DESC:THE PATENTS ACT, 1970
(39 of 1970)
&
The Patent Rules, 2003
COMPLETE SPECIFICATION
[See Section 10 and Rule 13]
1. TITLE OF THE INVENTION
AN IMPROVED PROCESS AND SYSTEM FOR MANAGING HEALTHCARE NETWORK
PERFORMANCE
2. APPLICANTS
(a) CITIUSTECH HEALTHCARE TECHNOLOGY PRIVATE LIMITED
(b) an Indian company,
(c) of Teritex Building, 41/2 Saki Vihar Road, Andheri (East), Mumbai 400072,
Maharashtra INDIA
3. PREAMBLE TO THE DESCRIPTION
The following specification particularly describes the invention and the manner in which it is
to be performed.
5
2
FIELD OF THE INVENTION
The present invention relates to the field of healthcare and more particularly to an improved
process and system to allow efficient collaboration between various stakeholders in
healthcare industry, such as but not limited to providers, payers and 5 ancillary service
providers, and beneficiaries to enable low cost and real-time identification of opportunities
for improvement in quality of healthcare services delivered to a beneficiary (i.e. patient).
BACKGROUND OF THE INVENTION
10
Stakeholders in the healthcare industry have defined standards of care in order to increase
efficiency in the industry and to provide an improved level of healthcare to the general
population. The Key Performance Indicators (KPIs) of healthcare network performance and
quality of care include regulatory clinical quality measures, Diagnosis, Cohorts, Protocols,
15 contractual quality measures, operational quality measures, financial measures, risk
stratification methods (example Hierarchical Conditional Coding), as well as the particular
actions such as recommended or required screenings, tests and treatments, standard care
guideless etc. For example, clinical quality measures are well defined KPIs to determine
whether appropriate care was delivered and are usually calculated using healthcare data such
20 as both clinical and financial data, including coding and clinical results and tests. This
information often needs to be shared with other healthcare organizations (such as payer,
ACOs, CINs, IPNs and IPAs). Standards of care for each individual are based on individual's
demographics and medical conditions. The standards of care may also define certain time
frames and/or locations that are recommended or required for the particular actions of care
25 delivery to take place, and may define which of the healthcare stakeholders should perform
the particular actions, various standards of care include different lists of predefined
opportunity in care to help stakeholders efficiently identify and prioritize recommended or
required actions to be completed to optimize the delivery of care to an individual or
population. Opportunity refers to the deviation in delivering care to a patient. Further, the
30 opportunity includes a gap in clinical quality, assessment and/or stratification, diagnosis,
care, screening, tests, treatments, assessment, documentation, waste avoidance, data
accuracy, compliance etc.
3
In the modern era of health care, most providers have adopted electronic health records
(EHR) that document the electronic health record of beneficiary and services provided. The
provider, service provider or healthcare provider is an individual who provides preventive,
curative, promotional or rehabilitative health care services in a systematic way to people,
families or communities. These are effective tools for recording historical 5 information that
was once charted on paper, and most EHRs can offer directions and reminders that may help
bridge opportunity in care. However, these systems are ill suited for closing the health care
opportunity among providers and fully supporting the coordination of care across all health
and social services. Health systems recognize the importance of integrating physical,
10 behavioural, and social determents of health, new technology solutions must be adopted to
support care among providers and stakeholders in healthcare industry.
Actual care is provided at the time of visit to various places, care settings, where care is
delivered such as Physician Offices, Clinics, Hospital etc. Thus, at the time of visit the
15 healthcare provider is burdened to manage an enormous amount of information in order to
identify all opportunities in care for each of their beneficiary, i.e. person seeking care, at the
appropriate time. Traditional methods do not place prime focus on addressing opportunities
or are able to address opportunities only partially because of limited set of data. Also,
traditional healthcare systems do not ensure that gaps are closed within the existing
20 workflows of the healthcare service providers and payers (who pay for service provided by
healthcare service provider). Often the opportunities are identified months after the patient
leaves the providers office.
The contemporary processes of closing gaps are time consuming, costly and inefficient
25 processes which are not scalable for large population of patients or health plan members.
The contemporary process either requires a tremendous amount of time and focus by
providers that takes them away from seeing patients or involves retrospective review of the
data to determine which patients should visit the provider or has additional gaps. This often
requires data collection/exchange through a manual process, commonly known as chart
30 chase or charting, wherein one healthcare organization (such as payer) reaches out to another
healthcare organization (such as a provider) through mail, email, phone, fax, in person visits
etc. to gather detailed healthcare information on one or more individuals or through new
processes driven by care management or charter to engage the patient outside their visit.
4
Highly-skilled and high cost professionals, specially nurses, end up spending large amount
of time in interpreting the requirements of this data collection and facilitating it. This time
can be used more efficiently if physicians are able to focus on treating patients and the
identification of the data needed to close the gaps is done within the normal data exchange
processes, such as claims coding and processing, that already exist in 5 traditional healthcare
systems. Another drawback of the contemporary method is the long-time gap, usually in the
timeframe of weeks or months, between identification and closure of gaps. Another
drawback of the contemporary method is the high cost of reactive gap identification and gap
closure through contemporary processes including but not limited to medical record
10 retrieval (MRR), chart chases, chart abstraction, population health dashboards etc.
In order to address the problems discussed above, the present invention aims to provide a
new process which identifies the opportunity to deliver care at the time of patient visit.
Opportunity refers to the deviation in delivering care to a patient. Further, the opportunity
15 includes a gap in clinical quality, assessment and/or stratification, diagnosis, care, screening,
tests, treatments, assessment, documentation, waste avoidance, data accuracy, compliance
etc. The present invention comprises of multiples data sets for gathering information of the
patient. Thus, the present invention enables healthcare provider to indicate which
opportunity was addressed in the course of providing care and include the addressed
20 opportunity with the claim and clinical documentation created by a coder and charter to
ensure the accurate tracking of action in the existing process rather than creating a separate
follow-up to ensure that the opportunities are properly addressed. For addressing
opportunity of care that require follow-up after the coding process, the invention will drive
workflow appropriately to either the physician or any other stakeholder, a follow-up
25 appointment or tracking additional care is completed in appropriate amounts of time. This
process increases quality of healthcare delivery while controlling the cost involved in it.
