Pharmacy Episodes of Care

• US 20090198517A1
• Filed: 02/06/2008
• Published: 08/06/2009
• Est. Priority Date: 02/06/2008
• Status: Active Grant

• Current Assignee: Cognizant Trizetto Software Group Incorporated (Cognizant Technology Solutions Corp.)
• Original Assignee: Trizetto Group Incorporated (Cognizant Technology Solutions Corp.)
• Inventors: Lieberman, Richard, Ruben, Manon S.
• Granted Patent: US 8,099,306 B2
• Time in Patent Office: Days
• US Class Current: 705/3
• CPC Class Codes: G06Q 10/087 Inventory or stock management, e.g. order filling, procurement or balancing against orders
• CPC Class Codes: G16H 20/10 relating to drugs or medications, e.g. for ensuring correct administration to patients
• 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 computer-implemented method for grouping, categorizing, and profiling pharmaceutical claims data to assist health care managers in determining (a) medication treatment experience, outcomes, and medication compliance behaviors of patients and (b) appropriate drug prescribing, medication coordination, and cost-efficiency of health care providers. An objective means is provided for categorizing and quantifying patterns of prescription drug utilization as a health care service within a clinically relevant time frame. A pharmacy episode group (PEG) is a pharmacologically homogenous grouping of drugs with the same therapeutic ingredients used by a patient once or over an extended period of time. The PEG is a patient-centered pharmacy classification unit, which uses script-level pharmacy claim data as input data and assigns each script to the appropriate episode. Pharmacy episodes are categorized based on algorithms linking the pattern of a physician'"'"'s recommended use (drug supply) and the patient'"'"'s pattern of compliance (intervals between fill dates). The system also identifies multi-drug and concurrent use drug episodes, flags patients'"'"' records where intervals between scripts suggest non-compliance with recommended therapy, selects the most recent claims, resets windows (episode start and end dates), and ultimately assigns all pharmacy claims to episodes.

Claims

1. A computer-implemented method comprising:

receiving pharmaceutical claims data records;

validating each of the data records for a valid national drug code or a generic drug code and a valid patient unique identifying number;

establishing for each unique patient identified the number of pharmacy events, their temporal sequence and days of treatment supplied for each drug identified; and

storing in computer memory all pharmacy events and attendant data recorded for each unique patient identified.

2. The method of claim 1 wherein said receiving comprises:

reading said pharmaceutical claims data records into a computer memory.

3. The method of claim 1 further comprising:

applying at least one predefined algorithm comprising a listing of constraints that defines each eligible pharmacy episode categorization for all pharmaceutical drugs based upon thresholds for the relationships between the supply of the drug and intervals between scripts.

4. The method of claim 3 further comprising:

grouping the validated data records for each unique patient identified to one or more pharmacy episode categories based upon the at least one predefined algorithm;

evaluating each subsequent validated drug claim to any open pharmacy episodes by category for each patient, and

grouping the pharmacy claim record to the open pharmacy episode based upon the category constraints.

5. The method of claim 4 further comprising:

differentiating pharmacy episode category based upon a predefined algorithm and data establishing multi-drug status.

6. The method of claim 4 further comprising:

differentiating pharmacy episode category based upon a predefined algorithm and data establishing its concurrent use status.

7. The method of claim 4 further comprising:

distinguishing intervals of patient non-compliance within the pharmacy episode category based upon data which do not conform to predefined algorithms setting thresholds for the relationship between the supply of the drug and intervals between scripts.

8. A method comprising:

receiving pharmacy claim data;

determining from the received pharmacy claim data one or more corresponding pharmacy episodes; and

categorizing the one or more corresponding pharmacy episodes into one of a plurality of different categories, wherein the plurality of different categories comprise maintenance episode (ME), acute intervention episode (AI), and extended intervention episode (EI).

9. The method of claim 8 wherein an acute intervention episode is identified for a given patient having a newly identified prescription and no more than one refill at an interval less than two times the prescription'"'"'s days supply.

10. The method of claim 8 wherein a maintenance episode is identified for a given patient where an identical prescribed drug recurs three or more times and the intervals between successive fill dates are less than two times the days supply.

11. The method of claim 8 wherein an extended intervention is identified for a given patient where the received pharmacy claim data includes a newly prescribed drug and subsequent refill claim or claims where the interval between the original and subsequent refill fill date is three times or more than the days supply for the original prescription of the drug.

12. The method of claim 8 wherein said categorizing comprises:

sorting each episode into one of at least three different groups, wherein the at least three different groups comprise a first group for episodes containing a single pharmacy claim instance, a second group for episodes containing two pharmacy claim instances, and a third group for episodes containing three or more pharmacy claim instances.

