Abstract:
A computerized clinical action system and method supports a comprehensive view of member health status and identification of candidates for numerous clinical actions such as health alerts and clinical interventions. The computerized system and method facilitate clinical action integration and coordination by providing the infrastructure to share key member information among clinical actions. The computerized system and method comprises a clinical guidance exchange (CGX) that receives and accesses member data from a plurality of sources to facilitate creation of integrated member profiles. The CGX further receives and accesses clinical data from a clinical data hub that integrates clinical data from numerous sources. A rules guidance exchange (RGX) facilitates the identification of candidates for clinical actions through the application of clinical and business rules. The RGX assists in identifying the most appropriate actions for a member and routing communications to the member regarding the most appropriate actions.

Description:
CROSS-REFERENCES TO RELATED APPLICATIONS 
       [0001]    This application claims the benefit of U.S. Provisional Patent Application Ser. No. 61/785,437, filed Mar. 14, 2013, titled COMPUTERIZED CLINICAL ACTION SYSTEM AND METHOD, the contents of which is incorporated herein by reference. 
     
    
     BACKGROUND 
       [0002]    Many health benefit plan providers use clinical interventions for their plan members in an effort to support quality healthcare, improve clinical outcomes, and have a positive impact on the health and well-being of their membership. Participants of clinical intervention programs typically receive comprehensive educational and counseling services directed to management of a specific health condition. Clinical interventions are available for a wide array of health conditions and problems such as diabetes, chronic obstructive pulmonary disease, and cardiovascular disease as well as substance abuse, pharmacy, etc. Clinical intervention programs may be developed and administered by the health benefit provider or by third parties that contract with the health benefits provider to provide services to plan members. 
         [0003]    Many clinical intervention programs are supported by software applications used by professionals to identify candidates for specific programs and to track members&#39; progress in the programs .Although such software applications are very useful to the professionals that rely on them, they are typically designed to accept and analyze only a portion of a member&#39;s health and claim data in order to identify a specific health condition or problem that could be addressed in a clinical intervention. Because each software application and related candidate identification process is very specialized, health benefit providers do not have a comprehensive, collective approach to clinical interventions for all of their members. For health benefit providers that offer many clinical interventions and therefore, rely on many software applications and candidate identification processes, coordination that is necessary to provide a clear, comprehensive view of each member&#39;s health status is lacking. 
         [0004]    Although formal clinical intervention programs involving ongoing education and counseling are important to health outcomes, less formal and more frequent communication between healthcare providers and members or their healthcare providers can also be beneficial to members and help to improve outcomes. For example, alerting healthcare providers of such events as a possible gap-in-care or a drug-on-drug interaction for a member can be an important element of a member&#39;s ongoing care. As is true for identifying candidates for clinical interventions, identifying appropriate alerts requires a comprehensive view of a member&#39;s health conditions as well as the clinical conditions warranting a clinical alert. Tracking of alerts and adherence to alerts is also an important aspect of care. However, candidate identification for alerts and other important communications is typically another independent activity that is not supported by a clear and comprehensive view of each member&#39;s health status. 
         [0005]    Health benefit providers have a need for a computerized system and method that supports a comprehensive view of member health status so they can meet the needs of their member populations. Health benefit providers also have a need for a computerized system and method that supports a variety of clinical interactions with their member populations. Furthermore, employer groups and other organizations that sponsor health benefit plans for member populations are looking for a comprehensive clinical approach to numerous health conditions to control escalating costs and to better serve their plan beneficiaries. There is a need for a system and method that supports a comprehensive view of member health status and that assists in identifying candidates for clinical actions, clinical interventions, clinical alerts, clinical communications, and other numerous health programs and activities. 
       SUMMARY 
       [0006]    The present disclosure is directed to a computerized system and method that supports a comprehensive view of member health status and identification of candidates for clinical actions such as clinical interventions, clinical alerts, clinical communications, and other numerous health programs and activities. The computerized system and method supports a single process to identify clinical action candidates and eliminates the need to maintain multiple, independent candidate identification processes targeted to specific health conditions. The computerized system and method facilitate clinical action integration and coordination by providing the infrastructure to share key member information among clinical action opportunities. Processes for transferring and sharing information are HIPAA compliant to ensure member data is appropriately protected. 
         [0007]    In an example embodiment, the computerized system and method comprises a clinical guidance exchange (CGX) that generates customized member profiles based on the needs of a diverse user community. The CGX receives and accesses member data from a plurality of sources to facilitate creation of integrated member profiles and to identify appropriate clinical actions. The CGX further receives and accesses clinical data from a clinical data hub that integrates clinical data from numerous sources. Member data and clinical data is analyzed and combined according to workflow requirements of the diverse user community to identify candidates for numerous clinical actions. The appropriate member information is directed to the right user base and allows those users to prioritize the work based on operational needs that may change daily. 
         [0008]    In an example embodiment, the computerized system and method comprises a rules-based engine that facilitates the identification of candidates for clinical actions. The rules-based engine assists in identifying the most appropriate actions and interventions for a member and routing the member to the appropriate clinical activity. The integrated member profiles provide a complete view of member information that is important to the clinical process and identification of the appropriate clinical activity. A rules management process for the rules-based engine facilitates editing and updating of rules that are applied to member profile data to identify candidates. The computerized system and method further supports the exchange of information among clinical action identification processes so the appropriate information is considered in selecting members and routing them to clinical activities and interventions. The rules management process further supports the ability to exclude members based on plan, participation, and risk scores. 
         [0009]    The computerized system and method supports the implementation of a comprehensive and coordinated clinical strategy for all members of a health benefits plan. 
     
