U.S. patent application number 11/063268 was filed with the patent office on 2006-08-24 for systems and methods for assessing and optimizing healthcare administration.
Invention is credited to Richard Merkin.
Application Number | 20060190295 11/063268 |
Document ID | / |
Family ID | 36913935 |
Filed Date | 2006-08-24 |
United States Patent
Application |
20060190295 |
Kind Code |
A1 |
Merkin; Richard |
August 24, 2006 |
Systems and methods for assessing and optimizing healthcare
administration
Abstract
A comprehensive patient data assessment system and method for
use in generating, tracking and analyzing medical data related to
healthcare administered by a group of physicians to a specified
patient population. The system is operative to track data related
to the claims history, case management, pharmacy data, and lab
tests/results for each patient treated by each patient's primary
care physician preferably through electronic medical records that
are accessible over a computer network. The system is operative to
generate data indicative of the utilization of healthcare resources
utilized to treat each patient within the patient population, as
well as ensure that each primary care physician utilizes
appropriate codes for each diagnosis and procedure/test
administered to each patient. The system further provides for
categorization of patients afflicted with chronic conditions that
require high-cost care. The systems are exceptionally effective in
conserving medical resources, ensuring uniformity in administering
healthcare, and achieving optimal patient outcomes.
Inventors: |
Merkin; Richard;
(Northridge, CA) |
Correspondence
Address: |
STETINA BRUNDA GARRED & BRUCKER
75 ENTERPRISE, SUITE 250
ALISO VIEJO
CA
92656
US
|
Family ID: |
36913935 |
Appl. No.: |
11/063268 |
Filed: |
February 22, 2005 |
Current U.S.
Class: |
705/2 |
Current CPC
Class: |
G16H 15/00 20180101;
G16H 50/70 20180101; G16H 10/60 20180101; G16H 40/20 20180101; G16H
70/60 20180101 |
Class at
Publication: |
705/002 |
International
Class: |
G06Q 10/00 20060101
G06Q010/00 |
Claims
1. A method of administering healthcare comprising the steps: a.
identifying a patient population to which healthcare is
administered; b. identifying a group of physicians responsible for
administering care to said patient population identified in step a;
c. receiving a request from a patient within said patient
population for medical services to be rendered by a respective one
of said physicians identified in step b; d. implementing a coding
practice in response to said request made in step c wherein said
physician requested to render medical services in response to said
request inputs in to an electronic medical records system a
diagnosis code indicative of the physician's diagnosis of the
patient's condition and a code indicative of the medical services
rendered to treat the patient's condition; e. assessing said
diagnosis code input in step d for accuracy and appropriateness of
the code input in step d for the prescribed medical services
tendered; and f. statistically tracking any incidence of inaccurate
diagnosis or inappropriate medical services rendered in step e.
2. The method of claim 1 wherein in step d, additional medical
information is input into said electronic medical record, said
additional information comprising the identity of the patient, the
identity of the physician, the facility where medical services were
rendered and the date said medical services were rendered.
3. The method of claim 2 wherein in step d, said medical
information input into said electronic medical records further
comprises information identifying any laboratory tests ordered in
connection with the treatment of said patient, results of such
laboratory tests, and the date such arbitrary tests were
ordered.
4. The method of claim 2 wherein in step d, said medical
information input into said electronic medical records further
comprises pharmacy data related to any prescription medications
prescribed to said patient in connection with the medical services
rendered by said physician, said pharmacy data comprising
identifying the prescribing physician, identifying the medication
prescribed, indicating the strength of the medication prescribed,
indicating the dosage of the medication prescribed, identifying the
quantity of medication prescribed, and indicating the date such
medication was prescribed.
5. The method of claim 1 wherein said method further comprises
repeating steps a-f such that electronic medical records are
generated for each patient within the patient population
corresponding to each time each patient has requested medical
services from physicians specified within the group of
physicians.
6. The method of claim 5 further comprising the step of
periodically reviewing and evaluating said electronic medical
records to determine the accuracy of diagnoses and utilization of
healthcare resources as administered by said physicians amongst
said patients within the patient population.
7. The method of claim 1 wherein in step b, said group of
physicians comprises primary care physicians.
8. The method of claim 1 wherein in step d, said coding practice
further comprises identifying a high-cost chronic condition code to
the extent said patient seeking medical services is diagnosed with
a high-cost chronic condition.
9. The method of claim 8 wherein said high-cost chronic condition
is selected from the group of conditions consisting of cancer,
cardiovascular disease, diabetes, dialysis condition,
HIV/opportunistic infection, liver disease, pulmonary disease and
quadriplegia/extensive paralysis.
10. The method of claim 9 wherein when said patient is diagnosed
with a high-cost chronic condition, step e further comprises
reviewing and confirming said diagnosis of said high-cost chronic
condition, periodically reviewing said patient's condition to
determine whether further coding is required, and reviewing said
patient's condition to determine whether said patient needs to be
diagnosed as having a related medical condition.
11. The method of claim 10 wherein in step d, said medical
treatment administered to said patient conforms to a standardized
criteria of care.
12. The method of claim 11 wherein said standardized criteria of
care substantially conforms to criteria established by the National
Committee for Quality Assurance.
13. The method of claim 12 wherein in step d, said electronic
medical records are accessible over a computer network.
14. The method of claim 13 wherein said electronic medical records
are accessible over the Internet.
15. The method of claim 12 wherein in step e, a standardized
evaluation is implemented to ensure that patients afflicted with a
high-cost chronic condition are continuously evaluated according to
a standardized medical criteria consisting of clinical questions
regarding the progression of the patient's disease and a review of
the patient's medical records.
