245] In addition, information from the service recipient record
can be used to print a variety of hard copy reports (as in the case
of printed authorizations or prescriptions, as defined above).
Software operable on the service provider's computer allows the
provider to select a print option which then brings up a list of
standardized (and customized) reporting formats, including but not
limited to: service authorizations, prescriptions, full health care
history record of the service recipient, letters, discharge
summaries, evaluation queries, insurance forms, school and camp
certificates, trend reports and graphs.
[0246] When the service provider uses the on-line diagnostic
functions in AI Medications/Procedures, the central host(s) uses
the search record sent by the service provider (described above) to
construct a query of the Medications/Procedures database. This
diagnostic information can be used to assist the health care
service provider in determining whether a procedure or medication
is, for example, effective and safe, cost-effective, and whether it
produces desired outcomes.
[0247] A summary of reference information is returned to the
service provider's computer, where the service provider selects an
item and, if it is a reference only, can choose to see the entire
record, including images, video or other forms of multimedia. The
service provider can select diagnostic, treatment, procedure or
medication codes and electronically add them to the service
recipient's record and can run an alert check on the updated
service recipient record to identify any elements causing a care or
treatment conflict. Alert checks are performed by the central
host(s) by running a central host program for a treatment,
procedure or medication code against the flag edits for those care
components.
[0248] Conflicts are identified within the
treatment/procedure/medication record by their standard code. These
include other medications and procedures currently prescribed to
research the effects, dosages, and side effects of medications
prior to issuing a prescription, and also covers allergy or
personal information such as age and condition factors which can
result in complications or treatment incompatibilities. The result
of this process is returned to the service provider's computer and
displayed visually on the screen and can in addition provide an
audio signal, allowing the service provider to select a different
care option.
[0249] If the alerted care component is kept in the treatment plan
for the service recipient, an alert message is included in the
service recipient's record and on any printed record of the service
recipient's care plan, including prescriptions. These processes are
performed on-line to the central host(s) with software operable on
the service provider's computer used to search, review results,
check for care component conflicts, communicate to others in the
health care process, and add search results to the service
recipient's record. Information in the AI Procedures/Medication
database can only be updated by licensed authoritative
organizations with secured access to the central host(s) as defined
in Update Medications/Procedures, described below.
[0250] The invention permits a practitioner to communicate
electronically with other practitioners, either practicing with the
same health care service provider or with other Providers using the
invention. The health care service provider can use the invention
to review service recipient plan parameters, including
identification of procedures, pharmaceuticals, referral providers
and other care plan components covered by the plan,
payment/reimbursement ceilings and out-of-network services coverage
parameters. The provider to is thereby assisted in generating an
optimal care plan that maximizes the service recipient's
coverage.
[0251] The preferred embodiment of the invention includes a feature
within the central host(s) database processing steps for checking
data integrity to ensure that data are not lost or unknowingly
corrupted. During the processes whereby new records are added to a
database (such as the subscriber/medical history database), data
elements are run through edit routines defined within the central
data dictionary to ensure that data values are for correct standard
diagnostic or procedural codes and that variable values are within
correct ranges. If invalid entries are detected, the central
host(s) returns a data error message to the service provider
initiating the entry which defines the problem with the attempted
entry and requests the service provider to review and re-submit the
entry.
[0252] In this way full data integrity checking is incorporated in
database update processing. Also, to ensure unauthorized updates
are not made, all data owners have update capabilities limited by
their security access. For example, medical insurer/benefit
providers are limited to update capabilities for their plans only
within the total Plan/Benefit database, the addition of subscribers
to their plans in the subscriber/medical history database and
adding service providers affiliated to their plans in the service
provider database. Records other than their own, or fields within
those databases which lie outside their required functions cannot
be updated under their security parameters.
[0253] These security parameters are also identified within the
central host(s) data dictionary. Security parameters such as these
are defined for all system users through security management.
