“Enhancing Patient Referral Outcome Through Structuring Data For Efficient Place Of Service Utilization Rate Analysis” in Patent Application Approval Process (USPTO 20230274808): Emblemhealth Inc.
2023 SEP 15 (NewsRx) -- By a
This patent application is assigned to
The following quote was obtained by the news editors from the background information supplied by the inventors: “It may be a fundamental interest of a healthcare provider and/or a healthcare network that a patient has a positive outcome in receiving healthcare services. An important factor in creating a positive outcome is ensuring patient accessibility (which may also be referred to as “access”) to the healthcare services. For example, high degree and/or sufficient amount of access may mean that the patient has a healthcare provider nearby where the patient resides, that the patient is seen by the healthcare provider promptly, that any subsequent procedures are performed on time, and/or that special needs of the patient can be accommodated. What may be another important factor in a positive outcome is value of the healthcare services provided. Value may be based on a number of factors, but may for example be based on an appropriate balancing of monetary cost, healthcare service complexity (e.g., complexity of a procedure, recovery time, side effects), and/or risk access considerations.
“The healthcare industry may be facing increasing pressure to provide positive patient outcomes, including increased access and value in providing healthcare services. For example, payers (such as employers, insurance companies, and government agencies such as the
“What may be a major factor in generating positive patient outcomes is an efficient referral process of the patient between healthcare providers. A first healthcare provider, called the “referring provider,” will generally refer a patient to a different healthcare provider, called a “referral provider,” when the referring provider is not qualified or otherwise able to provide a needed healthcare service for the patient. Referrals within the healthcare industry are common, especially within a healthcare network (e.g., an HMO, an ACO). A healthcare provider may be an individual, such as a solo clinician licensed to practice medicine or provide medical services (who may be referred to as an “individual provider”). The healthcare provider may also be a hospital, group of individual health professionals, or other business entity or other organization, some or all of which are licensed to practice a health provision or to perform health care services (which may be referred to as a “group provider”). Healthcare providers also generally desire for referred patients to be transferred efficiently, with an emphasis on good access to medical services once the patient is transferred to the referral provider.
“The referral process in which the patient is referred from one healthcare provider to another can pose challenges to maximizing patient outcome, including access to and/or value of healthcare services. First, the referring provider may generally have little or no ability to gather or assess information about a referral provider. For example, referrals may be made based on habit or subjective criteria such as general notoriety within a healthcare network rather than awareness of any information related to patient outcome. This may partially occur for practical reasons because the referring provider has little time (e.g., 20-minute appointments of a clinician) and/or any evaluation assessment of referral providers may be a discrete process from providing the healthcare service.
“Even where referrals may be optimal at one time (e.g., in terms of value and/or access), they may later become sub-optimal. Access and/or value of a referral provider may change on a monthly, daily, or even real-time basis. For example, even a healthcare provider providing historically high-value healthcare services may be a poor referral provider at a given time because they have low access. Such a referral provider may have a patient backlog, diminished capacity due to retiring clinicians, or have changed facilities and/or locations.
“Access and/or value may also be context dependent, for example varying based on the circumstances and/or needs of the patients. A healthcare provider with generally good access and value for orthopedic surgeries may not provide more specific surgery (e.g., hand surgery) with good access or at high value. Conversely, a healthcare provider may be known to provide excellent access and good value for a given procedure, but may not excel in a broader category of healthcare services or may not excel in other defined incentives that may shift behaviors toward increased value and/or access.
“Finally, even where some data-based and/or objective insight may be present and available to a clinician at the time a referral must be made, it may be difficult for a healthcare provider and/or healthcare network to promote its values or policies related to access and/or value. For example, there may be a challenge in communicating insights to the healthcare providers of the network.
“One or more of these challenges may result in detriment to one or more of the stakeholders of a healthcare network. Patients may not receive healthcare services promptly, may not receive healthcare services best suited for their particular needs, and/or may decide not to receive healthcare services where the value and/or access is low, raising their health risk and potentially long-term cost when a health issue is not efficiently addressed. Healthcare providers working hard to establish good access and high value may not be rewarded with referrals that would reinforce their positive efforts. Healthcare providers lose revenue and may be at increased risk of malpractice where patients are not met with sufficient access. Payers may pay increased amounts and may therefore continue to support sub-optimal referral and/or healthcare utilization practices. On what may be a larger scale, a healthcare network may continue to operate with inefficiencies, resulting in network-wide sub-optimal value and access that can affect patient loyalty, damage reputation and brand stature, increase long-term health care costs, and/or reduce long-term revenue. There is a continuing need for technologies that support and increase the efficiency of the referral process.”
