System and method for clinical strategy for therapeutic pharmacies

• US 7,711,583 B2
• Filed: 10/04/2006
• Issued: 05/04/2010
• Est. Priority Date: 10/05/2005
• Status: Active Grant

• Current Assignee: Express Scripts Strategic Development, Inc. (The Cigna Group)
• Original Assignee: Medco Health Solutions Incorporated (The Cigna Group)
• Inventors: Anand, Tej, Anderson, Roger W., Klepper, Kenneth, Epstein, Robert, Proulx, Mark
• Primary Examiner(s): O'Connor; Gerald J.
• Assistant Examiner(s): NGUYEN, TRANG T
• Application Number:
  US11/542,898
• Publication Number:
  US 20070214009A1
• Time in Patent Office: 1,308 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: G16H 10/60 for patient-specific data, e.g. for electronic patient records
• CPC Class Codes: G16H 20/10 relating to drugs or medications, e.g. for ensuring correct administration to patients
• CPC Class Codes: G16H 20/13 delivered from dispensers
• CPC Class Codes: G16H 40/63 for local operation
• CPC Class Codes: G16H 50/20 for computer-aided diagnosis, e.g. based on medical expert systems
• CPC Class Codes: G16H 50/30 for calculating health indices; for individual health risk assessment
• CPC Class Codes: G16H 50/70 for mining of medical data, e.g. analysing previous cases of other patients
• CPC Class Codes: G16H 70/60 relating to pathologies
• CPC Class Codes: G16Z 99/00 Subject matter not provided for in other main groups of this subclass

Abstract

A system and method of distributing pharmaceutical prescriptions within a network of pharmacies based on the review of prescription claim data and patient medical state to enable stratification of patients, wherein each pharmacy within the network has been established to handle one or more particular patient medical states.

Claims

1. A method for routing a pharmaceutical prescription to a therapeutic pharmacy within a network of therapeutic pharmacies, wherein the method is suitable for selecting a therapeutic pharmacy for filling the prescription based upon patient medical records and prescription claims, comprising the steps of:

a. receiving a pharmaceutical prescription for a patient at an intake computer system configured to receive prescriptions electronically for one or more diseases, and wherein computer system resolves protocol, performs drug utilization review for the subsequent filling and dispensing prescriptions for one or more diseases;

b. retrieving medical records and prescription claims for the patient from an information warehouse containing patient prescription claims and medical records;

c. analyzing the medical records and prescription claims to stratify the patient into a disease category using the computer system, wherein the computer system electronically analyzes the prescription claims and the medical records, and classifies the patient into a disease state;

d. assigning a score to the patient based on a degree of wellness, using a clinical score system;

e. electronically communicating with a communication network of therapeutic pharmacies, wherein each therapeutic pharmacy communicating with the network is associated with a wellness category;

f. classifying the pharmaceutical prescription to the wellness category, for routing the pharmaceutical prescription to a therapeutic pharmacy within the network of therapeutic pharmacies based on the wellness category using a patient record system, wherein the patient record system electronically uses the stratification and the score information and a rules-based system comprising patient health insurance and formulary information to classify and route the pharmaceutical prescription;

g. electronically routing the prescription, responsive to the patient stratification, the clinical score, and the coverage rules from the patient record system, and wherein said routing utilizes a workflow and load-balancing system to route the prescription based on the patient stratification, the score information, the coverage rules, and the classifying to the pharmacy for filling and dispensing the pharmaceutical prescription to the patient.

2. The method according to claim 1, further comprising receiving the pharmaceutical prescription through at least one of telephonic, mail, hand, and electronic delivery.

3. The method according to claim 2, wherein the electronic delivery is by way of the Internet.

4. The method according to claim 1, wherein retrieving medical records and prescription claims comprise gathering available prescription claims and medical records of a patient within a data repository.

5. The method according to claim 1, wherein analyzing medical records and prescription claims comprises determining particular diseases category and assigning a patient to a disease category.

6. The method according to claim 5, wherein the disease category comprises neurology or psychiatry, pulmonary, cardiovascular, diabetes, gastroenterology, oncology or hematology, rare diseases, pediatrics and combinations thereof.

7. The method according to claim 5, wherein the disease category of neurology or psychiatry comprises pain, insomnia, depression, seizures, and combinations thereof.

8. The method according to claim 5, wherein the disease category of pulmonary comprises cystic fibrosis, Chronic Obstructive Pulmonary Disease, asthma, pediatric and combinations thereof.

9. The method according to claim 5, wherein the disease category of cardiovascular comprises coagulation disorders, coronary diseases, hyperlipidemia, hypertension and combinations thereof.

10. The method according to claim 5, wherein the disease category of diabetes comprises type I, type 11, pediatric, metabolic syndrome and combinations thereof.

