Abstract:
An apparatus and method for processing health care transactions through a common interface in a distributed computing environment using specialized remote procedure calls. The distributed computing environment includes a user interface tier for collecting user inputs and presenting transaction outputs, a data access tier for data storage and retrieval of health care transaction information, a transaction logic tier for applying a predetermined set of transaction procedures to user inputs and health care transaction information resulting in transaction output, an electronic network connecting the user interface tier, data access tier and transaction logic tier to each other and a communication interface for exchanging health care transaction information among the tiers. The communication interface includes an interface definition language generating transaction-specific communication codes whereby data is exchanged through a common interface structure regardless of the origin of the data.

Description:
FIELD OF THE INVENTION 
     The present invention relates generally to the field of computer-implemented data processing systems. More specifically, the present invention is directed to an apparatus and method for processing health care transactions through a common interface in a distributed computing environment. 
     BACKGROUND OF THE INVENTION 
     The use of computer systems to process health care transactions is widespread. This is the problem. Each generator of health care transactions stores information particular to its needs in a database format optimized for its processes in a computer environment developed from its technical skill level, growth and history. 
     For example, hospitals store a wealth of information on each patient, health care provider and medical intervention occurring within its walls. Hospitals store information such as, for example, in-patient and out-patient records (including patient charts), doctor privileges, nurse care schedules, operating room schedules and equipment inventories. Traditionally, hospitals transmit only as much of this information to health care insurers as needed to be reimbursed for health care costs. 
     In another example, physician offices also keep electronic records on each patient. Such information may include patient&#39;s personal data, patient immunization records, patient health history records and details about each patient visit. Again, health care providers typically transmit only as much of this information to health care insurers as needed to be reimbursed for health care costs. 
     In another example, dental offices also keep electronic records on each patient. Such information may include patient&#39;s personal data, patient dental cleaning history, records of upcoming appointments, patient health history records and details about each patient visit. Again, dental care providers typically transmit only as much of this information to health care insurers as needed to be reimbursed for dental care costs. 
     In yet another example, pharmacies keep electronic records concerning patient prescriptions, patient allergies and patient personal data. Again, pharmacies typically transmit only as much of this information to health care insurers as needed to be reimbursed for pharmacy costs. 
     The information requesting reimbursement for health care provided to a patient typically is transferred to the health care insurer in the form of a claim. The exact format of a claim takes many different electronic forms depending on the entity that generates the claim. A health care provider entity may be, for example, a hospital, physician office, dentist office or pharmacy. In addition, some claims pass through third party claims clearinghouses before being accepted by the health care insurer which may further change their electronic format. Payment obligations may pass to claims clearinghouses, other insurers, or a financial institution. 
     The data transfer itself may occur through very different transfer protocols and data error detection processes resulting in transforming data into even different formats. 
     The difficulty of communicating among different types of information stored in different electronic structures in different electronic environments is compounded when that information may be encrypted and/or compressed as well using different encryption and compression schemes. 
     In addition, the information itself may be stored in different human languages. Claims generating from a hospital in France are written in French in addition to the French data being encoded in a different database format in a different computer environment. For example, the common format for recording a date in the United States is month/day/year but in Europe, the common format is day•month•year. Though a perhaps minor difference, the erroneous transposition of the month and day in a data format would seriously undermine the integrity of all the records of an entire file. 
     There is a continued need for a system capable of communicating between a multiplicity of different computer environments. 
     SUMMARY OF THE INVENTION 
     The present invention is an apparatus and method for processing health care transactions through a common interface in a distributed computing environment. In particular, the present invention provides seamless communication between different computer systems and the data stored within each system through the use of specialized remote procedure calls. 
     It is a primary objective of the present invention to provide a common interface structure for processing health care transactions, regardless of the data&#39;s native format, compression, encryption, native language, country of origin, or operating environment of origin. 
     It is another objective of this invention to minimize computing time and resources in processing health care transactions. 
     It is a further objective of this invention to provide flexible system architecture for processing health care transactions in a constantly changing world. 
