Computerized system and methods for generating and processing integrated transactions for healthcare services

• US 20060259324A1
• Filed: 01/06/2006
• Published: 11/16/2006
• Est. Priority Date: 01/06/2005
• Status: Active Grant

• Current Assignee: Cerner Innovation, Inc. (Oracle Corporation)
• Original Assignee: Cerner Innovation, Inc. (Oracle Corporation)
• Inventors: Patterson, Neal L.
• Granted Patent: US 7,870,009 B2
• Time in Patent Office: Days
• US Class Current: 705/2
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 40/02 Banking, e.g. interest calculation or account maintenance credit or loans G06Q40/03
• CPC Class Codes: G06Q 40/08 Insurance
• CPC Class Codes: G16H 10/20 for electronic clinical trials or questionnaires

Abstract

A method for adjudicating and reimbursing a care provider for services provided for a clinical event is provided. The method includes the step of receiving a transaction having a number of clinical data elements. The method also includes the steps of accessing a data store including payer information and determining whether the transaction is eligible for reimbursement by at least one payer. The method also includes the steps of accessing a first knowledge base comprising evidence-based standards for providing medically appropriate care and selectively performing analysis of the clinical data elements of the transaction against at least one standard to determine if the care provided is medically appropriate. The method further includes the steps of accessing a second knowledge base containing at least one criterion for assessing quality of care and selectively performing analysis of the clinical data elements of the transaction against the at least one criterion to determine if the care provided is medically appropriate. Also, the method includes determining a level of reimbursement based on the medical appropriateness and quality of the care provided and authorizing reimbursement of the care provider from at least one payer.

Claims

1. A method in a computing environment for adjudicating and reimbursing a care provider for services provided for a clinical event, comprising:

receiving a transaction including a number of clinical data elements for the clinical event;

accessing a data store including payer information;

determining whether the transaction is eligible for reimbursement by at least one payer;

accessing a first knowledge base comprising evidence-based options for providing medically appropriate care;

selectively performing analysis of the clinical data elements of the transaction against at least one option from the first knowledge base to determine if the care provided is medically appropriate;

accessing a second knowledge base comprising at least one criterion for assessing quality of care;

selectively performing analysis of the clinical data elements of the transaction against the at least one criterion to determine the quality of care; and

determining a level of reimbursement based on the medical appropriateness and quality of the care provided and authorizing reimbursement of the care provider from at least one payer.

2. The method according to claim 1, further comprising reimbursing the care provider in real-time.

3. The method according to claim 1, wherein the clinical data elements are documented as part of the provision of care.

4. The method according to claim 3, wherein the clinical data elements include clinical event details associated with the clinical event and data elements stored within a community electronic health record.

5. The method according to claim 1, further comprising storing the integrated transaction in a data store containing a number of transactions.

6. The method according to claim 5, further comprising providing consumer access to the stored transactions.

7. The method according to claim 1, further comprising receiving a number of integrated transactions from a number of care providers.

8. The method according to claim 1, further comprising receiving payer information from a number of payers.

9. An integrated transaction, the transaction being generated according to a method of:

in a computing environment, receiving a number clinical data elements from a care provider describing healthcare services provided;

determining eligibility for reimbursement based on the clinical data elements;

selectively performing a comparative analysis of the clinical data elements against a first knowledge base to determine medical appropriateness;

selectively performing a comparative analysis of the clinical data elements against a second knowledge base to determine quality of care; and

if eligible, determining a level of reimbursement based on the medical appropriateness and quality of care.

10. An integrated transaction according to claim 9, wherein the step of receiving clinical data elements further comprises receiving administrative and financial data elements.

11. A system for adjudicating and reimbursing a care provider for healthcare services in a computing environment, comprising:

a first interface adapted to receive a number of transactions from a number of care providers, wherein each transaction includes clinical data elements captured during provision of the healthcare services;

an eligibility engine configured to analyze the transaction to determine if the transaction is eligible for reimbursement;

a first knowledge base comprising a set of clinical guidelines;

an appropriateness engine configured to selectively perform comparative analysis of the clinical data elements against the first knowledge base to determine medical appropriateness of the care provided;

a second knowledge base comprising a set of quality criteria; and

a quality engine configured to selectively perform comparative analysis of the clinical data elements against the second knowledge base to determine the quality of the care provided.

12. The system according to claim 11, further comprising a reimbursement module for determining a level of reimbursement for the transaction based on the medical appropriateness and quality of the care provided.

13. A method in a computing environment for providing a community electronic medical record, comprising:

receiving a number of transactions from a number of providers requesting reimbursement for healthcare services, each transaction including clinical data elements;

associating each transaction with a unique person identifier;

determining the level of reimbursement for each transaction and automatically initiating reimbursement to the provider submitting the reimbursement; and

storing the transactions and selectively providing access to the transactions to the healthcare providers.

14. The method according to claim 13, wherein one or more transactions are associated with a person to form an electronic medical record for the person.

15. The method according to claim 13, wherein the transactions are in a standard pre-defined format.

16. The method according to claim 15, wherein a portion of the clinical data elements of the transactions are organized in structured charts.

17. The method according to claim 13, wherein the step of determining the level of reimbursement comprises determining the eligibility of the transaction and analyzing the clinical data elements of the transaction to determine the medical appropriateness of the healthcare services provided.

18. The method according to claim 17, wherein the step of determining the level of reimbursement further comprises analyzing the clinical data elements of the transaction to determine the quality of the healthcare services provided.

19. The method according to claim 13, further comprising the step of selectively providing access to the transactions to a number of payers.

20. The method according to claim 13, further comprising the step of selectively providing access to the transactions to a number of consumers.