11. The method according to claim 5, wherein the disease category of gastroenterology comprises Gastro Esophageal Reflux Disease, peptic ulcer disease, inflammatory bowel diseases, irritable bowel syndrome and combinations thereof.

12. The method according to claim 5, wherein the disease category of oncology or hematology comprises common cancers, anemia, transplants, blood diseases, and combinations thereof.

13. The method according to claim 5, wherein the disease category of rare diseases comprises pulmonary hypertension, hemophilia, Gaucher'"'"'s Disease and combinations thereof.

14. The method according to claim 1, wherein the network of therapeutic pharmacies comprises individual pharmacies for neurology or psychiatry, pulmonary, cardiovascular, diabetes, gastroenterology, oncology or hematology, rare diseases and combinations thereof.

15. The method according to claim 1, wherein the wellness categories comprises well, acute, chronic, and complex.

16. The method according to claim 1, wherein routing the pharmaceutical prescription further comprises correlating the disease category with a plurality of pharmacies established to fill prescriptions for the disease category, routing the pharmaceutical prescription to one of the pharmacies based on the wellness category and the disease category for filling and dispensing the prescription by the one of the pharmacies.

17. The method of claim 1, further comprising, when a plurality of therapeutic pharmacies within the network of therapeutic pharmacies are suitable for filling the patient pharmaceutical prescription, electronically routing the patient pharmaceutical prescription to a therapeutic pharmacy based on the workload of the plurality of suitable therapeutic pharmacies.

18. The method of claim 17, further comprising electronically routing the patient pharmaceutical prescription to the therapeutic pharmacy with the lowest workload.

19. The method of claim 1, further comprising electronically routing the patient pharmaceutical prescription based on minimizing the number of contacts that are made to the prescriber.

20. The method of claim 1, further comprising, determining that a plurality of therapeutic pharmacies within the network of therapeutic pharmacies are eligible for filling the patient pharmaceutical prescription responsive to the combined prescription stratification, score information, and the coverage rules, routing the patient pharmaceutical prescription to one of the plurality of pharmacies based on specific pharmacy experience trained to provide medical services responsive to particular wellness or disease categories associated with the patient pharmaceutical prescription.

21. A system for routing a pharmaceutical prescription to a therapeutic pharmacy within a network of therapeutic pharmacies, wherein the system is suitable for selecting a therapeutic pharmacy for filling the prescription based upon patient medical records and prescription claims, comprising:

a. plurality of individual therapeutic pharmacy computer systems within a network of therapeutic pharmacies, wherein the individual pharmacies are configured to receive prescriptions electronically for one or more diseases using the pharmacy computer systems, wherein the diseases are selected from the group comprising neurology or psychiatry, pulmonary, cardiovascular, diabetes, gastroenterology, oncology/or hematology, rare diseases, pediatrics and combinations thereof;

b. a plurality of pharmacy station computers located in the individual pharmacies able to resolve protocol, perform drug utilization review, and fill and dispense prescriptions for one or more diseases, wherein the diseases are selected from the group comprising neurology or psychiatry, pulmonary, cardiovascular, diabetes, gastroenterology, oncology or hematology, rare diseases and combinations thereof;

c. an information warehouse database containing patient prescription claims and medical records;

d. a patient stratification or classification system in electronic communication with the information warehouse database, wherein the stratification or classification system electronically retrieves prescription claims and medical records from the information warehouse database, and classifying a patient into a disease state;

e. a clinical score system in electronic communication with the information warehouse database and the patient stratification or classification system electronically retrieves information from the information warehouse database and assigning a score to a patient based upon a degree of wellness;

f. a patient on-line authoritative record system in electronic communication with the patient stratification or classification system and the clinical score system, wherein the patient on-line authoritative record system electronically receives the stratification and the score information;

g. a rules-based system comprising patient health insurance and formulary information, wherein the rules-based system is in electronic communication with and provides insurance coverage information to the patient on-line authoritative record system;

h. a prescription receiving system electronically receiving the prescription and refill orders for the prescription, requesting the patient stratification, the clinical score and the coverage rules from patient on-line authoritative record unit; and

i. an optimal workflow and load-balancing unit capable of receiving combined prescription-stratification-score information from the prescription receiving system and routing the pharmaceutical prescription, based on the combined prescription stratification, score information and the coverage rules to at least one of the plurality of individual therapeutic pharmacy computer systems within the network for filling and dispensing prescriptive medication.

22. The system according to claim 21, further comprising an integrated contact management system in electronic communication with the optimal workflow and load-balancing unit, the therapeutic pharmacies, and the patient on-line authoritative record unit, wherein the integrated contact management system electronically receives the combined prescription-stratification-score information from the optimal workflow and load-balancing unit and resolving prescription protocols prior to forwarding the prescription to the individual therapeutic pharmacy.

23. The system according to claim 21, wherein the wellness categories comprise well, acute, chronic, and complex.