Care assessment tool for health management

• US 8,032,398 B1
• Filed: 02/13/2009
• Issued: 10/04/2011
• Est. Priority Date: 06/11/2001
• Status: Expired due to Fees

• Current Assignee: Express Scripts Strategic Development, Inc. (The Cigna Group)
• Original Assignee: Medco Health Solutions Incorporated (The Cigna Group)
• Inventors: Lotvin, Alan M., Kelly, Miriam A.
• Primary Examiner(s): Rines; R. David
• Application Number:
  US12/371,056
• Time in Patent Office: 963 Days
• Field of Search: 705/2, 705/3, 705/4
• US Class Current: 705/3
• CPC Class Codes: G06Q 10/06 Resources, workflows, human or project management; Enterprise or organisation planning; Enterprise or organisation modelling
• CPC Class Codes: G06Q 10/06398 Performance of employee with respect to a job function
• CPC Class Codes: G06Q 40/08 Insurance
• CPC Class Codes: G16H 10/20 for electronic clinical trials or questionnaires
• 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 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: Y10S 128/903 Radio telemetry
• CPC Class Codes: Y10S 128/904 Telephone telemetry
• CPC Class Codes: Y10S 128/923 by comparison of patient data to other data
• CPC Class Codes: Y10S 128/924 using artificial intelligence
• CPC Class Codes: Y10S 128/925 Neural network

Abstract

An interactive computer assisted method compiles comprehensive health care information on patients in a central repository, assesses and analyzes this information, and identifies high utilizers of health care services using a computer and a user associated therewith. The method includes the steps of creating a central repository of various databases containing patient information, including demographic information and behavior, and optionally the results of a core survey of health status questions. The invention optionally involves the step of determining the appropriate core questions and the criteria to determine whether and when to ask certain questions of particular patients based on their response to prior questions. The invention accurately predicts risk of a medical condition or progression of a medical condition utilizing an interactive administration of a set of core survey questions combined with diagnostic data and places patients efficiently, reliably, and accurately into the appropriate treatment intervention programs. The invention eliminates redundant, repetitive surveying of patients with multiple medical conditions.

Claims

1. An interactive computer assisted method of reviewing, analyzing, and compiling patient profile information from a plurality of different sources into a centralized patient profile database, including an interactive survey designed to evaluate the health status of a health care consumer, said method comprising the steps of:

(a) storing in a first database interactive questions for the interactive survey of the patient to assess the overall health status wherein the survey questions are interactively modified, priority of questions reordered based on answers to the questions, and questions are automatically selected based on previous answers;

(b) storing in the first database at least one answer to the interactive survey of the patient;

(c) storing rules for determining if the patient is likely to be a high utilization health care consumer, and storing patient eligibility information;

(d) periodically accessing the patient profile information from the centralized patient profile database and determining if at least one core survey was completed during a predetermined time interval;

(e) utilizing, by the computer, the patient profile information stored in the centralized patient profile database to update core questions, and querying a predetermined number of the patients using at least one of the core survey and the updated core questions to determine if the patient is at risk responsive to the at least one answer by interactively presenting the questions to the predetermined number of the patients, and at least one of reordering the priority of questions based on answers to the questions received from the predetermined number of the patients and automatically selecting at least one of a plurality of the questions and additional questions based on previous answers;

(f) determining if the patient is likely to be the high utilization health care consumer responsive to the patient profile information, the at least one answer and the rules;

(g) determining, automatically by the computer, whether at least one intervention program may reduce health care utilization and improve health of the patient using the results from said survey and said patient profile when the patient is determined to likely be a high utilization health care consumer;

(h) determining if the patient is eligible for the at least one intervention program responsive to the patient eligibility information;

(i) when the patient is eligible for the at least one intervention program, enrolling the patient in the at least one intervention program or other health care program;

(j) generating reports on the state of the at least one intervention program including patient drug utilization, patient evaluation, patient health, comparisons with respect to desired patient health, patient satisfaction, and other information; and

(k) updating patient profiles, and periodically modifying the rules for determining the risk behaviors for the high utilization health care consumer.

