US 5,018,067 A · Apparatus and method for improved estimation of health resource consumption through use of diagnostic and/or procedure grouping and severity of illness indicators

Abstract

The likely consumption of health provider resources that are necessary to treat a particular medical patient are estimated within the framework of the existing Federal mandated system that uses Diagnostic Related Groups (DRG's) for setting the amount of payment that a hospital or other health provider will receive from the United States Government for that patient under the Medicare reimbursement system. The amount of payment is made from a calculation using the DRG system, regardless of the actual cost to the health provider. The Federal system results in a wide variation of health care costs occurring within each DRG, resulting from varying degrees of overall sickness among patients that are similarly classified. The present invention works within the DRG system and all of the sub-groups of DRG's including groups of diagnosis codes and individual diagnosis codes. Hidden information is extracted from the same input data that is used by the DRG system, in order to classify each patient into sub-categories of resource consumption, or other outcome variable, within a designated DRG or DRG sub-group. The invention is implemented by a general purpose computer system.

Claims27

Dependent claims

A method of monitoring the performance of a health provider in rendering medical services to a patient, comprising the steps of:

(1) predicting an outcome of treatment of the patient by the health provider by a method including the following steps executed on a computer:
converting into digital electronic signals input medical codes of at least a patient's principal diagnosis, any secondary diagnoses, any surgical procedures, sex and age,
identifying a few of an existing plurality of diagnostic and/or procedure groups of illnesses that are appropriate for either one of the surgical procedures signals or the principal diagnosis signals,
selecting from those few identified groups a single diagnostic or procedure group that is consistent with the signals of any secondary diagnoses and the patient's age and sex, and
calculating a sub-category within the single selected diagnostic or procedure group for predicting at least one outcome by a formula that mathematically combines various of the medical code input signals with constants unique to the single selected diagnostic or procedure group, the constants having been determined from a statistical analysis of a large amount of actual patient data within the single selected diagnostic or procedure group by use of the same formula;
(2) predicting from the calculated sub-category at least one outcome of patient treatment;
(3) comparing said predicted outcome with the actual outcome of patient treatment;
(4) monitoring the performance of health providers through use of said comparison;
and
(5) providing counseling to said health provider if the performance level of the health provider falls below an established level.

7 more elements

A method of monitoring the performance of a health provider in rendering medical services to a patient, comprising the steps of:

(1) in a computer system having data of a medical patient that includes the patient's age, a numerical representation of the patient's sex, an ICD code of a principal diagnosis of the patient's condition, one or more ICD codes of secondary diagnosis of the patient's condition, and a DRG determined from the ICD codes in accordance with a Government grouper algorithm, a method of predicting by computer processing an outcome of treatment of the patient, comprising the steps of:
providing a computer static data base that includes a first table of DRG categories into which each of a plurality of ICD codes is mapped, and a second table of Government mandated weights of the individual DRG categories,
determining from the first table the DRG categories into which each of the ICD codes is mapped,
reading from the second table the weights of each of the determined DRG categories,
summing the read DRG weights, and
predicting an outcome of the patient treatment by use of the sum of the read DRG weights;
(2) comparing said predicted outcome with the actual outcome of patient treatment;
(3) monitoring the performance of health providers through use of said comparison;
and
(4) providing counseling to said health provider if the performance level of the health provider falls below an established level.

7 more elements

A method of monitoring the performance of a health provider in rendering medical services to a patient, comprising the steps of:

(1) for use with a system that estimates the amount of resources that are likely to be consumed to treat a specific patient illness by classifying the patient into one of a large number of categories of estimated resource consumption on the basis of input information that includes a principal diagnosis and/or a surgical procedure performed or to be performed, any secondary diagnoses, the patient's age and sex, a method of more accurately estimating an outcome of treatment of the patient by a health provider within said one category, comprising the following steps executed on a computer:
determining a category for each of a plurality of diagnoses and/or procedures of the input information as if it was the only diagnosis or procedure to be considered, and noting the resource estimate for each such category,
determining from said input information a plurality of other quantities relating to the patient's condition, and
calculating a refined resource estimate within the determined one category by solving an algebraic equation that combines the noted category resource estimates and the other quantities derived from the input information after multiplication by a plurality of constants, said constants having been derived by statistical analysis of a large amount of actual data of input information and the resources consumed by patients classified in said one category by use of said algebraic equation;
(2) comparing said calculated resource estimate with the amount of resources actually used;
(3) monitoring the performance of health providers through use of said comparison;
and
(4) providing counseling to said health provider if the performance level of the health provider falls below an established level.