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         [0010]      FIG. 1  is an architecture diagram for a computerized clinical action system and method according to an example embodiment; 
           [0011]      FIG. 2  is a CGX workflow details diagram according to an example embodiment; 
           [0012]      FIG. 3  is a data flow diagram for a CGX according to an example embodiment; 
           [0013]    FIGS.  4 A 1 ,  4 A 2 ,  4 B 1 ,  4 B 2 , and  4 C illustrate rules processing by a RGX according to an example embodiment; and 
           [0014]      FIG. 5  is a provider connectivity diagram according to an example embodiment. 
       
    
    
     DETAILED DESCRIPTION 
       [0015]    Referring to  FIG. 1 , an architecture diagram for a computerized clinical action system and method according to an example embodiment is shown. In an example embodiment, members of a health benefits plan receive communications regarding clinical actions that are appropriate for them based on their current health status and conditions  100 . A clinical guidance exchange (CGX)  104  generates customized member profiles for a diverse user base that includes healthcare providers, health plan clinicians, health plan customer service representatives, pharmacists, client quality review associates, and risk adjustment associates  102 . Data for customized member profiles is received from a clinical data hub  118  that receives and/or extracts data from a plurality of sources such as a personalized health program (e.g., Humana Vitality), health risk assessments, pharmacy claims data, medical claims data (e.g., paid, pended, and rejected claims), health benefits plan structure, laboratory and test results, a personal health profile, biometric and health fairs, and other external data sources. The clinical data hub  118  supports an integrated member profile  106  containing data for various clinical views of claims, laboratory, pharmacy and other medical data at the member level as well as plan and demographic data that is used in decisioning. 
         [0016]    A rules guidance exchange (RGX)  110  comprises a plurality of rules-based processes such as a clinical rules/predictive modeling process  116  to facilitate identification, both proactive and retroactive, of a member&#39;s clinical and health conditions and a business rules process  114  to identify clinical actions that may be offered by a health plan sponsor and that may be appropriate for members of the sponsor&#39;s health plan. The RGX  110  provides clinical inference data containing the results of the clinical rules/predictive modeling process  116  executed against clinical member profile data. The RGX  110  then generates clinical actions (e.g., alerts or interventions)  112  to members and/or their caregivers, physicians and other healthcare providers, and clinicians  102 . In an example embodiment, health alerts may comprise evidence-based medicine gap-in-care, HEDIS, drug-to-drug interaction, drug-to-disease interaction, medication possession ratios (medication adherence), and utilization analysis alerts. The alerts may be distributed to various portals (e.g., an eligibility and benefits web page for members and their caregivers, a care profile web page, vendor partners that provide support for programs such as state dual eligibility, and/or a member summary document) as well as through various messaging channels (e.g., fax, e-mail, postal mail, text/SMS, live calls, etc.). 
         [0017]    The RGX business rules process  114  supports automation in a wide variety of clinical business processes such as utilization management, case management, clinical messaging, program eligibility, and workflow routing. The rules define clinical policies and business rules for authorization approval, automated queue routing based on intervention programs, clinical condition identification, stratification, and routing, and may further support predictive modeling processes, clinical notes, tasks, and alert generation, clinical messaging generation, aggregation, and routing and care alert generation. The use of a rules-based process provides flexibility to support rapidly changing and emerging business needs in the area of clinical actions and support. The routing of authorizations for various actions may be controlled based on qualification criteria in the form of rules for each clinical intervention. Additionally, rules to prioritize activities may be applied in the event multiple signals or calls to action are triggered. 
         [0018]    In an example embodiment, the CGX  104  comprises a member profile process  106  that receives member data from the clinical data hub  118  and the rules-based engine  110  and generates and stores in a clinical profile database an integrated member profile  106  comprising the member&#39;s health condition data, care gaps and quality alerts, a 90-day health history summary, risk scores, and a utilization summary. Access to the integrated member profile data is controlled through workflow applications  108  that support the diverse user community. Each user group  102  interacts with the CGX  104  though a workflow process designed to meet the needs of the group. Each user group is provided with access to member data that is most relevant to their responsibilities. An integrated medical record viewer  120  provides users with access to healthcare provider medical records accessible through the clinical data hub  118 . 
         [0019]    Referring to  FIG. 2 , a CGX workflow details diagram according to an example embodiment is shown. In an example embodiment, the CGX  104  supports a plurality of user groups  122  that assist members of a health benefits plan in a variety of ways. Groups may provide clinical intake services, senior care services home health assessments, improved lifestyle support services, mental health services, personal nurse services, new mother and infant services, commercial case management services, services for transplant patients, triage nurse services, disease management services, etc. Each user group is supported by a clinical workflow application  124  that accesses an integrated member profile  106  and RGX  110  to facilitate identification of candidates for various clinical actions, interventions, alerts, programs, etc. The CGX  104  comprises a plurality of clinical functions and clinical tools as well as enterprise tools that provide access to enterprise systems  126  operated by the health benefits company. The enterprise systems may provide functionality such as generating communications for members that are relevant to their health conditions and that identify appropriate clinical actions. The enterprise systems further transmit the member communications through various communication channels such as member web portals, email messages, telephone messages, and direct mail. 
         [0020]    Referring to  FIG. 3 , a data flow diagram for a CGX  104  according to an example embodiment is shown. Users interacting with workflow applications initiate requests (e.g., automated or manual authorization requests)  130  that are serviced by the CGX  104  using integrated member profile data  106  and a RGX  110 . Each workflow application is designed to meet the needs of multiple user groups. Workflow applications may provide the following functionality. 
         [0000]    
       
         
               
             
               
               
             
           
               
                 TABLE 1 
               
             
             
               
                   
               
               
                 Workflow Functionality 
               
             
          
           
               
                 User Group 
                 Workflow Requests 
               
               
                   
               
               
                 Member 
                 My Work workflow management of automated referrals 
               
               
                 Care/Case 
                 to clinical programs 
               
               
                 Management 
                 Nurse referrals of members to internal programs; 
               
               
                 130 
                 Various applicable health risk scores to determine 
               
               
                   
                 potential complex chronic membership and proactively 
               
               
                   
                 reach out 
               
               
                   
                 Clinical Program Case Management (CP CM) cases for 
               
               
                   
                 management of a member within a clinical program 
               
               
                   
                 Assessments to evaluate a member&#39;s health conditions 
               
               
                   
                 and identify opportunities for improvement, 
               
               
                   
                 including external care plans and assessments being 
               
               
                   
                 managed by vended partners 
               
               
                   
                 Care Plan to manage a member&#39;s problems, goals, and 
               
               
                   
                 clinician Interventions 
               
               
                   
                 Documentation of all contact with members and 
               
               
                   
                 providers and the outcome of the call 
               
               
                   
                 Manage lists of medications, allergies, and 
               
               
                   
                 immunizations for a member 
               
               
                   
                 Post-Discharge Care Coordination, including an 
               
               
                   
                 integrated member profile 
               
               
                 Utilization 
                 Electronic authorization 
               
               
                 Management 
                 Manually entered authorization 
               
               
                 130 
                 Authorization management including decision support 
               
               
                   
                 and workflow processes and including question/answer 
               
               
                   
                 driven authorization determination 
               
               
                   
