Automatic processing and management of referrals of specialty healthcare services

• US 20050209885A1
• Filed: 11/24/2004
• Published: 09/22/2005
• Est. Priority Date: 11/26/2003
• Status: Abandoned Application

• Current Assignee: IDX Systems Corporation (General Electric Company)
• Original Assignee: IDX Systems Corporation (General Electric Company)
• Inventors: Lamb, Michael, Keen, Ronald, Stavrinakis, Kimberly, Preiss, Erik
• Application Number:
  US10/997,435
• Publication Number:
  US 20050209885A1
• Time in Patent Office: Days
• US Class Current: 705/2
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 40/08 Insurance
• 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 80/00 ICT specially adapted for facilitating communication between medical practitioners or patients, e.g. for collaborative diagnosis, therapy or health monitoring

Abstract

According to various embodiments, methods and systems are provided for facilitating and managing communications between healthcare service referrers and healthcare service providers. Such communications are transacted via digital networks in connection with a healthcare information system. Referral of various diagnostic and therapeutic specialties is tracked from the initiation by the referrers to the completion of the services by the specialty service providers. Validation of insurance authorization is performed automatically if needed. Reports on the results of a requested specialty service as well as intermediate recommendations are made available to the referrer or other relevant entities upon completion of the service.

Claims

1. A digital medical referral management system for automatically monitoring a specialty referral order received from a referring provider system, the system comprising:

an order processing engine for processing the received order and storing the order in the referral order management system;

a data store engine for receiving subsequent modifications to the order; and

a notification module for notifying the referring provider system of the subsequent modifications to the order.

2. The system of claim 1, wherein the order includes an ordered procedure to be performed on a patient, and wherein the processing module is further adapted to validate the received order, schedule the ordered procedure, and update the stored order with the scheduled procedure.

3. The system of claim 2, wherein the data store engine is further adapted to store mappings between medical procedures and resources to be used to perform the procedures;

and wherein scheduling the ordered procedure further comprises identifying an available resource to be used to perform the ordered procedure.

4. The system of claim 1, wherein the order includes an ordered procedure to be performed on a patient and the data store engine stores an indication of whether a medical procedure requires preauthorization by an insurance carrier system, and wherein the system further comprises:

an eligibility and preauthorization module for using the indication to determine whether preauthorization is required for performing the procedure indicated in the order and requesting the preauthorization in response to the determination.

5. The system of claim 4, wherein the eligibility and preauthorization module is further adapted to determine whether the requesting step can be done electronically, and wherein the notification module is further adapted to notify the referring provider system in response to the determination that the requesting cannot be done electronically.

6. The system of claim 4, wherein the eligibility and preauthorization module is further adapted to receive from the insurance carrier system a preauthorization response and store the response in the data store in association with the order.

7. The system of claim 4, wherein the data store engine further maintains mappings between insurance carriers and medical procedures eligible by reimbursement by insurance carriers and wherein the eligibility and preauthorization module is further adapted to use the mappings to determine whether the procedure indicated in the order is eligible for reimbursement by an insurance carrier associated with a patient for whom the order is created.

8. The system of claim 7, wherein the notification module is further adapted to notify the referral provider system responsive to the determination that the procedure indicated in the order is not eligible for reimbursement by the insurance carrier.

9. The system of claim 1, wherein subsequent modifications to the order specify an order status update, and wherein the notification module is further adapted to notify the referring provider system of the order status update.

10. The system of claim 1, wherein subsequent modifications to the order specify an order results update, and wherein the notification module is further adapted to notify the referring provider system of the order results update.

11. The system of claim 1, wherein subsequent modifications to the order specify an update to order preauthorization information, and wherein the notification module is further adapted to notify the referring provider system of the update to the order preauthorization information.

12. The system of claim 1, wherein the notification module is further adapted to notify the referring provider office of the processed order.

13. The system of claim 1, wherein subsequent modifications to the order specify follow up recommendations to the order, and wherein the notification module is further adapted to notify the referring provider office of the follow up recommendations to the order.

14. The system of claim 1, wherein the referral order management system is in communication with a specialty department system adapted to provide subsequent modifications to the order to the referral order management system, and wherein the notification module is further adapted to notify the specialty department system of the processed order.

15. The system of claim 1, wherein subsequent modifications to the order specify at least one of an order status update, order result update, and an update to an order preauthorization information.

16. The system of claim 1, wherein the data store engine maintains subsequent modifications to the order in the form of events, each event is associated with an identification of the order having modifications that triggered the event, an event type, and a time stamp indicating when the event occurred;

and wherein the notification module is further adapted to query the data store for events having a time stamp greater than a time stamp of events of which a notification has been provided and use the identification of the order to notify the referring provider office of the events.

17. The system of claim 4, wherein the data store engine further maintains various data representations utilized by the insurance carrier system, and wherein the system further comprises a communication module adapted to map the preauthorization request to the representation utilized by the insurance carrier system and forward the request to the insurance carrier system.