Unauthorized attempts at information access are logged within the
central host(s) Security management platform services. These audit
trails are monitored by central host security administration and
may be communicated to authorized agencies as defined within the
data dictionary security parameters (as an example; breaches of
security within the service provider network may be reported to the
Agency for Health Care Policy and Research or a delegated security
organization).
[0254] In the preferred embodiment of the invention, the data
dictionary contains one or more acceptable values tables to
standardize codes and provide a uniform health care vocabulary. For
each element defined in the central data dictionary, valid entries
(or acceptable values) are defined and updated as additional
categories or new ranges are approved. These values can be defined
by authorized expert organizations, such as national health
management organizations (such as the Agency for Health Care Policy
and Research, the Food and Drug Administration, or other
organizations to which these responsibilities have been delegated
by legislation or agreement) in determining standardized diagnostic
codes and data ranges.
[0255] Processes by which this information is incorporated into the
central host(s) is defined in Update Medications/Procedures and
Update service provider information described later in this
document. These standardized codes are what ensures data integrity
throughout the data value chain as defined within this document and
ensures its universal consistency and therefore its value. Such
standard codes are used to link related information within the
system, such as health care literature and specialists.
[0256] Another process of this invention provides uploading of the
newly revised time-stamped service recipient care records for
updating the central information system and the service recipient's
portable information device.
[0257] The Service Payments And Record keeping processes 148 of the
invention provide documentation of services and automation of
service payments, insurance claims submissions, and electronic fund
transfers for service payments. Such documentation can include the
preparation of periodic accounting reports.
[0258] A record of non-reimbursed amounts may also be maintained.
An automated billing can therefore be submitted for un-reimbursed
services. Payment records can be updated to reflect manually
received payments and adjustments to records. The preferred
embodiment of the invention provides electronic payment services
between service providers and medical insurer/benefit providers (as
described from the Medical Insurers' Service Payment Accounting
functions earlier in this document. Electronic funds transfer
payments are noted on matching records in the provider service
history/Payment database 114 and to the matching record in the
subscriber/medical history database.
[0259] Using the software operable on the service provider's
computer, the service provider uses software operable on their
computer to access the central host(s) and perform security
functions. An audit file of payments made to their provider ID
during the last central host payment processing file is downloaded.
The service provider can then download full records from the
central host(s) under their provider ID from the provider service
history/Payment database.
[0260] In addition, all or selected subsets of records can be
downloaded (such as between selected dates, all records with unpaid
balances, all records with recent payments or any combination of
the above) for use in off-line administrative processing.
Electronic messages to the service provider including
communications, exceptions and other exchanges can also be
downloaded. The service provider can then disconnect from the
central host(s) and can perform account administration functions
off-line.
[0261] Authorizations for current services (the result of
activities described above in Update Medical History) are appended
to the downloaded records as they are created. During the day's
activities, software operable on the service provider's computer
can be used to log payments made by service recipient or other
adjustments to service/payment records. In addition, if the service
provider wishes to perform a manual billing process for unpaid
services, the contents of this file can be used with a report
feature on their computer to print invoices for unpaid balance.
[0262] As each provider service history/Payment record is updated
it can be selected for later batched transmission to the central
host. Transmission during the next on-line session is the default,
however future record transmission dates can be chosen. Other
software operable on the service provider's computer allows the
user to select a record in which there are questions, exceptions or
other process problems associated and construct a message to the
appropriate party (such as the medical insurer/benefit provider,
etc) or to request affiliation in a new plan, communication with
other service providers or any other party with access to the
central host(s).
[0263] All communications and updated records are batched for
transmission during the next on-line session (or the requested
future dated session) with the central host(s). Software operable
on the service provider's computer is used to access the central
host(s) and perform security procedures. At that time, files bound
for the service provider are transferred from the central host(s)
to the service provider's computer and files bound for the central
host(s) are transmitted for central host processing.
[0264] Medical research processes (see FIG. 3, element 60) support
research organizations in such areas as product development, public
health, utilization and quality review, regulatory and compliance
review, education, and scientific and health care research. FIG. 8
is a flow diagram of the medical research processes according to
the preferred embodiment of the invention health care service
providers and service recipients can also use the medical research
processes to research treatment options and development support and
information networks.
