Patient data quality review method and system

• US 5,307,262 A
• Filed: 01/29/1992
• Issued: 04/26/1994
• Est. Priority Date: 01/29/1992
• Status: Expired due to Fees

• Current Assignee: Applied Medical Data Incorporated
• Original Assignee: Applied Medical Data Incorporated
• Inventors: Ertel, Paul Y.
• Primary Examiner(s): NOT, DEFINED
• Assistant Examiner(s): Tran, Khai
• Application Number:
  US07/827,376
• Time in Patent Office: 818 Days
• Field of Search: 364/413.01, 364/413.02, 364/401, 364/408, 364/406
• US Class Current: 705/2
• CPC Class Codes: G16H 10/60 for patient-specific data, e.g. for electronic patient records
• CPC Class Codes: G16H 15/00 ICT specially adapted for medical reports, e.g. generation or transmission thereof
• 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 method and system is provided to review and control clinical data quality in the reporting of hospital claims data. The method and system perform data quality checks and generate turn-around documents that establish communications between coders and physicians in order to obtain the best description of a case for reporting purposes. The system provides file security and tracks cases through the entire review process to final reporting. Patient data and system performance data are aggregated into a common data base. From this integrated data base, a variety of summary reports are generated to identify systematic problems in data quality and to assess the success of the data correction process. The system interfaces with existing data systems to optimize the performance efficiency of a total health information system functioning within a hospital or within third-party claims review organizations including payers of hospital claims.

Claims

1. In an automated patient data review system including a system memory, a program of instructions stored in the system memory, a processor coupled to the system memory and a system output device coupled to the processor, a method for automatically detecting, analyzing and classifying patient data reported on a plurality of payment claims, the method comprising the steps of:

storing collections of patient data including patient identifiers and clinical data, misreporting tables and message tables in data files in the system memory;

storing classification data and case review tables in the data files in the system memory; and

automatically processing a plurality of patient cases, the step of processing the patient cases being performed by the processor in accordance with the program of instructions and including the steps of;

determining whether misreporting conditions exist in the stored clinical data, the misreporting conditions including actual or potential non-compliance with federally mandated coding and reporting rules and actual or potential failure to properly report complexities of the case;

generating at least one data quality message based upon the misreporting tables, the message tables and the determined misreporting conditions;

classifying the data quality messages generated for a case based upon the probability and relative seriousness or consequences of noncompliance with federal coding and reporting rules or the failure to report case complexities adequately;

displaying via the system output device the patient data including the patient identifiers and the clinical data;

displaying via the system output device at least one message based on the determined misreporting conditions in the patient data;

automatically accumulating aggregate case data and system analysis data on a plurality of patient cases and storing the aggregate case data and system analysis data in system data files in the system memory;

automatically analyzing the aggregate case data in order to identify patterns of aggregate case data; and

generating at least one analysis report for a plurality of patient cases based upon the analyzed aggregate case data.

2. The method as claimed in claim 1 wherein a plurality of data quality messages are generated and wherein the method further comprises the step of classifying the data quality messages.

3. The method as claimed in claim 2 wherein the step of classifying the data quality messages is performed in an hierarchical manner.

4. The method as claimed in claim 1 wherein the step of classifying each case is performed in an hierarchical manner.

5. The method as claimed in claim 1 wherein the step of classifying each case is based on the type of the determined misreporting condition.

6. The method as claimed in claim 1 wherein the step of classifying data quality messages generated for a case includes determining a probably cause of the misreporting conditions.

7. The method as claimed in claim 1 wherein the step of classifying each case is based on the consequences of the determined misreporting condition.

8. The method as claimed in claim 1 wherein the step of classifying the data quality messages for a case is based on user-defined prioritization criteria.

9. The method as claimed in claim 1 wherein the step of displaying patient data includes the step of presenting the patient data in a final, reportable form.

10. The method as claimed in claim 9 wherein the patient data are presented for each patient case.

11. The method as claimed in claim 9 wherein the patient data are presented in aggregate form for the plurality of patient cases.

12. The method as claimed in claim 1 wherein the step of displaying the at least one message includes the step of displaying the at least one message for each patient case.

13. The method as claimed in claim 11 wherein the step of displaying the at least one message includes the step of presenting the at least one message for each case in aggregate form for the plurality of patient cases.

14. The method as claimed in claim 12 further comprising the steps of routing the at least one message to appropriate personnel by comparing the classification results to selection criteria and displaying the at least one message via a system output device.

15. The method as claimed in claim 14 wherein the at least one message is an alternative message text stored in the data files that is appropriate in orientation, vocabulary, and format to the professional status of the appropriate personnel.

16. The method as claimed in claim 9 wherein the step of displaying patient data includes the step of displaying messages corresponding to determined misreporting conditions concurrently with the step of presenting.