In addition to the background information obtained for this patent application, NewsRx journalists also obtained the inventors’ summary information for this patent application: “Disclosed are a method, a device, and/or a system of enhancing patient referral outcome through structuring data for efficient place of service utilization rate analysis. In one embodiment, a device for structuring and processing data for efficient selection of a referral provider for a patient includes a processor, a memory, computer readable instructions that when executed extract a set of utilization logs, a referral request agent, a profile matching engine, a dataset reduction subroutine, a utilization rate routine, and a set of computer readable instructions that when executed select the first healthcare provider for inclusion in a referral data.
“The log data structure includes a set of data each modeling healthcare providers and each associated by one or more referral logs, and also includes a group of utilization logs each associated with a data from the set of data each modeling the healthcare providers. The group of utilization logs includes a first utilization log of a different patient that was previously served by a first healthcare provider at a facility to result in a healthcare utilization log. The first utilization log includes a provider UID of the first healthcare provider and a place of service value that describes a type of facility associated with a healthcare utilization record.
“The referral request agent includes computer readable instructions that when executed generate and/or receive a referral profile generated for the patient. The profile matching engine includes computer readable instructions that when executed compare the referral profile to the set of utilization logs. The dataset reduction subroutine includes computer readable instructions that when executed generate a reduced dataset that includes a subset of utilization logs extracted from the set of utilization logs matching the referral profile. The number of healthcare providers associated with the reduced dataset is compared to a minimum threshold of healthcare providers to determine a sufficient number of healthcare providers within the reduced dataset.
“The utilization rate routine includes computer readable instructions that when executed calculates, using the subset of utilization logs in the reduced dataset, a POS utilization rate of the first healthcare provider for each instance of the place of service value. The POS utilization rate is a set of percentage values, each percentage value begin a number of utilization logs in the reduced dataset that includes an instance of the place of service value within a place of service range relative to a total number of utilization logs in the reduced dataset.
“The set of computer readable instructions that when executed select the first healthcare provider for inclusion in a referral data makes the selection based on criteria that includes the POS utilization rate for transmission of a name of the first healthcare provider and/or the provider UID of the first healthcare provider to a computing device for generation of a referral selection for the patient.
“The device may also include a utilization extraction routine including computer readable instructions that when executed determine generation of the healthcare utilization record and determine the place of service value that describes the type of facility associated with the healthcare utilization record. The healthcare utilization record may include a patient UID of the different patient and the provider UID of the first healthcare provider.
“The device may also include a log storage module that includes computer readable instructions that when executed generates the first utilization log including the provider UID of the first healthcare provider, the place of service value, and/or a utilization time associated with providing a healthcare service to the different patient and/or generation of the healthcare utilization record. The log storage module may include computer readable instructions that when executed stores a utilization log in the log data structure.
“The device may include a referral profile generation routine that includes computer readable instructions that when executed generates the referral profile for the patient. The referral profile may include the place of service range and a time range. A referral request may be initiated on a user interface of a clinical documentation workflow of a point-of-care application. The point-of-care application may be run by a second healthcare provider to refer the patient of the second healthcare provider to the referral provider.
“A second set of computer readable instructions may also be included in the device, that when executed, apply a utilization ruleset to score, rank, and/or qualify the first healthcare provider selected based on criteria including the POS utilization rate and add the provider UID of the first healthcare provider to the referral data.
“The device can also include a third set of computer readable instructions that when executed transmit the referral data over a network to the computing device. The computing device may be utilized by a second healthcare provider and may be running a point-of-care application. The referral data may be integrated within a user interface of a clinical documentation workflow of the point-of-care application.
“The device may include a patient query engine that includes computer readable instructions that when executed query a patient profile of the different patient with a patient UID of the different patient and extract from the patient profile of the different patient a patient data including a demographic data of the different patient, a coverage type of the different patient, and/or a diagnosis code of the different patient. The first utilization log may further include the patient data. The referral profile may further include a patient data range. The patient data range may include a demographic data of the patient, a coverage type of the patient, and/or a diagnosis code of the patient.