    
    
     BRIEF DESCRIPTION OF THE DRAWINGS 
     FIG. 1A is a block diagram showing the computer processing system of the preferred embodiment of the present invention. 
     FIG. 1B is a block diagram showing the computer processing system of an alternate embodiment of the present invention. 
     FIG. 2 is a block diagram showing different subsystems operating with the computer processing architecture depicted in FIG. 1. 
     FIG. 3 is an illustration of example service requests generated in accordance with the present invention. 
     FIG. 4 is a flowchart describing the general method for processing client and server stubs. 
     FIG. 5 is a flowchart describing the general method for processing health care transactions in accordance with the present invention. 
     FIG. 6 is a flowchart depicting the Validation step of FIG. 5 in greater detail. 
     FIG. 7 is a user interface screen depicting user entry of data in the provider contracting subsystem. 
     FIG. 8 is a user interface screen depicting entry of a data request in the provider contracting subsystem. 
     FIG. 9 is a user interface screen depicting the on-line response to the data request of FIG. 8. 
     FIG. 10 is a block diagram showing the logical relationships among data within the provider contracting subsystem. 
     FIG. 11 is a block diagram of the member enrollment subsystem. 
    
    
     DETAILED DESCRIPTION OF THE INVENTION 
     The present invention provides a system for processing health care transactions in response to a user&#39;s request in a heterogeneous computing network. This is accomplished with an international managed care administrative system architecture. 
     The preferred embodiment of the present invention is implemented in a heterogeneous computer network environment that divides applications into parts or tiers that can be run independently on multiple systems that are connected via a network. More specifically, referring now to the drawings, wherein like reference numerals denote like elements throughout the several views, FIGS. 1A and 1B show block diagrams of a computer network 10 including several networked systems 12. 
     The applications 14 operating within systems 12 are developed using a three-tiered architecture. Each network system 12 implements applications 14 including a user interface tier 16, business logic tier 18, data access tier 20 and communication interface 22. The systems 12 are connected through a network connection 24. 
     Each application tier 16, 18, 20 may be implemented on a separate computer system 24 within the network system 12 such as shown in FIG. 1A. The computer system 12 running one application tier may be completely different from the computer system on which another tier is running. In the preferred embodiment, referring to FIG. 1A, each application tier 16, 18, 20 is implemented on an independent computer system 12 networked in a client/server environment. In an alternated embodiment, one or more of the application tiers 16, 18, 20 may be running in the same computer system 12 as shown in FIG. 1B. 
     In the context of this disclosure, the systems 12 to which the terms client and server are attached include programs that are running on some machine connected to a network. More specifically, a &#34;server&#34; is a program that advertises services it is capable of providing and a &#34;client&#34; is any program that requests services from one or more servers. In many cases a server is also a client of other servers in the network 10. 
     In the preferred embodiment, user interface tier 16 is implemented on a personal computer providing a graphical user interface (GUI). More specifically, in the preferred embodiment, the personal computer functions under an operating system consistent with Microsoft Windows operating system standards and is configured, at a minimum, with an Intel &#39;386 processor chip or its equivalent and 8 MB RAM. 
     Business logic tier 18 is implemented on a server system in the preferred embodiment. It is understood that the server system may be a computer system 12 of any size from personal computer to mainframe to supercomputer depending on the computer resources required. In the preferred embodiment, the business logic server system is implemented on Unix computer systems, such as, IBM RS/6000 running AIX 3.2.5 and programmed in ANSI C and SQL (Structured Query Language). 
     Data access tier 20 is implemented in a database system. It is understood that the database system can be maintained in a computer system 12 of any size from personal computer to supercomputer, depending on the nature and volume of the data stored. In the preferred embodiment, the database system is a relational database server utilizing SQL for database access, such as the one vended by Sybase Corporation, in a UNIX operating environment. 
