Adjudicating integrated transactions

Abstract

A method for adjudicating and reimbursing a care provider for services provided for a clinical event is provided. The method includes referencing an integrated transaction including a number of clinical data elements, wherein the clinical data elements include clinical event details and electronic medical record data elements associated with a patient. Clinical data elements are used to select medical appropriateness criteria from an appropriateness knowledge base. Thereafter, it is determined that an electronic medical record data element affects the selected medical appropriateness criteria. As a result, the medical appropriateness criteria is adjusted in accordance with the electronic medical record data elements determined to affect the medical appropriateness criteria. The adjusted medical appropriateness criteria is used to determine whether the clinical data element(s) satisfy the adjusted medical appropriateness criteria.

What is claimed is: 
     
         1 . One or more computer readable storage media having computer-executable instructions stored thereon that executes a method in a computing environment, the method comprising:
 referencing an integrated transaction including a number of clinical data elements, wherein the clinical data elements comprise clinical event details electronically documented by the care provider at a point of care for the clinical event for which reimbursement is sought and electronic medical record data elements associated with a patient from an electronic medical record data store of a central computing system having historical electronic medical record data elements received from a plurality of sources;   using one or more clinical data elements to select medical appropriateness criteria from an appropriateness knowledge base;   determining that one or more of the electronic medical record data elements affect the selected medical appropriateness criteria;   adjusting the medical appropriateness criteria in accordance with the one or more of the electronic medical record data elements determined to affect the medical appropriateness criteria; and   using the adjusted medical appropriateness criteria to determine whether the clinical data elements satisfy the adjusted medical appropriateness criteria.   
     
     
         2 . The media of  claim 1 , wherein the method further comprises identifying the one or more clinical data elements to select medical appropriateness criteria based on relevance to the clinical event for which reimbursement is sought. 
     
     
         3 . The media of  claim 2 , wherein the selected medical appropriateness criteria are defined for a particular condition of the patient. 
     
     
         4 . The media of  claim 2 , wherein the selected medical appropriateness criteria are relevant to the integrated transaction. 
     
     
         5 . The media of  claim 1 , wherein the method further comprises storing the determination of whether the clinical data elements satisfy the adjusted medical appropriateness criteria. 
     
     
         6 . The media of  claim 1 , wherein when the clinical data elements are determined to satisfy the adjusted medical appropriateness criteria, reimbursement is initiated. 
     
     
         7 . The media of  claim 1 , wherein when the clinical data elements are not determined to satisfy the adjusted medical appropriateness criteria, notifying the care provider that one or more of the adjusted medical appropriateness criteria are unsatisfied. 
     
     
         8 . The media of  claim 7 , wherein the care provider is notified in real-time that the one or more of the adjusted medical appropriateness criteria are unsatisfied. 
     
     
         9 . The media of  claim 8  further comprising receiving one or more additional clinical event details pertaining to the care provided at the point of care. 
     
     
         10 . The media of  claim 9 , wherein the one or more additional clinical event details are stored in association with the integrated transaction. 
     
     
         11 . The media of  claim 8  further comprising receiving an explanation or a justification for not satisfying the adjusted medical appropriateness criteria. 
     
     
         12 . The media of  claim 11  further comprising determining that the explanation or the justification is acceptable and that the adjusted medical appropriateness criteria are satisfied. 
     
     
         13 . A method in a computing environment, the method comprising:
 referencing an integrated transaction including a number of clinical data elements, wherein the clinical data elements comprise clinical event details electronically documented by the care provider at a point of care for the clinical event for which reimbursement is sought and electronic medical record data elements associated with a patient from an electronic medical record data store of a central computing system having historical electronic medical record data elements received from a plurality of sources;   identifying one or more quality criteria associated with the integrated transaction;   determining that one or more of the electronic medical record data elements affect a quality criterion of the one or more quality criteria;   adjusting the quality criterion in accordance with the one or more of the electronic medical record data elements determined to affect the quality criterion; and   applying at least the adjusted quality criteria to determine the relative success of the care provided to the patient.   
     
     
         14 . The method of  claim 13 , wherein the one or more quality criteria are defined for the clinical event. 
     
     
         15 . The method of  claim 13 , wherein each of the one or more quality criteria comprises a measurable or observable condition indicating relative success of the care provided to the patient. 
     
     
         16 . The method of  claim 15  wherein each of the one or more quality criteria comprises a mortality, a morbidity, a length of visit or stay, an onset of another condition, a recurrence, an elimination of a presented problem, a quality of life indicator, a patient satisfaction indicator, or a combination thereof. 
     
     
         17 . The method of  claim 13 , wherein the quality criterion is adjusted in accordance with predetermined rules based on a presence or absence of an electronic medical record data element. 
     
     
         18 . The method of  claim 13 , wherein the determined relative success of the care provided to the patient is used to calculate an adjustment to a base level of reimbursement identified for an appropriate payer plan. 
     
     
         19 . The method of  claim 18 , wherein the calculated adjustment is applied to the base level of reimbursement identified for the appropriate payer plan to result in an adjusted level of reimbursement.