SUMMARY AND OBJECTS OF THE INVENTION
30 A primary object of the present invention is to improve overall healthcare network
performance and improve the quality of healthcare services and ensure that adequate care is
delivered by creating a closed loop system for tracking and documenting care completion
throughout their lifecycle.
5
Another object of the present invention is to include multiple data sets for tracking updated
records of beneficiary (i.e. a patient) with more metric(s).
Another object of the present invention is to efficiently provide opportunity 5 for delivering
care to the beneficiary.
Another object of the present invention is to provide more key performance indicators (KPI)
with pre-built rules as well as flexibility to create and/or modify the rules based on the
10 measured performance of the service provider.
Another object of the present invention is to reduce time and costs of monitoring and
improve quality of healthcare services.
15 Another object of the present invention is to build scalable processes of monitoring and
improving quality of healthcare for large populations of patients.
Another object of the present invention is to provide an improved process to identify the
opportunity to deliver care at the time of visit, enable simple documentation by the provider
20 of addressing the opportunity and compare the delivered opportunity with the
documentation (claims and clinical documentation) needed to ensure the accurate tracking
within the existing process rather than creating a separate follow-up so organizations can
ensure opportunities are properly addressed. The new process will create and/or capture
additional data which can be used by stakeholders, involved in delivering care, to document
25 the addressing of opportunity. This is often clinical documentation that is not included in a
claim to ensure successfully providing the opportunity of care to the beneficiary.
Another object of the present invention is to provide an improved process which allows for
improved quality of healthcare reducing time and costs by presenting accurate and right
30 amount of information to care giver, such as physicians, during a patient visit so that they
can identify opportunities that they have closed in the visit and then ensure the proper
documentation is created in the coding and charting after the visit or encounter.
6
A further object of the present invention is to provide an improved process that takes
administrative burden off highly-skilled, high cost professionals such as physicians and,
thus allow them to focus on their core responsibility of treating patients.
Another objective of the present invention is to track the addressing of opportunity(5 s) after
the visit for follow-ups that should occur and ensure their completion in a timely manner.
Enabling notification of correct stakeholders if the correct actions have not been taken.
Yet another object of the present invention is to provide an improved process which allows
10 interpretation and automated flow of healthcare information in the normal exchange of
records between various stakeholders such as health plans, care givers, physicians, lab
services etc improving the quality of healthcare services.
Accordingly, a first aspect of the invention relates to a new process which helps in
15 identifying the opportunity in care and communicating them to healthcare service providers
so that they can take appropriate action such as delivering a certain type of care or ordering
a new test. Then charter documents delivered care as per charting guidelines. Then the
coders will enable the coding process to compare the coded data with the data to be coded
provided by the healthcare service provider or charter, and accordingly document codes
20 based on the action taken by the healthcare service provider or charter to ensure that the
accurate tracking of action in the existing process is correct and the process will create or
capture additional data to communicate the appropriate information to indicate opportunity
have been addressed rather than creating a separate retrospective follow-up so organizations
can ensure opportunities are properly addressed and to successfully provide the opportunity
25 of care to the beneficiary.
The process of the invention allows for improving quality of delivered healthcare services,
reducing both time and cost of identifying opportunity of care information in the most
simplistic way possible at the time of visit itself (e.g. during patient visit to physician) and
30 to the coder, to ensure that all the care provided is documented in the claim and additional
supplemental data sent to stakeholders. The process also enables coders and administrators
to test and validate the opportunity that have been addressed by physicians during a visit
and are closed in documentation – claims and appropriate attachments are updated
7
accordingly. For opportunity that have not been addressed, workflow to track appropriate
work enables transparency and appropriate follow-ups. The process further enables
improved quality of healthcare services by freeing up bandwidth of highly skilled and highcost
professionals such as physicians and transferring the administrative burden to other
relatively lower cost team members such as medical coders, medical assistants, 5 etc. The
improved process also automates transfer of healthcare information between various
stakeholder healthcare organizations such as health plans and providers, thereby providing
improved scalable processes of monitoring and improving quality of healthcare for large
populations of patients.
10
The process is implemented by or on a computer, server, workstation, system, or other
device. A memory stores information. A processor, executing instructions, performs the
acts, such as mining, causing storage, converting, evaluating, identifying, and outputting.
Other devices may be used with or by the processor, such as a user input and display being
15 used for editing and/or other activity.
Accordingly, a method for collaboration between various stakeholders in healthcare
industry to correctly identify and compute key performance indicators (KPIs), and
communicating any opportunity, which increases performance on said KPIs, to all
20 stakeholders, and ensuring identification, codification and completion of required services
addressing said opportunity, the method comprising the steps of: identifying beneficiary
data or information from various sources across healthcare network; defining KPIs for
setting the rules to process the incorporated data or information of the beneficiary for
identification of an opportunity; computing the performance based on said KPIs (137)
25 against the data collected on the beneficiary; examining and identifying whether there exists
any opportunity for improvement in delivering healthcare services to beneficiary; reviewing
the identified opportunity and enabling appropriate stakeholder to engage with the
beneficiary in the appropriate way to addressed the opportunity; reviewing the identified
opportunity and enabling appropriate stakeholders to engage with the beneficiary in the
30 appropriate way to close the gap; for beneficiaries that require care, notifying them through
direct outreach or through electronic notification so that the beneficiary can schedule their
own appointment; reviewing the identified opportunity(s) when the beneficiary comes for
care during an encounter/visit of the beneficiary and capturing that the opportunity has been
8
addressed, further care is needed, the care has already been provided or there is an exclusion
or exception that means the care is not needed for the said beneficiary; charting said captured
information in a proper manner to address the identified opportunity as per the defined KPI
to provide the care to the beneficiary; coding the charted information in a proper manner to
ensure that said opportunities as per the defined KPIs are addressed properly; 5 re-evaluating
the captured information to determine whether the data created in the coding and charting
completed the intent of the KPIs or a follow up visit/encounter is needed with beneficiary;
ascertaining the care provided and marking the KPIs and opportunities as addressed; and
updating the information of the beneficiary to the analytic system and payer system.
