System for gap in care alerts

• US 10,262,756 B2
• Filed: 11/21/2013
• Issued: 04/16/2019
• Est. Priority Date: 11/21/2012
• Status: Active Grant

• Current Assignee: Humana Incorporated
• Original Assignee: Humana Incorporated
• Inventors: Ghouri, Ahmed, Sugavanam, Raghu
• Primary Examiner(s): Long, Fonya M
• Assistant Examiner(s): Lultschik, William G
• Application Number:
  US14/086,652
• Publication Number:
  US 20160357910A1
• Time in Patent Office: 1,972 Days
• Field of Search: None
• CPC Class Codes: G16H 10/60 for patient-specific data, e.g. for electronic patient records

Abstract

The present invention is a gap in care alert system for alerting someone associated with a patient (including in one embodiment the patient himself) that a gap in heath care will soon occur or in another embodiment that a gap in care has occurred for the patient based on the occurrence of a triggering event and the absence of a follow-up event occurring. Health insurance claims data may be used in the process to determine gaps in care.

Claims

1. A system comprising:

a computer network for receiving health insurance claims data for a health insurance provider, wherein said health insurance claims data is generated after an insured patient receives medical treatment from a health care provider, said health insurance claims data being received by said health insurance provider from or on behalf of said health care provider for payment for said treatment that was provided to said insured patient;

a database comprising predetermined medical treatment protocols for a plurality of medical conditions, wherein said medical treatment protocols include time periods for medical treatment follow-up for particular medical conditions, wherein said time periods are determined using performance measure rules selected from the group consisting of;

HEDIS and STAR;

at least one computer processor in association with said computer network for analyzing said received health insurance claims data to identify a triggering event for an insured patient, wherein said triggering event is a date when a healthcare provider performs a medical procedure on said insured patient;

said at least one computer processor in electronic communication with said database and an electronic storage device comprising software instructions, which when executed cause said at least one computer processor to obtain an expected date for a follow-up event for said insured patient in response to the identification of the triggering event, wherein said expected date for a follow-up event is determined by associating said triggering event with a selected treatment protocol from said medical treatment protocols, retrieving the associated time period for medical treatment follow-up for the selected treatment protocol and associated medical condition, adding the associated time period and a grace period to the triggering event, and automatically generating a gap in care alert if subsequently gathered health insurance claims data does not indicate that medical treatment follow-up has occurred for said patient by said expected date;

said at least one computer processor configured to automatically deliver said alert electronically to a receiver; and

said electronic storage device comprises additional software instructions, which when executed by said at least one computer processor cause said at least one computer processor to receive health care provider recommendations for follow up events, compare the health care provider recommendations against the selected treatment protocol, and generate a message to the health care provider if the received health care provider recommendations do not match the selected treatment protocol, wherein the generated message comprises a prompt to revise the health care provider recommendations to be consistent with the selected treatment protocol.

2. The system of claim 1, wherein:

said receiver is in electronic communication with an electronic medical record system having an electronic medical record stored therein for said insured patient.

3. The system of claim 1, wherein:

said receiver is in electronic communication with said insured patient'"'"'s personal mobile communications device and said alert is sent in the form of a text message to said mobile communications device.

4. The system of claim 1, wherein:

said electronic storage device comprises additional software instructions, which when executed, cause said at least one computer processor to determine an early warning date by subtracting a predetermined number of days from the expected date for a follow-up event for said insured patient, and automatically generate an approaching gap in care alert if subsequently gathered health insurance claims data does not indicate that medical follow-up has occurred for said patient by said early warning date.