18. A method performed by a medical referral management system for automatically monitoring an order received from a referring provider system, the method comprising:

processing the received order and storing the order in the referral management system;

receiving subsequent modifications to the order; and

notifying the referring provider system of the subsequent modifications to the order.

19. The method of claim 18, wherein subsequent modifications to the order specify at least one of an order status update, order result update, and an update to an order preauthorization information.

20. The method of claim 18, wherein subsequent modifications to the order specify that an order status has been updated, and wherein the method further comprises notifying the referring provider system that the order status has been updated.

21. The method of claim 18, wherein subsequent modifications to the order specify an order status update, and wherein the method further comprises notifying the referring provider system of the order status update.

22. The method of claim 18, wherein subsequent modifications to the order specify an order results update, and wherein the method further comprises notifying the referring provider system of the order result update.

23. The method of claim 18, wherein subsequent modifications to the order specify an update to order preauthorization information, and wherein the method further comprises notifying the referring provider system of the update to order preauthorization information.

24. The method of claim 18, wherein the order includes an ordered procedure to be performed on a patient, and wherein processing of the order further comprises:

validating the received order;

scheduling the ordered procedure; and

updating the stored order with the scheduled procedure.

25. The method of claim 18, further comprising:

storing subsequent modifications to the order in the form of events, an event is associated with an event type; and

providing the notifications of subsequent modifications to the order responsive to the type of the event.

26. The method of claim 18, further comprising:

storing subsequent modifications to the order in the form of events, an event is associated with an event type and a time stamp indicating when the event occurred; and

querying for the events having a time stamp greater than a time stamp of events of which a notification has been provided.

27. The method of claim 18, wherein processing of the order further includes scheduling a procedure indicated in the order, and wherein the method further comprises notifying the referring provider office that the procedure has been scheduled for the order.

28. The method of claim 18, wherein subsequent modifications of the order specify follow up recommendations to the order, and wherein the method further comprises notifying the referring provider office of the follow up recommendations to the order.

29. The method of claim 18, wherein the referral order management system is in communication with a specialty department system adapted to communicate subsequent modifications to the order to the referral order management system, and wherein the method further comprises notifying the specialty department system of the processed order.

30. The method of claim 18, wherein the referral order management system further comprises an eligibility and preauthorization module adapted to determine whether a procedure indicated in the order requires preauthorization, and wherein the method further comprises notifying the eligibility and preauthorization module of the processed order.

31. The method of claim 18, wherein the referral order management system is in communication with an insurance carrier system, and wherein the method further comprises:

sending an insurance preauthorization request to the insurance carrier system.

32. A computer program product comprising:

a computer-readable medium having computer program code embodied therein for automatically monitoring an order received by a referral management system from a referring provider system, the computer program code adapted to;

process the received order and store the order in the referral management system;

receive subsequent modifications to the order; and

notify the referring provider system of the subsequent modifications to the order.

33. The computer program code of 32, wherein subsequent modifications to the order specify at least one of an order status update, order result update, and an update to an order preauthorization information.

34. The computer program code of 32, wherein subsequent modifications to the order specify that an order status has been updated, and wherein the computer program code further adapted to notify the referring provider system that the order status has been updated.

35. The computer program code of 32, wherein subsequent modifications to the order specify an order status update, and wherein the computer program code is further adapted to notify the referring provider system of the order status update.

36. The computer program code of 32, wherein subsequent modifications to the order specify an order results update, and wherein the computer program code is further adapted to notify the referring provider system of the order result update.

37. The computer program code of 32, wherein subsequent modifications to the order specify an update to order preauthorization information, and wherein the computer program code is further adapted to notify the referring provider system of the update to order preauthorization information.

38. The computer program code of 32, wherein the order includes an ordered procedure to be performed on a patient, and wherein processing of the order further comprises:

validating the received order;

scheduling the ordered procedure; and

updating the stored order with the scheduled procedure.

39. The computer program code of 32, further comprising:

storing subsequent modifications to the order in the form of events, an event is associated with an event type; and

providing the notifications of subsequent modifications to the order responsive to the type of the event.

40. The computer program code of 32, further comprising:

storing subsequent modifications to the order in the form of events, an event is associated with an event type and a time stamp indicating when the event occurred; and

querying for the events having a time stamp greater than a time stamp of events of which a notification has been provided.

41. The computer program code of 32, wherein processing of the order further includes scheduling a procedure indicated in the order, and wherein the method further comprises notifying the referring provider office that the procedure has been scheduled for the order.

42. The computer program code 32, wherein subsequent modifications of the order specify follow up recommendations to the order, and wherein the computer program product is further adapted to notify the referring provider office of the follow up recommendations to the order.

43. The computer program 32, wherein the referral order management system is in communication with a specialty department system adapted to communicate subsequent modifications to the order to the referral order management system, and wherein the computer program code is further adapted to notify the specialty department system of the processed order.