10
The step of ascertaining the addressing an opportunity of care includes creating additional
records to submit where a claim does not support the ability to capture data needed to
delivering opportunity as a modification to existing claim format, or adding an additional
data exchange format hardcopy or electronic-copy to existing claim format, or replacing the
15 existing claim format by some other data exchange format hardcopy or electronic-copy.
Another aspect of the invention relates to a system for addressing an opportunity in
healthcare services. The system for collaboration between various stakeholders in healthcare
industry, such as but not limited to providers, payers and ancillary service providers, and
20 beneficiaries to enable low cost identification and addressing an opportunity in quality of
healthcare services delivered to a beneficiary i.e. patient includes a network of computers,
storage, graphical user interface and servers and one or more of backend information
systems, modules etc. One or more of these systems may be non-local and may be accessed
over a wide-area network (WAN) and/or the internet.
25
The aspects of the present disclosure may be embodied as a system, method, or computer
program product. Accordingly, aspects of the present disclosure may take the form of an
entirely hardware embodiment, an entirely software embodiment (including firmware,
resident software, micro-code, etc.), or an embodiment combining software and hardware
30 aspects that may generally be referred to herein as a module or system.
9
It is to be understood that the aspects of the present disclosure, as generally described herein,
can be arranged, substituted, combined, separated, and designed in a wide variety of
different configurations, all of which are explicitly contemplated herein.
Furthermore, aspects of the present disclosure may take the form of 5 a computer program
product embodied in one or more non-transitory computer readable medium(s) having
computer readable program code encoded thereon.
Any combination of one or more non-transitory computer readable medium(s) may be
10 utilized. The computer readable medium may be a computer readable signal medium or a
computer readable storage medium. A computer readable storage medium may be, for
example, but not limited to, an electronic, magnetic, optical, electromagnetic, infrared, or
semiconductor system, apparatus, or device, or any suitable combination of the foregoing.
In the context of this document, a computer readable storage medium may be any tangible
15 medium that can contain or store a program for use by or in connection with an instruction
execution system, apparatus or device.
Any one or more of the aspects described above may be used alone or in combination.
20 BRIEF DESCRIPTION OF THE ACCOMPANYING DRAWINGS:
The foregoing and other objects, features, and advantages of the invention will be apparent
from the following detailed description taken in conjunction with the accompanying
drawings, wherein:
25 Fig. 1 illustrates an exemplary process for providing opportunity of care in
healthcare system according to the present invention;
Fig. 2 illustrates by means of an exemplary process flow diagram the overall process
for addressing opportunity(s) of care in healthcare system according to the present
invention.
30
10
DETAILED DESCRIPTION OF THE INVENTION
Embodiments of the presently disclosed invention will now be described in detail with
reference to the drawings. The disclosed system and method automatically identify
opportunity(s) to provide services in care of individual patients, enables 5 providers to view
the identified opportunity of care and to take efficient action to address those opportunities.
As used in this specification, real-time refers to an action that occurs contemporaneously or
nearly contemporaneously (e.g., within several seconds of) with another event.
10
As used in this specification, a healthcare opportunity or opportunity or opportunities or
opportunities in quality of healthcare refer to deviations, in delivering care to a beneficiary
i.e. patients, from industry standard or commonly accepted guidelines of providing care and
can be identified through mechanisms including, but not limited to, processing of clinical
15 quality measures, financial metrics, operational metrics, risk assessment (example
Hierarchical Condition Coding) evidence based care guidelines, clinical decision support
rules etc. For example, a healthcare opportunity may refer to a gap in clinical quality,
diagnosis, care, screening, tests, treatments, assessment, documentation, waste avoidance,
data accuracy, compliance etc. It should be understood that the change of healthcare state
20 and the updated status may be based on changes in a patient’s health parameters but may
also be based on other parameters such as record keeping parameters in which gaps may
include incorrect coding or an incomplete chart in a patient’s health record or gaps in a
claims submission, or other parameters such as the timeframe and the underlying data being
considered to evaluate presence of gap. For example, the gaps in care may also include gaps
25 in risk adjusted conditions, gaps in screening and counselling and gaps in clinical quality
and preventive care, medications etc. The first set of rules that define gaps in care may
include identifying inconsistent information in the healthcare information of the patient as
a gap in care of the patient.
30 As used in this specification, a healthcare facility, healthcare industry, healthcare network
or healthcare service providing institutions includes physician’s offices, hospitals, clinics,
ambulatory surgical centres, emergency care departments, or other locations or
organizations for treating illness or injury. The patient may stay for a part of a day or for
11
one or more days at a healthcare facility for diagnosis and/or treatment herein referred to as
a visit or encounter. In some cases, the visit may be only minutes. The care of the patient
before, during, and after any visit/encounter at a healthcare facility or physician’s office is
managed. By identifying an opportunity in care, the treatment and/or diagnosis may be
improved, the processes at a healthcare facility or physician’s office 5 may be improved,
and/or quality of care may be determined.
As used in this specification, a payer or healthcare payer, generally refers to entities other
than the patient that finance or reimburse the cost of health services. In most cases, this term
10 refers to insurance carriers, other third-party payers, or health plan sponsors (employers or
unions) etc.
As used in this specification, a provider, service provider or healthcare provider is an
individual who provides preventive, curative, promotional or rehabilitative health
15 care services in a systematic way to people, families or communities. A provider may
operate within all branches of health care including medicine, surgery, dentistry, midwifery,
pharmacy, psychology, nursing or allied health professions etc.