[0265] Data warehouse queries 160 are conducted using the
standardized definitions stored in the data dictionary. The
frequency of a data search can be specified. Thus, automated
periodic data download subscriptions are available for long-term
research projects. Changes may also be made to existing periodic
data subscriptions. Using the software operable on the medical
researcher's computer, the medical researcher accesses the central
host(s), provides required security responses, accesses the
Research Request database and downloads data dictionary information
for the central host databases (subscriber/medical history 122,
Plan/Benefit 102, service provider 104 and provider service history
114) before disconnecting from the central host(s).
[0266] This information can be stored on the medical researcher's
computer for further data selection, until such time as the
information is no longer current (date of last update of the
central data dictionary can be checked for currency). The medical
researcher can then use software operable on their computer to
construct their data query by selecting desired data fields from
the data dictionary of the central databases, ensuring from the
rules in the data dictionary that appropriate authority is
available for access to the data (security rules limit access to
certain fields, and requests for non-authorized data will be
returned from central host processing with a security restriction
message).
[0267] Data queries can be specified as one-time only or can be
requested on an ongoing, time-specific basis for continuing
research efforts. When all data queries have been completed,
software within the medical researcher computer accesses the
central host(s) and performs the security procedure, then the
request file is downloaded to the central host(s) and questions
regarding desired implementation dates are answered by the medical
researcher.
[0268] The change queue request is verified, the medical researcher
can disconnect from the central host(s) and the central host(s)
performs the data search requests on the appropriate databases and
communicates the resulting data extract files (or error messages if
the query was not constructed correctly or encountered security
restrictions if requests were made for unauthorized information) to
the medical researcher for their access and manipulation using
software operable on their computer, as needed.
[0269] The reporting format for data received in response to such
query may also be defined. For example, individual histories can be
selected according to such criteria as prognosis, treatment codes,
severity of illness, treating organization or individual care unit,
and for episodes of care. For confidentiality purposes, data can be
stripped of identifying information and searched, for example, by
location or diagnostic codes. Information returned from the search
can then be accessed by standard data analysis tools or by
customized models allowing the researcher to perform the modeling
or reporting methods needed to support their project.
[0270] A user's query is transmitted to the Research Request
database 162 for processing through the Communication Link With
Statistical Reporting processes 166. The Research Request database
uses the query parameters to link keys within to the appropriate
system databases, and the responsive information is returned, for
example, electronically (or in print image format, if desired) to
the user. This electronic information can then be used for
statistical and graphical analysis, for example, by loading into
standard statistical software packages.
[0271] The health care data can be provided for research, education
and monitoring purposes. Such data can be used by health
professional schools and programs, accreditation organizations,
licensing agencies, disease registries, government agencies,
lawyers, health care researchers, clinical investigators,
technology developers and manufacturers, health data organizations,
health sciences publications, research centers, medical peer review
organizations, quality assurance organizations, risk management
organizations, utilization review and utilization management
organizations, and other users of health care information.
[0272] As the researcher is able to define the data elements and
parameters of their search, the researcher has significant
flexibility in identifying the desired research database, which is
selected from the full system databases. Therefore, the data
elements and selected values to be extracted can exhibit wide
variety and customization to the actual needs of the organization
performing the search.
[0273] Because of this, the invention can also provides data access
for regulatory purposes. Such information includes evidence for
litigation, assessment of compliance with laws or standards of
care, accreditation of care providers and organizations, and
comparisons of health care organizations, professionals and
procedures.
[0274] For example, if a regulatory agency wished to identify
service providers engaged in fraudulent procedures, a search could
be constructed defining target codes defining episodes of care from
the provider service history/Payment database and, linked to the
service provider database, would add identification fields to the
targeted records. If insurance plan information were also under
investigation and long term analysis of the service recipient care
were being analyzed, the search could be extended to select records
with linking fields from the Plan/Benefit database and the
subscriber/medical history database.
