Methods and systems for disease management care coordination

• US 8,799,030 B1
• Filed: 12/28/2011
• Issued: 08/05/2014
• Est. Priority Date: 01/21/2011
• Status: Active Grant

• Current Assignee: Express Scripts Strategic Development, Inc. (The Cigna Group)
• Original Assignee: Express Scripts Incorporated (The Cigna Group)
• Inventors: Chen, Michael Z., Hilstrom, Ann, Grillo, Anthony L.
• Primary Examiner(s): Ebersman, Bruce I
• Application Number:
  US13/338,860
• Time in Patent Office: 951 Days
• US Class Current: 705/4
• 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 20/10 relating to drugs or medications, e.g. for ensuring correct administration to patients
• CPC Class Codes: G16H 50/30 for calculating health indices; for individual health risk assessment
• CPC Class Codes: G16H 80/00 ICT specially adapted for facilitating communication between medical practitioners or patients, e.g. for collaborative diagnosis, therapy or health monitoring

Abstract

Methods and systems for disease management care coordination are described. In one embodiment, claim data associated with a prescription drug is integrated with additional health data from a plurality of data feeds received from a client device, a care coordination device, and a health management vendor device. The integrated data is targeted to identify a member. The integrated data associated with the member is transmitted to a patient evaluator device. The integrated data is updated using additional member information received from the patient evaluator device. Other methods and systems are described.

Claims

1. A method comprising:

storing, on a processor, an association of prescription drug claim data of a plan member of a pharmacy benefit plan with additional health data of the member from a plurality of data feeds received from a client device associated with a client of a pharmacy benefit manager, a care coordination device associated with a care coordinator that facilitates communication among a plurality of healthcare entities to address population pharmacy issues on behalf of the client, and a health management vendor device associated with a health management vendor to create integrated data associated with the member, the pharmacy benefit manager administering the pharmacy benefit plan for the member on behalf of the client;

accessing, on the processor, targeting data including a plurality of clinical-defined queries;

running, on the processor, the plurality of clinical-defined queries on the integrated data to identify a plurality of opportunity-available members as having an opportunity for clinical outreach;

determining, on the processor, for each of the plurality of opportunity-available members a prescription drug spend, a number of concurrent open healthcare coordinator cases, and a pill burden threshold;

calculating, on the processor, for each of the plurality of opportunity-available members a predicted adherence risk score for a disease state;

calculating, on the processor, a total risk score for each of the plurality of opportunity-available members based on the prescription drug spend, the number of concurrent open healthcare coordinator cases, the pill burden threshold, and the predicted adherence risk score for the disease state;

selecting, on the processor, a high risk member portion among the plurality of opportunity-available members based on the total risk score for each of the plurality of opportunity-available members;

transmitting, on the processor, the integrated data associated with the high risk member portion of the plurality of opportunity-available members to a patient evaluator device, the patient evaluator device associated with a patient evaluator;

updating, on the processor, the integrated data associated with the plan member using additional member information received from the patient evaluator device to create updated integrated data, the additional member information including documentation of clinical outreach performed on the member by the patient evaluator, the plan member being among the high risk member portion of the plurality of opportunity-available members; and

generating, on the processor, a report based on the updated integrated data.

2. The method of claim 1, further comprising:

associating the member with a case designation based on identification of the member as having an opportunity for clinical outreach; and

assigning the case designation to the patient evaluator among a plurality of available patient evaluators.

3. The method of claim 2, further comprising:

receiving an evaluation request from the patient evaluator device, the evaluation request identifying the patient to be evaluated by the patient evaluator;

transmitting a patient profile to the patient evaluator device, the patient profile including trigger data and the integrated data associated with the member;

updating the patient profile using information received from the patient evaluator device; and

generating a response to the evaluation request based on updating the patient profile.

4. The method of claim 2, wherein assignment of the case designation is based on relative experience of the plurality of available patient evaluators, background of the plurality of available patient evaluators, case load of the plurality of available patient evaluators, or combinations thereof.

5. The method of claim 2, further comprising:

running the plurality of clinical-defined queries on the updated integrated data to identify the member as having an additional opportunity for clinical outreach;

transmitting the updated integrated data associated with the member to an additional patient evaluator device, the additional patient evaluator device associated with an additional patient evaluator that is different than the patient evaluator; and

further updating the updated integrated data associated with the member using further additional member information received from the additional patient evaluator device, the additional member information including documentation of the clinical outreach performed on the member by the additional patient evaluator.