13. The method of claim 12 wherein the single pharmacy claim instance sorted into the first group is classified as an acute intervention episode if it satisfies the criterion:

no more than one refill at an interval less than two times the first prescription'"'"'s days supply.

14. The method of claim 13 wherein the two pharmacy claim instances sorted into the second group are classified as follows:

if two claim instances each meet the criterion for classification as an acute episode and fall within six times the days supply added to the last fill for that drug combination, then those claim instances are classified as a single acute intervention episode;

if determined that one of the two claim instances falls within six times the days supply added to the last fill date for that drug combination and one claim instance is greater than six times the days supply added to the last fill for that drug combination, then the two claim instances are classified as two separate acute intervention episodes; and

if the interval between the original and subsequent refill “

fill date”

for the two claim instances is three times or more than the days supply for the original prescription, the two claim instances are classified as an extended intervention episode.

15. The method of claim 14 wherein the three or more pharmacy claim instances sorted into the third group are classified as follows:

if the intervals between successive fill dates of the three or more pharmacy claim instances are less than two times the days supply, all the three or more pharmacy claim instances are classified as one maintenance episode.

16. The method of claim 8 further comprising:

determining whether each episode is an open or closed episode.

17. The method of claim 16 wherein an episode is determined as open if a load date is equal to or less than six times the days supply added to the last fill date for that drug combination, and an episode is closed when the load date is greater than six times the days supply added to the last fill for that drug combination.

18. A method comprising:

receiving, into a pharmacy episode grouping (PEG) system, pharmacy claim data;

determining, by the PEG system, from the received pharmacy claim data one or more corresponding pharmacy episodes; and

categorizing, by the PEG system, the one or more corresponding pharmacy episodes into one of a plurality of different categories, wherein said categorizing comprises;

categorizing the one or more corresponding pharmacy episodes as an acute intervention (AI) episode when said pharmacy claim data for a given patient comprises a newly identified prescription and no more than one refill at an interval less than two times the prescription'"'"'s days supply,

categorizing the one or more corresponding pharmacy episodes as a maintenance episode (ME) when said pharmacy claim data for the given patient comprises an identical prescribed drug that recurs three or more times and the intervals between successive fill dates are less than two times the days supply, and

categorizing the one or more corresponding pharmacy episodes as an extended intervention (EI) episode when said pharmacy claim data for the given patient includes a newly prescribed drug and subsequent refill claim or claims where the interval between the original and subsequent refill fill date is three times or more than the days supply for the original prescription of the drug.

19. The method of claim 18 further comprising:

determining whether each episode is an open or closed episode, wherein an episode is determined as open if a load date is equal to or less than six times the days supply added to the last fill date for that drug combination, and an episode is closed when the load date is greater than six times the days supply added to the last fill for that drug combination.

20. A method comprising:

receiving, into a pharmacy episode grouping (PEG) system, pharmacy claim data;

determining, by the PEG system, from the received pharmacy claim data one or more corresponding pharmacy episodes; and

categorizing, by the PEG system, the one or more corresponding pharmacy episodes into one of a plurality of different categories, wherein said categorizing comprises;

a) sorting each episode into one of at least three different groups, wherein the at least three different groups comprise a first group for episodes containing a single pharmacy claim instance, a second group for episodes containing two pharmacy claim instances, and a third group for episodes containing three or more pharmacy claim instances;

b) categorizing the single pharmacy claim instance sorted into the first group as an acute intervention (AI) episode if it satisfies the criterion;

no more than one refill at an interval less than two times the first prescription'"'"'s days supply;

c) categorizing the two pharmacy claim instances sorted into the second group as follows;

if the two pharmacy claim instances each meet said criterion for classification as an AI episode and fall within six times the days supply added to the last fill for that drug combination, then categorizing the two pharmacy claim instances as a single AI episode,

if determined that one of the two claim instances falls within six times the days supply added to the last fill date for that drug combination and one claim instance is greater than six times the days supply added to the last fill for that drug combination, then categorizing the two pharmacy claim instances as two separate AI episodes, and

if an interval between the original and subsequent refill “

fill date”

for the two pharmacy claim instances is three times or more than the days supply for the original prescription, then categorizing the two pharmacy claim instances as an extended intervention (EI) episode; and

d) categorizing the three or more pharmacy claim instances sorted into the third group as follows;

if the intervals between successive fill dates of the three or more pharmacy claim instances are less than two times the days supply, then categorizing all the three or more pharmacy claim instances as one maintenance episode (ME).