[0275] Using the same query selection process this invention
permits users to access information for research purposes. Such
research purposes include new product development, clinical
research, technology assessment, service recipient outcomes,
identification of at risk populations, service recipient care
effectiveness and treatment cost-effectiveness, and the development
of registries and databases.
[0276] The invention can also provide data for analysis of past
clinical experience within a provider setting. Search parameters of
the subscriber/medical history database in these cases would
primarily focus on standard diagnostic codes and could return
entire case histories for the Researcher's use in modeling and
analysis. When analysis of cost-effectiveness are needed, the
search parameters would also include information within the
provider service history/Payment database. All requested fields for
all records would be returned in a relational database format for
use by standard relational database modeling systems and
applications.
[0277] Constructing an appropriate search from all available data
dictionary fields, the invention can provide information to assist
in policy development, such as resource allocation, workload
assessment, risk assessment, strategic planning and public health
monitoring, trend analysis, forecast development and cost
management. The invention can also provide information for use in
the health care industry, such as research and development,
marketing strategy planning, case mix documentation, quality
assurance planning and implementation, and cost management policy
planning and implementation.
[0278] Information may be supplied for institutional uses, such as
cost reporting, budgetary, productivity and quality assurance
purposes, for hospital accreditation, risk management and market
placement analysis, personnel recruitment, equipment acquisition,
and facilities development.
[0279] Standardized pre-selected information processes 164 support
integration of new subscription search data with original baseline
data for ongoing research. Subscription query criteria or search
frequency can be updated and electronically transmitted to the
system. For example, adverse reactions to a medication or
occurrences of a disease can be automatically tracked over a period
of time.
[0280] Features of the software operable on the Medical
Researcher's computer support simplified processes for appending
data returned from ongoing periodic searches of the system
databases onto a previously collected relational database located
on the medical researcher's computer. The software will provide the
data format of the newly retrieved database and will request the
target local database. When the researcher identifies the target
database, the software will provide the data format of the target
database and note any discrepancies. If there are no format
discrepancies, the software will perform a record append process.
If there are format discrepancies, the software help screens will
be available for the researcher to resolve the discrepancies prior
to another attempt to append the new data.
[0281] The invention also supports comparisons of local, state,
national and international health data such as prognosis, treatment
options, and cost of care. This information can then be used to
promote regional, national and international health objectives.
Such information includes data on mortality, morbidity and
disability, injuries, personal, environmental and occupational risk
factors, preventative and treatment services, costs, and actuarial
analyses. As in the descriptions of the data selection process for
other disciplines, field values within the databases provide the
search base and are performed in the same manner as described
above. In this way, service recipient location identifiers,
standardized job codes, diagnostic codes for injuries or any other
key selection criteria included in the system databases and defined
in the data dictionary can be used to provide the researcher with
their population base for their chosen research purpose.
[0282] Service support processes support internal maintenance and
product billing functions. FIG. 9 is a flow diagram of the service
support (see FIG. 3, element 62) processes, according to the
preferred embodiment of the invention. The diagram shows the
underlying platform of central host shared processing applications,
services and utilities which enable functional use of the central
host(s) databases. This shared platform of services includes:
database update processing 178, applications/management 180,
database management 182, data dictionary 184, security management
186, account parameters 188, system activity file 190,
communication/file transfer 192 and a central electronic
output/archive 194.
[0283] System/service management processes 170 provide system
control over processing functionality and service management
support for system customers. The shared platform of services are
used by all central host computing functions, perform automated
processing, update and systems management support functions and are
monitored by system maintenance personnel who have override
capabilities via central maintenance control panels on their
computers.
[0284] Among the central host system management functions are full
data backup and restore capabilities, for example, ensuring that
data stored in the medications/procedures database 146 can be
completely restored in the event of a system failure. In this case,
a coded instruction set within applications/management 180 would be
initiated at a pre-determined time to use a backup utility program
under it's central control to perform a backup operation to the
electronic output/archive 194. If a database failure were
experienced, system maintenance personnel can use their central
maintenance control panels on their computers to initiate a restore
process on the medications/procedures database.