Referring to Fig. 1, a process 100 is illustrated for addressing an opportunity in healthcare
20 services according to the present invention. The process 100 starts with identification of
beneficiary using or gathering data from various sources across healthcare system in step
102. For example, data may be obtained from payers, providers, laboratories, imaging,
hospital systems, claims data or the like. Beneficiary can also encounter/visit a service
provider because they fell sick or for a wellness visit and not because they were scheduled
25 for an encounter/visit because of the identified opportunity. Such beneficiary is also
examined for identifying the opportunity for services in medical care. The beneficiary with
opportunities are identified in step 104. Identified beneficiary having one or more addressed
opportunities are notified and an appointment with a service provider and a care team is
scheduled in step 106. Beneficiary encounter/visit can also happen for patients not identified
30 under step 104 for various other reasons such as patient proactively visiting provider due to
sickness, for a wellness visit, regular consultation etc. and the steps of this new process will
also apply to such beneficiary and for those beneficiaries who visiting first to the service
provider. At step 108 all types of the opportunities for given beneficiary is identified and a
12
check list of such identified opportunity is provided to the care team. The identified one or
more opportunities enable the care team at step 110 to collect data relating to such
opportunities or schedule ancillary services to addressing the opportunity. Care team
provides information on opportunity in beneficiary’s care and enables providers and medical
assistants to substantiate their findings and upload necessary supporting 5 documentation. The
care team also identifies risk adjustment related opportunity such as suspected conditions,
conditions that have been documented in the past, or screenings that are due to be performed.
When the patients arrive for an appointment at step 112, they are checked, and care provided
at point of care by provider and care team. Step 112 may include review of opportunities in
10 care, and the beneficiary has the option to voluntarily disclose any opportunities in care that
may have already been addressed or kept pending. At the end of the appointment at step
114, charting, coding and billing is done. In addition to the claims coding, the identified
additional data for addressing an opportunity is coded in step 116, in existing file formats,
or modified versions of existing file formats, or by introducing additional file formats, new
15 or existing, to currently used claims files, here onwards referred to as enriched claims data
or claim data or claim. The data or information being coded in the process is not limited to
existing file formats only but can be coded in new ones or modified file formats or
encompasses all other existing and/or new file formats which may be developed in due
course. The collected beneficiary data is revaluated at step 118 to assess if opportunity has
20 been addressed or not. If it is found that the opportunities relating to the beneficiary is not
addressed the entire step from 106 to 114 is repeated. The beneficiary is re-routed for
another appointment as in step 106 with the care team and all the identified opportunities
are attended to by the care team as in step 112 and the opportunities are provided. Once the
opportunity has been provided ascertained in step 118 and based thereon an enriched claim
25 data is submitted for evaluation at step 120 together with data or documents evidencing for
providing opportunities as shown in step 122. When a claim received contains diagnostic
code(s) and/or procedure code(s) and/or medications that indicate that an opportunity in care
is addressed, for the patient mentioned on the claim. The submitted claim data is evaluated
at step 124 and good claims are settled and erroneous claims shuttle back and forth between
30 the service provider of healthcare service (entity who incurred cost) and payer of these
healthcare costs.
13
Between different beneficiary found with opportunities in care, there is no ordering implied
on the steps to be performed. For example, it is not necessary to complete the check ins for
all beneficiaries with opportunities in care before executing the check out for any patient. It
is not intended in the illustration.
5
Referring now to Fig. 2, a method for collaboration between various stakeholders in a
healthcare industry to correctly identify and compute key performance indicators (KPIs),
and any opportunity, which increases performance on said KPIs communicated to all
stakeholders ensuring identification, codification and completion of required services
10 addressing said opportunity the entire method is processed by three different systems. The
first system is an analytics system which comprises a central database server that hosts all
the data, including but not limited to clinical, claims, risk and others, about the patient. It
receives information from multiple sources, transforms, reconciles and stores the
information for processing. The central database server also hosts a Rules Management
15 Module (RMM) which is an intuitive interface which allows creation of KPIs easily. RMM
helps in improvement of turnaround time of creating new, customizing existing and
implementing KPIs such as clinical quality measures, hierarchal condition coding, cohorts
and other types of KPIs described earlier. Clinical quality measures (CQMs) are tools that
help measure and track the quality of health care services that eligible professionals (EPs),
20 eligible hospitals, and critical access hospitals (CAHs). CQMs could be defined by a
number of regulatory bodies including by not limited to NCQA, CMS, ONC, State Medicaid
programs and Official Registries, contractual measures which are defined as individual
contracts between payers and providers to drive quality improvement, operational measures
defined to create consistent care, Risk Adjustment Measures defined to categorize a patients
25 list of comorbidities, Clinical Decision Support measures defined to create alerts on the
process of care for patients and Cohorts which is used to define a group of patients who
have similar comorbidities, which may be monitored over a period of time. The analytics
system is powered by BI-Clinical Rules engine with uses rules defined in RMM and data
from database to produce compliance statues.
30
The next system is service provider system, these are mainly electronic health records
(EHR) or electronic medical records (EMR) with or without traditional Network
14
Performance Improvement Workflow. This system empowers provider practices during
patient encounters.
The last system is payer system which usually receives the claims data from various system
which includes service provider systems or data analytics 5 system or the like.
The process for identifying and providing opportunity of care in healthcare system will
begin when a beneficiary will encounter/visit the healthcare service provider who is
registered with the analytics system. The analytics system compiles set of data which
10 comprises claims data, patient clinical data, public health data and electronic health record
(EHR) or scheduling data of the patient. When the beneficiary encounter/visits the
healthcare service provider, the service provider checks the history of the beneficiary from
the analytics system by using the client device. The client device may include one or more
processing devices, and may be, or include, a mobile telephone (e.g., a smartphone), a laptop
15 computer, a handheld computer, a tablet computer, a network appliance, or a combination
of any two or more of these data processing devices or other data processing devices.
Alternatively, a mobile device associated with the beneficiary may detect, e.g., using a
global positioning system (GPS) sensor, a Wi-Fi sensor, or a beacon detector, that its
location matches a location that is associated with the location of the doctor, thereby
20 triggering the beneficiary encounter/visit notification.
