Patent Issued for System For Gap In Care Alerts (USPTO 10,262,756)

2019 APR 30 (NewsRx) -- By a News Reporter-Staff News Editor at Hospital & Nursing Home Daily -- According to news reporting originating from Alexandria, Virginia, by NewsRx journalists, a patent by the inventors Ghouri, Ahmed (San Diego, CA); Sugavanam, Raghu (La Jolla, CA), filed on November 21, 2013, was published online on April 29, 2019.

The assignee for this patent, patent number 10,262,756, is Humana Inc. (Louisville, Kentucky, United States).

Reporters obtained the following quote from the background information supplied by the inventors: “The health care profession has known that gaps in patient care can lead to worsening health for the patient, and if that occurs there is the potential for much higher costs of health care for the patient. For example, it is known that if a diabetic patient does not follow medical advice with respect to insulin treatment schedules the patient’s health may deteriorate. It is also known that if a patient has had surgery and a scheduled follow up visit to the doctor is missed the patient’s recovery from surgery may be endangered which may result in the patient having to be readmitted to the hospital. Yet another example is in the area of pharmacies. Patients given renewable prescriptions who fail to renew the prescription for a needed drug may result in the patient’s condition worsening.

“All of the above scenarios are generally defined as gaps in care. There are many reasons why patients may have gaps in care, ranging from forgetfulness, a life changing event, financial reasons, not taking the care instructions seriously, etc. Whatever the reason may be it is important to alert the patient or other entity concerned with the patient (such as their healthcare provider) of a possible gap in care. Systems and methods have been used to alert various entities of medical information important to convey. For example, U.S. Pat. No. 5,754,111 shows one such system. Systems have been developed that use known medical data about a patient compared to historically collected medical data about drugs, conditions, interactions, contraindications, etc., to improve care for the patient. U.S. Pat. No. 7,809,585 describes such a system and method. The entireties of both of these patents are hereby incorporated by reference herein.

“The danger in having a gap in care is that the failure to follow medical instructions can result in undesirable outcomes for the patient. These undesirable outcomes may include a slower recovery, a complete lack of recovery potentially resulting in a chronic condition that could have been avoided, or in some cases, a dangerous worsening of a patient’s condition. These results are undesirable for the patient’s health but also often result in increased health care costs. Incomplete health care can lead to inefficiencies in care. The public, the news media, and some government agencies have become increasingly concerned about the cost and quality of health care. One set of factors that have been applied to measure the quality of care provided is the Heathcare Effectiveness Data and Information Set (HEDIS). HEDIS was developed by the National Committee for Quality Assurance. In addition to the general increase in public awareness of medical care cost and quality, the HEDIS factors provide additional incentive for medical service and health insurance providers to work to control costs and improve patient care. In addition to HEDIS, the Centers for Medicare and Medicaid Services (CMS) have deployed an additional rating system known as ‘STAR.’

“In addition to helping to ensure that the performance in the areas considered by HEDIS and STAR are optimized, solutions that minimize the impact of gaps in care have the beneficial effects of improving the quality of care provided to patients, keeping patients healthy or improving their health, and reducing the cost of medical care.

“Today’s existing computer technologies allow the gathering and analysis of medical data of a patient’s medical history. Today, a patient’s medical records are often stored electronically, sometimes in records or files known as electronic medical records or EMRs. EMRs are well known such that details of their formation, updating, storing, sending, and receiving electronically via computer network are not explained herein. This electronic storage provides a repository of patient care information that can be leveraged by the health care system to improve a patient’s care and reduce the overall cost of a patient’s medical treatment. Methods of leveraging a patient’s medical record(s) to reduce gaps in care have been developed but can fall short in their ability to change the behavior of patients when it comes to avoiding gaps in care.

“The present invention resides in improvements to the means for developing, generating, and communicating the potential for or the existence of a gap in care for a patient. This is done in such a way as to encourage a change in the patient’s behavior sufficiently to cause the patient to take the actions required to eliminate or prevent the gap in care. This communication is also delivered in a manner calculated to minimize the actual time of gap in care or prevent a gap in care from happening in the first place. It is understood that once a gap in care approaches or begins, a lengthy delay in communication may widen the time of a gap in care and in doing so, increase the likelihood of an unfavorable impact on the patient or increase the cost of care required to make the patient well.