     The use of the three-tiered architecture accommodates the scalability of applications. Desired functionality extends to operate on a number of computer systems 12 throughout the network. Portability of applications from one system 12 to another is enhanced within the three-tiered architecture of the distributed computer network environment because of the modular structure of the applications. The modular design encapsulates each application 14 and its operation such that much of the application&#39;s operation and implementation information is hidden from a user. Each application 14 uses an interface to present its abstractions cleanly with no extraneous implementation information. Thus, applications are scalable to the environment in which they reside as long as a clean interface is maintained. 
     Communication interface 22 provides the standard mechanism for inter-tier communication. Rigorous definition of the communication interface 22 allows one tier of an application to be replaced without effecting other tiers. The replaced portion of the application is kept current with the latest technologies without requiring rewriting of an entire application each time one part is upgraded. For example, the user interface tier 16 can be independently replaced with a different technology or system 12 without affecting the business logic 18 or data access 20 tiers. 
     In the preferred embodiment, communication interface 22 is implemented via remote procedure calls (RPCs). The RPCs are implemented through the use of Open Environment Corporation&#39;s (OEC) Entera product consistent with Open Software Foundation&#39;s Distributed Computing Environment (DCE). DCE defines a vendor-independent definition of RPC communication in a heterogeneous, distributed network. Use of DCE provides a robust, open systems definition for client/server communications. In the preferred embodiment, the communication interface 22 transfers data among the tiers 16, 18, 20 over standard TCP/IP (Transmission Control Protocol/Internet Protocol) connections. Tiers 16, 18, 20 provide processing for health care transactions. 
     Referring to FIG. 2, health care transactions can originate from many different sources or clients, such as, for example, enrollment subsystems 26, billing subsystems 28, benefits subsystems 30, provider contracting subsystems 32, provider network management 34, claims processing subsystems 36, security and authorization subsystems 38, check processing subsystems 40, customer service subsystems 42, case management subsystems 44, cost containment subsystems 46, provider electronic data interchange (EDI) subsystems 48 and/or browser subsystems 50. It is understood that each subsystem 26-50 may be maintained on completely different computer hardware systems from the other subsystems. Each hardware configuration operates with its own operating system environment storing information in potentially widely varying data formats. 
     Depending on the health care transaction processed, the client request for the transaction service is sent to an appropriate server for the requested information. Servers include, for example, the business logic tier 18 and data access tier 20 of the enrollment subsystems 26, billing subsystems 28, benefits subsystems 30, provider contracting subsystems 32, provider network management 34, claims processing subsystems 36, security and authorization subsystems 38, check processing subsystems 40, customer service subsystems 42, and case management subsystems 44. 
     The requests for transaction service are generally implemented as remote procedure calls (RPCs). Remote procedure calls are ideally suited to handling multiplicity of health care transactions. Once modified to handle health care transactions, RPCs provide a method for communication among systems with very different types of data maintained in very different formats and computing environments while maintaining the integrity and character of that data. Though the client request is generated in one computer system 12 or subsystem 26-50 and the requested information lies within another computer system 12 or subsystem 26-50, the communication interface 22 provides a common interface for completing the transaction service requested by the RPC. 
     More specifically, referring to FIG. 3, as each application within tier 16, 18, 20 is added to network 10, an interface communication file 52 is created for each client program 54 and each remote server procedure 56. The interface communication file 52 generates communications code 58. The generated communications code 58 is referred to as client stubs 60 and server stubs 62. In the preferred embodiment, client stub 60 and server stub 62 are incorporated into applications 54, 56. With OEC Entera product, client stubs 60 are generated in PowerBuilder™, C, or perl, depending on the need. Server stubs 62 are generated in C and perl. 
     Use of a common communication interface 22 in the system architecture of the present invention enables the use of open systems technologies, adherence to international data processing standards and internationalization standards while utilizing an architecture that promotes vendor independence. This distributed computing model can operate in both a local area network as well as over a wide-area network or over the Internet. 
     In the preferred embodiment, the RPCs have been modified to generate health care transaction-specific client stubs 60 and server stubs 62. The client and server stubs generators 52 are incorporated into applications during the compilation process. More specifically, the incorporation process occurs automatically through the use of specialized compilation tools. 