                 Automation of electronic authorizations via other 
               
               
                   
                 systems 
               
               
                   
                 MyWork workflow management of authorizations via 
               
               
                   
                 queues and filters 
               
               
                   
                 Documentation of clinical reviews for level of care 
               
               
                   
                 and authorization status determination (including 
               
               
                   
                 creation of case notes, tasks for follow-up, and 
               
               
                   
                 attachment of a member&#39;s clinicals) 
               
               
                   
                 Regional medical director workflow and documentation, 
               
               
                   
                 including consultation documentation between nurses, 
               
               
                   
                 clinical leaders and doctors 
               
               
                   
                 Letter templates and fulfillment automation for 
               
               
                   
                 approval/denial letters as well as other letters 
               
               
                   
                 generated to both members, providers/caregivers 
               
               
                   
               
             
          
         
       
     
         [0021]    As requests are received at the CGX  104  from workflow applications, CGX  104  engages a clinical service bus  126  to locate rules from the RGX  110  that are relevant to the request. Business rules  114  support the identification, evaluation, decisioning, and routing processes. Identification rules indicate what signals are needed to trigger an evaluation process according to the clinical rules  116 . Automatically generated signals may include medical claims (e.g., paid, pended and rejected), pharmacy claims, laboratory results, authorizations, market-specific requirements, and referrals. Manually generated signals may include transition of care activities, health risk assessments, specialized programs and activities (e.g., nurse triage service, senior care case management, disease management, personal nurse, transplant, new mother and infant, etc.), and customer contact calls. 
         [0022]    Evaluation rules define what action should take place based on the interpretation of a signal or signals and member specific data residing in the integrated member profile  106 . Actions may include the automatic generation of an intervention referral (internal or external), the automatic generation of a claim data extract for transmission to an intervention vendor (external), the automatic generation of a reminder in the form of a secured message sent to a member, and the automatic generation of alerts and notifications related to members that are routed to intervention areas already involved with a member. 
         [0023]    Routing rules define the parameters that are used in the delivery of the resulting action or actions of the evaluation process. The parameters may include parameters for timing or scheduling of the delivery and how the delivery is made (e.g., web transactions, FTP, FAX, telephone, etc.).  4 A 1 ,  4 A 2 ,  4 B 1 ,  4 B 2 , and  4 C are tables illustrating rules processing by a RGX according to an example embodiment. The tables illustrate identification, evaluation, and routing for converting inpatient authorizations that are best served as observation stays. 
         [0024]    FIGS.  4 A 1 - 4 A 2  illustrate rules for identifying members eligible for utilization management services. Inpatient hospital authorizations are processed. In particular, a plurality of conditions shown in the columns of FIGS.  4 A 1 - 4 A 2  are evaluated such as the “authorization case type,” whether a “member disenrollment date” field is populated, how the case authorization submission date relates to the member disenrollment date, and other utilization management parameters. The rules are applied to member data to reach a conclusion regarding utilization management as shown in FIG.  4 A 2 . 
         [0025]    FIGS.  4 B 1 - 4 B 2  illustrate rules for utilization management eligible members that are evaluated to determine the types of interventions for which the member qualifies and the appropriate routing for the member. As indicated in FIGS.  4 B 1 - 4 B 2  observation data, acute admission data, per diem facility admission data, length of stay, discharge data, and other parameters are collected and evaluated. Following application of the rules, a utilization management action is determined as shown in FIG.  4 B 2  and a work information action is set. 