16. A system for facilitating the administration of healthcare
comprising: a. a computer network operative to receive, generate,
store, retrieve and transmit data; b. an electronic medical records
system operative to receive, generate, store, retrieve and transmit
medical data indicative of medical diagnoses and services rendered
by individual physicians to individual patients, said electronic
medical records system being operatively interfaced with said
computer network; c. a standardized criteria of care integrated
within said electronic medical records system for comparing a
standardized criteria of care to care rendered by said physicians
to said patients as documented by said electronic medical records;
and d. a review authority for comparing said differences in said
standardized criteria of care and said care identified in said
electronic medical records.
17. The system of claim 16 wherein said electronic medical records
system is operative to receive coding information corresponding to
diagnostic information and coding information corresponding to
medical treatment information as rendered by said individual
physicians to said individual patients.
18. The system of claim 19 wherein said electronic medical records
system is further operative to receive data indicative of the
diagnosis and treatment of patients afflicted with a high-cost
chronic condition and said standardized criteria of care integrated
within said electronic medical records system is operative to
provide an indication to the physicians treating said patients with
said high-cost chronic condition to determine whether treatment of
said patient requires further coding and whether said patient
requires diagnosis of a related medical condition.
Description
CROSS-REFERENCE TO RELATED APPLICATIONS
[0001] Not Applicable
STATEMENT RE: FEDERALLY SPONSORED RESEARCH/DEVELOPMENT
[0002] Not Applicable
BACKGROUND OF THE INVENTION
[0003] The present invention is directed to systems and methods for
comprehensively assessing and optimizing the administration of
healthcare as rendered by a group of physicians to a specific
patient population. More particularly, the present invention
comprises systems and methods that conserve medical resources
utilized to care for the patient population, ensure uniformity in
the procedures/tests utilized to render such care, identify and
assess those patients afflicted with a chronic condition requiring
high-cost healthcare, and provide means to continuously monitor and
evaluate the quality of healthcare delivered.
[0004] Essential to high quality and cost-effective health care is
the proper diagnosis of a patient's condition. From a proper
diagnosis, the appropriate medical attention utilized to treat the
underlying condition, whether it be the performance of a medical
procedure, laboratory tests and/or prescription of medication, can
be determined. To that end, and as is well-known in the art,
standard diagnoses codes are extensively utilized pursuant to
conventional disease classification techniques that provide a
quick, well-understood method to document medical care administered
to a patient. Exemplarily of and perhaps most widely utilized of
such formats is the International Classification of Diseases
9.sup.th Edition (ICD number 9) three digit codes. Likewise, with
respect to the medical treatment that has been rendered, such
procedures are typically referenced according to Current Procedural
Terminology (CPT). Also frequently referenced in connection with
the delivery of health care are drug codes (e.g., NDC), other
service codes (e.g., HCPCS), among others.
[0005] Notwithstanding such basic principles of medicine, as well
as an infrastructure of coding practices to help facilitate the
delivery of health care and documentation of patient treatment, the
current administration of healthcare in the United States is
subject to tremendous abuse and is grossly inefficient. In this
regard, patients, healthcare providers and healthcare providing
institutions often encourage wasteful practices that result in
needless procedures and tests being performed. Moreover, healthcare
providers and healthcare providing institutions, such as hospitals,
clinical laboratories, outpatient and rehabilitation facilities,
engage in capricious billing practices that enable such providers
and institutions to charge for a multiplicity of services that may
be available under a single clinical event that is typically
identified by a single CPT code.
[0006] Further problematic with such practice is that healthcare
providers and healthcare providing institutions frequently utilize
the wrong codes for diagnosis or otherwise use incorrect or
multiple CPT codes to seek reimbursement, whether it be from an
insurance company, health maintenance organization or government
sponsored healthcare program, such as Medicare. In this regard, by
failing to follow any type of uniform healthcare delivery system,
and hence uniform coding practice commensurate therewith, results
in overcharges for procedures that have been unnecessarily
performed, improper diagnosis and duplicative and unnecessary tests
and procedures.
[0007] In addition to health care providers and institutions,
patients themselves contribute substantially to the cost and
ineffective utilization of health care resources. As is well-known,
patients can and frequently do seek unnecessary medical treatment
or otherwise attempt to influence the judgment of the health care
provider by demanding that unnecessary tests or procedures be
performed, that the patients have access to specialists or
particular medications, and/or seek in-patient services in
situations where the patient's clinical condition clearly does not
justify such level of care. Such potential abuses are particularly
likely where patients are allowed the discretion to directly access
specialists, as is typical in several well-known health care
insurance plans, such as Blue Cross and Blue Shield, which thus
bypasses the critical role played by the primary care physician in
making an initial assessment of a patient's condition and whether
the same truly warrants the attention of a particular specialist,
and not to mention the specialist best suited to handle a
particular condition.
[0008] Such conventional health care practices are particularly
wasteful in the context of providing healthcare to patients
afflicted with a chronic condition requiring aggressive medical
management. Such conditions, known as high-cost chronic conditions,
include cancer, cardiovascular disease, diabetes, HIV, liver
disease and pulmonary disease, among several others. To treat such
high-cost chronic conditions typically involves continuous patient
treatment, which may take the form of a variety of medical
procedures, tests, prescription medicines, and the like, as well as
continuously monitoring the patient's condition to make sure that
the underlying chronic condition does not develop to a more advance
state, develop complications, and/or give rise to further related
medical condition. Current practices, however, are ill suited to
dynamically treat the progression of disease, and most physicians
and healthcare institutions merely react to the patient's condition
as opposed to be proactively involved in and anticipate the
potential future needs of the patient. Such lack of responsiveness
is typically reflected in the coding practices associated with the
care delivered to the patient, which often times can be inaccurate
and inappropriate based upon a general lack of patient history
documentation and anticipated need to follow up with the patient.