“Various known means of communication may be useful with the present invention. For example, outbound automated phone dialers in electronic communication with a computer system (such as used by telemarketing companies) may be useful in phoning someone about a gap in care. Known computer automated email servers or texting services may also be used to contact someone about a gap in care. Connected to a computer system that determines when to issue an alert or to send an alert, such known systems can be useful in delivering the alert.

“In an exemplary embodiment of the present invention, a computer system analyzing patient medical data detects an approaching potential for gap in care and initiates the generation of an alert message and delivery of a communication containing the message directly to the patient in the form of an automated phone call. A communication directly to the patient serves as an efficient and cost effective method to inform and encourage action to eliminate the gap in care. In another exemplary embodiment of the invention, such a phone call is made to a home health care service which then may attempt to contact the patient by an in-person visit to the patient’s residence in order to check on the patient’s condition and further encourage the patient to conform to the care recommendations provided by their health care provider. Other means for delivering the alerts will be described in the following detailed description, as will means for generating an alert.

“In addition to the novel features and advantages mentioned above, other benefits will be readily apparent from the following descriptions of the drawings and exemplary embodiments.”

In addition to obtaining background information on this patent, NewsRx editors also obtained the inventors’ summary information for this patent: “The health care profession has known that gaps in patient care can lead to worsening health for the patient, and if that occurs there is the potential for much higher costs of health care for the patient. For example, it is known that if a diabetic patient does not follow medical advice with respect to insulin treatment schedules the patient’s health may deteriorate. It is also known that if a patient has had surgery and a scheduled follow up visit to the doctor is missed the patient’s recovery from surgery may be endangered which may result in the patient having to be readmitted to the hospital. Yet another example is in the area of pharmacies. Patients given renewable prescriptions who fail to renew the prescription for a needed drug may result in the patient’s condition worsening.

“All of the above scenarios are generally defined as gaps in care. There are many reasons why patients may have gaps in care, ranging from forgetfulness, a life changing event, financial reasons, not taking the care instructions seriously, etc. Whatever the reason may be it is important to alert the patient or other entity concerned with the patient (such as their healthcare provider) of a possible gap in care. Systems and methods have been used to alert various entities of medical information important to convey. For example, U.S. Pat. No. 5,754,111 shows one such system. Systems have been developed that use known medical data about a patient compared to historically collected medical data about drugs, conditions, interactions, contraindications, etc., to improve care for the patient. U.S. Pat. No. 7,809,585 describes such a system and method. The entireties of both of these patents are hereby incorporated by reference herein.

“The danger in having a gap in care is that the failure to follow medical instructions can result in undesirable outcomes for the patient. These undesirable outcomes may include a slower recovery, a complete lack of recovery potentially resulting in a chronic condition that could have been avoided, or in some cases, a dangerous worsening of a patient’s condition. These results are undesirable for the patient’s health but also often result in increased health care costs. Incomplete health care can lead to inefficiencies in care. The public, the news media, and some government agencies have become increasingly concerned about the cost and quality of health care. One set of factors that have been applied to measure the quality of care provided is the Heathcare Effectiveness Data and Information Set (HEDIS). HEDIS was developed by the National Committee for Quality Assurance. In addition to the general increase in public awareness of medical care cost and quality, the HEDIS factors provide additional incentive for medical service and health insurance providers to work to control costs and improve patient care. In addition to HEDIS, the Centers for Medicare and Medicaid Services (CMS) have deployed an additional rating system known as ‘STAR.’

“In addition to helping to ensure that the performance in the areas considered by HEDIS and STAR are optimized, solutions that minimize the impact of gaps in care have the beneficial effects of improving the quality of care provided to patients, keeping patients healthy or improving their health, and reducing the cost of medical care.

“Today’s existing computer technologies allow the gathering and analysis of medical data of a patient’s medical history. Today, a patient’s medical records are often stored electronically, sometimes in records or files known as electronic medical records or EMRs. EMRs are well known such that details of their formation, updating, storing, sending, and receiving electronically via computer network are not explained herein. This electronic storage provides a repository of patient care information that can be leveraged by the health care system to improve a patient’s care and reduce the overall cost of a patient’s medical treatment. Methods of leveraging a patient’s medical record(s) to reduce gaps in care have been developed but can fall short in their ability to change the behavior of patients when it comes to avoiding gaps in care.

“The present invention resides in improvements to the means for developing, generating, and communicating the potential for or the existence of a gap in care for a patient. This is done in such a way as to encourage a change in the patient’s behavior sufficiently to cause the patient to take the actions required to eliminate or prevent the gap in care. This communication is also delivered in a manner calculated to minimize the actual time of gap in care or prevent a gap in care from happening in the first place. It is understood that once a gap in care approaches or begins, a lengthy delay in communication may widen the time of a gap in care and in doing so, increase the likelihood of an unfavorable impact on the patient or increase the cost of care required to make the patient well.