         [0026]      FIG. 4C  illustrates routing rules. Relevant data points (e.g., CGX queue, referral reason, referral source, date of service, and diagnosis) are delivered to a utilization management nurse to perform various workflow actions for the member. Data from the databases  106  is accessed according to the relevant rules. Data from the integrated member profile may be displayed for the user to facilitate the user&#39;s interaction with the member or to facilitate advising the member on clinical actions. The RGX  110  may access one or more external data sources. A clinical rules process  116  may access a clinical data hub  118  to provide input to a clinical rules engine that generates various types of clinical actions such as health alerts. The clinical data hub may further access external resources  132  (e.g., laboratory results or pharmacy data from a third party vendor) to obtain additional data relevant to the request. A campaign management component  134  supports clinical messaging for actions to members and providers. Campaigns may be initiated throughout the year to inform members about services and programs that may be of interest based on their health status and clinical needs. 
         [0027]    The RGX  110  identifies members for actions by accessing and analyzing data from a plurality of sources, many of which are accessible through a clinical data hub  118 . A member&#39;s demographic data, medical, pharmacy, and laboratory claims data as well as prior authorizations, referrals data, and external vendor care plans and/or assessments may be analyzed to identify a member&#39;s clinical conditions. Members may also self-report information through a health risk assessment, nurse assessment, or other instrument. Predictive models may be applied to member data to identify members at risk for various health conditions. Predictive model scores may be used to stratify member populations for actions directed to specific health conditions. A clinical intervention appropriateness (CIA) score and/or claims based algorithm (CBA) score may also be calculated and considered in selecting candidates for interventions. One or more profile flags may be set in a member&#39;s profile to further facilitate identification of candidates for actions. Additional factors that may be considered are major clinical or chronic care needs categories, prior intervention program participation information, utilization information, contact results from customer service calls, web-site visits, secured messages, and VAT calls, needs recognized through transition of care information, information derived from test and laboratory results, and information gathered during initial contact calls with members. A member&#39;s data from a variety of sources may be stored in an integrated member profile to facilitate the identification of clinical conditions and appropriate actions. 
         [0028]    A customer profile identifies the actions, alerts, interventions, and/or programs each customer selects for its employees or sponsored participants. The customer profile data may be used to establish business rules that are applied by the RGX as members are identified for action. 
         [0029]    A clinical action profile defines the clinical actions such as health alerts, clinical interventions, and/or programs that are supported by the health benefit plan providers. Additional details in the clinical action profile include programs and campaigns that may be offered to qualifying members to educate them about the actions and interventions and to encourage them to respond or participate. The clinical action profile further identifies the administrator (e.g., internal or vended), the cost of the actions, and the business segments that are eligible. The clinical action profile may also comprise information for exclusions (e.g., based on provider group, enterprise, customer, and subgroup levels, product, segment, platform, market, current participation, and member request). 
         [0030]    In an example embodiment, the CGX  104  uses profile data and business and clinical rules from the RGX  106  and  114  to identify candidates for clinical actions. Criteria may be established to stratify and rank action candidates by assigning a numeric value to each medical condition used in a stratification process. A total score may be calculated for each candidate by tallying the scores associated with each candidate&#39;s medical conditions. The candidates may then be ranked from highest score to lowest score. Rules and stratification parameters may be updated and applied quickly to meet the needs of the businesses. 
         [0031]    The CGX  104  may select candidates for actions based on each candidate&#39;s stratification score and pre-determined business defined threshold levels that are stored with other evaluation rules. Thresholds may be varied based on market and quickly modified based on changing business needs. The thresholds may have the following characteristics:
       4. The thresholds may be set by either specifying an absolute number of referrals (i.e., the ‘x-number’ candidates with the highest score) or by specifying a target score (i.e., any candidate with a score over ‘###’);   5. Separate thresholds may be set for administrative services only (ASO) and fully insured candidates; and   6. Fully insured thresholds may be separated into thresholds for commercial and non-commercial candidates.       
 