The client device can communicate with the service provider which may include for
example a cloud-based system, anything as a service (XaaS) system, a standard server, a
group of such servers, or a rack server system, and may be accessed via any network such
25 as the wired or wireless local area network (LAN), wide area network (WAN).
Those beneficiaries who have are not explicitly scheduled to visit can also visit a service
provider because they fell sick or for a wellness visit. Such beneficiary is also examined
based on the information provider by the electronic health records EHR / electronic medical
30 records EMR or public health data for identifying the opportunities and to take action to
provide the identified opportunities at beneficiary visits.
15
Referring to Fig. 2 an exemplary process flow diagram for collaboration between various
stakeholders in a healthcare industry to correctly identify and compute key performance
indicators (KPIs), and any opportunity, which increases performance on said KPIs
communicated to all stakeholders ensuring identification, codification and completion of
required services addressing said opportunity according to the present 5 invention, the
healthcare provider system may access the population information system 131 of the
analytic system to obtain the identified opportunity. The population information system 131
compile claims data, beneficiary clinical data, public health data and electronic health record
(EHR) or scheduling data of the beneficiary or the like. The population system 131 further
10 process the data to the key performance indicator (KPI) library. This KPI library define rules
or protocols for Clinical Quality Measures, Diagnosis, Cohorts, Protocols, Contractual
Measures, Financial Measures, Operational Measures, Risk Adjustment Measures or the
like to process the incorporated data or information of the beneficiary for identification of
an opportunity. These rules or set of protocol define the prescribed time in which the
15 opportunity has to be addressed to the beneficiary. Once the rules or standard set of protocols
are defined by the KPI library 132 the population information system processed the
incorporated data or information of the beneficiary. At step 137 the performance is
computed on said KPIs against the data collected of the beneficiary at step 131. At step 133
the data analytics system checks whether the beneficiary required further opportunity for
20 improvement in the provided services. If yes, then the identified opportunity 135 is shared
with the service provider system. If no opportunity exists on a KPI and then beneficiary is
compliant 134. Provider incentive may optionally be calculated as an additional step 136.
Now, the process moves to the provider system where an identified opportunity of the
25 beneficiary is shared with the provider system. The service provider system reviewing the
identified opportunity and enabling appropriate stakeholders to engage with the beneficiary
in the appropriate way to address the opportunity at step 201. Based on the identified
opportunity the service provider system decides how to examine this opportunity by
scheduling the appointment by the beneficiary at step 202 or if care will be provided without
30 scheduling appointments by further providing improvement in opportunities at step 203.
At step 204 beneficiary is notified about the need to address identified opportunity as per
the clinic’s protocol and in terms of scheduling, process, outcome etc. The clinical
16
module/system provides information in such a way that more opportunity and/or all the
opportunity relating to the identified beneficiary can be addressed in one scheduled
encounter/visit. Then the scheduler schedules the appointment of the beneficiary with the
provider for addressing an opportunity at step 205 wherein a service provider system uses
all the demographic and clinical data available to identify the opportunity 5 in care for
beneficiary. The identification is done by running the beneficiary that are scheduled against
all potential clinical quality measures and using that to identify any opportunity in care. The
notification of the schedule to the beneficiary is either through direct outreach or through
electronic notification so the beneficiary can schedule their own appointment. Accordingly,
10 a list of beneficiaries to be contacted is created. The identified opportunities which required
further improvement in care and the opportunities which identified by beneficiary
encounter/visit are forwarded to the provider at step 206 where the provider review and
examine the details of the opportunities which are encountered at step 206.
15 For the identified beneficiary, it is checked and assessed whether all the identified and
additional opportunities can be addressed in the scheduled visit of the beneficiary at step
206. The information available at step 206 relating to a beneficiary is further examined at
step 207 to provide easy view to healthcare provider into care guidelines for the said
beneficiary. Tracking the captured opportunity to be addressed against a workflow which
20 tracks orders or tests and informs appropriate stakeholders whether the additional
procedures, medications or tests performed or not performed in appropriate timeframes
(208) for addressing an opportunity. The service provider suggests at step 209, what the
next action required to address the encountered opportunity at step 207.
25 The service provider reviews all the available information relating to the beneficiary so that
they are enabled to mark the beneficiary record with the facts/updates, for example, address
opportunity of care during the visit, ordered a test or procedure or mark the opportunity as
not valid due to pre-existing conditions or exclusions and define next steps at step 208. The
ordered test can either be driven by a person (i.e. scheduling a beneficiary for a follow-up)
30 or for system tracking of progress on ordered procedures (for example, colonoscopy) or test
(i.e. labs). The care that has already been provided or there is an exclusion or exception that
means the care is not needed for the said beneficiary. The results of the ordered test that are
generated are evaluated to determine if they address an opportunity at step 210. If the results
17
do not address an opportunity directly, then the result will forward to the charter for
additional documentation at step 212. If the results do address an opportunity, then the
results will be determined if they were received in a prescribed time limit at step 211 and if
they were, the received results will be forward to the charter for documentation. If the results
are not received within time limit, then the results will forward to the 5 provider system 201
for finding the lack of opportunity for delivering the results.
Once all the available and additional data is captured it is ensured at step 212 that all care
provided by the provider is documented and recorded and the documentation/charting
10 relating to the opportunities has been done. Charter compare the already documented data
with the data to be documented for the service provider for addressing the opportunity as
per the defined KPIs. Then charter informed what provider has done and his next action to
do based on the documentation that is done for the beneficiary’s encounter/visit at step 212.
This is a two-way communication between a provider and a charter to ensure the
15 opportunities that have been identified as addressed are re-run with the new data that was
documented for the encounter/visit. If the opportunity remains, the system informs the
provider of potential missing data or values that will address an opportunity. The charting
can either be driven by a person (i.e. documenting data on paper) or by a system/software
(for example, computer system or laptop or Microsoft office).
