Computer implemented medical integrated decision support system

• US 6,697,783 B1
• Filed: 09/29/1998
• Issued: 02/24/2004
• Est. Priority Date: 09/30/1997
• Status: Expired due to Term

• Current Assignee: Express Scripts Strategic Development, Inc. (The Cigna Group)
• Original Assignee: Medco Health Solutions Incorporated (The Cigna Group)
• Inventors: Gattinella, Wayne, Brinkman, Thomas, Stettin, Glen, Kleinfelter, William, Teagarden, J. Russel, Angaran, David
• Primary Examiner(s): MEINECKE DIAZ, SUSANNA M
• Application Number:
  US09/161,960
• Time in Patent Office: 1,974 Days
• Field of Search: 705/2, 705/3
• US Class Current: 705/3
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• 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 40/67 for remote operation
• CPC Class Codes: G16H 50/20 for computer-aided diagnosis, e.g. based on medical expert systems
• CPC Class Codes: G16H 70/40 relating to drugs, e.g. their side effects or intended usage
• CPC Class Codes: G16H 70/60 relating to pathologies

Abstract

A software-based, integrated member decision support system provides a method for corporations, insurance carriers, health maintenance organizations, physicians, physician groups, or other clients to efficiently provide medical, pharmaceutical, and health benefit advice and information for an enrolled population. The system contains one or more databases which include member profiles, clinical information and guidelines, pharmaceutical information and guidelines, health benefit information, and optional additional information. A caller establishes communication with the system, which directs the caller to an operator who provides the caller with medical, pharmaceutical, and/or health benefit advice based on an inquiry from the caller and the information stored on the system. The system may automatically alert the caller or the operator of important medical or pharmaceutical information. At the conclusion of the call, the system or the system with the operator'"'"'s input, may update the caller'"'"'s member profile, request written materials, generate referrals, order prescriptions, or generate reports.

Claims

1. A computer-implemented and user assisted method of providing integrated decision support to gather, maintain and update medical, pharmaceutical, demographic, psychographic, and health benefit information of members and to maintain and provide medical, pharmaceutical, and customer service information and advice using a computer system, a caller, and one or more operators, said method comprising the steps of:

(a) receiving by the one or more operators a communication from the caller, the one or more operators receiving information in the communication from the caller explaining the reason for the communication including a health related issue associated with at least one pharmaceutical that the caller is currently using;

(b) providing, by the computer system, the one or more operators with member profile information associated with the caller including health benefit plan information, prescription drug history, self-reported health information, and recent contact history, including, when present, a list of allergies, prescriptions, and pre-existing health conditions associated with the caller;

(c) providing, by the computer system, the one or more operators access to at least one database storing clinical information including clinical guidelines, clinical rules, clinical algorithms, clinical operating protocols, and clinical procedures to assist the one or more operators in identifying recommended forms of treatment, medications, and courses of action for the caller responsive to the communication;

(d) providing, prior to diagnosis by a physician with respect to the communication from the caller and the health related issue relating thereto, by the computer system, the one or more operators with pharmaceutical information including prescription drug side effects and complications that may be associated with particular drugs or combinations of drugs that the caller is currently using or which the one or more over-the-counter medications operators intend to recommend, and health benefit information including insurance company rules, member information, and benefit plan resources associated with the pharmaceutical information;

(e) automatically linking, prior to the diagnosis by the physician, by the computer system, the member profile information including the health benefit plan information, the prescription drug history, the self-reported health information, and the recent contact history, with the pharmaceutical information and the clinical rules, the clinical guidelines, and the clinical algorithms to assist the one or more operators in providing advice for the communication;

(f) generating, prior to the diagnosis by the physician, by the computer system, responsive to said providing steps (b), (c) and (d) and linking step (e) at least one of alerts and messages that are designed for the communication by caller, the messages including appropriate prescription drug use, medications the caller should avoid or use in moderation or speak to a physician before using, suggested forms of treatment based on the caller'"'"'s symptoms, prescription refill reminders, and prescription renewal reminders;

(g) generating, by the computer system, at least one of reports with respect to the health related issue and notices including information collected during the communication with the caller, combined with specific pharmacy information, for delivery to the physician of the caller, and the caller'"'"'s health plan with respect to the health related issue;

(h) receiving by at least one of the physician of the caller and the caller'"'"'s health plan the at least one of reports and notices to assist performing health care services by the one of the physician or the caller'"'"'s health plan;

