Computerized system and methods for generating and processing integrated transactions for healthcare services

• US 7,870,009 B2
• Filed: 01/06/2006
• Issued: 01/11/2011
• Est. Priority Date: 01/06/2005
• Status: Active Grant

• Current Assignee: Cerner Innovation, Inc. (Oracle Corporation)
• Original Assignee: Cerner Innovation, Inc. (Oracle Corporation)
• Inventors: Patterson, Neal L.
• Primary Examiner(s): Gilligan; Luke
• Assistant Examiner(s): MOLINA, ANITA C
• Application Number:
  US11/326,734
• Publication Number:
  US 20060259324A1
• Time in Patent Office: 1,831 Days
• Field of Search: 705 2- 4
• US Class Current: 705/3
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 40/02 Banking, e.g. interest calculation or account maintenance credit or loans G06Q40/03
• CPC Class Codes: G06Q 40/08 Insurance
• CPC Class Codes: G16H 10/20 for electronic clinical trials or questionnaires

Abstract

A method for adjudicating and reimbursing a care provider for services provided for a clinical event is provided. The method includes the step of receiving a transaction having a number of clinical data elements. The method also includes the steps of accessing a data store including payer information and determining whether the transaction is eligible for reimbursement by at least one payer. The method also includes the steps of accessing a first knowledge base comprising evidence-based standards for providing medically appropriate care and selectively performing analysis of the clinical data elements of the transaction against at least one standard to determine if the care provided is medically appropriate. The method further includes the steps of accessing a second knowledge base containing at least one criterion for assessing quality of care and selectively performing analysis of the clinical data elements of the transaction against the at least one criterion to determine if the care provided is medically appropriate. Also, the method includes determining a level of reimbursement based on the medical appropriateness and quality of the care provided and authorizing reimbursement of the care provider from at least one payer.

Claims

1. One or more computer readable storage media having computer-executable instructions stored thereon that executes a method in a computing environment for adjudicating and reimbursing a care provider for services provided for a clinical event, comprising:

referencing an integrated transaction including a number of clinical data elements, wherein the clinical data elements comprise clinical event details electronically documented by the care provider at a point of care for the clinical event for which reimbursement is sought and electronic medical record data elements associated with a patient from an electronic medical record data store of a central computing system having historical electronic medical record data elements received from a plurality of sources;

accessing a data store including payer information;

determining whether at least a portion of medical care described in the integrated transaction is eligible for reimbursement by at least one payer by comparing the clinical data elements to plan information;

accessing a first knowledge base comprising evidence-based criteria for providing medically appropriate care, wherein the evidence-based criteria comprises one or more guidelines and standards;

selectively performing analysis of the clinical data elements of the integrated transaction against at least one evidence based criterion from the first knowledge base to determine if the care provided is medically appropriate;

accessing a second knowledge base comprising at least one quality criterion for assessing quality of health care, wherein the at least one quality criterion comprises a mortality, a morbidity, a length of visit or stay in a healthcare facility, an onset of another condition due to poor care, a recurrence, an elimination of a presenting problem, a quality of life indicator, a patient satisfaction, and an unplanned visit due to poor care;

selectively performing analysis of the clinical data elements of the integrated transaction against the at least one quality criterion to determine the quality of health care; and

determining a level of reimbursement for a patient based on the determined medical appropriateness and the determined quality of the health care provided to the patient and authorizing reimbursement of the care provider from the at least one payer.

2. The media according to claim 1, further comprising storing the integrated transaction in a data store containing a number of transactions.

3. The media according to claim 2, further comprising providing consumer access to the stored transactions.

4. The media according to claim 1, further comprising reimbursing the care provider in real-time.

5. The media according to claim 1, further comprising receiving a number of transactions from a number of care providers.