20
The process then moves to the stage of coding wherein at step 213 the coder ensures that all
the care provided is coded. The coder compares the coded data with the data to be coded
provided by the service provider or charter. The coder provides information about the work
which has been done by the provider or charter etc. If the coder does not find out any
25 evidence of the action taken by the service provider or charter, then coder requests for
additional information from the service provider and charter and further suggests and
generate inbuilt codes for the next action to be taken to ensure the KPIs are accurately
addressed at step 213. There is also a two-way communication between the charter and the
coder to ensure that all the documentation provided by the charter has been coded by the
30 coder for proper addressing an opportunity. The coding can either be driven by a software
or a combination of software or hardware. At step 214 the coder trying to address an
opportunity based on the suggested code or other codes if the suggested codes being not
able to address an opportunity. Intermediate opportunity was addressed based on the action
18
taken by the coder at step 216. The intermediate opportunity that has been addressed is
forwarded to the data analytics system for updating the data of the beneficiary. Further, at
step 217 follow up or appointment of the beneficiary is required if the opportunities was not
addressed at step 215. Those opportunities which have been addressed at step 215 are further
updated in terms of claims or clinical 5 data at step 216.
The updated information of the beneficiary received from step 216 is forwarded to the
population information system 101 for updating the information (i.e. opportunity provided
to the beneficiary has been addressed/not required follow-up or not). The updated
10 information of the beneficiary received from step 216 is further forwarded to the clinical
data of the payer system at step 303 which comprises information of the beneficiary health
(i.e. GIC forms etc.) provided by the provider for billing. The updated information of the
beneficiary received from step 216 is further forwarded to the claim data of the payer
system.
15
Moving to the next step, it is made sure that all the completed claims or clinical data which
are obtained from step 216 should be submitted to payer for billing.
The system/modules of payers will receive enriched claims data (i.e. clinical and financial
20 data etc.) to the insurer for settlement and address opportunity at step 301. Submission of
claims is a standard process in requesting and receiving payment in healthcare. In addition,
clinical or supplemental data can be gathered to support the closure of opportunities. The
system gathers the appropriate clinical information relating to the beneficiary from the
received claims at step 303. The clinical data 303 and financial data 304 is forwarded to the
25 data analytics system for upgrading the information of the beneficiary. Where the
information does not exist in structured data, the system prompts the population information
system (or the appropriate stakeholder) to enter the value of the missing clinical data to be
captured and submits them to the insurer or appropriate stakeholders. The results generated
after processing the clinical and financial data is updated to the data analytics system. If,
30 however any new opportunity is identified in the claim or additional clinical data, the data
relating to such identified opportunity is shared across healthcare network (i.e. providers or
practice administrators) and the entire process discussed above is repeated to be address the
identified opportunities.
19
The steps of the process are performed in response to a trigger event or as part of the standard
workflow process of generating payment through the claims process, such as entry of
information for one or more beneficiary into an electronic medical record. The steps are
performed during a encounter/visit at a clinic, physician’s office, hospital 5 or other healthcare
facility or during the normal processing of a claim which often happens after the beneficiary
has completed the visit and left the physician’s office or facility. By performing the steps of
the process during an encounter/visitor within existing processes, the care of the beneficiary
is tuned based on the most recent data in order to identify an opportunity. The care of the
10 beneficiary is managed based on the current status of the beneficiary derived from
beneficiary specific data and determination of any opportunity in the care.
In one embodiment, the act of coding includes that the data or information used in the
process is translated to a unified coding. The mining from the different data sources with
15 many possible different formats existing or new allows storage of the data into a database
with a unified coding. A given format is used for the database. Clinical data extracted from
different sources and in respective different formats is stored in a unified coding. One format
is used for the data mined from many different formats. In one embodiment, the unified
coding is of medical entities or concepts, attributes of the entities, and values of the
20 attributes. Alternatively, other unified coding formats existing or new for the values may be
used.
Embodiments of the subject matter described in this specification can be implemented in a
computing system that includes a back-end component, e.g., as a data server, or that includes
25 a middleware component, e.g., an application server, or that includes a front-end component,
e.g., a client computer having a graphical user interface or a web browser through which a
user can interact with an implementation of the subject matter described in this specification,
or any combination of one or more such back-end, middleware, or front-end components.
The components of the system can be interconnected by any form or medium of digital data
30 communication, e.g., a communication network. Examples of communication networks
include a local area network (LAN) and a wide area network (WAN), an inter-network (e.g.,
the Internet), and peer-to-peer networks (e.g., ad hoc peer-to-peer networks).
20
A system of one or more computers can be configured to perform particular operations or
actions by virtue of having software, firmware, hardware, or a combination of them installed
on the system that in operation causes or cause the system to perform the actions. One or
more computer programs can be configured to perform particular operations or actions by
virtue of including instructions that, when executed by data processing apparatus, 5 cause the
apparatus to perform the actions.
The computing system can include clients and servers. A client and server are generally
remote from each other and typically interact through a communication network. The
10 relationship of client and server arises by virtue of computer programs running on the
respective computers and having a client-server relationship to each other. In some
embodiments, a server transmits data (e.g., an HTML page) to a client device (e.g., for
purposes of displaying data to and receiving user input from a user interacting with the client
device). Data generated at the client device (e.g., a result of the user interaction) can be
15 received from the client device at the server. The computing system can use one or more
client and server to process the data in the healthcare system.
Although, the present invention has been disclosed in the context of certain preferred
embodiments and examples, it will be understood by those skilled in the art that the present
20 invention extends beyond the specifically disclosed embodiments to other alternative
embodiments and/or uses of the invention and obvious modifications and equivalents
thereof. Thus, from the foregoing description, it will be apparent to one of ordinary skill in
the art that many changes and modifications can be made thereto without departing from
the spirit or scope of the invention. Practitioners of the art can derive several embodiments
25 and domains of applicability of the present invention.
For example, in other embodiments, the process encompasses setting up an electronic visit
or an e-visit for the beneficiary to communicate with the provider. An e-care summary sheet
generated for the e-visit lists the opportunity in care identified, that can be discussed
30 between the provider and the beneficiary to arrive at a remedial action plan. The obvious
benefit of the e-visit is that the beneficiary does not need to physically visit the provider.