         [0035]    Customer reporting features  138  are also supported by the clinical data hub  118 . 
         [0036]    Referring to  FIG. 5 , a provider connectivity diagram according to an example embodiment is shown. As indicated in  FIG. 5 , healthcare provider communication may be facilitated through a “carehub”  150  comprising the CGX  104  and other components that support clinical actions. 
         [0037]    Having shown and described a preferred embodiment of the present invention, those skilled in the art will realize that many variations and modifications may be made to the described invention and still be within the scope of the claimed invention. Many of the elements indicated above may be altered or replaced by different elements that provide the same or substantially the same result and fall within the spirit of the claimed invention. Various aspects or elements of the integrated member profile and the business and clinical rules may be varied and fall within the scope of the claimed invention. Various aspects of the candidate identification process for clinical actions may change and fall within the scope of the claimed invention. The types and nature of the communications regarding clinical actions may be changed and fall within the spirit of the claimed invention. Therefore, as can be understood from a review of the foregoing description and accompanying drawing figures, the computerized system and method supports clinical actions for members of health benefit plans to improve outcomes. Consequently, while certain exemplary embodiments of the present invention are described in detail above, the scope of the invention is not to be considered limited by such disclosure, and modifications are possible without departing from the spirit of the invention as evidenced by the following claims: