System and method for clinical strategy for therapeutic pharmacies

• US 10,192,034 B2
• Filed: 07/01/2013
• Issued: 01/29/2019
• Est. Priority Date: 10/05/2005
• Status: Active Grant

• Current Assignee: Express Scripts Strategic Development, Inc. (The Cigna Group)
• Original Assignee: Express Scripts Strategic Development, Inc. (The Cigna Group)
• Inventors: Epstein, Robert S., Anand, Tej, Anderson, Roger W., Klepper, Kenneth, Proulx, Mark
• Primary Examiner(s): Nguyen, Hiep V
• Assistant Examiner(s): Nguyen, Trang
• Application Number:
  US13/932,689
• Publication Number:
  US 20130297349A1
• Time in Patent Office: 2,038 Days
• Field of Search: 705 2, 705 3
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G16H 10/60 for patient-specific data, e.g. for electronic patient records
• CPC Class Codes: G16H 20/10 relating to drugs or medications, e.g. for ensuring correct administration to patients
• CPC Class Codes: G16H 20/13 delivered from dispensers
• CPC Class Codes: G16H 40/63 for local operation
• CPC Class Codes: G16H 50/20 for computer-aided diagnosis, e.g. based on medical expert systems
• CPC Class Codes: G16H 50/30 for calculating health indices; for individual health risk assessment
• CPC Class Codes: G16H 50/70 for mining of medical data, e.g. analysing previous cases of other patients
• CPC Class Codes: G16H 70/60 relating to pathologies
• CPC Class Codes: G16Z 99/00 Subject matter not provided for in other main groups of this subclass

Abstract

A system and method of distributing pharmaceutical prescriptions within a network of pharmacies based on the review of prescription claim data and patient medical state to enable stratification of patients, wherein each pharmacy within the network has been established to handle one or more particular patient medical states.

Claims

1. A method for integrated management of stratification and clinical scoring of patients with a three tiered architecture to route a prescription for a tangible prescription drug to an appropriate pharmacy, comprising:

receiving, at a first processor of an analytic engine, a pharmaceutical prescription associated with a patient remote from a prescriber device and a pharmacy device;

converting the received pharmaceutical prescription to a warehouse server request using an intermediate server;

downloading, on a second processor remote from the pharmacy device using the warehouse server request, a first set of rules, a second set of rules, a medical record and a plurality of prescription claims for the patient, wherein downloading includes accessing a central fact table that links to a plurality of physical claim tables, the central fact table storing having a reduced data set related to plurality of prescription claims for the patient and reference pointers, the plurality of physical claim tables including a client subject table storing client reference data, a drug table storing drug reference data, a patient table storing patient reference data, and a provider table storing practitioner reference data, wherein the reference pointers point to the client subject table, the drug table, the patient table, and the provider table;

analyzing with the first set of rules, on the second processor remote from the pharmacy device, the medical record and the plurality of prescription claims accessed through the central fact table from at least the drug table and the patient table to stratify the patient into a disease category, wherein the first set of rules to have the central fact table to access at least one of the reference pointers point to the client subject table, the drug table, the patient table, the provider table or combinations thereof to display dynamically at least one of a plurality of service type selections and routing a prescription;

dynamically scoring, on the second processor using the second set of rules, a patient clinical score based on the plurality of prescription claims, the medical record, formulary information, and patient health insurance information from the drug table and the patient table, along with an indication of risk for the patient taking a medication associated with the pharmaceutical prescription;

storing the patient clinical score remote from the pharmacy device in a warehouse server;

routing, from a third processor using a third set of rules, the pharmaceutical prescription to a therapeutic pharmacy among a network of therapeutic pharmacies based on the disease category and the patient clinical score, each therapeutic pharmacy within the network of therapeutic pharmacies being established in accordance with a particular disease category for the therapeutic pharmacy that received the routed, pharmaceutical prescription to fill and dispense a drug for the pharmaceutical prescription, wherein routing includes;

dynamically monitoring a workload of each therapeutic pharmacy in the network of therapeutic pharmacies and each worker in the therapeutic pharmacy,

computing a utility score of the therapeutic pharmacy based on the dynamically monitored workload, wherein the utility score represents a current work load, time to complete a candidate schedule, and value of filling prescription at the therapeutic pharmacy, wherein the value of filling prescription represents a productivity rate to perform operations of filling pharmaceutical prescription under the current work load, and the candidate schedule, and

dynamically optimizing a prescription fulfillment using the utility score and the clinical score to assign the pharmaceutical prescription to the therapeutic pharmacy; and

filling and dispensing a tangible drug for the pharmaceutical prescription at the therapeutic pharmacy that received the routed, pharmaceutical prescription using a protocol for the particular disease category and a prescribed drug in which the therapeutic pharmacy has established the protocol.