As a result of such poor practices, medical costs associated with
the treatment of chronic conditions become astronomical and almost
always beyond the capability of most individuals to pay.
[0009] In order to counter such wasteful and abusive practices,
attempts have been made to implement certain procedures to contain
health care costs and conserve the utilization of health care
resources. Exemplary of such attempts include requiring prior
authorization and approval by an intermediate entity, such as a
health maintenance organization or health insurance plan, to the
extent a physician seeks to take a specified action, such as
perform surgery, order a medical supply or refer the patient to a
specialist. Also utilized are the practices of bundling, whereby a
physician is paid a single payment for two or more medical
services, and capitation whereby a health care provider is paid a
set dollar amount as determined by a per member, per month
calculation to deliver medical services to a specific patient
population (i.e., members of a health maintenance organization).
Still further examples include the use of preferred provider
discounts, which encourage the use by patients of specific health
care providers, and usual and customary reductions, which impose a
reduction in the payment of medical services rendered as deemed
justified by a health plan or insurance company based upon what is
considered to be the justified value of such services as rendered
in a particular geographical area.
[0010] Despite such attempts, however, there has yet to be devised
any type of health care administration system or method that
substantially conserves utilization of health care resources that,
as a consequence, can dramatically lower the costs associated with
providing care to a specific patient population, especially in
connection with the treatment of patients with high cost chronic
conditions. Such attempts have likewise failed to maintain any
degree of consistent quality of health care insofar as prior art
cost containment practices have been and continue to be riddled
with "loopholes" with insufficient cost-deterrent mechanisms
necessary to conserve and optimally utilize a finite amount of
health care resources to treat accurately diagnosed patients.
[0011] As a result of the aforementioned abuses and inefficiencies
associated with the utilization of health care resources, the cost
of health care has and continues to increase substantially while
the quality of the health care provided has not necessarily
improved. As such, there is a substantial need in the art for a
health care administration system and method that are operative to
effectively and efficiently utilize health care resources to
administer care to a patient population as compared to conventional
practices. There is additionally a need for a healthcare
administration system and method that utilizes a standardized
coding practice that adheres to a standardized diagnosis treatment
scheme that can be reviewed for accuracy and physician competency.
There is still further a need in the art for such a system and
method that is generally effective in eliminating the wasteful
practices associated with the allocation and utilization of health
care resources, especially in connection with the treatment of
patients affected with chronic ailments, without adversely
compromising clinical outcomes or quality of care.
BRIEF SUMMARY OF THE INVENTION
[0012] The present invention specifically addresses and alleviates
the above-identified deficiencies in the art. In this regard, the
present invention is directed to a comprehensive medical
information and treatment system that is operative to compile,
track and provide means for reviewing the administration of
healthcare by a group of physicians and healthcare administration
institutions to a specific patient population. In this respect, the
present invention is operative to assess the appropriateness of
each and every diagnosis, as well as the specific tests and
procedures that have been ordered/rendered by a primary care
physician to specific patients within the patient population. The
system specifies, through a uniform coding procedure, each
diagnosis and every test/procedure ordered/rendered by each
physician for each patient such that a comprehensive medical
history is compiled for each patient. The system further tracks
each event for which medical care was rendered (claims history),
the patient's case management, pharmacy information related to all
medications prescribed to the patient, and any and all laboratory
tests and results therefrom, including the specific dates that such
procedures and tests were performed and medications prescribed. The
compiled data will preferably be managed as electronic medical
records accessible through a computer network, and in particular
the Internet.
[0013] From such compilation of data, an assessment is made
according to standardized care criteria and coding practices
whereby a specific physician can be assessed as to the
appropriateness of the diagnosis made, as well as the care he or
she has rendered based upon the specific procedures and tests that
were rendered/ordered to the specific patients under his of her
care. In this regard, it is contemplated that the competency and
efficiency by which a specific physician practices medicine can be
adjudged according to the appropriateness of the coding practices
followed by the physician, which will correlate with the proper
diagnosis and specific type of procedures and tests administered to
specific patients on specific occasions. Along these lines, it is
contemplated that a number of statistical analyses can be applied
in reviewing the electronic medical records that are operative to
assess potentially inappropriate coding practices, which are thus
indicative of wasteful, unnecessary or sub-optimal healthcare.
[0014] In addition to the foregoing compilation and assessment of
healthcare as administered by a select group of physicians to a
specific patient population, the system further integrates data
related to the diagnosis and treatment associated with the care of
patients within the patient population afflicted with high-cost
chronic conditions, such as cancer, cardiovascular disease,
diabetes, pulmonary disease or quadriplegia. The system is further
particularly sensitive with respect to the treatment of high-cost
chronic conditions in order to ensure that such chronic conditions
have been properly diagnosed, whether further coding (indicative of
further specific procedures and tests) may be warranted, whether
additional coding is appropriate based upon additional related
diagnoses based upon the current diagnosis (potential hierarchical
review), and review to ensure that the treating physician has
complied with all proper coding procedures indicative of the most
cost-effective medical management practices coupled with the most
favorable patient outcome.
[0015] With regard to those patients that have been properly
identified as being afflicted with a high-cost chronic condition,
the system of the present invention is operative to separately
compile data related thereto to thus enable those patients to be
assessed based upon the type of condition and required long-term
treatment necessary to secure the most favorable patient outcome.
Additionally, such information associated with those members having
a high-cost chronic condition can be utilized to develop
cost-effective treatment strategies that may be custom tailored to
provide an optimal patient treatment.
