System for gap in care alerts

Abstract

A gap in care alert system and method includes a computer network which receives health insurance claims data. A database with medical treatment protocols for medical conditions is in electronic communication with one or more processors, the computer network, and an electronic storage device. The processor is configured to analyze said health insurance claims data to identify a triggering event for an insured patient, establish a date for a follow-up event based on a treatment protocol, and generate a gap in care alert if subsequently gathered health insurance claims data does not contain the follow-up event by said date. An alert delivery subsystem delivers said alert electronically to a receiver.

What is claimed is: 
     
         1 . A system comprising:
 a computer network for receiving health insurance claims data;   a database comprising predetermined medical treatment protocols for a plurality of medical conditions;   an electronic storage device comprising executable software instructions;   at least one processor in electronic communication with said computer network, said database, and the electronic storage device, wherein the executable software instructions, when executed, configure the processor to analyze said health insurance claims data to identify a triggering event for an insured patient, determine a medical treatment protocol associated with the triggering event, establish a date for a follow-up event for said insured patient based at least in part on said associated medical treatment protocol, and generate a gap in care alert if subsequently gathered health insurance claims data does not contain the follow-up event by said date; and   an alert delivery subsystem configured to deliver said alert electronically to a receiver.   
     
     
         2 . The system of  claim 1 , wherein:
 said triggering event is a date when a healthcare provider performs a medical procedure on said patient.   
     
     
         3 . The system of  claim 1 , wherein:
 said processor is configured to generate said alert a number of days in advance of said date for the follow-up event.   
     
     
         4 . The system of  claim 1 , wherein:
 said processor is configured to generate said alert a number of days after said date for the follow-up event.   
     
     
         5 . The system of  claim 1 , wherein:
 said medical treatment protocols includes recommended steps for medical treatment for particular medical conditions.   
     
     
         6 . The system of  claim 5 , further comprising:
 additional executable software instructions, stored at said electronic storage device, which when executed, further configure the processor to receive health care provider prescribed steps, generate an alert message if said prescribed steps do not match said recommended steps, and deliver said alert message by way of said alert delivery subsystem.   
     
     
         7 . The system of  claim 6 , wherein:
 said alert message comprises a prompt for the health care provider to consider revising the prescribed steps to be consistent with the recommended steps.   
     
     
         8 . The system of  claim 1 , wherein:
 said alert is automatically generated and automatically sent to said receiver.   
     
     
         9 . The system of  claim 8 , wherein:
 said receiver is associated with an electronic medical record system for an insured patient.   
     
     
         10 . The system of  claim 8 , wherein:
 said receiver is a patient's personal mobile communications device and said alert is a text message.   
     
     
         11 . The system of  claim 1 , wherein:
 said medical treatment protocols include time periods associated with each recommended step.   
     
     
         12 . The system of  claim 11 , wherein:
 said time periods are determined using performance measure rules.   
     
     
         13 . The system of  claim 12 , wherein:
 said performance measure rules are selected from the group consisting of: HEDIS and STAR.   
     
     
         14 . The system of  claim 1 , wherein:
 said triggering events is determined using performance measure rules selected from the group consisting of: HEDIS and STAR.   
     
     
         15 . A system comprising:
 a computer network for receiving health insurance claims data from a number of insured members of a health insurance provider;   a database comprising predetermined medical treatment protocols for a plurality of medical conditions, wherein said medical treatment protocols comprise recommended treatment steps and associated time periods between each of said treatment steps;   an electronic storage device comprising executable software instructions;   at least one processor in electronic communication with said computer network, said database, and the electronic storage device, wherein said executable software instructions, when executed, configure the processor to analyze said health insurance claims data to identify a triggering event for an insured patient, determine the medical treatment protocol associated with the triggering event, determine one or more recommended treatment steps and associated follow-up dates, and generate a gap in care alert if subsequently gathered health insurance claims data for the insured patient does not contain the one or more recommended treatment steps by the associated follow-up dates; and   an alert delivery subsystem configured to deliver said gap in care alert electronically to a receiver, wherein said gap in care alert message comprises a prompt to follow up with said health care provider for the recommended treatment step.   
     
     
         16 . The system of  claim 15 , further comprising:
 additional software instructions, which when executed, configure the at least one processor to receive health care provider prescribed treatment steps, compare said prescribed steps to said recommended treatment steps, and generate a treatment advice message if said prescribed steps do not match said recommended treatment steps, wherein said treatment advice message comprises a prompt to consider revising the prescribed treatment steps to match the recommended treatment steps.   
     
     
         17 . The system of  claim 15 , wherein:
 said follow-up dates are determined using performance measure rules selected from the group consisting of: HEDIS and STAR.   
     
     
         18 . A system comprising:
 a computer network configured to receive health insurance claims data for a number of insured patients of a health insurance provider;   a database comprising predetermined medical treatment protocols for a plurality of medical conditions, wherein said medical treatment protocols comprise recommended treatment steps and associated time periods for medical treatment follow-up for particular medical conditions;   an electronic storage device comprising software instructions;   a gap in care alert module comprising at least one computer processor in electronic communication with said computer network, said database, and said electronic storage device, wherein said software instructions, when executed, configure said at least one computer processor to analyze said received health insurance claims data to identify a triggering event for an insured patient, identify a medical treatment protocol associated with said triggering event, determine an expected date for a follow-up event by retrieving the time period associated with the next recommended treatment step of the identified medical treatment protocol and adding the 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; and   a treatment advice module comprising at least one computer processor in electronic communication with said computer network, said database, and the electronic storage device, wherein software instructions, when executed, further configure said at least one computer processor to retrieve recommended treatment steps associated with said identified medical treatment protocol and generate a message to the health care provider if subsequently gathered health insurance claims data does not indicate that the health care providers treatment steps do not match the recommended treatment steps, wherein the generated message comprises a prompt for the health care provider to consider performing the recommended treatment steps.   
     
     
         19 . The system of  claim 18 , 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.   
     
     
         20 . The system of  claim 18 , wherein:
 said triggering event is a date when a healthcare provider performs a medical procedure on said insured patient.