Healthcare management system using patient profile data

• US 10,402,538 B2
• Filed: 03/23/2015
• Issued: 09/03/2019
• Est. Priority Date: 12/27/2004
• Status: Active Grant

• Current Assignee: Cognizant Trizetto Software Group Incorporated (Cognizant Technology Solutions Corp.)
• Original Assignee: Cognizant Trizetto Software Group Incorporated (Cognizant Technology Solutions Corp.)
• Inventors: Dean, Val C.
• Primary Examiner(s): Nguyen, Trang T
• Application Number:
  US14/664,979
• Publication Number:
  US 20150193582A1
• Time in Patent Office: Days
• CPC Class Codes: G06Q 40/08 Insurance
• CPC Class Codes: G16H 10/60 for patient-specific data, e.g. for electronic patient records
• CPC Class Codes: G16H 40/20 for the management or administration of healthcare resources or facilities, e.g. managing hospital staff or surgery rooms
• CPC Class Codes: G16H 40/63 for local operation

Abstract

The present disclosure is directed to a system and method which gathers information from all of a person'"'"'s healthcare providers and abstracts from that information the data necessary for a healthcare provider to render informed medical decisions. In one embodiment, information necessary to process proper payment to a provider (re: reimbursement to the insured patient) is used to develop a holistic view of the medical condition pertaining to the patient. Since this information comes from a myriad of providers, including physicians, surgeons, nursing care, druggists, testing labs, mental health counselors, dentists, oral surgeons, etc., the holistic view that is developed is comprehensive. In one embodiment, the system and method could set parameters on critical data such that if that data is outside the set parameters, alerts can be sent to the appropriate caregivers and/or patients.

Claims

1. A method for providing a medical alert using consolidated medical information for an individual from multiple sources aggregated continually at a common point, said method comprising:

receiving by adaptors of a reimbursement system multiple claims for reimbursement, wherein each of the multiple claims for reimbursement is from a different medical service provider and each of the multiple claims for reimbursement pertains to a medical service provided to the individual and further wherein, each of the multiple claims is in a different data exchange format and a different adaptor is provided for each of the different data exchange formats;

abstracting by the adaptors from each of the multiple received claims each of the following first portions of information if included in the received claim;

medical test results for the individual, prescription information for the individual, medical diagnosis information for the individual, wherein the abstracted first portions are converted from each of the different data exchange formats and provided by the adaptors to a rules engine;

processing the abstracted first portions of information by a rules engine against one or more overall rules for identifying health-related diagnoses stored therein to determine if the abstracted first portions of information support identify the individual as a patient with one or more health-related diagnose;

storing the first abstracted portions as consolidated medical information for the individual in a database of the reimbursement system in accordance with any identified one or more health-related diagnoses;

storing in the rules engine of the reimbursement system one or more specific rule sets provided by one or more of the different medical service providers, wherein each of the one or more specific rule sets is specific to the individual;

receiving by the adaptors of the reimbursement system at least one additional claim pertaining to the individual after storage of the consolidated medical information in the database and storage of the overall rules and one or more specific rules sets;

abstracting by the adaptors from the at least one additional claim each of the following second portions of information if included in the received at least one additional claim;

medical test results for the individual, prescription information for the individual, medical diagnosis information for the individual, symptoms being experienced by the individual, over-the-counter medication taken by the individual;

processing the abstracted second portions of information by the rules engine against the one or more overall rules for identifying health-related diagnoses stored therein to determine if the abstracted second portions of information support identify the individual as a patient with one or more additional health-related diagnoses; and

examining by the rules engine the abstracted second portions of information by applying the one or more specific rule sets thereto;

determining from the processing and examination that at least one of the overall rules and the one or more specific customer rules has been attained and that an alert is necessary;

generating by a monitor application of the reimbursement system an alert to one or more of the multiple providers and the individual, wherein the alert is related the individual'"'"'s one or more health-related diagnoses; and

receiving from the adaptors, each of the multiple claims for reimbursement at a payor, determining a reimbursement amount and sending determined reimbursement amounts to each of the different medical service providers.

2. The method according to claim 1, further comprising:

updating the consolidated medical information of the individual by storing the second abstracted portions in the database of the reimbursement system to include the individual'"'"'s one or more health-related diagnoses.

3. The method according to claim 1, wherein the at least one additional claim pertaining to the individual is received by the adaptors from the individual.

4. The method according to claim 1, wherein the at least one additional claim pertaining to the individual is received by the adaptors from one of the multiple service providers.

5. The method according to claim 1, wherein the at least one additional claim pertaining to the individual is received by the adaptors from a new service provider.

6. The method according to claim 1, further comprising receiving by the adaptors additional medical information for the individual from a credit card profile system.

7. A method for providing a medical alert using medical information for an individual from multiple sources aggregated continually at a common point, said method comprising:

storing in a rules engine of a reimbursement system overall rules for identifying health-related diagnoses;

receiving by adaptors of a reimbursement system multiple claims for reimbursement, wherein each of the multiple claims for reimbursement is from a different medical service provider and each of the multiple claims for reimbursement pertains to a medical service provided to the individual and further wherein, each of the multiple claims is in a different data exchange format and a different adaptor is provided for each of the different data exchange formats;

abstracting by the adaptors from each of the multiple received claims each of the following first portions of information if included in the received claim;

medical test results for the individual, prescription information for the individual, medical diagnosis information for the individual, wherein the abstracted first portions are converted from each of the different data exchange formats and provided by the adaptors to a rules engine;

processing the abstracted first portions of information to determine if the abstracted first portions of information support identify the individual as a patient with one or more health-related diagnoses;

determining from the processing that at least one of the overall rules has been attained and that an alert is necessary;

generating by a monitor application of the reimbursement system an alert to one or more of the multiple providers and the individual, wherein the alert is related the individual'"'"'s one or more health-related diagnoses; and

receiving from the adaptors, each of the multiple claims for reimbursement at a payor, determining a reimbursement amount and sending determined reimbursement amounts to each of the different medical service providers.