(i) targeting for follow up action, by the computer system, members of the health plan using the member profile information including the health benefit plan information, the prescription drug history, the self-reported health information, and the recent contact history in combination with the messages including the appropriate prescription drug use, the suggested forms of treatment based on the caller'"'"'s symptoms, the prescription refill reminders, and the prescription renewal reminders; and

(j) targeting for new action, by the computer system, the members associated with the health plan using the member profile information including the health benefit plan information, the prescription drug history, the self-reported health information, and the recent contact history when at least one of the clinical information, the pharmaceutical information and the health benefit information are updated.

2. A computer-implemented and user assisted method of providing integrated decision support according to claim 1, further comprising the steps of ensuring that client-specified standards of performance are being met, including auditing of procedures and processes, random monitoring of a select number of calls, and a comparison of call reports with an overall set of performance standards.

3. A computer-implemented and user assisted method of providing integrated decision support according to claim 2, further comprising the steps of requesting by the one or more operators, using the computer system, written documents for the caller including self-care texts, brochures, newsletters, promotional materials, and other written materials which may be automatically ordered from the computer system for current and future delivery to the caller, the caller'"'"'s health care plan, a physician, and optionally a pharmacist.

4. A computer-implemented and user assisted method of providing integrated decision support according to claim 3, further comprising the steps of requesting by the one or more operators, using the computer system, at least one of a new prescription, a prescription refill and a prescription renewal and arranging for direct delivery to or pick up by the caller.

5. A computer-implemented and user assisted method of providing integrated decision support according to claim 4, further comprising the steps of determining by the one or more operators, using the computer system, while analyzing the communication from the caller, that the caller must visit a physician, requesting that the computer system generate a referral in accordance with the health benefit plan rules, and accessing a database of participating providers and rules associated with referring members to specific physicians, based on the health related issue described by the caller.

6. A computer-implemented and user assisted method of providing integrated decision support according to claim 5, further comprising the steps of generating a report including the caller'"'"'s communication, any prescriptions ordered, refilled, or renewed, treatments or action items suggested, and referrals provided to the caller using the computer system, and notifying the health care plan associated with the caller and a health care provider associated with the caller for updating and follow up action or treatment.

7. A computer-implemented and user assisted method of providing integrated decision support according to claim 6, further comprising the steps of updating by the one or more operators, using the computer system, while analyzing the communication from the caller, the member profile based on the communication and information given by the caller, and updating by the one or more operators the caller'"'"'s self-reported health information that includes data on the allergies, existing health conditions, demographics that contribute to risk stratification, and other data applicable to helping the member with health care information needs.

8. A computer-implemented and user assisted method of providing integrated decision support according to claim 1, further comprising the steps of ensuring that client-specified standards of performance are being met, including auditing of procedures and processes, random monitoring of a select number of calls, and a comparison of call reports with an overall set of performance standards.

9. A computer-implemented and user assisted method of providing integrated decision support according to claim 1, further comprising the steps of requesting by the one or more operators using the computer system, written documents for the caller including self-care texts, brochures, newsletters, promotional materials, and other written materials which may be automatically ordered from the computer system for current and future delivery to the caller, the caller'"'"'s health care plan, a physician, and optionally a pharmacist.

10. A computer-implemented and user assisted method of providing integrated decision support according to claim 1, further comprising the steps of requesting by the one or more operators, using the computer system, at least one of a new prescription, a prescription refill and a prescription renewal and arranging for direct delivery to or pick up by the caller.

11. A computer-implemented and user assisted method of providing integrated decision support according to claim 1, further comprising the steps of determining by the one or more operators, using the computer system, while analyzing the communication from the caller, that the caller must visit a physician, requesting that the computer system generate a referral in accordance with the health benefit plan rules, and accessing a database of participating providers and rules associated with referring members to specific physicians, based on the health related issue described by the caller.

12. A computer-implemented and user assisted method of providing integrated decision support according to claim 1, further comprising the steps of generating a report including the caller'"'"'s communication, any prescriptions ordered, refilled, or renewed, treatments or action items suggested, and referrals provided to the caller using the computer system, and notifying the health care plan associated with the caller and a health care provider associated with the caller for updating and follow up action or treatment.