2. An interactive computer assisted method according to claim 1, further comprising the step of conducting the patient survey and assessing whether the patient is the high utilization health care consumer through a nurse triage or other demand care telephone call from the patient to a nurse, survey taker or other health care professional, said conducting further comprises the steps of:

(1) responding to the specific patient inquiries that caused the patient to call the nurse triage or the other demand care telephone call;

(2) administering the core survey questions;

(3) interactively evaluating based on patient response to the core survey questions received in said step (2) whether the patient is the high utilization health care consumer;

(4) determining whether there are other intervention programs which could reduce utilization and improve health of the patient;

(5) determining if the patient is eligible for the other intervention programs;

(6) when eligible, enrolling the patient in the other intervention program;

(7) generating at least one report; and

(8) updating the patient profile and the centralized patient profile database.

3. An interactive computer assisted method according to claim 1, further comprising the step of administrating the at least one core survey and assessing whether the patient is the high utilization health care consumer, said administrating step further comprises the steps of:

(1) responding to specific patient inquiries regarding health care conditions;

(2) administering the at least one core survey;

(3) interactively evaluating based on the response to the questions, if the patient is the high utilization health care consumer;

(4) determining if there are other intervention programs which could reduce utilization and improve health of the patient;

(5) determining if the patient is eligible for the other intervention programs;

(6) when eligible, enrolling the patient in the intervention program or the other intervention program;

(7) generating at least one report; and

(8) updating the patient profile and the centralized patient profile database.

4. An interactive computer assisted method according to claim 1, further comprising the step of conducting the at least one core survey and assessing whether the patient is at risk an Internet inquiry from the patient as part of a demand care system, said conducting step comprising the steps of:

(1) responding to specific patient inquiries regarding health care conditions via the Internet;

(2) administering the at least one core survey via the Internet;

(3) interactively evaluating via the Internet based on the response to the questions, if the patient is the high utilization health care consumer;

(4) determining if there are other intervention programs which could reduce utilization and improve health of the patient;

(5) determining if the patient is eligible for the other intervention programs;

(6) when eligible, enrolling the patient in the intervention program or the other intervention program via the Internet;

(7) generating at least one report; and

(8) updating the patient profile and the centralized patient profile database.

5. An interactive computer assisted method according to claim 1, wherein the patient profile information includes at least current medications, medication use pattern, over the counter medication use, patient understanding of treatment goals, adverse effects, compliance history, medical history, family history, hospitalization history, pertinent laboratory work, patient demographics, and the response to the at least one core survey.

6. An interactive computer assisted method according to claim 1, where when the at least one core survey is administered, the determination of whether the patient is a health risk and potentially a high utilization health care consumer, the availability of health care intervention programs, and the enrollment of the patient in the appropriate program is performed automatically by an automated computer expert system rather than the physician, the nurse, the survey taker, or the other health care personnel.

7. An interactive computer assisted method according to claim 1, where when the at least one core survey is administered, the determination of whether the patient is the high utilization health care consumer, the availability of health care intervention programs, and the enrollment of the patient in the appropriate program is performed with the assistance of an automated computer expert system to be used in conjunction with, or by, the physician, the nurse, the survey taker, or the other health care personnel.

8. An interactive computer assisted method according to claim 1, further comprising generating a list of core question if the patient profile is incomplete.

9. An interactive computer assisted method according to claim 8, further comprising updating the patient profile in real time based upon the patient'"'"'s response.

10. An interactive computer assisted method according to claim 9, wherein the generated report comprises at least one of the state of the plan, a drug evaluation, an update of the patient profile and an update of the central repository.

11. An interactive computer assisted method according to claim 1, further comprising updating the patient profile in real time based upon the patient'"'"'s response.

12. An interactive computer assisted method according to claim 1, wherein the generated report comprises at least one of the state of the plan, a drug evaluation, an update of the patient profile and an update of the central repository.

13. An integrated method of reviewing, analyzing, and compiling patient profile information from a plurality of different sources into a centralized patient profile database, including an interactive survey designed to identify high utilization health care consumers, said method comprising the steps of:

(a) storing questions in a questions database for the survey of the patients to assess the utilization of health care;

(b) storing rules in a rules database for determining which of the patients are likely to be the high utilization health care consumer, and storing patient eligibility information;

(c) periodically accessing, using the computer, the patient profile information, drug claims records, self-reported information, medical claims records, general demographic data, eligibility data, and demand for medical services from the centralized patient profile database and determining if at least one core survey was completed during a predetermined time interval, the patient profile information including at least current medications, medication use pattern, over the counter medication use, patient understanding of treatment goals, adverse effects, compliance history, medical history, family history, hospitalization history, pertinent laboratory work, patient demographics, patient behavior and lifestyle risk factor information, and the response to the at least one core survey;