2. The method according to claim 1, wherein the network of therapeutic pharmacies includes individual pharmacies for neurology, psychiatry, pulmonary, cardiovascular, diabetes, gastroenterology, oncology, hematology, rare diseases, and combinations thereof,

wherein the routing includes the third set of rules that are set at a graphical user interface connected to the warehouse server with the graphical user interface including a first sub-display and a second sub-display to configure the third set of rules in which if a parameter of the first sub-display, then a routing selection of the second sub-display;

and

wherein routing includes a fourth set of rules to implement bundling of multiple pharmaceutical prescriptions together to send more than one pharmaceutical prescription to a same therapeutic pharmacy in a same communication, load balancing of pharmaceutical prescription fulfillment based on monitored workload of the therapeutic pharmacy and each worker in the therapeutic pharmacy, matching tasks for pharmaceutical prescription fulfillment to workers with sufficient skill training and a load factor to complete task, matching efficiency to a worker at the therapeutic pharmacy, and matching worker preferences for preferred tasks associated with the pharmaceutical prescription.

3. The method of claim 1, wherein assigning the pharmaceutical prescription is based on skill and ability of a pharmacist and load balancing, the load balancing being based on current work load, schedule, and productivity rate of a plurality of pharmacists, and assigning includes:

generating a first graphical user interface capacities of the therapeutic pharmacies within the network of therapeutic pharmacies;

generating a second graphical user interface of a plurality of disease category competencies at the therapeutic pharmacy among a network of therapeutic pharmacies; and

producing a routing rule at the second graphical user interface to be part of the second set of rules.

4. The method of claim 1, wherein the pharmaceutical prescription is received at a pharmacy intake center and the plurality of prescription claims are accessed from an information warehouse.

5. The method of claim 1, wherein routing, using the third set of rules, the pharmaceutical prescription to the therapeutic pharmacy is based on the disease category, the patient clinical score, and load balancing, the load balancing being based on current work load, schedule, and productivity rate.

6. The method of claim 1, wherein the pharmaceutical prescription is received over a computer network.

7. The method of claim 1, wherein the therapeutic pharmacy is capable of filling the pharmaceutical prescription for the patient.

8. The method of claim 1, wherein the third processor is deployed with a computing device, the computing device configured to resolve protocol and perform drug utilization review for the subsequent filling and dispensing prescriptions for one or more diseases.

9. The method of claim 1, wherein the therapeutic pharmacy is further established to dispense a plurality of prescription drugs associated with the disease category, the pharmaceutical prescription being for a prescription drug among the plurality of prescription drugs.

10. The method of claim 1, wherein the patient clinical score reflects a relative level of compliance by the patient with the medication associated with the pharmaceutical prescription.

11. The method of claim 1, wherein the patient clinical score reflects a relative level of possibility for the patient to utilize a less costly medication than the medication associated with the pharmaceutical prescription.

12. The method of claim 1, wherein the medical record and the plurality of prescription claims are further analyzed using the first set of rules to stratify the patient into a wellness category, and wherein the routing of the pharmaceutical prescription is based on the disease category, the wellness category, and the patient clinical score.

13. The method of claim 12, wherein the wellness category is based on a disease state, the disease state being based on a medical category.

14. The method of claim 13, wherein the therapeutic pharmacy is capable of filling a prescription associated with the disease state.

15. The method of claim 1, further comprising:

analyzing at least some of the plurality of prescription claims of the patient to determine a number of unique drugs obtained by the patient;

analyzing at least some of the plurality of prescription claims of the patient to identify concurrent drug utilization review (CDUR) alert protocols that have a specific resolution code;

analyzing at least some of the plurality of prescription claims of the patient to identify listed therapy optimization and omission of therapy rules that have triggered an alert;

analyzing at least some of the plurality of prescription claims of the patient to determine whether the patient is late with prescription refilling; and

providing the indication of risk based on a determination of the number of unique drugs obtained by the patient, an identification of the CDUR alert protocols that have a specific resolution code, an identification of the listed therapy optimization and omission of therapy rules that have triggered an alert, and a determination that the patient is late with prescription refilling.

16. The method of claim 15, wherein at least some of the plurality of prescription claims are the plurality of prescription claims associated with a certain period of time.