“The utilization rate routine may also include computer readable instructions that when executed calculates, using a different set of utilization logs of two or more healthcare providers, a POS utilization rate of the two or more healthcare providers for each instance of the place of service value within the place of service range. The selection of the first healthcare provider may be based on criteria including the POS utilization rate of the first healthcare provider relative to a statistical average of the POS utilization rate of the two or more healthcare providers.
“The device may further include a referral rate routine that includes computer readable instructions that when executed calculates, using the subset of the set of referral logs in the reduced dataset, an inbound re-referral rate of the referral healthcare provider. The inbound re-referral rate can be calculated as a proportion of (i) the subset of the set of referral logs that each store a database association drawn into the data modeling the referral healthcare provider and that comprise a database association linked to one or more of the subset of the set of referral logs that store a database association drawn out of the data modeling the referral healthcare provider (where a timestamp of each referral log storing the database association drawn into the data modeling the referral healthcare provider and a timestamp of each referral log storing the database association drawn out of the data modeling the referral healthcare provider are within a first time period value), relative to (ii) other instances within the subset of the set of referral logs that each store database associations drawn into the data modeling the referral healthcare provider. The place of service value may be stored in computer memory as a POS code value, and the place of service range, a patient data range, and/or a time range of the referral profile is selected by the clinician through the point-of-care application.
“In another embodiment, a method for structuring and processing data for efficient selection of a referral provider for a patient includes extracting a set of utilization logs from a log data structure. The log data structure includes a set of data each modeling healthcare providers and each associated by one or more referral logs, and also includes a group of utilization logs each associated with a data from the set of data each modeling the healthcare providers. The group of utilization logs includes a first utilization log of a different patient that was previously served by a first healthcare provider at a facility to result in a healthcare utilization log. The first utilization log includes a provider UID of the first healthcare provider and a place of service value that describes a type of facility associated with a healthcare utilization record.”
There is additional summary information. Please visit full patent to read further.”
The claims supplied by the inventors are:
“1. A device for structuring and processing data for efficient selection of a referral provider for a patient, the device comprising: a processor, a memory, computer readable instructions that when executed extract a set of utilization logs from a log data structure comprising (i) a set of data each modeling healthcare providers and each associated by one or more referral logs, and (ii) a group of utilization logs each associated with a data from the set of data each modeling the healthcare providers, wherein the group of utilization logs comprises a first utilization log of a different patient that was previously served by a first healthcare provider at a facility to result in a healthcare utilization log, and wherein the first utilization log comprising a provider UID of the first healthcare provider and a place of service value that describes a type of facility associated with a healthcare utilization record; a referral request agent comprising computer readable instructions that when executed at least one of generate and receive a referral profile generated for the patient; a profile matching engine comprising computer readable instructions that when executed compares the referral profile to the set of utilization logs; a dataset reduction subroutine comprising computer readable instructions that when executed generate a reduced dataset comprising a subset of utilization logs extracted from the set of utilization logs matching the referral profile, wherein a number of healthcare providers associated with the reduced dataset is compared to a minimum threshold of healthcare providers to determine a sufficient number of healthcare providers within the reduced dataset; a utilization rate routine comprising computer readable instructions that when executed calculates, using the subset of utilization logs in the reduced dataset, a POS utilization rate of the first healthcare provider for each instance of the place of service value, wherein the POS utilization rate is a set of percentage values, each percentage value a number of utilization logs in the reduced dataset comprising an instance of the place of service value within a place of service range relative to a total number of utilization logs in the reduced dataset; and a set of computer readable instructions that when executed select the first healthcare provider for inclusion in a referral data based on criteria comprising the POS utilization rate for transmission of at least one of a name of the first healthcare provider and the provider UID of the first healthcare provider to a computing device for generation of a referral selection for the patient.
“2. The device of claim 1, further comprising: a utilization extraction routine comprising computer readable instructions that when executed: determine generation of the healthcare utilization record, wherein the healthcare utilization record comprising a patient UID of the different patient and the provider UID of the first healthcare provider; and determine the place of service value that describes the type of facility associated with the healthcare utilization record; a log storage module comprising computer readable instructions that when executed: generates the first utilization log comprising the provider UID of the first healthcare provider, the place of service value, and a utilization time associated with at least one of providing a healthcare service to the different patient and generation of the healthcare utilization record; and stores a utilization log in the log data structure.
“3. The device of claim 2, further comprising: a referral profile generation routine comprising computer readable instructions that when executed generates the referral profile for the patient, the referral profile comprising the place of service range and a time range, wherein a referral request is initiated on a user interface of a clinical documentation workflow of a point-of-care application that is run by a second healthcare provider to refer the patient of the second healthcare provider to the referral provider.