[0016] In addition to the foregoing, it is further contemplated
that by virtue of existing preferably in an electronic medical
record format, the systems and methods of the present invention
will be exceptionally useful in performing standardized electronic
transactions as provided for in the Health Insurance Portability
and Accountability Act (HIPAA) of 1996. In this regard, such
transactions, as set forth in HIPAA, expressly include claims,
remittance and payment advice, claims status, enrollment and
disenrollment in a health plan, premium payments, eligibility
inquiries and responses, referral certifications and
authorizations, coordination of benefits, and the like, all of
which can be facilitated through use of the present invention
according to a standardized transaction format, which can include
the uniform use of codes typically associated with conventional
billing practices, such as diagnosis codes mentioned above (i.e.,
ICDM-9-CM, CPT-4, NDC, and HCPCS).
[0017] All of these objectives and more are accomplished by the
present invention.
BRIEF DESCRIPTION OF THE DRAWINGS
[0018] These, as well as other features of the present invention,
will become more apparent upon reference to the drawings
wherein:
[0019] FIG. 1 is a flowchart depicting the steps for practicing the
present invention as it relates to administering and documenting
healthcare administered by primary care physicians to a patient
population, including healthcare administered to patients within
the patient population afflicted with high-cost chronic
conditions.
[0020] FIG. 2 is a flowchart depicting information obtained in
order to generate a claims history for each incident medical care
is rendered to a patient within the patient population.
[0021] FIG. 3 is a flowchart depicting the steps fro obtaining
information relating to all laboratory tests performed for each
patient within the patient population, as well as the results of
such tests.
[0022] FIG. 4 is a flowchart depicting information to be obtained
in connection with pharmacy data/prescription information for each
medication prescribed to each patient within the patient
population.
[0023] FIG. 5 is a list of high-cost chronic conditions that
further includes specific sub-categories of such high-cost chronic
conditions wherein each sub-category diagnosis is assigned a
specific HCC code.
[0024] FIG. 6 is a listing of the high-cost chronic conditions of
FIG. 5 that are identified as possibly requiring further coding
with respect to additional medical procedures and tests that may be
essential to provide care for a patient afflicted with a high-cost
chronic condition.
[0025] FIG. 7 is a list of medical factors and questions to be
taken into consideration by a physician when treating a patient
properly diagnosed with cancer.
[0026] FIG. 8 is a list of medical factors and questions to be
taken into consideration by a physician when treating a patient
properly diagnosed with cardiovascular disease.
[0027] FIG. 9 is a list of medical factors and questions to be
taken into consideration by a physician when treating a patient
properly diagnosed with dialysis condition.
[0028] FIG. 10 is a list of medical factors and questions to be
taken into consideration by a physician when treating a patient
properly diagnosed with HIV/opportunistic infections.
[0029] FIG. 11 is a listing of potential additional related
diagnoses that a physician must take into consideration when
treating a patient having been diagnosed with a specific high-cost
chronic condition.
DETAILED DESCRIPTION OF THE INVENTION
[0030] The detailed description set forth below is intended as a
description of the presently preferred embodiment of the invention,
and is not intended to represent the only form in which the present
invention may be constructed or utilized. The description sets
forth the functions and sequences of steps for constructing and
operating the invention. It is to be understood, however, that the
same or equivalent functions and sequences may be accomplished by
different embodiments and that they are also intended to be
encompassed within the scope of the invention.
[0031] Referring now to FIG. 1, there is schematically illustrated
the various steps by which the system and method of the present
invention 10 operate to generate data related to the delivery of
healthcare to a patient population and how such delivery of
healthcare can be optimized. To that end, it is contemplated that
the present invention will be utilized exclusively by healthcare
providers, which includes physicians, hospitals, medical groups,
healthcare plans, health maintenance organizations, or any entity
that provides healthcare to a patient population.
[0032] To create such framework, a patient population is first
established 102 to which healthcare will be provided. To that end,
it is contemplated that the identification of the patient
population may take any of a variety of forms well-known in the
art, including the teachings of Applicant's co-pending patent
applications U.S. patent application Ser. No. 10/615,640, filed
Jun. 8, 2003 entitled HEALTHCARE ADMINISTRATION METHOD and U.S.
patent application Ser. No. 10/679,178 entitled HEALTHCARE
ADMINISTRATION METHOD HAVING QUALITY ASSURANCE, filed on Oct. 3,
2003, each of which are expressly incorporated herein by
reference.
[0033] To care for such patient population, there is further
provided a network or infrastructure of healthcare providers and
healthcare providing institutions that will preferably comprise an
integrated medical delivery system consisting of physicians and
in-patient and out-patient facilities capable of comprehensively
delivering medical treatment to those patients within the patient
population. In this respect, and as per the teachings of
Applicant's aforementioned pending patent applications, the present
invention relies upon a procedural framework whereby primary care
physicians are responsible for the initial assessment, diagnosis
and treatment of those patients within the patient population
seeking treatment. Moreover, for reasons discussed more fully
below, such primary care physicians (PCP's) are further obligated
to closely adhere to a strict coding procedure that accurately and
efficiently standardizes medical diagnosis and, based upon such
diagnosis, helps dictate what medical services, both short term
and, where applicable, long term, are to be rendered in relation to
a specific patient's condition.
[0034] To that end, and in order to deliver healthcare to patients
within the patient population, primary care physicians (PCP's) will
be assigned to patients within the patient population via 104 and
will be primarily responsible for administering care thereto. With
respect to such arrangements, it is contemplated that any of a
variety of well-known techniques and healthcare practices known in
the art can be utilized, such as those established by insurance
carriers, health maintenance organizations, and the like are made
available to patients within the patient population to access for
treatment. In this respect, it is contemplated that conventional
office-based appointments/doctors visits will be coordinated
between patients in the patient population and their respective
PCP's according to conventional practice.