17. The method of claim 1, further comprising:

generating and transmitting a message based on routing of the pharmaceutical prescription.

18. The method of claim 1, wherein analysis of the medical record and the plurality of prescription claims includes identifying a concurrent drug utilization review alert protocol that have a resolution code and generating a patient clinical score includes using the identified concurrent drug utilization review alert protocol to determine the patient clinical score.

19. The method of claim 18, wherein the pharmaceutical prescription is received at a pharmacy intake center and the plurality of prescription claims are accessed from an information warehouse,

wherein routing the pharmaceutical prescription to the therapeutic pharmacy is based on the disease category, the patient clinical score, and load balancing, the load balancing being based on current work load, schedule, and productivity rate,

wherein the pharmaceutical prescription is received over a computer network,

wherein the therapeutic pharmacy is capable of filling the pharmaceutical prescription for the patient, and

wherein the processor is deployed with a computing device, the computing device configured to resolve protocol and perform drug utilization review for the subsequent filling and dispensing prescriptions for one or more diseases.

20. The method of claim 1, wherein the second set of rules includes a pharmacist selection rule to assign the pharmaceutical prescription to a pharmacist among a plurality of pharmacists in the therapeutic pharmacy based on skill and ability of the pharmacist, wherein the pharmacist selection rule is set at a third graphical user interface that uses at least one of a client parameter, a drug parameter, the patient clinical score, an index parameter or combinations thereof to route the prescription to the pharmacist among the plurality of pharmacists in the therapeutic pharmacy;

and

wherein dynamically scoring the patient clinical score includes;

assigning a polypharmcy point score based on a patient'"'"'s paid pharmacy claims history over a recent time period to determine a number of unique drugs dispensed to the patient from any pharmacy;

assigning a home delivery concurrent drug utilization review score based on the patient'"'"'s paid pharmacy claims history over the recent time period;

assigning a retail concurrent drug utilization review score based on the patient'"'"'s paid pharmacy claims history over the recent time period;

assigning a retrospective delivery concurrent drug utilization review score based on the patient'"'"'s paid pharmacy claims history over the recent time period; and

assigning a late to fill score based on the patient history to determine a persistence lateness, a non-persistence and a discontinuance of persistency.

21. A non-transitory machine-readable medium comprising instructions, which when executed by one or more processors, cause the one or more processors to perform the following operations:

displaying a graphical user interface including a first sub-display and a second sub- display to configure a first set of rules and a second set of rules;

receive at an analytic engine a pharmaceutical prescription associated with a patient from a remote device;

access a medical record, the first set of rules, the second set of rules, and a plurality of prescription claims for the patient, wherein accessing includes accessing a central fact table that links to a plurality of physical claim tables, the central fact table storing having a reduced data set related to plurality of prescription claims for the patient and reference pointers, the plurality of physical claim tables including a client subject table storing client reference data, a drug table storing drug reference data, a patient table storing patient reference data, and a provider table storing practitioner reference data, wherein the reference pointers point to the client subject table, the drug table, the patient table, and the provider table;

analyze using the first set of rules the medical record and the plurality of prescription claims with prescription claim data from at least two of the plurality of physical claim tables to stratify the patient into a disease category by the one or more processor remote from the pharmacy;

score a patient clinical score using the second set of rules based on the plurality of prescription claims, the medical record, formulary information, patient health insurance information, and an indication of risk for the patient taking a medication associated with the pharmaceutical prescription;

store the patient clinical score remote from the remote device;

route the pharmaceutical prescription to a therapeutic pharmacy among a network of therapeutic pharmacies based on the disease category and the patient clinical score, each therapeutic pharmacy within the network of therapeutic pharmacies being established in accordance with a particular disease category for the therapeutic pharmacy that received the routed, pharmaceutical prescription to fill and dispense a drug for the pharmaceutical prescription, wherein the route operation includes;

dynamically monitoring a workload of each therapeutic pharmacy in the network of therapeutic pharmacies and each worker in the therapeutic pharmacy,

computing a utility score of the therapeutic pharmacy based on the dynamically monitored workload, wherein the utility score represents a current work load, time to complete a candidate schedule, and value of filling prescription at -a the therapeutic pharmacy wherein the value of filling prescription represents a productivity rate to perform operations of filling pharmaceutical prescription under the current work load, and the candidate schedule, and

dynamically optimizing a prescription fulfillment using the utility score and the clinical score to assign the pharmaceutical prescription to the therapeutic pharmacy; and

filling and dispensing a drug for the pharmaceutical prescription at the therapeutic pharmacy that received the routed, pharmaceutical prescription using a protocol for the particular disease category and a prescribed drug in which the therapeutic pharmacy has established the protocol.