5 more elements

A method of monitoring the performance of a health provider in rendering medical services to a patient, comprising the steps of:

(1) for use with a system that estimates the amount of resources that are likely to be consumed to treat a specific patient illness by classifying the patient into one of a large number of categories of estimated resource consumption on the basis of input information that includes a principal diagnosis and/or a surgical procedure performed or to be performed, any secondary diagnoses, the patient's age and sex, a method of forecasting an outcome of treatment of the patient by a health provider, comprising the following steps executed on a computer:
determining a plurality of quantities relating to the patient's illness, such a determination being made only from (A) the input information about the patient and the patient's illness that is used to determine said one category, and (B) a static database including but not limited to information about the categories, diagnoses, procedures and category estimated resource consumption, and
calculating a refined resource estimate within the determined one category by solving an algebraic equation that combines said plurality of quantities after multiplication by a plurality of constants, said constants having been derived from use of said algebraic equation by statistical analysis of a large amount of actual data of input information and the resources consumed by patients classified in said one category;
(2) comparing said calculated resource estimate with the amount of resources actually used;
(3) monitoring the performance of health providers through use of said comparison;
and
(4) providing counseling to said health provider if the performance level of the health provider falls below an established level.

4 more elements

A method of monitoring the performance of a health provider in rendering medical services to a given patient from patient information including illness diagnoses, surgical procedures performed or to be performed, if any, age and sex, comprising the steps of:

establishing on a computer a mathematical relationship of said treatment outcome with a plurality of variables developed from said patient information,
inputing to the computer data including said information and resulting treatment outcomes for a large population of actual patients,
utilizing the mathematical relationship to determine by calculations with the computer a set of elements in the mathematical relationship from said actual patient data which minimize differences between the actual outcomes and those calculated by said mathematical relationship from the actual patient information,
forming by calculation on the computer the mathematical relationship variables from said given patient information,
solving on the computer said mathematical relationship with said given patient variables and said determined set of elements, thereby to provide a prediction of the outcome of treatment for said given patient;
comparing said predicted outcome with the actual outcome of patient treatment;
monitoring the performance of health providers through use of said comparison;
and
providing counseling to said health provider if the performance level of the health provider falls below an established level.

6 more elements

A method of monitoring the performance of a health provider in rendering medical services to a patient from patient information including illness diagnoses, surgical procedures performed or to be performed, if any, age and sex, comprising the steps of:

(1) in a computer system that includes means for mapping a medical patient's condition and/or treatment into a single group of related diagnoses and/or procedures from information of the patient that includes a principal diagnosis code, one or more surgical procedure codes, if any, one or more secondary diagnosis codes, if any, the patient's age, and the patient's sex, a method of predicting an outcome of treatment of the patient by a health provider by use of said computer system, comprising the steps of;
calculating a plurality of variables from said patient information, and
mathematically combining said variables with the use of a plurality of constants that have been determined by statistical analysis of data from an actual patient population within said single group of related diagnoses and/or procedures, thereby to predict an outcome of treatment of the patient;
(2) comparing said predicted outcome with the actual outcome of patient treatment;
(3) monitoring the performance of health providers through use of said comparison;
and
(4) providing counseling to said health provider if the performance level of the health provider falls below an established level.

4 more elements

Dependencies are inferred from the claim text.

Apparatus and method for improved estimation of health resource consumption through use of diagnostic and/or procedure grouping and severity of illness indicators

Life of this patent

Apparatus and method for improved estimation of health resource consumption through use of diagnostic and/or procedure grouping and severity of illness indicators

Life of this patent

Abstract

Claims27