System and Method for a Patient-Specific and Clinician-Specific Pay-For-Performance Management System

• US 20080162190A1
• Filed: 12/14/2007
• Published: 07/03/2008
• Est. Priority Date: 12/14/2006
• Status: Abandoned Application

• Current Assignee: Humana Incorporated
• Original Assignee: SafeMed, Inc. (Humana Incorporated)
• Inventors: Ghouri, Ahmed
• Application Number:
  US11/957,387
• Publication Number:
  US 20080162190A1
• Time in Patent Office: Days
• US Class Current: 705/3
• CPC Class Codes: G06Q 10/06 Resources, workflows, human or project management; Enterprise or organisation planning; Enterprise or organisation modelling
• CPC Class Codes: G06Q 30/0217 involving input on products or services in exchange for incentives or rewards
• 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

Abstract

A pay for performance system and method are described in which doctors of a patient are compensated based on the work performed for the patient using incentives that are insurer-specific, patient-specific, and visit-specific.

Claims

1. A system for pay for performance for care of a patient by one or more physician who care for the patient, the system comprising:

a health record containing information about a patient, one or more physicians associated with the patient and a medical history of the patient;

a pay for performance gateway having a rules matrix with a plurality of guidelines wherein each guideline associates a care option for care of a patient with a pay for performance incentive and generator unit that generates a patient specific guideline list for the one or more physicians associated with a particular patient based on the medical history of the particular patient and rules matrix; and

one or more physician units, wherein each physician unit has a pay for performance unit that is configured to, display the patient specific guideline list for the particular patient and permit the physician to indicate that the care option contained in the patient specific guideline list has been performed wherein the physician is incentivized to provide the care option based on the pay for performance incentive.

2. The system of claim 1, wherein the pay for performance gateway further comprises a payment unit wherein the physician that performed the care option in the patient specific guideline list is credited with the pay for performance incentive associated with the performed care option in the rules matrix.

3. The system of claim 1, wherein the rules matrix further comprises a set of reason codes wherein each reason code states a reason why a particular care option was not provided to a patient and wherein a particular reason code for a particular care option associated with a particular patient is stored in the health record associated with the particular patient.

4. The system of claim 1, wherein each physician unit further comprises a personal computer, a Windows CE based device, a smartphone, a PDA, a Palm operating system based device, a cellular phone, a mobile phone, a tablet computer, a laptop computer or a dumb computer terminal.

5. The system of claim 4, wherein the pay for performance gateway further comprises one or more server computers.

6. The system of claim 1 further comprising an electronic datastore that stores the health records for one or more patients.

7. The system of claim 6, wherein the electronic datastore further comprises a database maintained by a database server.

8. The system of claim 6, wherein each health record further comprises information about a patient, information about the one or more physicians that care for the patient and a medical history of the patient including any diseases, medical conditions, and risk factors of the patient.

9. The system of claim 1 further comprising an electronic datastore that stores the rules matrix.

10. The system of claim 9, wherein each guideline in the rules matrix further comprises a rule for a particular care option that includes an eligibility standard for the particular care option and a detailed description of the particular care option.

11. The system of claim 1, wherein the pay for performance incentive is a cash reward.

12. The system of claim 1, wherein the health record further comprises a patient owned health record, a physician owned health record, an employer owned health record, or an insurer owned health record.

13. A method for pay for performance for care of a patient by one or more physician who care for the patient in a system that has an electronic health record containing information about a patient, one or more physicians associated with the patient and a medical history of the patient, the method comprising:

associating, in a rules matrix in a pay for performance gateway having a plurality of guidelines, each guideline for a care option for care of a patient with a pay for performance incentive;

generating a patient specific guideline list for the one or more physicians associated with a particular patient based on the medical history of the particular patient and rules matrix;

displaying the patient specific guideline list for a physician who is currently caring for the specific patient; and

crediting the physician with the pay for performance incentive associated with a particular guideline in the patient specific guideline list when the physician performs the care option specified by the particular guideline.

14. The method of claim 13, wherein the rules matrix further comprises a set of reason codes wherein each reason code states a reason why a particular care option was not provided to a patient and wherein a particular reason code for a particular care option associated with a particular patient is stored in the electronic health record associated with the particular patient.

15. The method of claim 13 further comprising storing the electronic health records in an electronic datastore.

16. The method of claim 15, wherein each health record further comprises information about a patient, information about the one or more physicians that care for the patient and a medical history of the patient including any diseases, medical conditions and risk factors of the patient.

17. The method of claim 16 further comprising storing the rules matrix in the electronic datastore.

18. The method of claim 17, wherein each guideline in the rules matrix further comprises a rule for a particular care option that includes an eligibility standard for the particular care option and a detailed description of the particular care option.

19. The method of claim 13, wherein crediting the physician further comprises providing a cash incentive to the physician.

20. The method of claim 13, wherein the health record further comprises a patient owned health record, a physician owned health record, an employer owned health record or an insurer owned health record.