22. The medium of claim 21, wherein analyzing the medical record and the plurality of prescription claims includes identifying a concurrent drug utilization review alert protocol that have a resolution code, and

wherein generating the patient clinical score includes using the identified concurrent drug utilization review alert protocol to determine the patient clinical score.

23. The medium of claim 22, further comprising instructions to:

analyze at least some of the plurality of prescription claims of the patient to determine a number of unique drugs obtained by the patient;

analyze at least some of the plurality of prescription claims of the patient to identify concurrent drug utilization review (CDUR) alert protocols that have a specific resolution code;

analyze at least some of the plurality of prescription claims of the patient to identify listed therapy optimization and omission of therapy rules that have triggered an alert;

analyze at least some of the plurality of prescription claims of the patient to determine whether the patient is late with prescription refilling; and

provide the indication of risk based on a determination of the number of unique drugs obtained by the patient, an identification of the CDUR alert protocols that have a specific resolution code, an identification of the listed therapy optimization and omission of therapy rules that have triggered an alert, and a determination that the patient is late with prescription refilling.

24. A method for distributing a tangible prescription drug, comprising:

receiving, at an analytic engine from a remote device, a pharmaceutical prescription for a tangible prescription drug associated with a patient;

accessing, on a processor of the analytic engine remote from a pharmacy device using the received pharmaceutical prescription, a first set of rules, a second set of rules, a medical record and a plurality of prescription claims for the patient, wherein the pharmacy device includes a central fact table that links to a plurality of physical claim tables, the central fact table storing having a reduced data set related to plurality of prescription claims for the patient and reference pointers, the plurality of physical claim tables including a client subject table storing client reference data, a drug table storing drug reference data, a patient table storing patient reference data, and a provider table storing practitioner reference data, wherein the reference pointers point to the client subject table, the drug table, the patient table, and the provider table;

analyzing, on the processor with the first set of rules, the medical record and the plurality of prescription claims to stratify the patient into a disease category, wherein analysis of the medical record and the plurality of prescription claims includes identifying a concurrent drug utilization review alert protocol that have a resolution code;

generating, on the processor using the second set of rules, a patient clinical score based on the identified concurrent drug utilization review alert protocol to determine the patient clinical score and the plurality of prescription claims, the medical record, formulary information, patient health insurance information, and an indication of risk for the patient taking a medication associated with the pharmaceutical prescription;

routing, on the processor using a third set of rules, the pharmaceutical prescription to a mail-order, therapeutic pharmacy among a network of therapeutic pharmacies based on the disease category and the patient clinical score, each mail-order therapeutic pharmacy within the network of therapeutic pharmacies being established in accordance with a particular disease category for the mail-order therapeutic pharmacy to dispense the tangible prescription drug, wherein the network of therapeutic pharmacies includes individual pharmacies for neurology, psychiatry, pulmonary, cardiovascular, diabetes, gastroenterology, oncology, hematology, rare diseases, and combinations thereof, wherein routing includes;

dynamically monitoring a workload of each therapeutic pharmacy in the network of therapeutic pharmacies and each worker in the therapeutic pharmacy,

computing a utility score of the therapeutic pharmacy based on the dynamically monitored workload, wherein the utility score represents a current work load, time to complete the candidate schedule and value of filling prescription at the therapeutic pharmacy, wherein the value of filling prescription represents a productivity rate to perform operations of filling pharmaceutical prescription under the current work load, and the candidate schedule, and

dynamically optimizing a prescription fulfillment using the utility score and the clinical score to assign the pharmaceutical prescription to the therapeutic pharmacy;

wherein dispensing the tangible prescription drug includes filling and dispensing the pharmaceutical prescription at the therapeutic pharmacy by picking and packing the tangible prescription drug; and

wherein the pharmaceutical prescription is received at a pharmacy intake center and the plurality of prescription claims are accessed from an information warehouse,

wherein routing the pharmaceutical prescription to the therapeutic pharmacy is based on the disease category, the patient clinical score, and load balancing, the load balancing being based on current work load, schedule, and productivity rate,

wherein the pharmaceutical prescription is received over a computer network,

wherein the mail-order therapeutic pharmacy is to formulate and fill the pharmaceutical prescription for the patient, and

wherein the processor is deployed with a computing device, the computing device configured to resolve protocol and perform drug utilization review for the subsequent filling and dispensing prescriptions for one or more diseases.