[0035] Key to the practice of the present invention occurs in step
106, which is implemented every time a PCP treats a patient within
the patient population. According to such step, significant
documentation will be obtained in relation to the nature of medical
care administered to a patient by a PCP, or other specialist as may
be required, as discussed more fully below in relation to FIGS.
2-4. To that end, it is expressly contemplated that the systems and
methods of the present invention will incorporate the use of
electronic medical records that are operative to facilitate the
input, storage, retrieval, transfer and review of medical
information to other entities involved in the delivery of
healthcare to patients within the patient population, including
hospitals, in-patient and out-patient facilities, labs, insurance
carriers, physicians offices, and the like. Exemplary of certain
lesser-preferred formats operative to generate electronic medical
records include medical record software produced by American
Medical Software of Edwardsville, Ill.; Smart Doctor EMR, produced
by Intelligent Medical Systems, Inc. of Alpine, Tex.; SOAPware EMR
Software produced by Docs, Inc. of Springdale, Ariz.; and EMR
Medical Software produced by Expert System Applications, Inc. of
Solon, Ohio.
[0036] In a preferred embodiment, the medical records generated
electronically through the preferred practice of the present
invention will be accessible over the Internet or through secure
intranet computer networks well-known to those skilled in the art.
Exemplary of a most-preferred implementation of the systems and
methods of the present invention include proprietary medical data
management the website http://www.hmshcc.com operated by Heritage
Medical Systems of Reseda, Calif. As will be readily understood by
those skilled in the art, by providing a web-based system greatly
facilitates access to medical records, as well as is operative to
provide secure means by which such data can be generated, stored,
retrieved and reviewed.
[0037] Given the electronic medical record format by which the
delivery of healthcare will be documented according to step 106,
there will further be implemented a coding practice associated with
the delivery of such healthcare. The documentation and coding
practice will preferably be consistent with the schematics as set
forth in FIGS. 2-4.
[0038] With reference to FIG. 2, there is shown a first area of
data to be collected in connection with the treatment of a specific
patient within the patient population by the patient's PCP. Such
information is directed to the creation and documentation of a
claims history. To that end, for each incident for which medical
care is rendered, there will be documented the identity of the
treating physician 200 and a specialty description of that
physician, and whether or not the same is the patient's PCP or
otherwise a medical specialist. A diagnosis will further be
identified in 202 that, for reasons discussed more fully below,
will be consistent with a conventional coding practice, such as
ICD-9-CM, well-known to those skilled in the art. Of substantial
significance, and likewise discussed more fully below in connection
with step 108, is whether or not the diagnosis involves a high-cost
chronic condition determined in step 204, which if accurate, is
operative to trigger a comprehensive on-going medical assessment
that ensures that all aspects of the patient's condition are
adequately reviewed and considered when implementing treatment.
[0039] In response to the identified diagnosis made in 202,
documentation is further obtained with respect to the specific
medical procedure that was rendered to treat such condition in step
206, as well as where such services were rendered, whether it be a
hospital, in-patient or out-patient facility, and the date the
medical services were rendered. To facilitate the input of such
information, it is contemplated that the description of the medical
procedures as performed may be consistent with the use of
conventional CPT codes, such as CPT-4 and other service codes, such
as HCPCS, among others. Key with the identification of the
description of the medical procedure/services rendered will be an
assessment as to how the same were effective and appropriate in
treating the condition diagnosed.
[0040] In addition to the claims history information generated as
part of the implementation of the documentation and coding practice
of step 106 of FIG. 1 and sub-steps 200-206 of FIG. 2, is the
documentation of all lab results for each service provided to each
patient. With respect to the documentation of such information,
there is depicted in FIG. 3 the information that should necessarily
be obtained in connection with any tests ordered in connection with
the treatment of a specific patient within the patient population.
As illustrated, the physician ordering the specific tests should be
documented 300, along with the physician's diagnosis warranting the
specific tests 302. To that end, it is contemplated that
standardized diagnoses and procedure/service codes can be utilized.
It is further preferred that a description of the lab test be
provided 304 as well as the results of the prescribed tests 306.
Where applicable, to the extent information regarding specific
tests has some type of clinically meaningful outcome, the same
should be indicated in 308. It is further contemplated that the
dates of such tests are rendered likewise be documented as part of
step 308.
[0041] As a further component of the documentation and coding
practice implemented in connection with the delivery of healthcare
set forth in step 106 of FIG. 1, there is shown in FIG. 4 the
documentation to be obtained in connection with any relevant
pharmacy data. As illustrated, such information gathering includes
the steps of identifying the prescribing physician 400, identifying
the medication prescribed 402, including the strength/dosage
thereof. With respect to the latter, it is contemplated that the
medication will be identified by name, daily dosage (when
applicable), and the strength of the medication prescribed (e.g.,
famotidine 40 mg hs). Further pharmacy data to be documented
include the quantity, such as the number of tablets prescribed to a
specific patient and, in step 404, the date when such prescription
is filled.
[0042] Comprehensively documenting all such information as part of
the delivery of healthcare by PCP's to the patients they treat
within the patient population will be operative to not only
generate an extremely comprehensive, easily accessible, and easily
updatable electronic medical record system, but will further enable
the accuracy of the diagnoses to be assessed, as well as the
appropriateness of the healthcare administered in relation thereto.