“Various known means of communication may be useful with the present invention. For example, outbound automated phone dialers in electronic communication with a computer system (such as used by telemarketing companies) may be useful in phoning someone about a gap in care. Known computer automated email servers or texting services may also be used to contact someone about a gap in care. Connected to a computer system that determines when to issue an alert or to send an alert, such known systems can be useful in delivering the alert.

“In an exemplary embodiment of the present invention, a computer system analyzing patient medical data detects an approaching potential for gap in care and initiates the generation of an alert message and delivery of a communication containing the message directly to the patient in the form of an automated phone call. A communication directly to the patient serves as an efficient and cost effective method to inform and encourage action to eliminate the gap in care. In another exemplary embodiment of the invention, such a phone call is made to a home health care service which then may attempt to contact the patient by an in-person visit to the patient’s residence in order to check on the patient’s condition and further encourage the patient to conform to the care recommendations provided by their health care provider. Other means for delivering the alerts will be described in the following detailed description, as will means for generating an alert.

“In addition to the novel features and advantages mentioned above, other benefits will be readily apparent from the following descriptions of the drawings and exemplary embodiments.”

The claims supplied by the inventors are:

“What is claimed is:

“1. A system comprising: a computer network for receiving health insurance claims data for a health insurance provider, wherein said health insurance claims data is generated after an insured patient receives medical treatment from a health care provider, said health insurance claims data being received by said health insurance provider from or on behalf of said health care provider for payment for said treatment that was provided to said insured patient; a database comprising predetermined medical treatment protocols for a plurality of medical conditions, wherein said medical treatment protocols include time periods for medical treatment follow-up for particular medical conditions, wherein said time periods are determined using performance measure rules selected from the group consisting of: HEDIS and STAR; at least one computer processor in association with said computer network for analyzing said received health insurance claims data to identify a triggering event for an insured patient, wherein said triggering event is a date when a healthcare provider performs a medical procedure on said insured patient; said at least one computer processor in electronic communication with said database and an electronic storage device comprising software instructions, which when executed cause said at least one computer processor to obtain an expected date for a follow-up event for said insured patient in response to the identification of the triggering event, wherein said expected date for a follow-up event is determined by associating said triggering event with a selected treatment protocol from said medical treatment protocols, retrieving the associated time period for medical treatment follow-up for the selected treatment protocol and associated medical condition, adding the associated time period and a grace period to the triggering event, and automatically generating a gap in care alert if subsequently gathered health insurance claims data does not indicate that medical treatment follow-up has occurred for said patient by said expected date; said at least one computer processor configured to automatically deliver said alert electronically to a receiver; and said electronic storage device comprises additional software instructions, which when executed by said at least one computer processor cause said at least one computer processor to receive health care provider recommendations for follow up events, compare the health care provider recommendations against the selected treatment protocol, and generate a message to the health care provider if the received health care provider recommendations do not match the selected treatment protocol, wherein the generated message comprises a prompt to revise the health care provider recommendations to be consistent with the selected treatment protocol.

“2. The system of claim 1, wherein: said receiver is in electronic communication with an electronic medical record system having an electronic medical record stored therein for said insured patient.

“3. The system of claim 1, wherein: said receiver is in electronic communication with said insured patient’s personal mobile communications device and said alert is sent in the form of a text message to said mobile communications device.

“4. The system of claim 1, wherein: said electronic storage device comprises additional software instructions, which when executed, cause said at least one computer processor to determine an early warning date by subtracting a predetermined number of days from the expected date for a follow-up event for said insured patient, and automatically generate an approaching gap in care alert if subsequently gathered health insurance claims data does not indicate that medical follow-up has occurred for said patient by said early warning date.”

For more information, see this patent: Ghouri, Ahmed; Sugavanam, Raghu. System For Gap In Care Alerts. U.S. Patent Number 10,262,756, filed November 21, 2013, and published online on April 29, 2019. Patent URL: http://patft.uspto.gov/netacgi/nph-Parser?Sect1=PTO1&Sect2=HITOFF&d=PALL&p=1&u=%2Fnetahtml%2FPTO%2Fsrchnum.htm&r=1&f=G&l=50&s1=10,262,756.PN.&OS=PN/10,262,756RS=PN/10,262,756

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