6. The method of claim 5, wherein the patient evaluator is associated with clinical outreach for a first disease and the additional patient evaluator is associated with clinical outreach for a second disease state, the first disease state being a different disease state than the second disease state.

7. The method of claim 1, wherein the client associated with the client device is an employer group.

8. The method of claim 1, wherein the additional health data of the member includes demographic information of the member, claims information associated with the member, and historical target information identifying a past instance where the member has been targeted for patient evaluator care coordination.

9. The method of claim 1,

wherein the report is an operational level report including data from the plurality of data feeds associated with the member.

10. The method of claim 1,

wherein the report is a summary level report including data from the plurality of data feeds associated with a plurality of members, the plurality of members including the member.

11. The method of claim 1, further comprising:

providing a data feed of the updated integrated data.

12. The method of claim 1, wherein the additional health data includes lab results, clinical notes, notes associated with outcomes resulting from member interaction, data derived from member interaction, or combinations thereof.

13. The method of claim 1, wherein the additional health data includes medical claims data.

14. The method of claim 1, further comprising:

receiving the additional member information from the patient evaluator device,

wherein updating the integrated data is based on receipt of the additional member information.

15. The method of claim 14, wherein the additional member information received from the patient evaluator device includes information received by the patient evaluator device regarding a communication between the member and the patient evaluator.

16. The method of claim 15, wherein the communication between the member and the patient evaluator is associated with a particular aspect of the integrated data.

17. The method of claim 1, further comprising:

receiving the prescription drug claim data from the care coordination device.

18. The method of claim 1, further comprising:

receiving the prescription drug claim data from an additional care coordination device, the additional care coordination device being a different device than the care coordination device.

19. The method of claim 1, wherein a member population of the client includes the plurality of opportunity-available members and a plurality of additional members.

20. The method of claim 1, wherein a clinical-defined query of the plurality of clinical-defined queries includes patient-inclusive criteria, patient-exclusive criteria, or both patient-inclusive criteria and patient-exclusive criteria for member identification.

21. The method of claim 1, wherein running the plurality of clinical-defined queries on the integrated data associated with the member identifies a plurality of members having an opportunity for clinical outreach, the plurality of members including the member, wherein transmitting the integrated data associated with the member includes transmitting the integrated data associated with the plurality of members to the patient evaluator device, the method further comprising:

receiving member identification of the member from the patient evaluator device,

wherein updating the integrated data associated with the member is based on receipt of the member identification.

22. The method of claim 1, wherein the plurality of clinical-defined queries include a plurality of predefined-clinical queries.

23. 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:

store an association of prescription drug claim data a of a member of a pharmacy benefit plan with additional health data of the member from a plurality of data feeds received from a client device associated with a client of a pharmacy benefit manager, a care coordination device associated with a care coordinator that facilitates communication among a plurality of healthcare entities to address member population pharmacy issues on behalf of the client, and a health management vendor device associated with a health management vendor to create integrated data associated with the member, the pharmacy benefit manager administering the pharmacy benefit plan for the member on behalf of the client;

access targeting data including a plurality of clinical-defined queries;

run the plurality of clinical-defined queries on the integrated data to identify a plurality of opportunity-available members as having an opportunity for clinical outreach;

determine for each of the plurality of opportunity-available members a prescription drug spend, a number of concurrent open healthcare coordinator cases, and a pill burden threshold;

calculate for each of the plurality of opportunity-available members a predicted adherence risk score for a disease state;

calculate a total risk score for each of the plurality of opportunity-available members based on the prescription drug spend, the number of concurrent open healthcare coordinator cases, the pill burden threshold, and the predicted adherence risk score for the disease state;

select a high risk member portion among the plurality of opportunity-available members based on the total risk score for the plurality of opportunity-available members;

transmit the integrated data associated with the high risk member portion of the plurality of opportunity-available members to a patient evaluator device, the patient evaluator device associated with a patient evaluator; and

update the integrated data associated with the member using additional member information received from the patient evaluator device to create updated integrated data, the additional member information including documentation of clinical outreach performed on the member by the patient evaluator, the member being among the high risk member portion of the plurality of opportunity-available members; and

generate a report based on the updated integrated data.