(d) storing in an answer database at least one answer to the interactive survey of the patient;

(e) utilizing the patient profile information stored in the centralized patient profile database and information received in said periodically accessing step to update core questions, and querying a predetermined number of the patients using at least one of the core survey and the updated core questions to determine which of the patients are likely to be the high utilization health care consumers responsive to the at least one answer by interactively presenting the questions to the predetermined number of the patients, and at least one of reordering the priority of questions based on answers to the questions received from the predetermined number of the patients and automatically selecting at least one of a plurality of the questions and additional questions based on previous answers;

(f) determining, using the computer, whether the patient is likely to be the high utilization health care consumer responsive to the at least one answer and the rules;

(g) determining, using the computer, whether at least one intervention program may reduce health care utilization and improve health of the patient when the patient is determined to likely be a high utilization health care consumer;

(h) determining if the patient is eligible for the at least one intervention program responsive to the patient eligibility information;

(i) when the patient is eligible, enrolling the patient in the at least one intervention program or other health care program;

(j) generating reports, using the computer, on the state of the at least one intervention program responsive to said enrolling, including patient drug utilization, patient evaluation, patient health, comparisons with respect to desired patient health, patient satisfaction, and other information; and

(k) periodically updating the patient profile information, and periodically modifying the rules for determining the high utilization health care consumer.

14. An interactive computer assisted method according to claim 13, wherein said determining step further comprises the steps of:

(1) determining from a review of the centralized patient profile database which patient to call as part of the survey;

(2) interactively evaluating based on the response to the questions, if the patient is the potential high utilization health care consumer;

(3) determining if there are intervention programs which could reduce utilization and improve health of the patient;

(4) determining if the patient is eligible for such programs;

(5) if eligible, enrolling the patient in the intervention program or other health care program;

(6) generating at least one report;

(7) updating the patient profile and the centralized patient profile database.

15. An interactive computer assisted method according to claim 13, where when the at least one core survey is administered, the determination of whether the patient is at risk and potentially a high utilization health care consumer, the availability of health care intervention programs, and the enrollment of the patient in the appropriate program is performed with the assistance of an automated computer expert system rather than the physician, the nurse, the survey taker, or the other health care personnel.

16. An interactive computer assisted method according to claim 13, where when the at least one core survey is administered, the determination of whether the patient is the high utilization health care consumer, the availability of health care intervention programs, and the enrollment of the patient in the appropriate program is performed with the assistance of an automated computer expert system to be used in conjunction with, or by, the physician, the nurse, the survey taker, or the other health care personnel.

17. An interactive computer assisted method of reviewing, analyzing, and compiling patient profile information from a plurality of different sources into a centralized patient profile database, including an interactive survey designed to identify high utilization health care consumers, said method comprising the steps of:

(a) storing questions for the interactive survey of a patient to assess the utilization of health care;

(b) storing rules for determining if the patient is likely to be the high utilization health care consumer, and storing patient eligibility information;

(c) periodically accessing the patient profile information from the centralized patient profile database and determining if at least one core survey was completed during a predetermined time interval, the patient profile information including one or more of the following;

at least current medications, medication use pattern, over the counter medication use, patient understanding of treatment goals, adverse effects, compliance history, medical history, family history, hospitalization history, pertinent laboratory work, patient demographics, patient behavior and lifestyle risk factor information, and the response to the at least one core survey;

(d) storing in the patient profile database at least one answer to the interactive survey of the patient;

(e) utilizing the patient profile information stored in the centralized patient profile database and information received in said periodically accessing to update core questions, and querying a predetermined number of the patients using at least one of the core survey and the updated core questions to determine which of the patients are likely to be the high utilization health care consumers by interactively presenting the questions to the predetermined number of the patients, and at least one of reordering the priority of questions based on answers to the questions received from the predetermined number of the patients and automatically selecting at least one of a plurality of the questions and additional questions based on previous answers;

(f) determining, using the computer, if the patient is likely to be the high utilization health care consumer responsive to at least one of said utilizing and responsive to the at least one answer and the rules;

(g) determining, using the computer, whether at least one intervention program may reduce health care utilization and improve health of the patient;

(h) determining if the patient is eligible for the at least one intervention program responsive to the patient eligibility information;

(i) when the patient is eligible, enrolling the patient in the at least one intervention program or other health care program;

(j) generating, responsive to said enrolling, reports on the at least one intervention program including patient drug utilization, patient evaluation, patient health, comparisons with respect to desired patient health, patient satisfaction, and other information; and

(k) periodically updating, the patient profile information, and periodically modifying the rules for determining the high utilization health care consumer.