13. A computer-implemented and user assisted method of providing integrated decision support according to claim 1, further comprising the steps of updating by the one or more operators, using the computer system, while analyzing the communication from the caller, the member profile based on the communication and information given by the caller, and updating by the one or more operators the caller'"'"'s self-reported health information that includes data on the allergies, existing health conditions, demographics that contribute to risk stratification, and other data applicable to helping the member with health care information needs.

14. A computer-assisted method of providing clinical, pharmaceutical, and health benefit information and advice according to claim 1, further comprising the step of updating a member record in the member information database to include the one or more of clinical advice, pharmaceutical advice, and health benefit advice provided to the caller.

15. A computer-assisted method of providing clinical, pharmaceutical, and health benefit information and advice according to claim 1, further comprising the step of notifying a health care provider of the one or more of clinical advice, pharmaceutical advice, and health benefit advice.

16. A computer system of providing integrated decision support to gather, maintain and update medical, pharmaceutical, demographic, psychographic, and health benefit information of members and to maintain and provide medical, pharmaceutical, and customer service information and advice using a computer system, a caller, and one or more operators, comprising:

(a) means for receiving by the one or more operators a communication from the caller, the one or more operators receiving information in the communication from the caller explaining the reason for the communication including a health related issue associated with at least one pharmaceutical that the caller is currently using;

(b) means for providing, by the computer system, the one or more operators with member profile information associated with the caller including health benefit plan information, prescription drug history, self-reported health information, and recent contact history, including, when present, a list of allergies, prescriptions, and pre-existing health conditions associated with the caller;

(c) means for providing, by the computer system, the one or more operators access to at least one database storing clinical information including clinical guidelines, clinical rules, clinical algorithms, clinical operating protocols, and clinical procedures to assist the one or more operators in identifying recommended forms of treatment, medications, and courses of action for the caller responsive to the communication;

(d) means for providing, prior to diagnosis by a physician with respect to the communication from the caller and the health related issue relating thereto, by the computer system, the one or more operators with pharmaceutical information including prescription drug side effects and complications that may be associated with particular drugs or combinations of drugs that the caller is currently using or which the one or more operators intends to recommend, and health benefit information including insurance company rules, member information, and benefit plan resources associated with the pharmaceutical information;

(e) means for automatically linking, prior to the diagnosis by the physician, by the computer system, the member profile information including the health benefit plan information, the prescription drug history, the self-reported health information, and the recent contact history, with the pharmaceutical information and the clinical rules, the clinical guidelines, and the clinical algorithms to assist the one or more operators in providing advice for the communication;

(f) means for generating, by the computer system, prior to the diagnosis by the physician, at least one of alerts and messages that are designed for the communication by the caller, the messages including appropriate prescription drug use, medications the caller should avoid or use in moderation or speak to a physician before using, suggested forms of treatment based on the caller'"'"'s symptoms, prescription refill reminders, and prescription renewal reminders;

(g) means for generating, by the computer system, at least one of with respect to the health related issue reports and notices including information collected during the communication with the caller, combined with specific pharmacy information, for delivery to the physician of the caller, and the caller'"'"'s health plan with respect to the health related issue;

(h) means for receiving by at least one of the physician of the caller and the caller'"'"'s health plan the at least one of reports and notices to assist performing health care services by the one of the physician or the caller'"'"'s health plan;

(i) means for targeting for follow up action, by the computer system, members of the health plan using the member profile information including the health benefit plan information, the prescription drug history, the self-reported health information, and the recent contact history in combination with the messages including the appropriate prescription drug use, the suggested forms of treatment based on the caller'"'"'s symptoms, the prescription refill reminders, and the prescription renewal reminders; and

(j) means for targeting for new action, by the computer system, the members associated with the health plan using the member profile information including the health benefit plan information, the prescription drug history, the self-reported health information, and the recent contact history when at least one of the clinical information, the pharmaceutical information and the health benefit information are updated.