17. The method as claimed in claim 1 wherein the data files contain patient data and systems analysis data which includes personnel performance data representing an assessment of trends in personnel efficiency and effectiveness of data correction activities in response to messages routed to appropriate personnel.

18. The method as claimed in claim 1 wherein the step of storing classification data and review tables in the data files includes the steps of entering and storing user-defined alternatives for diagnosis titles, procedure titles, DRG titles, and DRG cost weights to be accessed at user option in data displays.

19. The method as claimed in claim 1 wherein the step of determining whether misreporting conditions exist includes the step of determining whether a reporting sequence of the clinical data has resulted in a maximum achievable payment under a DRG-based payment mechanism.

21. The method as claimed in claim 17 further comprising the step of exchanging data with at least one automated data system.

22. The method as claimed in claim 17 wherein the step of automatically accumulating the aggregate case data and the system analysis data including the personnel performance data includes the step of accumulating summary statistics related to the aggregate case data and the system analysis data across reporting periods.

23. The method as claimed in claim, 17 wherein the step of generating the at least one analysis report includes the step of creating descriptive profiles from the aggregate case data, and system analysis data including the personnel performance data accumulated from a plurality of patients.

24. The method as claimed in claim 23 further comprising the step of characterizing the quality of patient data as to the type of data quality message generated.

25. The method as claimed in claim 23 further comprising the step of characterizing problems encountered with respect to the quality of the patient data based on the source of the patient data.

26. The method as claimed in claim, 14 further comprising the step of characterizing the impact of changes in patient data on payments based upon DRG assignments and payments.

27. The method as claimed in claim 17 wherein the step of generating the at least one analysis report includes the step of creating at least one comparison report from the aggregate case data, and the system analysis data including the personnel performance data from a plurality of patients.

28. The method as claimed in claim 27 further comprising the step of comparing data contained on the comparison report from a given hospital with data contained on a comparison report from another hospital.

29. The method as claimed in claim 27 further comprising the step of comparing data contained in the comparison report from a given hospital with averaged data based on the data contained in the group of comparison reports from a group of hospitals.

30. The method as claimed in claim 27 further comprising the step of comparing data contained in the comparison report from a given hospital with normative data.

31. The method as claimed in claim 27 further comprising the step of comparing data contained in the comparison report from a given hospital claims payer with data contained in a comparison report of another payer.

32. The method as claimed in claim 27 further comprising the step of comparing data contained in the comparison report from a given hospital claims payer with average data based in the data contained in a group of comparison reports from a group of payers.

33. The method as claimed in claim 1 wherein the step of generating at least one analysis report includes the step of creating time trend analyses from aggregated case data, and system analysis data including personnel performance data accummulated in the form of summary statistics.

34. The method as claimed in claim 33 wherein the time trend analyses include descriptive patient data compared across reporting periods.

35. The method as claimed in claim 33 wherein the time trend analyses include descriptive profiles of data quality compared across reporting periods.

36. The method as claimed in claim 33 wherein the time trend analyses include system activities compared across reporting periods.

37. The method as claimed in claim 33 wherein the time trend analyses include personnel performance compared across reporting periods.

38. The method as claimed in claim 33 wherein the time trend analyses include changes in payment levels to hospitals by payers compared across reporting periods.

39. A program storage device readable by a machine, tangibly embodying a program of instructions executable by the machine to perform the method steps of any of claims 1 through 38.

20. The method as claimed in claim wherein the step of determining whether misreporting conditions exist includes the step of determining the likelihood of truthfulness in reporting of claim data for a plurality of patients by quantifying unexploited opportunities to increase payment via the reporting of alternative diagnoses and procedure terms.

40. A system for automatically detecting, analyzing and classifying patient data reported on a plurality of payment claims, the system comprising:

a program of instructions for detecting, analyzing and classifying patient data;

a system memory for storing the program of instructions, data files of collections of patient data including patient identifiers and clinical data, misreporting tables and message tables, and classification data and case review tables;

a processor coupled to the system memory to carry out the program of instructions for;

determining whether misreporting conditions exist in the stored clinical data, the misreporting conditions including actual or potential non-compliance with federally mandated coding and reporting rules and actual or potential failure to properly report complexities of the case;

generating at least one data quality message based upon the misreporting tables, the message tables and the determined misreporting conditions;

classifying the data quality message generated for each case based upon the classification data, the review tables and the determined misreporting conditions to obtain classification results;

automatically accumulating aggregate case data and system analysis data on a plurality of patient cases and storing the aggregate case and system analysis data in system data files; and

automatically analyzing the aggregate case data in order to identify patterns of aggregate case data; and

a system output device coupled to the processor for;

displaying the patient data including the patient identifiers and the clinical data;

displaying at least one message based on the determined misreporting conditions in the patient data; and

generating at least one analysis report for a plurality of patient cases based upon the analyzed aggregate case data.