18. An interactive computer assisted method according to claim 17, wherein said determining step further comprises the steps of:

(1) determining from a review of the centralized patient profile database which patient to call as part of the survey;

(2) interactively evaluating based on the response to the questions, if the patient is the potential high utilization health care consumer;

(3) determining if there are intervention programs which could reduce utilization and improve health of the patient;

(4) determining if the patient is eligible for such programs;

(5) if eligible, enrolling the patient in the intervention program or other health care program;

(6) generating at least one report;

(7) updating the patient profile and the centralized patient profile database.

19. An interactive computer assisted method according to claim 17, where when the at least one core survey is administered, the determination of whether the patient is at risk and potentially a high utilization health care consumer, the availability of health care intervention programs, and the enrollment of the patient in the appropriate program is performed with the assistance of an automated computer expert system rather than the physician, the nurse, the survey taker, or the other health care personnel.

20. An interactive computer assisted method according to claim 17, when the at least one core survey is administered, the determination of whether the patient is the high utilization health care consumer, the availability of health care intervention programs, and the enrollment of the patient in the appropriate program is performed with the assistance of an automated computer expert system to be used in conjunction with, or by, the physician, the nurse, the survey taker, or the other health care personnel.

21. An interactive computer assisted method of reviewing, analyzing, and compiling patient profile information from a plurality of different sources into a centralized patient profile database, including an interactive survey designed to evaluate health status and identify high utilization health care consumers, said method comprising at least one of the sequential, non-sequential and sequence independent steps of:

(a) storing, using the computer, interactive questions for the interactive survey of the patients to assess whether the patient is at least one of a low, medium, and high utilizer of health care wherein the survey questions are interactively modified, priority of questions reordered based on answers to the questions, and questions are automatically determined based on previous answers, and storing patient eligibility information;

(b) storing rules determining which of the patients are likely to become the high utilization health care consumer responsive to said developing step (a);

(c) periodically accessing the patient profile information from the centralized patient profile database, the patient profile information including at least current medications, medication use pattern, over the counter medication use, patient treatment goals, adverse effects, compliance history, medical history, family history, hospitalization history, laboratory work, patient demographics, patient behavior and lifestyle risk factor information, and the response to the at least one core survey;

(d) storing in the centralized patient profile database at least one answer to the interactive survey of the patient;

(e) utilizing the patient profile information stored in the centralized patient profile database to update core questions, and querying a predetermined number of the patients using at least one of the core survey and the updated questions to determine which of the patients are at risk responsive to the at least one answer by interactively presenting the questions to the predetermined number of patients, and at least one of reordering the priority of the questions based on answers to the questions received from the predetermined number of the patients and automatically selecting at least one the plurality of questions and additional questions based on previous answers;

(f) determining, using the computer, whether the patient is at risk;

(g) determining, using the computer, whether at least one intervention program may reduce health care utilization and improve health of the patient responsive to the patient profile, the at least one answer and the rules;

(h) determining, using the computer, if the patient is eligible for the at lest one intervention program responsive to the patient eligibility information;

(i) when the patient is eligible, enrolling the patient in the at least one intervention program;

(j) generating reports on the state of the at least one intervention program including patient drug utilization, patient evaluation, patient health, comparisons with respect to desired patient health; and

(k) periodically updating the patient profile information and periodically modifying the rules for determining the high utilization health care consumer.

22. An interactive computer assisted method according to claim 21, where when the at least one core survey is administered, the determination of whether the patient is at risk and potentially a high utilization health care consumer, the availability of health care intervention programs, and the enrollment of the patient in the appropriate program is performed with the assistance of an automated computer expert system rather than the physician, the nurse, the survey taker, or the other health care personnel.