[0285] In the preferred embodiment of the invention, files
containing the adjusted values of social security, annuity,
retirement account and benefit information are automatically
updated. Again, software residing on the local computers of system
maintenance personnel can be used to schedule files to be
electronically appended to records in the target database. In this
case, processing control would be done through database update
processing 178 platform functions which would invoke database
management 182 services and data dictionary 184 updates if changes
to the format of the targeted databases were needed.
[0286] Records can be stored on the system indefinitely, or for a
specific period of time as defined for each field within each
database via retention parameters within the data dictionary. These
data dictionary parameters can only be changed through the system
maintenance instruction set. Such records can also be archived or
purged, if desired, through the data management services which
would transmit an archive copy of the database to the electronic
output/archive or would invoke purge processing functions within
the same shared platform service instruction set.
[0287] Security parameters defining access groups and identifying
data availability for these groups for each data field (or value
range within each field) in each system database are also under
secure central host(s) control within the security management 186
platform services. System security staff access computer screens
allowing them to define security instruction sets within the
security management platform services. These instruction sets
provide security access and capability levels for all system users
in all system processing activities.
[0288] Customer Service features, provides the central setting of
account parameters 188 in the central platform services to add new
system accounts such as medical Insurer/benefit providers, medical
researchers and service providers for inclusion in the system, to
define billing parties for the system services, any tiered pricing
parameters and parent/child account relationships for roll-up
billing. In addition, central service control functions are
provided via screen entries appended to central host(s) databases.
These operate as a central file system override by adding an update
record on the target central host(s) database.
[0289] This update record is appended to the original record and
both the original and the update are maintained to support full
audit availability for all system records. In addition, a problem
tracking system accessible to all system users can also be
implemented under the applications/management 180 set of shared
platform services. The preferred embodiment of the invention
provides full arbitration and dispute resolution support to all
system users by allowing customer service central personnel to use
software operable on their computers to scan documents into a
database record or select electronic messages, embed them in an
electronic folder via the communications/file transfer 192 shared
platform services and transmit them to any party with system
access.
[0290] In support of these dispute resolution capabilities,
customer service central personnel have authorized system security
access to update any file through appending an attached record to
the record under dispute, as described above. In this way a full
history on a record is maintained within the central host(s)
databases, however a customer service central record can override
an automated activity. An example would be a payment dispute, where
a service payment was made but has been questioned. As a result of
an investigation supporting payment reversal, the customer service
central staff member could append a funds reversal record on the
provider service history/payment database which would be calculated
during the central host(s) service payment accounting cycle as a
negative amount during the payment processing cycle and deducted
from the value of a future funds transmission between the
parties.
[0291] Additionally, questions from any system customer regarding
system billing can be supported through an on-line billing history
archive within the electronic output/archive 194 which allows a
customer service central staff member to select the applicable
subset of an electronic archived report (in central host
administered central storage) created during central host
processing cycles and, using software operable on their computer,
to embed the contents into an electronic message to the requester,
whether that requester is a service provider, a researcher, a
medical insurer/benefit provider, a health plan sponsor or a
service recipient for transmission by the central host
communication feature set within communications/file transfer 192
shared platform services.
[0292] The electronic communication features within the
messaging/file transfer shared platform services of the invention
is available to all central system maintenance, security and
customer service staff members to expedite addressing inquiries,
problem resolution, setting tiered rates, and making adjustments to
rates or for any other customer or system related reason.
[0293] Customer billing processes 172 provide integrated service
billing for client organizations, such as insurers, sponsors,
service providers and research users. As defined in the customer
service support under the System/Service Management functions
described above, organizations can define the appropriate billing
roll-up in accordance with their individual cost accounting
process. These parameters are used during the customer billing
processing cycle. During the on-going use by the system users of
the system features, as functions are performed counters for the
function per account are incremented in the system activity file
190 shared platform services.
