A computer-implemented method for communicating a significance of departure of a medical care provider from a plurality of process-of-care standards via dynamic highlighting on a graphical user interface (GUI) on a display device, the GUI comprising a first pane and a second pane, the significance communicated at a granularity of specific procedures and services performed for specific medical conditions, the method implemented by at least one processor in communication with a memory device, a user input device, and the GUI, the method comprising steps executed by the at least one processor of:
- retrieving a file of claim line item records numbering at least 100,000 from the memory device, each of the claim line item records corresponding to an episode of care associated with a claim submitted to a health plan;
- reorganizing the file of claim line item records based on episodes of care, wherein each of the episodes of care includes the claim line item records corresponding to the claim submitted to the health plan, and wherein an episode identifier for the associated episode of care is added to each of the claim line item records;
- storing the reorganized file of claim line item records in the memory device;
- retrieving, from the memory device, an episode file that assigns episode identifiers for a non-outlier subset of the episodes of care to corresponding medical care providers;
- retrieving, from the memory device, definitions for marker code groups, wherein each of the marker code groups comprises one or more related codes from the health plan and is associated with a corresponding one of a plurality of medical conditions, and wherein each marker code group and the associated medical condition defines a marker-condition pair;
- receiving user input at a service detail display displayed on the GUI in the first pane for selecting a medical care provider from among the plurality of medical care providers, the medical care provider associated with a medical specialty from among a plurality of medical specialties, each of the medical specialties associated in the dmemory device with a set of medical conditions from among the plurality of medical conditions and with marker-condition pairs associated with the set of medical conditions;
- receiving user input at a pass/fail threshold control displayed on the GUI in the first pane for selecting a threshold definition;
- receiving user input at a pass/fail highlight control displayed on the GUI in the first pane selecting one or more outlier ranges;
- while displaying the first pane, highlighting each cell of a plurality of cells of a protocol-range outlier table for which the value falls within the one or more outlier ranges selected via the user input at the pass/fail highlight control, the protocol-range outlier table comprising a plurality of rows corresponding to outlier thresholds and a plurality of columns corresponding to target points, each row and column intersecting at a cell of the plurality of cells;
- receiving user input at a target control displayed in the second pane of the GUI for selecting a target point definition of the target points displayed in the protocol-range outlier table, the second pane being displayed along with the first pane;
- receiving user input at a qualifying standard control displayed on the GUI in the second pane, wherein a qualifying standard requires a minimum number of episodes of the medical condition of the marker-condition pair attributed to the medical care provider;
- parsing the episode file to identify the episode identifiers assigned to the selected medical care provider for the non-outlier subset of the episodes of care for the set of medical conditions in the medical specialty associated with the selected medical care provider;
- parsing the claim line item records in the stored reorganized file of claim line item records having the identified episode identifiers to determine an actual rate of utilization by the selected medical care provider of the marker code groups for each marker-condition pair in the medical specialty associated with the selected medical care provider;
- retrieving, from the memory device, a protocol range for each marker-condition pair in the medical specialty associated with the selected medical care provider;
- retrieving, from the memory device for each marker code group of the marker-condition pairs associated with the medical specialty, a bundle cost associated with a single utilization of the marker code group;
- and
- generating an output for display in the second pane by switching content displayed in the second pane while displaying the first pane, the generated output including:
- a listing of the one or more marker-condition pairs associated with the medical specialty;
- for each of the listed marker-condition pairs, a target point for a rate of utilization of the marker code group for the associated medical condition, wherein the target point is determined by applying, by the at least one processor for each of the listed marker-condition pairs, the target point definition to the retrieved protocol range associated with the pair;
- for each of the listed marker-condition pairs, an indication of a status, wherein the status is selected from among a group comprising (i) a fail status with a first highlighting comprising a first color, assigned in response to the actual rate of utilization by the selected medical care provider for the marker-condition pair exceeding the target rate of utilization, and (ii) a pass status with a second highlighting comprising a second color, assigned in response to the actual rate of utilization by the selected medical care provider for the marker-condition pair not exceeding the target rate of utilization;
- and
- for each failed marker-condition pair, a calculated cost of overuse based on the bundle cost of the marker code group associated with the marker-condition pair and a difference between the actual rate of utilization for the marker-condition pair and the target rate of utilization for the marker-condition pair, wherein the cost of overuse communicates the significance of departures from the process-of-care standard for the associated marker-condition pair.