Healthcare performance measurement and equitable provider reimbursement system

Abstract

The present invention incorporates medical knowledge into the processes and algorithms that combine inpatient quality outcomes, ambulatory quality measures and health insurers' financial data into actionable information that hospitals and physicians can use to improve the efficacies and efficiencies of their care. It then quantifies the financial net savings that predictably accrue as a result of the providers' improved medical outcomes. This information enables a hospital or health insurer to equitably share the net saving with the physicians and hospitals as incentives to continuously improve the quality of their patients' care and control costs.

1 . A computer-implemented system for healthcare performance measurement and equitable provider reimbursement comprising:
 gather medical information from hospital patients charts data, hospital medical records department data, insurance company data, and physician's office data   aggregate the gathered data wherein said aggregation of data includes the use of a Sherlock computer program sub-system and memory database which targets cases by type, physician, severity and clinical services, diagnoses and procedures at a revenue code level, use of resources and create graphics by case;   wherein said Sherlock computer sub-system aggregated data is further analyzed by a Watson based computer sub-system which explains diagnoses and procedures by who by specific physician, what and why, sequence of events and what was not documented, explains specific resources by specific type of tests, breakdown of drugs, identifies why extra days were spent in hospital, and converts to true costs, and create a best practices framework by database of clinical variation by diagnosis and procedure, establishes a computerized physician order entry (CPOE) customization and facilitates clinical pathway construction; and calculating the following quality metrics: those National Hospital Quality Measures (NHQM) as determined to be mandated by Centers for Medicare and Medicaid Services (CMS), patient satisfaction, morbidity, mortality, reduction in variation (RIV), and resource consumption;   calculate an index of quality improvement (IQI) for each healthcare provider;   generate value sharing computations and calculate overall net savings; and   distribute said net savings to physicians, hospitals, Accountable Care Organizations (ACOs), CO-OPs and insurers in the form of reimbursements.   
     
     
         2 . (canceled) 
     
     
         3 . (canceled) 
     
     
         4 . A computer-implemented system for healthcare performance measurement and equitable provider reimbursement according to  claim 1 , wherein said system includes the element of ranking quality metrics as to importance for predicting quality and financial incentives, prior to calculating an index of quality improvement (IQI) for each healthcare provider. 
     
     
         5 . A computer-implemented system for healthcare performance measurement and equitable provider reimbursement according to  claim 1 , wherein said index of quality improvement (IQI) is calculated using the six enumerated metrics and ambulatory outcomes (AMB.O) and Accountable Care Organization metrics (ACO.M) outpatient physician's offices as a seventh metric added to the IQI calculation. 
     
     
         6 . A computer-implemented system for healthcare performance measurement and equitable provider reimbursement according to  claim 1 , wherein said IQI is tracked for one or more healthcare providers and for one or more years, with resulting IQI performance trend information sent to employers, consumers, public agencies, CO-OPs and hospital personnel for the purpose of making decisions regarding healthcare provider performance and improvement. 
     
     
         7 . A computer-implemented system for healthcare performance measurement and equitable provider reimbursement according to  claim 1 , wherein quality assurance and equitable reimbursement system (QAERS) algorithms are employed to generate value sharing computations and calculate overall net savings. 
     
     
         8 . A computer-implemented system for healthcare performance measurement and equitable provider reimbursement according to  claim 7 , wherein said value sharing computations and calculate overall net savings are used to calculate reimbursement rewards to be distributed to hospitals, clinical practice groups and physicians. 
     
     
         9 . A computer-implemented system for healthcare performance measurement and equitable provider reimbursement according to  claim 1 , wherein AIM technology algorithms are employed to aggregate data gathered from medical information from hospital patients charts data, hospital medical records department data, insurance company data, and physician's office data, prior to providing the resulting information to a Sherlock sub-system. 
     
     
         10 . A computer-implemented system for healthcare performance measurement and equitable provider reimbursement according to  claim 1 , wherein said IQI is calculated using future metrics at which time the become recognized national standards for measuring quality assurance and efficient performance of healthcare providers. 
     
     
         11 . A computer-implemented method for using a system for healthcare performance measurement and equitable provider reimbursement, comprising the steps of:
 (a) gathering medical information from hospital patients charts data, hospital medical records department data, insurance company data, and physician's office data;   (b) aggregating the gathered data wherein said aggregation of data includes the use of a Sherlock computer program sub-system and memory database which targets cases by type, physician, severity and clinical services, diagnoses and procedures at a revenue code level, use of resources and create graphics by case;   wherein said Sherlock computer sub-system aggregated data is further analyzed by a Watson based computer sub-system which explains diagnoses and procedures by who by specific physician, what and why, sequence of events and what was not documented, explains specific resources by specific type of tests, breakdown of drugs, identifies why extra days were spent in hospital, and converts to true costs, and create a best practices framework by database of clinical variation by diagnosis and procedure, establishes a computerized physician order entry (CPOE) customization and facilitates clinical pathway construction; and calculating the following quality metrics: National Hospital Quality Measures (NHQM), patient satisfaction, morbidity, mortality, reduction in variation, resource consumption;   (c) calculating an index of quality improvement for each healthcare provider;   (d) generating value sharing computations and calculating overall net savings; and   (e) distributing said net savings as a reimbursement to physicians, hospitals, Accountable Care Organizations (ACOs), CO-OPs and insurers in the form of reimbursements.   
     
     
         12 . (canceled) 
     
     
         13 . (canceled) 
     
     
         14 . The computer-implemented method for using a system for healthcare performance measurement and equitable provider reimbursement according to  claim 11 , wherein said method includes the step of ranking quality metrics as to importance for predicting quality and financial incentives, prior to said step of calculating an index of quality improvement (IQI) for each healthcare provider. 
     
     
         15 . The computer-implemented method for using a system for healthcare performance measurement and equitable provider reimbursement according to  claim 11 , wherein said index of quality improvement (IQI) is calculated using the six enumerated metrics and ambulatory outcomes (AMB.O) and Accountable Care Organization metrics (ACO.M) from outpatient and physician's offices as a seventh metric added to the IQI calculation. 
     
     
         16 . The computer-implemented method for using a system for healthcare performance measurement and equitable provider reimbursement according to  claim 11 , wherein said IQI is tracked for one or more healthcare providers and for one or more years, with resulting IQI performance trend information sent to employers, consumers, public agencies, CO-OPs and hospital personnel for the purpose of making decisions regarding healthcare provider performance and improvement. 
     
     
         17 . The computer-implemented method for using a system for healthcare performance measurement and equitable provider reimbursement according to  claim 11 , wherein quality assurance and equitable reimbursement system (QAERS) algorithms are employed to generate value sharing computations and calculate overall net savings. 
     
     
         18 . The computer-implemented method for using a system for healthcare performance measurement and equitable provider reimbursement according to  claim 17 , wherein said value sharing computations and calculate overall net savings are used to calculate reimbursement rewards to be distributed to hospitals, clinical practice groups and physicians. 
     
     
         19 . The computer-implemented method for using a system for healthcare performance measurement and equitable provider reimbursement according to  claim 11 , wherein AIM technology algorithms are employed to aggregate data gathered from medical information from hospital patients charts data, hospital medical records department data, insurance company data, and physician's office data, prior to providing the resulting information to a Sherlock sub-system. 
     
     
         20 . The computer-implemented method for using a system for healthcare performance measurement and equitable provider reimbursement according to  claim 11 , wherein said IQI is calculated using future metrics at which time they become recognized national standards for measuring quality assurance and efficient performance of healthcare providers.