41. The system as claimed in claim 40 wherein a plurality of data quality messages are generated and wherein the processor classifies the data quality messages.

42. The system as claimed in claim 41 wherein the processor classifies the quality messages in an hierarchical manner.

43. The system as claimed in claim 40 wherein the processor classifies each case in an hierarchical manner.

44. The system as claimed in claim 40 wherein the processor classifies each case based on the type of the determined misreporting condition.

45. The system as claimed in claim 40 wherein the processor classifies data quality messages generated for a case includes determining a probable cause of the misreporting conditions.

46. The system as claimed in claim 40 wherein the processor classifies each case based on the consequences of the determined misreporting condition.

47. The system as claimed in claim 40 wherein the processor classifies the data quality messages for a case based on the user-defined prioritization criteria.

48. The system as claimed in claim 40 wherein the system output device presents the patient data in a final, reportable form.

49. The system as claimed in claim 48 wherein the patient data are presented for each patient case.

50. The system as claimed in claim 48 wherein the patient data are presented in aggregate form for the plurality of patient cases.

51. The system as claimed in claim 40 wherein the system output device displays the at least one message for each patient case.

52. The system as claimed in claim, 50 wherein the system output device presents the at least one message for each case in aggregate form for the plurality of patient cases.

53. The system as claimed in claim 51 further comprising means for routing the at least one message to appropriate personnel, the means for routing comparing the classification results to selection criteria and wherein the system output device displays the at least one message.

54. The system as claimed in claim 53 wherein the at least one message is an alternative message text stored in the data files that is appropriate in orientation, vocabulary, and format to the professional status of the appropriate personnel.

55. The system as claimed in claim 48 wherein the system output device displays messages corresponding to determined misreporting conditions concurrently with presenting the patient data.

56. The system as claimed in claim 40 wherein the system analysis data includes personnel performance data representing an assessment of trends in personnel efficiency and effectiveness of data correction activities in response to messages routed to appropriate personnel.

57. The system as claimed in claim 40 wherein the system memory stores user-defined alternatives for diagnosis titles, procedure titles, DRG titles, and DRG cost weights to be accessed at user option in data displays.

58. The system as claimed in claim 40 wherein the processor determines whether a reporting sequence of the clinical data has resulted in a maximum achievable payment under a DRG-based payment mechanism.

59. The system as claimed in claim 40 wherein the processor determines the likelihood of truthfulness in reporting of claim data for a plurality of patients by quantifying unexploited opportunities to increase payment via the reporting of alternative diagnoses and procedure terms.

60. The system as claimed in claim 56 wherein the processor exchanges data with at least one automated data system.

61. The system as claimed in claim, 56 wherein the processor accumulates summary statistics related to the aggregate case data and the system analysis data across reporting periods.

62. The system as claimed in claim 56 wherein the processor creates descriptive profiles from the aggregate case data, and system analysis data including the personnel performance data accumulated from a plurality of patients.

63. The system as claimed in claim 62 wherein the processor characterizes the quality of patient data as to the type of data quality message generated.

64. The system as claimed in claim 62 wherein the processor characterizes problems encountered with respect to the quality of the patient data based on the source of the patient data.

65. The system as claimed in claim 53 wherein the processor characterizes the impact of changes in patient data on payments based upon DRG assignments and payments.

66. The system as claimed in claim 56 wherein the system output device creates at least one comparison report from the aggregate case data, and the system analysis data including the personnel performance data from a plurality of patients.

67. The system as claimed in claim 66 wherein the processor compares data contained on the comparison report from a given hospital with data contained on a comparison report from another hospital.

68. The system as claimed in claim 66 wherein the processor compares data contained in the comparison report from a given hospital with averaged data based on the data contained in the group of comparison reports from a group of hospitals.

69. The system as claimed in claim 66 wherein the processor compares data contained in the comparison report from a given hospital with normative data.

70. The system as claimed in claim 66 wherein the processor compares data contained in the comparison report from a given hospital claims payer with data contained in a comparison report of another payer.

71. The system as claimed in claim 66 wherein the processor compares data contained in the comparison report from a given hospital claims payer with average data based in the data contained in a group of comparison reports from a group of payers.

72. The system as claimed in claim 40 wherein the processor creates time trend analyses from aggregated case data, and system analysis data including personnel performance data accummulated in the form of summary statistics.

73. The system as claimed in claim 72 wherein the time trend analyses include descriptive patient data compared across reporting periods.

74. The system as claimed in claim 72 wherein the time trend analyses include descriptive profiles of data quality compared across reporting periods.

75. The system as claimed in claim 72 wherein the time trend analyses include system activities compared across reporting periods.

76. The system as claimed in claim 72 wherein the time trend analyses include personnel performances compared across reporting periods.

77. The system as claimed in claim 72 wherein the time trend analyses include changes in payment levels to hospitals by payers compared across reporting periods.