8. The method according to claim 7, further comprising storing the first abstracted portions as consolidated medical information for the individual in a database of the reimbursement system to include the individual'"'"'s one or more health-related diagnoses.

9. The method according to claim 8, further comprising;

receiving by the adaptors of the reimbursement system at least one additional claim pertaining to the individual after storage of the consolidated medical information in the database and storage of the overall rules in the rules engine;

abstracting by the adaptors from the at least one additional claim each of the following second portions of information if included in the received at least one additional claim;

medical test results for the individual, prescription information for the individual, medical diagnosis information for the individual, symptoms being experienced by the individual, over-the-counter medication taken by the individual, wherein the abstracted second portions are converted from each of the different data exchange formats and provided by the adaptors to a rules engine;

processing the abstracted second portions of information by the rules engine against the one or more overall rules for identifying health-related diagnoses stored therein to determine if the abstracted second portions of information support identifying the individual as a patient with one or more additional health-related diagnoses;

determining from the processing that at least one of the overall rules has been attained and that an alert is necessary;

generating by the monitor application an alert to one or more of the multiple providers and the individual, wherein the alert is related the individual'"'"'s one or more health-related diagnoses; and

updating the consolidated medical information of the individual by storing the second abstracted portions in the database of the reimbursement system to include the individual'"'"'s one or more health-related diagnoses.

10. The method according to claim 9, wherein the at least one additional claim pertaining to the individual is received by the adaptors from the individual.

11. The method according to claim 9, wherein the at least one additional claim pertaining to the individual is received by the adaptors from one of the multiple service providers.

12. The method according to claim 9, wherein the at least one additional claim pertaining to the individual is received by the adaptors from a new service provider.

13. The method according to claim 9, further comprising receiving by the adaptors additional medical information for the individual from a credit card profile system.

14. A method for providing a medical alert using consolidated medical information for an individual from multiple sources aggregated continually at a common point, said method comprising:

receiving by adaptors of a reimbursement system multiple claims for reimbursement, wherein each of the multiple claims for reimbursement is from a different medical service provider and each of the multiple claims for reimbursement pertains to a medical service provided to the individual and further wherein, each of the multiple claims is in a different data exchange format and a different adaptor is provided for each of the different data exchange formats;

abstracting by the adaptors from each of the multiple received claims each of the following first portions of information if included in the received claim;

medical test results for the individual, prescription information for the individual, medical diagnosis information for the individual, wherein the abstracted first portions are converted from each of the different data exchange formats and provided by the adaptors to a rules engine;

processing the abstracted first portions of information by a rules engine against one or more overall rules for identifying health-related diagnoses stored therein to determine if the abstracted first portions of information support identifying the individual as a patient with one or more health-related diagnoses;

storing the first abstracted portions as consolidated medical information for the individual in a database of the reimbursement system in accordance with any identified one or more health-related diagnoses;

storing in the rules engine of the reimbursement system one or more specific rule sets provided by one or more of the different medical service providers, wherein each of the one or more specific rule sets is specific to the individual and is related to the individual'"'"'s one or more health-related diagnoses;

receiving by the adaptors of the reimbursement system at least one additional claim pertaining to the individual after storage of the consolidated medical information in the database and storage of the one or more specific rules sets in the rules engine;

abstracting by the adaptors from the at least one additional claim each of the following second portions of information if included in the received at least one additional claim;

medical test results for the individual, prescription information for the individual, medical diagnosis information for the individual, symptoms being experienced by the individual, over-the-counter medication taken by the individual;

processing the abstracted second portions of information by the rules engine against the one or more overall rules for identifying health-related diagnoses stored therein to determine if the abstracted second portions of information support identifying the individual as a patient with one or more additional health-related diagnoses; and

examining by the rules engine the abstracted second portions of information by applying the one or more specific rule sets thereto;

determining from the processing and examination that at least one of the one or more specific rules has been attained and that an alert is necessary; and

generating by a monitor application of the reimbursement system an alert to one or more of the multiple providers and the individual, wherein the alert is related the individual'"'"'s one or more health-related diagnoses; and

receiving from the adaptors, each of the multiple claims for reimbursement at a payor, determining a reimbursement amount and sending determined reimbursement amounts to each of the different medical service providers.

15. The method according to claim 14, further comprising:

updating the consolidated medical information of the individual by storing the second abstracted portions in the database of the reimbursement system to include the individual'"'"'s one or more health-related diagnoses.

16. The method according to claim 14, wherein the at least one additional claim pertaining to the individual is received by the adaptors from the individual.

17. The method according to claim 14, wherein the at least one additional claim pertaining to the individual is received by the adaptors from one of the multiple service providers.

18. The method according to claim 14, wherein the at least one additional claim pertaining to the individual is received by the adaptors from a new service provider.

19. The method according to claim 14, further comprising receiving by the adaptors additional medical information for the individual from a credit card profile system, wherein the additional medical information is examined in accordance with the specific rule sets to determine if an alert is necessary.

20. The method according to claim 14, further comprising receiving by and saving in the database further health-related data for the individual from a different reimbursement system, wherein the further health-related data is examined in accordance with the specific rule sets to determine if an alert is necessary.