The beneficiary can connect and communicate with the provider from his/her mobile device
or personal computer or thorough emails, using electronic methods for meeting on the
21
internet. In a modification of this embodiment, the e-visit may be substituted by a phone or
mobile call
Accordingly, it is not intended that the scope of the foregoing description be limited to the
exact description set forth above, but rather that such description 5 be construed as
encompassing such features that reside in the present invention, including all the features
and embodiments that would be treated as equivalents thereof by those skilled in the relevant
art.
10 It will also be understood that each block/circle of the diagram and/or flowchart illustrations,
and combinations of blocks/circle in the diagrams and/or flowchart illustrations, can be
implemented by special purpose hardware-based systems which perform the specified
functions or acts, or combinations of special hardware and software instructions.
15 Thus, it is intended that the scope of the present invention herein disclosed should not be
limited by the embodiments described above but should be determined only by a fair reading
of the appended claims. ,CLAIMS:WE CLAIM:
1. A method for collaboration between various stakeholders in a healthcare industry to
correctly identify and compute key performance indicators (KPIs), and any opportunity,
which increases performance on said KPIs communicated to all 5 stakeholders ensuring
identification, codification and completion of required services addressing said opportunity,
the method comprising the steps of:
identifying beneficiary’s data or information from various sources across a
healthcare network (131);
10 defining key performance indicator(s) (KPI) for setting the rules to process the
incorporated data or information of the beneficiary for identification of an opportunity
(132);
computing the performance based on said KPIs (137) against the data collected of
the beneficiary (131);
15 examining and identifying whether beneficiary requires any opportunity for
improvement in healthcare services (133);
reviewing the identified opportunity and enabling appropriate stakeholders to
engage with the beneficiary in the appropriate way to address the identified opportunity
(201) for beneficiaries that require care, notifying the patients to schedule them either
20 through direct outreach or through electronic notification so the beneficiary can schedule
their own appointment (204/205)
reviewing the identified opportunities when the beneficiary comes for care during
an encounter/visit of the beneficiary (206) and capturing that the opportunity has been cared
(209), further care is needed (208), the care has already been provided or there is an
25 exclusion or exception that means the care is not needed for the said beneficiary (No number
on chart);
charting said captured information in a proper manner to address the identified
opportunity as per the defined KPI to provide the care to the beneficiary (212);
coding the charted information in a proper manner to ensure that said opportunities
30 as per the defined KPIs are addressed properly (213 and 214);
re-evaluating the captured information to determine whether the data created in the
coding and charting completed the intent of the KPIs or a follow up visit/encounter is needed
with beneficiary (217);
23
ascertaining the care provided and marking the KPIs and opportunities as addressed
(215); and
updating the information of the beneficiary to the analytic system and payer system
(216).
5
2. The method as claimed in claim 1, wherein the opportunity relates to the deviation in
delivering care to the beneficiary wherein deviation includes a gap in clinical quality, risk
assessment and/or stratification, diagnosis, care, screening, tests, treatments, assessment,
documentation, waste avoidance, data accuracy and compliance thereof.
10
3. The method as claimed in claim 1, wherein the step of examining and identifying whether
beneficiary requires further opportunity for improvement in healthcare services (133)
comprising the steps of:
reviewing identified opportunity (135);
15 notifying an administrator of said beneficiary for scheduling appointments with a
service provider (201);
sending scheduled information to the beneficiary (204);
capturing data or information of the beneficiary (205); and
providing care to the beneficiary on scheduled visit/encounter (206).
20
4. The method as claimed in claim 1, wherein the step of reviewing the identified
opportunity during the encounter/visit of the beneficiary receiving care and capturing the
information of said beneficiary (206) comprising the steps of:
capturing and displaying the opportunity that have to be addressed to care giver
25 (207);
tracking the captured opportunity to be addressed against a workflow which tracks
orders or tests and informs appropriate stakeholders whether the additional procedures,
medications or tests performed or not performed in appropriate timeframes (208);
30 5. The method as claimed in claim 1, wherein steps of charting of said captured information
in a proper manner to address the identified opportunity as per the defined KPIs (212)
comprising the steps of:
comparing the data already documented with the data to be documented by the
service provider for addressing the opportunity as per the defined KPIs; and
24
suggesting and generating next action, for one or more stakeholders, to be taken by
the coder for adding data or the service provider for additional care for addressing the
identified opportunity.
6. The method as claimed in claim 1, wherein steps of coding of the 5 charted information in
a proper manner to ensure that said opportunities as per the defined KPIs are addressed
properly (213 and 214) comprising the steps of:
comparing coded data with the data to be coded provided by the service provider
and/or charter;
10 identifying opportunity based on the action taken by service provider and/or charter
etc;
requesting information from the service provider and charter for ensuring that KPIs
are accurately addressed;
suggesting and generating inbuilt codes for the next action to be taken to ensure the
15 KPIs are accurately addressed; and
addressing intermediate opportunity based on the action taken.
7. The method as claimed to claim 1, wherein the step of re-evaluating the captured
information to determine whether the data created in the coding and charting completed the
20 intent of the KPIs or a follow up visit/encounter is needed with beneficiary (217) comprising
the steps of:
capturing and confirming all the information of charting and coding are completed
to address the opportunity (214);
addressing and ascertaining the addressed opportunity which includes creating
25 additional records to submit where the enriched claims do not support the ability to capture
data needed to address the opportunity as a modification to existing enriched claims format,
or adding an additional data exchange format to existing enriched claims format, or
replacing the existing enriched claims format by some other data exchange (216); and
converting addressed opportunity into the enriched claims for compliance or billing
30 (216).
8. The method as claimed in claim 1, wherein the step of updating the information of the
beneficiary to the analytic system and payer system (216) comprising the steps of:
delivering enriched claims to the payers for billing (301);
25
leveraging the data from enriched claim to update data in analytics system (131)
calculating the KPI based on the enriched claim which contains the information
included from the addressed opportunity (137); and
checking compliance based on the particular KPI (134).