To that end, and before discussing specific procedures followed in
connection with the proper diagnosis of a patient having a chronic
condition, the systems and methods of the present invention
integrate a review step 110 that is operative to enable overseeing
physicians, healthcare administrators, hospitalists or other
knowledgeable individuals having a thorough understanding of the
administration of healthcare to determine whether a submitted
diagnosis and procedure/test rendered in response thereto is
appropriate based upon a multiplicity of factors. In this regard,
it is expressly contemplated that those practices disclosed and
claimed in connection with Applicant's co-pending U.S. patent
application Ser. No. 10/615,640 can be implemented to ensure that
each of the PCP's administering healthcare to patients within the
patient population are following a standardized protocol that
strictly adheres to the delivery of quality, cost-effective
healthcare.
[0043] As a further means of reviewing the PCP's performance in
accurately diagnosing each specific condition for which each
specific patient is treated, the systems and methods of the present
invention may further incorporate the methodology of U.S. patent
application Ser. No. 10/679,178, which incorporates a reference for
standardized performance measures for rendering healthcare.
Exemplary of such standards expressly include the National
Committee for Quality Assurance's (NCQA) Healthplan Employer Data
and Information Set (HEDIS), which is well-known and recognized in
the art as a recognized standard for quality of healthcare and
service that healthcare plans should attempt to provide to their
members. Accordingly, such review of diagnosis and treatment,
coupled with standardized treatment practices recognized in the art
(as may be promulgated by consumer groups, government agencies, or
healthcare administration agencies, including HEDIS standards
discussed above), enables healthcare to be administered to the
patients within the patient population according to recognized
standards of care that can be continuously reviewed and
updated.
[0044] To that end, the systems and methods of the present
invention incorporate a further component, namely, component 112
shown in FIG. 1, that enables all of the diagnoses, treatment, lab
tests, and prescription information outlined above to be compiled,
assessed, and reviewed to ensure that the best medical management
practices are followed, as well as how the delivery of healthcare
can be administered as efficiently and cost-effectively as
possible. In this respect, it is contemplated that a number of
statistical techniques can be deployed to determine the rate of
error by which one of more physicians improperly diagnoses a
specific condition, perform an inappropriate procedure in response
to a diagnosed condition, order wrong or unnecessary tests in
response to a diagnosed condition, and/or prescribe medication that
is either inappropriate, sub-therapeutic or improperly indicated to
treat a specific condition. Along these lines, it is contemplated
that all of the PCP's administering healthcare to the patient
population can be continually reviewed and assessed for their
performance to thus ensure that not only are the most
cost-effective healthcare practices are being utilized, but to also
improve physician judgment, eliminate wasteful practices, and that
most cost-effective medical treatment is delivered. In this
respect, it is expressly contemplated that the systems and methods
of the present invention will achieve the dual purpose of
conserving medical resources while at the same time improving the
delivery of healthcare by ensuring that proper diagnosis, and hence
appropriate procedures, tests, and medications prescribed in
response thereto, are administered with little to no waste of
resources.
[0045] In addition to the implementation of procedures to document
and review the delivery of health care administered to a patient
population, particularly with respect to the diagnosis of specific
medical conditions and the procedures/tests performed in response
thereto, the systems and methods of the present invention are
particularly well suited for the cost-effective management of those
patents within the patient population afflicted with high-cost
chronic conditions. As discussed above in relation to FIGS. 1 and
2, as part of the diagnosis and treatment of each patient, each
physician will identify, where appropriate, whether such patient is
being treated for a high cost chronic condition, as identified in
step 108 of FIGS. 1 and 204 of FIG. 2. Essentially, whether or not
a patient is afflicted with a high-cost chronic condition will be
determined by conventional medical evaluation and will encompass
those specific chronic conditions specified in FIG. 5.
[0046] Presently, the present invention contemplates that high-cost
chronic conditions can be identified as falling within at least
eight (8) separate categories, namely cancer, cardiovascular
disease, diabetes, dialysis condition, HIV/opportunistic
infections, liver disease, pulmonary disease and
quadriplegia/extensive paralysis. As further illustrated in FIG. 5,
within each category of high-cost chronic conditions are specific
medical conditions that are identified by a separate code. For
example, for cancer, there are identified four (4) separate
cancerous conditions, each of which having its own high-cost
chronic condition (HCC) code. As shown, breast, prostate,
colorectal cancers are identified as HCC 10; lung, upper digestive
track and other sever cancers are identified as HCC 8; lymphatic,
head and neck, brain cancers are identified as HCC 9; and
metastatic cancer and acute leukemia are identified as HCC 7.
Similar subcategories with their own dedicated HCC codes are
further provided for each of the eight conditions. In this respect,
it should be recognized that the HCC codes are exemplary of those
that can be utilized in the coding practices utilized in the
practice of the present invention. Such coding practice is
significant insofar as the same not only reflect what should be the
most accurate diagnosis of a patient, but in the case of a
high-cost chronic condition, proper diagnosis is imperative to
insure that the best, most comprehensive and cost-effective
treatment can be delivered to the patient and that all relevant
factors and disease progression are taken into consideration.
[0047] As part of such process, the initial step begins with
confirming that a patient is in fact being treated for a high-cost
chronic condition in 114. Such diagnosis is reviewed as part of
such step to ensure that the diagnosis continues to accurately
reflect the condition of the patient. Advantageously, such
continuous review of the diagnosis ensures that the patient's
condition is accurately characterized with the most appropriate
treatment being utilized, as opposed to conventional wasteful
practices where a chronic condition, once diagnosed, is treated
indefinitely in a static, non-dynamic fashion which often time
neglects to take into consideration related medical diagnosis and
can result in suboptimal and even harmful care.