17. A computer-implemented and user assisted method of providing integrated decision support to gather, maintain and update medical, pharmaceutical, demographic, psychographic, and health benefit information of members and to maintain and provide medical, pharmaceutical, and customer service information and advice using a computer system, a caller, and one or more operators, said method comprising the steps of:

(a) receiving by the one or more operators a communication from the caller, the one or more operators receiving information in the communication from the caller explaining the reason for the communication including a health related issue associated with at least one pharmaceutical that the caller is currently using;

(b) providing, by the computer system, the one or more operators with member profile information associated with the caller including health benefit plan information, prescription drug history, self-reported health information, and recent contact history, including, when present, a list of allergies, prescriptions, and pre-existing health conditions associated with the caller;

(c) providing, by the computer system, the one or more operators access to at least one database storing clinical information including clinical guidelines, clinical rules, clinical algorithms, clinical operating protocols, and clinical procedures to assist the one or more operators in identifying recommended forms of treatment, medications, and courses of action for the caller responsive to the communication;

(d) providing, prior to diagnosis by a physician with respect to the communication from the caller and the health related issue relating thereto, by the computer system, the one or more operators with pharmaceutical information including prescription drug side effects and complications that may be associated with particular drugs or combinations of drugs that the caller is currently using or which the one or more operators intends to recommend, and health benefit information including insurance company rules, member information, and benefit plan resources associated with the pharmaceutical information;

(e) automatically linking, prior to the diagnosis by the physician, by the computer system, the member profile information including the health benefit plan information, the prescription drug history, the self-reported health information, and the recent contact history, with the pharmaceutical information and the clinical rules, the clinical guidelines, and the clinical algorithms to assist the one or more operators in providing advice for the communication;

(f) generating, prior to the diagnosis by the physician, by the computer system, responsive to said providing steps (b), (c) and (d) and linking step (e) at least one of alerts and messages that are designed for the caller, the messages including appropriate prescription drug use, medications the caller should avoid or use in moderation or speak to a physician before using, suggested forms of treatment based on the caller'"'"'s symptoms, prescription refill reminders, and prescription renewal reminders;

(g) generating, by the computer, system, at least one of with respect to the health related issue reports and notices including information collected during the communication with the caller, combined with specific pharmacy information, for delivery to the physician of the caller, and the caller'"'"'s health plan with respect to the health related issue;

(h) receiving by at least one of the physician of the caller and the caller'"'"'s health plan the at least one of reports and notices to assist performing health care services by the one of the physician or the caller'"'"'s health plan;

(i) targeting for follow up action, by the computer system, members of the health plan using the member profile information including the health benefit plan information, the prescription drug history, the self-reported health information, and the recent contact history in combination with the messages including the appropriate prescription drug use, the suggested forms of treatment based on the caller'"'"'s symptoms, the prescription refill reminders, and the prescription renewal reminders;

(j) targeting for new action, by the computer system, the members associated with the health plan using the member profile information including the health benefit plan information, the prescription drug history, the self-reported health information, and the recent contact history when at least one of the clinical information, the pharmaceutical information and the health benefit information are updated;

.

(k) ensuring that client-specified standards of performance are being met, including auditing of procedures and processes, random monitoring of a select number of calls, and a comparison of call reports with an overall set of performance standards;

(l) requesting by the one or more operators, using the computer system, written documents for the caller including self-care texts, brochures, newsletters, promotional materials, and other written materials which may be automatically ordered from the computer, system for current and future delivery to the,caller, the caller'"'"'s health care plan, a physician, and optionally a pharmacist;

(m) requesting by the one or more operators, using the computer system, at least one of a new prescription, a prescription refill and a prescription renewal and arranging for direct delivery to or pick up by the caller;

(n) determining by the one or more operators, using the computer system, while analyzing the communication from the caller, that the caller must visit a physician, requesting that the computer system generate a referral in accordance with the health benefit plan rules, and accessing a database of participating providers and rules associated with referring members to specific physicians, based on the health related issue described by the caller;

(o) generating a report including the caller'"'"'s communication, any prescriptions ordered, refilled, or renewed, treatments or action items suggested, and referrals provided to the caller using the computer system, and notifying the health care plan associated with the caller and a health care provider associated with the caller for updating and follow up action or treatment;

(p) updating by the one or more operators, using the computer system, while analyzing the communication from the caller, the member profile based on the communication and information given by the caller, and updating by the one or more operators the caller'"'"'s self-reported health information that includes data on the allergies, existing health conditions, demographics that contribute to risk stratification, and other data applicable to helping the member with health care information needs;

(q) updating a member record in the member information database to include the one or more of clinical advice, pharmaceutical advice, and health benefit advice provided to the caller; and

(r) notifying a health care provider of the one or more of clinical advice, pharmaceutical advice, and health benefit advice.