5
9. The method as claimed in claim 1, wherein the data and/or information of the beneficiary
is obtained, updated from and updated to various sources includes, beneficiary’s clinical
data, public health data, electronic health record and scheduling system, enriched claim,
payers, service providers, laboratories, imaging and hospital systems.
10
10. The method as claimed in claim 1, wherein the stakeholder in the healthcare industry
including but not limited to, hospitals, doctors, insurance companies, lab companies, nursing
homes, or any other entity involved in care of the beneficiary or the like.
15 11. A system for collaboration between various stakeholders in a healthcare industry to
correctly identify and compute key performance indicators (KPIs), and any opportunity,
which increases performance on the said KPIs communicated to all stakeholders ensuring
identification, codification and completion of required services addressing of said
opportunity, the system comprising:
20 one or more data analytics server;
one or more central database server;
one or more service provider server;
one or more mobile computing device;
one or more software, with or without a graphical user interface, to define KPIs;
25 one or more metrics engine for calculating KPIs;
one or more workflow engine for determining the right interaction between
stakeholders;
one or more graphical user interface to display information to and take input from
end users of the system;
30 one or more payer server associated with the healthcare network system;
one or more electronically storage medium for storing healthcare records; and
wherein said system configured to perform operations comprising:
identifying, information of the beneficiary from the central database server
(131);
26
compiling, data received from the database server by the data analytics server
(131);
defining, key performance indicator (KPI) for setting the rules to process the
incorporated data or information of the beneficiary for identification of an opportunity
5 (132);
computing the performance based on said KPIs (137);
examining and identifying at data analytics server, whether beneficiary
requires any opportunity for improvement in healthcare services (133);
reviewing by the service provider, the identified opportunity and enabling
10 appropriate stakeholders to engage with the beneficiary in the appropriate way to
address the identified opportunity (201) for beneficiaries that require care, notifying
the patients to schedule them either through direct outreach or through electronic
notification so the beneficiary can schedule their own appointment (204/205);
reviewing the identified opportunities when the beneficiary comes for care
15 during an encounter/visit of the beneficiary (206) and capturing the opportunity has
been cared (209), further care is needed (208), the care has already been provided or
there is an exclusion or exception that means the care is not needed for the said
beneficiary (No number on chart);
charting by the charter, said captured information in a proper manner to
20 address the identified opportunity as per the defined KPI to provide the care to the
beneficiary (212);
coding by the coder, the charted information in a proper manner to ensure
that said opportunities as per the defined KPI are addressed properly (213 and 214);
re-evaluating by the service provider server, the captured information to
25 determine whether the data created in the coding and charting completed the intent
of the KPIs or a follow up visit/encounter is needed with beneficiary (217);
ascertaining by the service provider server, the care provided and marking
the KPIs and opportunities as addressed (215); and
updating by the service provider server, information of the beneficiary to the
30 data analytic server and payer server (216).
12. The system as claimed in claim 11, wherein the analytics server examines (133),
whether beneficiary requires further opportunity for improvement in healthcare services and
configured to perform operations comprising
27
reviewing by the analytics system, identified opportunity (135);
notifying by provider system, to the administrator of said beneficiary for
scheduling appointments with a service provider (201);
sending by mobile computing device or email or SMS or notification being
updated on a portal, scheduled information to the 5 beneficiary (204);
capturing by the service provider server, data and information of the
beneficiary (205); and
providing by the service provider, care to the beneficiary on scheduled
visit/encounter (206).
10
13. The system as claimed in claim 11, wherein the service provider review, the identified
opportunity during the encounter/visit of the beneficiary receiving care and capturing the
information of said beneficiary (206) and configured to perform operations comprising
capturing the opportunity that have to be addressed (207); and
15 tracking the captured opportunity to be addressed against a workflow which tracks
orders or tests and informs appropriate stakeholders whether the additional procedures,
medications or tests performed or not performed in appropriate timeframes (208).
14. The system as claimed in claim 11, wherein the charter charting (212), said captured
20 information in a proper manner to address the identified opportunity as per the defined KPIs
(212) and configured to perform operations comprising
comparing the data already documented by the data provided by the service provider
for addressing the opportunity as per the defined KPIs; and
suggesting and generating by the service provider, next action to be taken by the
25 coder for adding data or the service provider for additional care for providing opportunity.
15. The system as claimed in claim 11, wherein the coder coding, the charted information
in a proper manner to ensure that said opportunities as per the defined in the KPIs (213 and
214) and configured to perform operations comprising comparing coded data with the data
30 which marked as addressed by the charter and / or provider;
identifying opportunity based on the action taken by service provider or charter etc;
requesting information from the service provider and charter for ensuring that KPIs
are accurately addressed;
28
suggesting and generating inbuilt codes for the next action taken to be taken to
ensure the KPIs are accurately addressed.; and
addressing intermediate opportunity based on the action taken.
16. The system as claimed to claim 11, wherein the service provider server 5 re-evaluate, the
captured information to determine whether the data created in the coding and charting
completed the intent of the KPIs (217) or if a follow up visit/encounter is needed with
beneficiary (217) and configured to perform operations comprising capturing and
confirming all the information of charting and coding are completed to address the
10 opportunity (214);
addressing and ascertaining the addressed opportunity includes creating additional
records to submit where the enriched claims does not support the ability to capture data
needed to address the opportunity as a modification to existing enriched claims format, or
adding an additional data exchange format to existing enriched claims format, or replacing
15 the existing enriched claims format by some other data exchange format (215); and
converting provided opportunity into the enriched claims for compliance or billing
(216).
17. The system as claimed in claim 11, wherein the service provider server update,
20 information of the beneficiary to the data analytic system and payer system (216) and
configured to perform operations comprising
delivering enriched claims to the payers for billing (301);
leveraging the data from enriched claim to update data in analytics system (131)
calculating the KPI based on the enriched claim which contains the information
25 included from the addressed opportunity (137); and
filing compliance based on the particular KPI (134).
Dated this 13th day of November, 2017.
30
VAIBHAV VUTTS
of VUTTS & ASSOCIATES LLP
AGENT FOR THE APPLICANTS
IN/PA No. 1215