[0048] In addition to continuously reviewing the appropriateness of
the high-cost chronic condition diagnosis, further assessment is
made in step 116 with respect to any type of insurance claims
submissions. As is well-known in the art, health care benefits are
typically treated on an annual basis, with deductibles for which
the patient is responsible for paying becoming due on the first of
the calendar year. By virtue of the fact that such high-cost
chronic conditions often times afflict patients for years, there is
advantageously built into the systems and methods of the present
invention procedures by which medical records are continuously
updated so that to the extent insurance benefits are renewed
periodically, such as a calendar year basis, all applicable
information is necessary to insure ongoing coverage, benefits, and
the like will be updated as part of step 116 such that a continuum
of care cannot only be provided to the patient, but that the
applicable benefits and coverage attendant thereto can be
administratively tracked and reviewed. As is well-known in the art,
to the extent such information is not timely updated, substantial
administrative problems can occur which can require resubmission of
claims information and potentially trigger the loss of certain
benefits or otherwise trigger an obligation for the patient to pay
higher deductibles, medical costs, and the like, which the patient
would not otherwise be obligated to do but for accurate and timely
diagnosis information that is properly updated.
[0049] In order to provide the most comprehensive care for such
patients afflicted with a high-cost chronic condition, the present
invention further takes into account potential medical
complications associated with each specific high-cost chronic
condition that enables the treating physicians to anticipate such
potential complications and related diagnoses. As illustrated in
step 118 of FIG. 1, there is integrated within the systems and
methods of the present invention an on-going patient assessment
whereby specific chronic conditions are reviewed to determine if
further coding is required. In this respect, and as depicted in
FIG. 6, a listing of the various chronic conditions will be
provided and, preferably through a link provided as part of the
electronic medical records for each patient, a series of pertinent
clinical questions specific for each condition that must be taken
into account by the treating physician in order to properly assess
whether or not further coding is required for a given patient. For
example, to the extent the patient has been diagnosed with cancer,
when updating the electronic medical records for such patient the
physician will be provided a quick reference to those questions
identified in FIG. 7 that will direct the treating physician to
continuously evaluate and assess the patient's condition and
ultimately direct the physician to follow the proper medical
protocol, through the coding practices referred to herein, to
ensure that not only are further medical procedures and test
warranted, but that the correct procedures and tests are prescribed
and carried out in a timely manner to provide the best patient care
possible. For example, in FIG. 7, to the extent a patient has been
diagnosed with cancer, the treating physician will necessarily be
prompted to review each of the questions identified, such as
whether or not the patient has been actively managed for malignant
neoplasms and whether the medical records for such patient
contained documentation of active treatment for pulmonary or
disseminated micro bacteria, among others. To the extent a patient
does have a specific type of condition, such as a malignant
neoplasm of the prostate or if the patient has malignant breast
cancer, additional coding may be required to provide adequate care
to the patient. Advantageously, by utilizing the extremely
comprehensive collection of data discussed above enables the
patient's condition to be thoroughly assessed to not only provide
the most practical health care but to also substantially minimize,
if not eliminate, potential liability for a misdiagnosis and
improper patient documentation.
[0050] Referring now to FIGS. 8-10, there is illustrated those
clinical questions that must be asked for those patients properly
diagnosed of other types of high-cost chronic conditions. In FIG.
8, there is illustrated the questions linked to cardiovascular
disease which every physician must review for each patient properly
diagnosed with such condition. As illustrated, the treating
physician must take into consideration whether the patient has
prior history of cardiopulmonary disorder predisposing to current
cardiac issues and whether the patient meets clinical criteria for
cardiomyopathy, among other considerations. Also, to the extent
atrial or ventricular arrhythmia is diagnosed, specific coding is
essential to ensure that the appropriate on-going medical
diagnosis, treatment and tests are prescribed.
[0051] FIG. 9 represents those considerations that must be made to
the extent the patient is properly diagnosed with a dialysis
condition. As illustrated, physicians must take into consideration
whether or not the patient was receiving accurate treatment for
chronic renal failure, chronic uremia, and other conditions while
the patient had previously been treated. Likewise, FIG. 10 depicts
those questions that the physician is directed to and is to take
into consideration to the extent that the patient has been properly
diagnosed with either HIV or an opportunistic infection. For
example, a treating physician must necessarily review and determine
whether or not the patient has previously been treated for candidal
pneumonia, aspergillous species, or other types of infections
attendant to the underlying treatment of the patient's chronic
condition.
[0052] With respect to the further coding that must be taken into
consideration as illustrated in FIGS. 6-10, it will be understood
by those skilled in the art that the specific questions and further
medical assessment that the physician will be prompted to take into
consideration will be continuously updated as improvements are made
in medicine regarding patient diagnosis and treatment. It is
likewise contemplated that additional high-cost chronic conditions
may be added to those identified in FIG. 6 and that for each such
additional chronic condition, a subset of the questions and
clinical treatment considerations will be identified using known,
objective diagnostic standards that will be agreed upon by the
medical community as providing a standard that all treating
physicians should follow according to best patient management
practices. Accordingly, the specific questions and considerations
set forth in FIGS. 7-10 are merely illustrative of the further
considerations that are made with present best medical management
practices.
[0053] As a further consideration to be documented as part of the
administration of care to patients with high-cost chronic
conditions, the treating physician will further identify whether or
not the patient afflicted with the high-cost chronic condition is
adjudged to have either a low, medium or high risk as part of step
118. Along these lines, and as is well-known to those skilled in
the art, the severity of a given condition can be readily assessed,
and the present invention takes such risk into consideration so
that the aggressiveness of medical treatment can be proportionately
tailored to address the same. The assignment of risk will be
periodically updated and reviewed for accuracy. To the extent a
patient is properly identified as being a higher risk patient, it
will be understood that more aggressive measures may be taken
should a favorable patient outcome be reasonably anticipated. On
the other hand, designating such a patient as high risk, depending
on the circumstances, may warrant that only palliative measures be
taken to thus not only conserve medical resources, but to also
treat the patient as realistically as practical.
