System, method, and graphical user interface for identifying medical care providers outside a process-of-care standard

A method, implemented on a computer system, of identifying medical care providers outside a process-of-care standard for a field of health care, the computer system including at least one processor, the method comprising:

• retrieving, by the at least one processor, claim line item information including at least 1,000 claim line item records for episodes of care attributable to a first medical care provider, the claim line item information including, in aggregate, at least 40 codes each used to report a corresponding one of a medical, surgical, or diagnostic procedure or service;
• retrieving, by the at least one processor from a database, definitions for marker code groups associated with each medical condition of a set of medical conditions, wherein each of the marker code groups comprises one or more related codes from among the at least 40 codes, and wherein each marker code group and the associated medical condition defines a marker-condition pair;
• deriving, by the at least one processor, for each marker-condition pair for the set of medical conditions, an actual rate of utilization of the marker code group for episodes of the associated medical condition in the claim line item information;
• assigning, by the at least one processor, a status to each marker-condition pair for the set of medical conditions, wherein the status is selected from among a group comprising (i) a fail status, assigned in response to the actual rate of utilization exceeding a target rate of utilization of the marker code group for episodes of the associated medical condition, and (ii) a pass status, assigned in response to the actual rate of utilization not exceeding the target rate of utilization;
• aggregating, by the at least one processor, the statuses across the marker-condition pairs of the set of medical conditions to obtain an overall score for the first medical care provider;
• and
• causing, by the at least one processor, an output to be displayed in a viewable format, the output including the overall score, each marker-condition pair of the set of medical conditions, and the status for each marker-condition pair of the set of medical conditions.

A non-transitory computer-readable medium containing computer instructions for identifying medical care providers outside a process-of-care standard for a field of health care, wherein when executed by a processor, the computer instructions cause the processor to perform steps of:

• retrieving claim line item information including at least 1,000 claim line item records for episodes of care attributable to a first medical care provider, the claim line item information including, in aggregate, at least 40 codes each used to report a corresponding one of a medical, surgical, or diagnostic procedure or service;
• retrieving, from a database, definitions for marker code groups associated with each medical condition of a set of medical conditions, wherein each of the marker code groups comprises one or more related codes from among the at least 40 codes, and wherein each marker code group and the associated medical condition defines a marker-condition pair;
• deriving, for each marker-condition pair for the set of medical conditions, an actual rate of utilization of the marker code group for episodes of the associated medical condition in the claim line item information;
• assigning a status to each marker-condition pair for the set of medical conditions, wherein the status is selected from among a group comprising (i) a fail status, assigned in response to the actual rate of utilization exceeding a target rate of utilization of the marker code group for episodes of the associated medical condition, and (ii) a pass status, assigned in response to the actual rate of utilization not exceeding the target rate of utilization;
• aggregating the statuses across the marker-condition pairs of the set of medical conditions to obtain an overall score for the first medical care provider;
• and
• causing an output to be displayed in a viewable format, the output including the overall score, each marker-condition pair of the set of medical conditions, and the status for each marker-condition pair of the set of medical conditions.

A graphical user interface (GUI) for use in evaluating a plurality of medical care providers against process-of-care standards, the GUI implemented by a processor in communication with a memory device, a user input device, and a display device, the GUI comprising:

• a configuration display tier comprising:
• a specialty control enabling a selection, via the user input device, of a medical specialty from among a plurality of medical specialties, each of the medical specialties associated in the memory device with one or more pairs of medical conditions and marker code groups, wherein each marker code group and the associated medical condition define a marker-condition pair;
• and
• a target control enabling a selection, via the user input device, of a target point definition;
• a services summary display tier, displayable in response to at least one selection, via the user input device, on the configuration tier display, the services summary display tier comprising:
• a listing of the one or more marker-condition pairs associated with the medical specialty selected via the specialty control;
• and
• 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 processor for each of the listed pairs, the target point definition to a protocol range associated with the pair in the memory device;
• and
• a service detail display tier displayable in response to a selection, via the user input device, of one of the listed marker-condition pairs on the services summary display tier, the service detail display tier comprising:
• a listing of qualifying medical care providers of the plurality of medical care providers, wherein the qualifying medical care providers meet a qualifying standard for analysis with respect to the selected pair;
• for each of the listed qualifying medical care providers, an indication of an amount of excess usage of the marker code group of the selected pair with respect to episodes of the medical condition of the selected pair, wherein the amount of the excess usage is determined, by the processor, by (i) parsing claim line item information stored in the memory device to determine an actual rate of utilization of the marker code group in episodes of the medical condition attributed to the respective listed qualifying medical care provider, and (ii) comparing the target point for the selected pair to the actual rate of utilization;
• and
• for each of the listed qualifying medical care providers, an estimated monetary savings realizable in response to a reduction of the actual rate of utilization to match the target point.