“4. The method of claim 1, further comprising: a second set of computer readable instructions that when executed: apply a utilization ruleset to at least one of score, rank, and qualify the first healthcare provider selected based on criteria comprising the POS utilization rate; and add the provider UID of the first healthcare provider to the referral data.
“5. The method of claim 1, further comprising a third set of computer readable instructions that when executed: transmit the referral data over a network to the computing device, wherein the computing device is utilized by a second healthcare provider and is running a point-of-care application, and wherein the referral data is integrated within a user interface of a clinical documentation workflow of the point-of-care application.
“6. The method of claim 1, further comprising: a patient query engine comprising computer readable instructions that when executed: query a patient profile of the different patient with a patient UID of the different patient; and extract from the patient profile of the different patient a patient data comprising at least one of a demographic data of the different patient, a coverage type of the different patient, and a diagnosis code of the different patient, wherein the first utilization log further comprising the patient data, wherein the referral profile further comprising a patient data range, and wherein the patient data range comprising at least one of a demographic data of the patient, a coverage type of the patient, and a diagnosis code of the patient.
“7. The method of claim 1, wherein the utilization rate routine further comprises computer readable instructions that when executed: calculates, using a different set of utilization logs of two or more healthcare providers, a POS utilization rate of the two or more healthcare providers for each instance of the place of service value within the place of service range, wherein the selection of the first healthcare provider is based on criteria comprising the POS utilization rate of the first healthcare provider relative to a statistical average of the POS utilization rate of the two or more healthcare providers.
“8. The method of claim 4, further comprising: a referral rate routine comprising computer readable instructions that when executed: calculates, using the subset of the set of referral logs in the reduced dataset, an inbound re-referral rate of the referral healthcare provider; wherein the inbound re-referral rate is calculated as a proportion of (i) the subset of the set of referral logs that each store a database association drawn into the data modeling the referral healthcare provider and that comprise a database association linked to one or more of the subset of the set of referral logs that store a database association drawn out of the data modeling the referral healthcare provider, where a timestamp of each referral log storing the database association drawn into the data modeling the referral healthcare provider and a timestamp of each referral log storing the database association drawn out of the data modeling the referral healthcare provider are within a first time period value, relative to (ii) other instances within the subset of the set of referral logs that each store database associations drawn into the data modeling the referral healthcare provider, wherein the place of service value is stored in computer memory as a POS code value, and wherein at least one of the place of service range, a patient data range, and a time range of the referral profile is selected by the clinician through the point-of-care application.
“9. A method for structuring and processing data for efficient selection of a referral provider for a patient, the method comprising: extracting a set of utilization logs from a log data structure comprising (i) a set of data each modeling healthcare providers and each associated by one or more referral logs, and (ii) a group of utilization logs each associated with a data from the set of data each modeling the healthcare providers, wherein the group of utilization logs comprises a first utilization log of a different patient that was previously served by a first healthcare provider at a facility to result in a healthcare utilization log, and wherein the first utilization log comprising a provider UID of the first healthcare provider and a place of service value that describes a type of facility associated with a healthcare utilization record; receiving a referral profile generated for the patient; comparing the referral profile to the set of utilization logs; generating a reduced dataset comprising a subset of utilization logs extracted from the set of utilization logs matching the referral profile, wherein a number of healthcare providers associated with the reduced dataset is compared to a minimum threshold of healthcare providers to determine a sufficient number of healthcare providers within the reduced dataset; calculating, using the subset of utilization logs in the reduced dataset, a POS utilization rate of the first healthcare provider for each instance of the place of service value, wherein the POS utilization rate is a set of percentage values, each percentage value a number of utilization logs in the reduced dataset comprising an instance of the place of service value within a place of service range relative to a total number of utilization logs in the reduced dataset; and selecting the first healthcare provider for inclusion in a referral data based on criteria comprising the POS utilization rate for transmission of at least one of a name of the first healthcare provider and the provider UID of the first healthcare provider to a computing device for generation of a referral selection for the patient.”
There are additional claims. Please visit full patent to read further.
URL and more information on this patent application, see: KELLY, TIMOTHY; Yang, Zoe. Enhancing Patient Referral Outcome Through Structuring Data For Efficient Place Of Service Utilization Rate Analysis.
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