23. An interactive computer assisted method of reviewing, analyzing, and compiling patient profile information from a plurality of different sources into a centralized patient profile database, including an interactive survey designed to identify high utilization health care consumers, said method comprising at least one of the sequential, non-sequential and sequence independent steps of:

(a) storing interactive questions for the interactive survey of the patients to assess the utilization of health care wherein the survey questions are interactively modified, priority of questions reordered based on answers to the questions, and questions are automatically determined based on previous answers, and storing patient eligibility information;

(b) conducting the at least one core survey and assessing whether the patient is at risk using an electronic communication as part of a demand care system, said conducting step comprising the steps of;

(1) administering the at least one core survey via the Internet;

(2) interactively evaluating, using the computer, based on the response to the questions, if the patient is the high utilization health care consumer by interactively presenting the questions to the patient, and at least one of reordering the priority of questions based on answers to the questions received from the patient and automatically selecting at least one of a plurality of the questions and additional questions based on previous answers;

(3) storing in the centralized patient profile database at least one answer to the interactive survey of the patient;

(4) determining, using the computer, if there are other intervention programs which could reduce utilization and improve health of the patient responsive to the at least one answer;

(5) determining if the patient is eligible for the other intervention programs responsive to the patient eligibility information;

(6) when eligible, enrolling the patient in the intervention program or the other intervention program via the Internet;

(7) generating at least one report; and

(8) updating the patient profile and the centralized patient profile database;

(c) updating rules for determining which of the patients are likely to be the high utilization health care consumer;

(d) accessing the patient profile information, drug claims records, self-reported information, medical claims records, general demographic data, eligibility data, and demand for medical services from the centralized patient profile database and determining if at least one core survey was completed during a predetermined time interval, the patient profile information including, when present, at least current medications, medication use pattern, over the counter medication use, patient treatment goals, adverse effects, compliance history, medical history, family history, hospitalization history, laboratory work, patient demographics, patient behavior and lifestyle risk factor information, and the response to the at least one core survey;

(e) utilizing the patient profile information stored in the centralized patient profile database to update core questions, and querying a predetermined number of the patients using the core survey and the updated core questions to determine which of the patients are likely to be the high utilization health care consumers;

(f) predicting if the patient is likely to be the high utilization health care consumer, and wherein said predicting is accomplished by a computer analyzing the centralized patient profile database, wherein the predicting if the patient is likely to be high utilization health care consumer, the availability of health care intervention programs, and the enrollment of the patient in the appropriate program is performed with the assistance of an automated computer expert system; and

(g) automatically presenting to the patient at least one of an intervention program, drug therapy program, and therapy program predicted by the computer to reduce health care utilization and improve health of the patient.

24. An interactive computer assisted method according to claim 23, when the at least one core survey is administered, the determination of whether the patient is the high utilization health care consumer, the availability of health care intervention programs, and the enrollment of the patient in the appropriate program is performed with the assistance of an automated computer expert system to be used in conjunction with, or by, the physician, the nurse, the survey taker, or the other health care personnel.

25. An interactive computer assisted method of reviewing, analyzing, and compiling patient profile information from a plurality of different sources into a centralized patient profile database, including an interactive survey designed to evaluate the health status of a health care consumer, said method comprising the steps of:

(a) storing interactive questions for the interactive survey, at least one answer to the interactive survey of the patient and rules for determining if the patient is likely to be a high utilization health care consumer, and storing patient eligibility information;

(b) utilizing, using the computer, the patient profile information stored in the centralized patient profile database to update core questions, and querying a predetermined number of the patients using at least one of the core survey and the updated core questions to determine if the patient is at risk responsive to the at least one answer by interactively presenting the questions to the predetermined number of the patients, and at least one of reordering the priority of questions based on answers to the questions received from the predetermined number of the patients and selecting at least one of a plurality of the questions and additional questions based on previous answers;

(c) determining, using the computer, if the patient is likely to be the high utilization health care consumer responsive to the patient profile information, the at least one answer and the rules;

(d) determining, using the computer, whether at least one intervention program may reduce health care utilization and improve health of the patient using the results from said survey and said patient profile when the patient is determined to likely be a high utilization health care consumer;

(e) determining if the patient is eligible for the at least one intervention program responsive to the patient eligibility information;

(f) when the patient is eligible for the at least one intervention program, enrolling the patient in the at least one intervention program or other health care program;

(g) generating, responsive to said enrolling, reports on the at least one intervention program including patient drug utilization, patient evaluation, patient health, comparisons with respect to at least one of desired patient health, patient satisfaction, and other information; and

(h) updating patient profiles, and periodically modifying the rules for determining the risk behaviors for the high utilization health care consumer.