     In particular, the specialized compilation tools have been implemented as a set of makefile templates for use in building servers. The makefile templates primarily contain macro definitions for the UNIX MAKE facility. These definitions provide information required by MAKE to compile and package a server. Sample makefile templates with common rules to build servers and clients are included in Appendix A. 
     It is understood that the contents of any macro will change depending on the application developed. For example, typical macros in the makefile templates include macros named SERVER, DB --  NAME, APPL --  NAME. The SERVER macro defines the name of the server. The DB --  NAME macro defines the name of the database to be accessed by an SQL server. The APPL --  NAME macro defines the name of the application. The particular macros used and the values assigned to them vary according to the type of server. For example, a server build in an SQL environment with C code uses one makefile template while a server built with embedded SQL requires a different template and a server built using C code uses a different template. 
     Once a server is built and logged on to the network 10, the server is ready to process requests from a client. The type of requests that the server will process depends on whether the server supports applications 14 for the user interface tier 16, business logic tier 18 or data access tier 20. 
     In operation, when a client makes a request for a service from a server, communication interface 22 provides the information to the server in the format that it requires to perform the service requested. More specifically, the communication interface 22 connects the client with the appropriate server and passes information between the server and client through client/server stubs 60, 62 generated during the request process. The client/server stubs 60, 62 are generated from interface specifications 52 coded during the compilation process according to the makefile templates. This generated stub code insulates the application developer from the underlying complexities of network programming. 
     Referring to FIGS. 3-6, the request process is initiated when a client makes a request for service (step 100 of FIG. 4). Typically, the request is initiated as an ordinary function call in the operation of the client application. For example, referring to FIG. 3, the client program 54 requests membership information 64. For convenience, the reference numbers of the elements of FIG. 3 will be used to aid in the description, however, it is understood that the example depicted in FIG. 3 is only an example and that many other types of requests are made within a health care transaction network 10. For example, request 64 for member enrollment information may be made by program 54 in the benefit subsystem 30. The benefit subsystem 30 holds information regarding benefit plans. Benefit plans define what services are covered and at what level each service is covered. Following this example and referring to FIG. 3, the benefit subsystem 30 is the client and the enrollment subsystem 26 is the server. Broadly, enrollment subsystem 26 processes benefit subsystem&#39;s 30 client request for member enrollment information and returns the information to benefit subsystem 30 appended to server stubs 62. 
     Referring to FIG. 4 for general functionality, client application makes a service request 64 (step 100). Client stub 60 is generated (step 102). Client stub 60 includes information for the remote procedure call, handling of input arguments and understanding of the client/server context. 
     Next, the client stub 60 locates the appropriate server to handle the request (step 104). If the client does not know the location of the appropriate server, client stub 60 queries a directory server for the list of locations (hostnames and ports) where a server is available. The directory server listens for client requests and maintain a list of locations of servers registered with the directory server. In response to the client stub 60 query, directory server returns the address(es) of available servers in the network 10. The client stub 60 caches the server address(es) for future requests and for redundancy purposes. If the address of the appropriate server is already cached, client stub 60 uses the cached information to locate the server. 
     After client stub 60 has located a server (step 104), it sends the client input arguments through the network 10 to its corresponding server stub 62 (step 106). The input arguments typically include a security ticket validating the client. The server then processes the request (step 108). More specifically, server stub 62 unpacks the input arguments and calls the function desired by the client application. For example, in FIG. 3, server program function 66 checks on membership status. Server function 66 returns output arguments (and any error parameters) to the server stub 62 which passes them back to the client stub 60 (step 110). Client stub 60 processes response to the request (step 112). More specifically, the client stub 60 unpacks the output arguments and returns them to the client application (step 112). 
     It is understood that whether the process is defined as a client process or a server process depends on the context and perspective of the client and server. For example, a server can make requests to other servers, making the process both a server and a client process. Generally, client stubs 60 are responsible for locating a server to handle the request, packaging input arguments and passing them over the network 10 to the server with the validation ticket, waiting for the server to reply and unpacking the return value and output arguments returned by the server. Server stubs 62 are responsible for listening for client requests, unpacking the input arguments, validating server access, calling server function, packaging the return value and output arguments returned by the server code, recording audit information, gathering performance data and passing return value and output arguments back to client stub 60 over network 10. 
