Patent Issued for Maximizing patient referral outcome through healthcare utilization and/or referral evaluation (USPTO 11682475): Emblemhealth Inc.
2023 JUL 07 (NewsRx) -- By a
Patent number 11682475 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, NewsRx journalists also obtained the inventors’ summary information for this patent: “Disclosed are a method, a device, and/or a system of maximizing patient referral outcomes through healthcare utilization and/or referral record evaluation.
“In one embodiment, a method for optimal determination of a healthcare referral provider includes determining generation of a healthcare utilization record that includes a patient UID (unique identifier) of a first patient and a provider UID of a first healthcare provider. A place of service value associated with the healthcare utilization record is determined along with a type of service associated with the healthcare utilization record. A first utilization log is generated comprising the provider UID of the first healthcare provider, the place of service value, the type of service value, and optionally comprising a utilization time associated with providing a healthcare service to the patient and/or associated with generation of the healthcare utilization record.
“The method initiates a referral request to refer a second patient of a second healthcare provider to a referral provider. A referral profile is generated for the second patient, the referral profile including a place of service range, a type of service range, and optionally a time range. The referral profile is compared to a utilization dataset comprising a set of utilization logs extracted from a utilization database including the first utilization log. A reduced dataset is generated that includes a subset of utilization logs extracted from the utilization dataset matching the referral profile.
“The method 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 within the place of service range. A utilization ruleset is then applied to score, rank, and/or qualify the first healthcare provider based on criteria comprising the POS utilization rate.
“The provider UID of the first healthcare provider is added to a referral data. The referral data is transmitted over a network from a server to a computing device of the second healthcare provider running a point-of-care application. The referral data is integrated within a user interface of a clinical documentation workflow of the point-of-care application.”
The claims supplied by the inventors are:
“1. A method for structuring electronic data logs for efficient determination of a healthcare referral provider from a point-of-care application, the method comprising: determining generation of a healthcare utilization record comprising a patient UID of a first patient and a provider UID of a first healthcare provider; determining a place of service value that describes a type of facility associated with the healthcare utilization record; determining a type of service associated with the healthcare utilization record; generating a first utilization log comprising the provider UID of the first healthcare provider, the place of service value, a type of service value, and a utilization time associated with at least one of providing a healthcare service to the first patient and generation of the healthcare utilization record; storing a utilization log in an electronic database storing a log data structure comprising: (i) a set of data each modeling healthcare providers associated by one or more referral logs, and (ii) a set of utilization logs each associated with a data from the set of data each modeling healthcare providers; initiating a referral request on a user interface of a clinical documentation workflow of the point-of-care application running on a computing device of a second healthcare provider to refer a second patient of the second healthcare provider to a referral provider; generating a referral profile for the second patient, the referral profile comprising a place of service range, a type of service range, and a time range, extracting the set of utilization logs from a utilization database, wherein the set of utilization logs comprises the first utilization log comprising the place of service value, and wherein the set of utilization logs each comprise at least one of the place of service value and a different instance of the place of service value; 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 within the place of service range, 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 the place of service range relative to a total number of utilization logs in the reduced dataset; applying a utilization ruleset to at least one of score, rank, and qualify the first healthcare provider based on criteria comprising the POS utilization rate; adding the provider UID of the first healthcare provider to a referral data; and transmitting the referral data over a network from a server to the computing device of the second healthcare provider running the point-of-care application, where the referral data is integrated within the user interface of the clinical documentation workflow of the point-of-care application.
“2. The method of claim 1, further comprising: querying a patient profile of the first patient with the patient UID of the first patient; and extracting from the patient profile of the first patient a patient data comprising at least one of a demographic data of the first patient, a coverage type of the first patient, and a diagnosis code of the first 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 second patient, a coverage type of the second patient, and a diagnosis code of the second patient.
“3. The method of claim 2, further comprising: calculating, using a different set of utilization logs of two or more healthcare providers within the utilization database, 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 at least one of the scoring, the ranking, and the qualifying 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 calculated from the utilization database.
“4. The method of claim 3, further comprising: receiving a selection of the second healthcare provider from a clinician through the point-of-care application; and automatically scheduling an appointment for the second patient with the first healthcare provider.
“5. The method of claim 4, further comprising: extracting from the patient profile of the second patient a location data associated with the second patient; and determining the second healthcare provider is within a predetermined distance based on the location data.
“6. The method of claim 5, wherein the utilization ruleset determines that the instance of the place of service value is a preferred instance of the place of service value based on criteria comprising the type of service.
“7. The method of claim 6, wherein the type of service value is at least one of a service category and a procedure code value, wherein the procedure code value is a CPT code value, 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, the type of service range, the patient data range, and the time range of the referral profile is selected by the clinician through the point-of-care application.”
There are additional claims. Please visit full patent to read further.
URL and more information on this patent, see: Kelly, Timothy. Maximizing patient referral outcome through healthcare utilization and/or referral evaluation.
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