6. The media according to claim 1, further comprising receiving payer information from a number of payers.

7. A method of generating an integrated transaction, the method comprising:

in a computing environment, referencing a number of clinical data elements comprising clinical event details provided by a care provider describing healthcare services provided and electronic medical record data elements associated with a patient from an electronic medical record data store of a central computing system having historical electronic medical record data elements received from a plurality of sources;

determining eligibility for reimbursement based on the clinical data elements as compared to stored plan information;

selectively performing a comparative analysis of the clinical data elements against a first knowledge base to determine medical appropriateness, wherein the first knowledge base includes appropriateness criteria comprising one or more guidelines and standards;

selectively performing a comparative analysis of the clinical data elements against a second knowledge base to determine quality of care, wherein the second knowledge base comprises quality of care criteria comprising one or more of a mortality, a morbidity, a length of visit or stay in a healthcare facility, an onset of another condition due to poor care, a recurrence, an elimination of presenting problem, a quality of life indicator, a patient satisfaction, and an unplanned visit due to poor care; and

determining a level of reimbursement for a patient based on the determined eligibility, the determined medical appropriateness, and the determined quality of health care provided to the patient.

8. The method according to claim 7, wherein the step of receiving clinical data elements further comprises receiving administrative and financial data elements.

9. A computerized system for adjudicating and reimbursing a care provider for healthcare services in a computing environment, comprising:

a processing unit; and

a memory for storing computer-executable instructions that when executed by the processing unit executes;

a first interface adapted to receive a number of transactions from a number of care providers, wherein each transaction includes clinical data elements comprising clinical event details captured during provision of the healthcare services, wherein the clinical data elements further comprise electronic medical record data elements associated with the patient from an electronic medical record data store of a central computing system having historical electronic medical record data elements received from a plurality of sources;

an eligibility engine configured to analyze the transaction to determine if the transaction is eligible for reimbursement by comparing the clinical data elements to stored plan information;

a first knowledge base comprising a set of clinical guidelines;

an appropriateness engine configured to selectively perform comparative analysis of the clinical data elements against the first knowledge base to determine medical appropriateness of the care provided;

a second knowledge base comprising a set of quality criteria, wherein the set of quality criteria comprises one or more of a mortality, a morbidity, a length of visit or stay in a healthcare facility, an onset of another condition due to poor care, a recurrence, an elimination of presenting problem, a quality of life indicator, a patient satisfaction, and an unplanned visit due to poor care;

a quality engine configured to selectively perform comparative analysis of the clinical data elements against the second knowledge base to determine the quality of the health care provided; and

a reimbursement module for determining a level of reimbursement for the transaction for a patient based on the determined eligibility, the determined medical appropriateness, and the determined quality of the health care provided to the patient.

10. One or more computer readable storage media having computer-executable instructions stored thereon that executes a method in a computing environment for providing a community electronic medical record, comprising:

receiving a number of transactions from a number of providers requesting reimbursement for healthcare services, each transaction including clinical data elements comprising clinical event details captured during provision of the healthcare services, wherein the clinical data elements further comprise electronic medical record data elements associated with a patient from an electronic medical record data store of a central computing system having historical electronic medical record data elements received from a plurality of sources;

associating each transaction with a unique person identifier corresponding with a patient;

selectively performing a comparative analysis of the clinical data elements against a knowledge base to determine quality of care provided to a particular patient, wherein the second knowledge base comprises one or more quality of care criteria comprising a mortality, a morbidity, a length of visit or stay in a healthcare facility, an onset of another condition due to poor care, a recurrence, an elimination of a presenting problem, a quality of life indicator, a patient satisfaction, and an unplanned visit due to poor care;

determining a level of reimbursement for each transaction for the particular patient based at least on the determined quality of health care provided to the particular patient; and

storing the transactions and selectively providing access to the transactions to the healthcare providers.

11. The media according to claim 10, wherein the transactions are in a standard pre-defined format.

12. The media according to claim 11, wherein a portion of the clinical data elements of the transactions are organized in structured charts.

13. The media according to claim 10, wherein the step of determining the level of reimbursement comprises determining eligibility of the transaction and analyzing the clinical data elements of the transaction to determine medical appropriateness of the healthcare services provided.

14. The media according to claim 13, wherein the step of determining the level of reimbursement further comprises analyzing the clinical data elements of the transaction to determine the quality of the healthcare services provided.

15. The media according to claim 10, further comprising the step of selectively providing access to the transactions to a number of payers.

16. The media according to claim 10, further comprising the step of selectively providing access to the transactions to a number of consumers.