24. The non-transitory machine-readable medium of claim 23, wherein the instructions are further executed by the one or more processors to

associate the member with a case designation based on identification of the member as having an opportunity for clinical outreach;

and

assign the case designation to the patient evaluator among a plurality of available patient evaluators.

25. The non-transitory machine-readable medium of claim 24, wherein the instructions are further executed by the one or more processors to

receive an evaluation request from the patient evaluator device, the evaluation request identifying the patient to be evaluated by the patient evaluator;

transmit a patient profile to the patient evaluator device, wherein the patient profile includes trigger data and the integrated data associated with the member;

update the patient profile using information received from the patient evaluator device; and

generate a response to the evaluation request based on updating the patient profile.

26. The non-transitory machine-readable medium of claim 23, wherein the instructions are further executed by the one or more processors to receive the additional member information from the patient evaluator device,

wherein updating the integrated data is based on receipt of the additional member information.

27. The non-transitory machine-readable medium of claim 23, wherein the instructions are further executed by the one or more processors to receive the prescription drug claim data from the care coordination device.

28. The non-transitory machine-readable medium of claim 23, wherein the instructions are further executed by the one or more processors to receive the prescription drug claim data from an additional care coordination device, the additional care coordination device being a different device than the care coordination device.

29. A system comprising:

a processor and a memory coupled to the processor;

an integration module deployed in the memory and executed by the processor to storing an association of prescription drug claim data of a member of a pharmacy benefit plan with additional health data of the member from a plurality of data feeds received from a client device associated with a client of a pharmacy benefit manager, a care coordination device associated with a care coordinator that facilitates communication among a plurality of healthcare entities to address member population pharmacy issues on behalf of the client, and a health management vendor device associated with a health management vendor to create integrated data associated with the member, the pharmacy benefit manager administering the pharmacy benefit plan for the member on behalf of the client;

a targeting module deployed in the memory and executed by the processor to access targeting data including a plurality of clinical-defined queries and run the plurality of clinical-defined queries on the integrated data to identify a plurality of opportunity-available members as having an opportunity for clinical outreach;

an integrated data transmission module deployed in the memory and executed by the processor to transmit the integrated data associated with the high risk member portion of the plurality of opportunity-available members to a patient evaluator device, the patient evaluator device associated with a patient evaluator;

an allocation module deployed in the memory and executed by the processor to determine for each of the plurality of opportunity-available members a prescription drug spend, a number of concurrent open healthcare coordinator cases, and a pill burden threshold, calculate for each of the plurality of opportunity-available members a predicted adherence risk score for a disease state, calculate a total risk score for each of the plurality of opportunity-available members based on the prescription drug spend, the number of concurrent open healthcare coordinator cases, the pill burden threshold, and the predicted adherence risk score for the disease state, and select a high risk member portion among the plurality of opportunity-available members based on the total risk score for the plurality of opportunity-available members;

an integrated data update module deployed in the memory and executed by the processor to update the integrated data associated with the member using additional member information received from the patient evaluator device to create updated integrated data, the additional member information including documentation of clinical outreach performed on the member by the patient evaluator, the member being among the high risk member portion of the plurality of opportunity-available members; and

a reporting module deployed in the memory and executed by the processor to generate a report based on the updated integrated data.

30. The system of claim 29, further comprising:

an allocation module deployed in the memory and executed by the processor to associate the member with a case designation based on identification of the member as having an opportunity for clinical outreach; and

a tracking module deployed in the memory and executed by the processor to assign the case designation to the patient evaluator among a plurality of available patient evaluators.

31. The system of claim 30, further comprising:

a request receiver module deployed in the memory and executed by the processor to receive an evaluation request from the patient evaluator, the evaluation request identifying the patient to be evaluated by the patient evaluator;

a transmission module deployed in the memory and executed by the processor to transmit a patient profile to the patient evaluator device, the patient profile includes trigger data and the integrated data associated with the member; and

the integrated data update module deployed in the memory and executed by the processor to update the patient profile using information received from the patient evaluator device;

wherein the request receiver module is configured to generate a response to the evaluation request based on updating the patient profile.

32. The system of claim 29, wherein the integration module is further configured to receive the additional member information from the patient evaluator device,

wherein updating the integrated data is based on receipt of the additional member information.

33. The system of claim 29, wherein the integration module is further configured to receive the prescription drug claim data from the care coordination device.

34. The system of claim 29, wherein the integration module to receive the prescription drug claim data from an additional care coordination device, the additional care coordination device being a different device than the care coordination device.