[0294] On billing processing dates (which can be defined in the
Account parameter 188 shared platform facility, the central billing
application reads the system activity file and the account
parameter records for the billing period and produces an electronic
invoice of costs per service categories and total service charges
per billing entity. These electronic invoices are transmitted
electronically to the customer through the communication/file
transfer 192 shared platform service with a copy transmitted to the
electronic output/archive 194. If desired, the electronic
transmission can accompany an electronic funds transfer from the
customer to the system central processing facility, also performed
through the Communication/file transfer platform services.
[0295] The Update Medications/Procedures 174 processes of the
invention provide entry of and changes to standardized codes for
all prognoses, treatments, medications and treatments. Designated
organizations and agencies can securely add values to field
categories within the data dictionary shared platform service and
access the medications/procedure database 146 to update medications
and procedures information. The authorized agencies can review
on-line, download, or print any of the information stored in the
medications/procedure database.
[0296] Using the software operable on the agency's computer, the
user accesses the central host(s), provides required security
responses and accesses and downloads the current data dictionary
and records within the Medications/procedures database. New
information for any of the appropriate sources can be added,
deleted or changed manually or through a file append feature within
their computer software. Such updates can include the
identification via new category codes, descriptions and codes
identifying warning conditions or incompatibilities, for new
diagnoses, procedures, pharmaceuticals, etc. and can add
informational records supporting any of these.
[0297] Changes are accompanied by active dates, defaulting to
current dates, which allow advance notification on developing
procedures or for upcoming FDA approval. Batched update features
and copy capabilities for current record information is available
to simplify changes to records. When all changes have been
completed, edited for format correctness and an on-line audit
approved, software within the agency's computer accesses the
central host(s) and performs the security procedure, then the
updated file is downloaded to the central host(s) and questions
regarding implementation dates/times, whether and to whom automated
notifications are to be generated, and whether other approval
communications are needed prior to submitting the change to the
data dictionary or the medications/procedures database. The change
queue request is verified, the agency can disconnect from the
central host(s) and the central host(s) performs the requested
operations.
[0298] The update service provider information processes 176 are
available to permit authorized organizations to create, update and
delete information stored in the service provider database 104.
This information includes records for licensed practitioners,
records for licensed organizations, and organizational ownership
information. Service provider records can also be updated to
reflect continuing education classes attended by, and disciplinary
action taken against a service provider.
[0299] Using the software operable on the agency's computer, the
user accesses the central host(s), provides required security
responses and accesses and downloads the appropriate current
records within the service provider database. New licensing,
continuing education, disciplinary action, organizational ownership
or other information for those records to which the agency has
security control can be added, deleted or changed manually or
through a file append feature within their computer software.
[0300] Changes are accompanied by active dates, defaulting to
current dates, which allow advance notification on organizational
ownership petitions, for example. Batched update features and copy
capabilities for current record information is available to
simplify changes to records. When all changes have been completed,
edited for format correctness and an on-line audit approved,
software within the agency's computer accesses the central host(s)
and performs the security procedure, then the updated file is
downloaded to the central host(s) and questions regarding
implementation dates/times, whether and to whom automated
notifications are to be generated, and whether other approval
communications are needed prior to submitting the change to the
service provider database. The change queue request is verified,
the agency can disconnect from the central host(s) and the central
host(s) performs the requested operations.
[0301] Although the invention is described herein with reference to
the preferred embodiment, one skilled in the art will readily
appreciate that other applications may be substituted for those set
forth herein without departing from the spirit and scope of the
present invention.
[0302] For example, the functional areas of the invention are
extensible to allow secure access to social security, annuity and
retirement account and benefit information. Individual service
recipients are thereby provided a unified view of their benefit and
payment status. This information is accessed using the individual
information device.
[0303] One skilled in the art will readily be able to construct the
hardware and software required for the invention using well-known
programming techniques and equipment. Accordingly, the invention
should only be limited by the claims included below.
* * * * *