     Referring to FIG. 5, when a client first makes a request, the network 10 first checks that the client is valid (step 114). Once the client is validated, the client requests can be sent through the network 10 (step 116) for processing by a server (step 118) to receive the appropriate output (step 120). 
     Referring to FIG. 6, the validation step 114 of FIG. 5 is depicted in greater detail. Validation step 114 starts by verifying that the client is connected to the network 10 (step 122). Then, network 10 checks that the client has been authenticated (step 124). More specifically, the network 10 checks whether the client has a valid ticket to request network services. The client stub must present a valid network-generated ticket when making a service request. Those skilled in the art will recognize that the form and contents of a valid ticket may vary depending on the security requirements of network 10. 
     Once the network 10 authenticates the client, the server checks whether or not the client is authorized to use the interfaces in the server (step 126). More specifically, the server verifies that the specified user is a member of a group that has permissions to perform the requested operation by comparing the ticket contents against the server&#39;s own database access control information. 
     Examples of the specific types of requests made and data flowing through a health care transaction network 10 are shown in FIGS. 7-11. FIGS. 7-10 show the provider contracting subsystem 32 which provides data management functions to build and maintain provider contracting definitions. Definitions managed within the provider contracting subsystem 32 include, for example, information about: health care providers, including physicians, hospitals and dentists; reimbursement agreements between providers and a company; effective dates; contracting entity; contracting companies; fee schedules and rates; rate type, such as, per diem, per hour, per stay, percentage; fee maximums; procedure codes; hospital categories; government health care program information, such as, Medicaid and Medicare; and data relating to costs associated with a medical service but for which a claim has not yet been received. 
     More specifically, for example, for the fee schedule, the data captured is the rate schedules used by the providers. In particular, the information stored includes a unique id for the fee schedule, a free form description of the schedule, the procedures and maximum fee rates for each procedure code covered in a fee schedule, and a resource based relative value scale rate (pre-determined). 
     The data may be entered in different formats. In the preferred embodiment, the data is entered as shown in FIG. 7. For example, demographic parameters for a particular health care procedure code include the type of procedure 130, specific procedure code 132, text description of procedure code 134, the effective and expiration dates for the use of procedure code 136, any gender limitation for procedure 138, any age limitation for the procedure entered as the limits of an age range 140 and information as to whether additional description is required 142. The specific procedure code is obtained from standard listing of procedure codes updated annually by national medical and insurance associations. Different demographic parameters are required for dental procedures 144. 
     Requests for procedure code fee schedule information are made as shown in FIG. 8. Procedure code information can be obtained by searching for a given procedure type 130, a particular procedure code or range of procedure codes 132 and/or procedure description 134. Procedure code fee information is returned, as shown, for example, in FIG. 9. In FIG. 9 the information is sorted by contract unit 146 and fee schedule 148. Procedure code data is stored in a database system. It is understood that the database system may be a single database system or different database systems. FIG. 10 shows the interconnectiveness of the data, its general storage and access relation to other files. Appendix B provides an example data dictionary listing variable names and descriptions. 
     In another example, enrollment subsystem 26 establishes and maintains individual membership health care plan enrollment records. Referring to FIG. 11, first a contract for managed care services is signed between an account and a managed care organization (step 150). An account may be an individual, family or company. Next, the contract information is entered into the subsystem 26 (step 152). Next, enrollment form information, provided by each individual member, is entered into the subsystem 26 (step 154). Enrollment additions, changes and terms are each entered as a transaction to the enrollment subsystem 26 (step 156). Enrollment information is retrieved from the enrollment subsystem 26 as needed by other subsystems such as, for example, the benefit subsystem 30. 
     Although the description of the preferred embodiment has been presented, it is contemplated that various changes could be made without deviating from the spirit of the present invention. Accordingly, it is intended that the scope of the present invention be dictated by the appended claims, rather than by the description of the preferred embodiment. ##SPC1##