[0054] In addition to continuous review of diagnosis, risk
assessment, claims updating and review of the patients' conditions
to determine whether or not further coding is appropriate, the
present invention further includes a component, identified as 120
of FIG. 1, that involves determining whether or not a given
high-cost chronic condition progresses to a further stage requiring
additional diagnosis. Specifically, patients that have been
properly diagnosed with a high-cost chronic condition will further
be continuously reviewed for potential additional related
diagnosis. As explained in connection with FIGS. 5 and 11, there is
illustrated the specific high-cost chronic conditions by specific
HCC codes in FIG. 5 and how those patients diagnosed with such
specific conditions will be reassessed by the treating physicians
to determine whether or not an additional related diagnosis
identified in FIG. 11 must also be made. For example, patients
diagnosed with a high-cost chronic condition code HCC 8, such as
lung cancer for example, will further be reviewed by the treating
physician to determine whether or not the patient should further be
diagnosed with HCC 7, namely metastatic cancer. Similarly, patients
diagnosed with diabetes with acute complications, HCC 17, will be
reviewed to determine whether or not a diagnosis of diabetes with
neurologic manifestation HCC 16 or diabetes with peripheral
circulatory manifestation HCC 15 are justified as additional
related diagnoses. Such review will be continuously documented as
part of the patient's medical records
[0055] The review for potential additional related diagnoses will
be consistent with objective, standardized medical management
practices, and may change from time to time as such medical
practices change in the art. With respect to the additional related
diagnosis identified in FIG. 11, it will thus be understood that
the same may change or become modified over time as such medical
practices dictate. Advantageously, by taking such related diagnoses
into account, the practices of the present invention enable a
patient's condition to be dynamically treated, especially if the
disease progresses on to the related conditions identified. For
example, patients with chronic hepatitis, HCC 27 or cirrhosis of
the liver HCC 26, will be continuously monitored to determine
whether or not the patient ultimately progresses to end-stage liver
disease HCC 25. All medically appropriate procedures and tests can
thus accordingly be assigned to such patient as the patient's
disease evolves, which in turn allows for the most applicable
medical treatment in conservation of medical resources.
[0056] The systems and methods of the present invention further
include, as part of such comprehensive diagnosis, treatment, review
and documentation of patients with high-cost chronic conditions, a
review component 122 that, per the practices discussed above,
ensure that the treating physicians are delivering the most
appropriate, objectively-reasonable health care as may be reviewed
by knowledgeable hospitalists, administrators, health care workers,
and the like. Along these lines, such review component plays an
important role in the management of high-cost chronic conditions
insofar as those patients properly diagnosed with high-cost chronic
conditions often times utilize vastly more medical resources and
require substantially greater care for longer periods of time than
the vast majority of the patients within the patient population.
Accordingly, one of the major objectives of the present invention
is to provide a tool operative to contain costs in delivering
health care to a patient population and by integrating such review
step allows not only for the best standard of care to be
administered utilizing objective criteria, but also be delivered in
extremely efficient and cost effective manner.
[0057] To that end, the present invention, by focusing on
delivering such cost effective health care for the treatment of
those patients afflicted with a high-cost chronic condition,
enables those patients to be readily identified in optional step
124 to define a subpopulation whose information can be readily
accessed, reviewed and scrutinized to determine whether or not the
best most efficient medical practices are being followed.
Identifying such patient population can be of additional use in
assessing the epidemiology and etiology of specific diseases and
medical conditions.
[0058] Additional modifications and improvements of the present
invention will be apparent to those of ordinary skill in the art.
Along these lines, the systems and methods of the present invention
can be implemented as part of virtually any health care delivery
system, including any conventional public or private system, such
as a health maintenance organization, health plan or government
sponsored program, that is responsible for overseeing the
utilization of health care resources of an integrated delivery
system to administer health care to a patient population. If
implemented correctly, the systems and methods of the present
invention can optimally administer and substantially conserve the
utilization of health care resources to thus enable high-quality
and objectively verifiable health care to be delivered while at the
same time enabling cost-effective services to be rendered. Indeed,
it is contemplated that the health care administration systems and
methods of the present invention can and will serve as a model from
which existing health care administration systems can and emulate
to not only conserve resources, but where applicable, substantially
increase profitability and improve patient outcomes.
[0059] Moreover, the system of the present invention, while
advantageously preserving the interests of privacy and security
related information, may further be useful in facilitating
standardized electronic transactions, consistent with the mandate
of HIPAA, as well as collecting information useful for research. In
this respect, the system of the present invention will be operative
to obtain information related to a specific medical practice,
hospital, or type of care provided in a general area, which may be
extremely useful in predicting trends and anticipating future
healthcare needs. In this regard, information related to hospital
admissions, type and nature of medical procedures or services
rendered by a specific medical practitioner or medical group, type
and volume of prescription medications that are prescribed by a
specific physician or medical group, and information related
generally to the diagnosis and clinical evaluation made by a
practitioner or medical group can be compiled through the system of
the present invention and useful in assessing the epidemiology and
etiology of a specific disease or abnormal condition. Furthermore,
in certain limited applications, the data created by the system of
present invention may be useful as marketing data which can be
utilized to determine the practice characteristics of a specific
practitioner or health group. Exemplary of the latter includes
prescribing habits, particularly with respect to volume and types
of medication prescribed by a given practitioner, which is
extremely useful as marketing data for determining sales
effectiveness, market share, and trends in medical management
practices.
[0060] Accordingly, the particular combination of parts and steps
described and illustrated herein will be understood to represent
only certain embodiments of the present invention, and are not
intended to serve as limitations of alternative systems and methods
falling within the scope of the present invention.
* * * * *
References