System and method for clinical strategy for therapeutic pharmacies

• US 8,478,611 B2
• Filed: 05/04/2010
• Issued: 07/02/2013
• 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: Epstein, Robert S., Anand, Tej, Anderson, Roger, Klepper, Kenneth, Proulx, Mark
• Primary Examiner(s): O'Connor, Gerald J.
• Assistant Examiner(s): NGUYEN, TRANG T
• Application Number:
  US12/773,567
• Publication Number:
  US 20100217626A1
• Time in Patent Office: 1,155 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 comprising:

receiving a pharmaceutical prescription associated with a patient;

accessing, on a processor, a medical record and a plurality of prescription claims for the patient;

analyzing, on the processor, the medical record and the plurality of prescription claims to stratify the patient into a wellness category, the wellness category being based on a disease state, the disease state being based on a medical category;

analyzing, on the processor, at least some of the plurality of prescription claims of the patient to determine a number of unique drugs obtained by the patient, to identify concurrent drug utilization review (CDUR) alert protocols that have a specific resolution code, to identify listed therapy optimization and omission of therapy rules that have triggered an alert, and to determine whether the patient is late with prescription refilling;

generating, on the processor, a patient clinical score based on the a determination of the number of unique drugs obtained by the patient, an identification of the CDUR alert protocols that have a specific resolution code, an identification of the listed therapy optimization and omission of therapy rules that have triggered an alert, a determination that the patient is late with prescription refilling, the medical record, formulary information, and patient health insurance information; and

routing, on the processor, the pharmaceutical prescription to a therapeutic pharmacy among a network of therapeutic pharmacies based on the wellness category and the patient clinical score, each therapeutic pharmacy within the network of therapeutic pharmacies being established in accordance with a particular wellness category.

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

3. The method according to claim 1, wherein the wellness categories include a well category, an acute category, a chronic category, and a complex category.

4. The method of claim 1, further comprising:

filling and dispensing the pharmaceutical prescription at the therapeutic pharmacy.

5. The method of claim 1, further comprising:

assigning the pharmaceutical prescription to a pharmacist among a plurality of pharmacists in the therapeutic pharmacy based on skill and ability of the pharmacist.

6. The method of claim 5, wherein assignment of the pharmaceutical prescription is based on the skill and ability of the pharmacist and load balancing, the load balancing being based on current work load, schedule, and productivity rate of the plurality of pharmacists.

7. The method of claim 1, wherein the pharmaceutical prescription is received at a pharmacy intake center and the plurality of prescription claims are accessed from an information warehouse.

8. The method of claim 1, wherein routing the pharmaceutical prescription to the therapeutic pharmacy is based on the wellness category, the patient clinical score, and load balancing, the load balancing being based on current work load, schedule, and productivity rate.

9. The method of claim 1, wherein the pharmaceutical prescription is received over a computer network.

10. The method of claim 1, wherein the therapeutic pharmacy is capable of filling the pharmaceutical prescription for the patient.

11. The method of claim 1, wherein the processor is deployed with a computing device, the computing device configured to resolve protocol and perform drug utilization review for the subsequent filling and dispensing prescriptions for one or more diseases.

12. The method of claim 1, wherein the therapeutic pharmacy is further established to dispense a plurality of prescription drugs associated with the wellness category, the pharmaceutical prescription being for a prescription drug among the plurality of prescription drugs.

13. The method of claim 1, wherein the patient clinical score reflects a relative level of compliance by the patient with a medication associated with the pharmaceutical prescription.

14. The method of claim 1, wherein the patient clinical score reflects a relative level of possibility for the patient to utilize a less costly medication than a medication associated with the pharmaceutical prescription.

15. The method of claim 1, wherein the medical record and the plurality of prescription claims are further analyzed to stratify the patient into a disease category, and wherein the routing of the pharmaceutical prescription is based on the disease category, the wellness category, and the patient clinical score.

16. The method of claim 1, wherein the therapeutic pharmacy is capable of filling a prescription associated with the disease state.

17. The method of claim 1, wherein at least some of the plurality of prescription claims are the plurality of prescription claims associated with a certain period of time.

18. The method of claim 1, wherein routing comprises:

routing, on the processor, the pharmaceutical prescription to the therapeutic pharmacy among the network of therapeutic pharmacies based on a disease state associated with the patient, the wellness category, and the patient clinical score, each therapeutic pharmacy within the network of therapeutic pharmacies being established in accordance with a particular wellness category and a particular disease state, the therapeutic pharmacy to which the pharmaceutical prescription is routed having the disease state of the patient as the particular disease state.

19. A non-transitory machine-readable medium comprising instructions, which when executed by one or more processors, cause the one or more processors to perform the following operations:

receive a pharmaceutical prescription associated with a patient;

access a medical record and a plurality of prescription claims for the patient;

analyze the medical record and the plurality of prescription claims to stratify the patient into a wellness category, the wellness category being based on a disease state, the disease state being based on a medical category;

analyze at least some of the plurality of prescription claims of the patient to determine a number of unique drugs obtained by the patient, to identify concurrent drug utilization review (CDUR) alert protocols that have a specific resolution code, to identify listed therapy optimization and omission of therapy rules that have triggered an alert, and to determine whether the patient is late with prescription refilling;

generate a patient clinical score based on the a determination of the number of unique drugs obtained by the patient, an identification of the CDUR alert protocols that have a specific resolution code, an identification of the listed therapy optimization and omission of therapy rules that have triggered an alert, a determination that the patient is late with prescription refilling, the medical record, formulary information, and patient health insurance information; and

route the pharmaceutical prescription to a therapeutic pharmacy among a network of therapeutic pharmacies based on the wellness category and the patient clinical score, each therapeutic pharmacy within the network of therapeutic pharmacies being established in accordance with a particular wellness category.