Abstract: A system and method for identifying safety concerns regarding a drug identify a first group of patients that have received the drug from a database of healthcare claims and extract one or more medical events that the first group of patients have experienced from the database. The system and method also identify a second group of patients that have received a comparator drug in the database and extract one or more medical events that the second group of patients have experienced. The medical events of the first group are compared to the medical events of the second group to determine at least one common occurrence therebetween. The common occurrence(s) is then filtered based upon one or more user defined outcomes, each including at least one diagnosis, procedure or therapeutic classification; non-medical criteria; and/or patient laboratory test data.

Abstract: System and methods for rapid assessment of lab value distributions are provided. In one embodiment, the system includes a data storage device and a server. The data storage device may be configured to store a database comprising one or more records, wherein the records are identified by one or more test codes. The server may receive a medical code, search the database to obtain a first group of records associated with individuals having the medical code, wherein each record of the first group of records is identified by a test code, search the database to obtain a second group of records associated with a control population, wherein each record of the second group of records is identified by the test code, and generate an output comprising a distribution graph on a shared scale from the first and second group of records.

Abstract: A system and computer-implemented method for grouping medical records implements a multi-level analysis of the records. The level of analysis for each record is determined based upon the time proximity of each record to the defining medical procedure or service (anchor procedure) to be analyzed. Once an anchor procedure is identified, claim records are processed to determine whether any of the records should be grouped with the anchor procedure into a procedure episode group (PEG). First, the date of service for each claim record is identified to determine whether the claim record falls within time window. The claim records falling within the window then are assessed to determine whether each claim record is sufficiently related to the anchor procedure (for example, by determining whether the diagnostic, procedure, or episode treatment group coding of each claim record is associated with the anchor procedure).

Abstract: A method and system for analyzing historical medical provider billings to statistically establish a normative utilization profile. Comparison of a medical provider's utilization profile with a normative profile is enabled. Based on historical treatment patterns and a fee schedule, an accurate model of the cost of a specific medical episode can be created. Various treatment patterns for a particular diagnosis can be compared by treatment cost and patient outcome to determine the most cost-effective treatment approach. It is also possible to identify those medical providers who provide treatment that does not fall within the statistically established treatment patterns or profiles.

Abstract: A computer-implemented method for profiling medical claims to assist health care managers in determining the cost-efficiency and service quality of health care providers. The method allows an objective means for measuring and quantifying health care services. An episode treatment group (ETG) is a patient classification unit, which defines groups that are clinically homogenous (similar cause of illness and treatment) and statistically stable. The ETG grouper methodology uses service or segment-level claim data as input data and assigns each service to the appropriate episode. The program identifies concurrent and recurrent episodes, flags records, creates new groupings, shifts groupings for changed conditions, selects the most recent claims, resets windows, makes a determination if the provider is an independent lab and continues to collect information until an absence of treatment is detected.

Abstract: An apparatus, system, and method for member matching. In one embodiment, the apparatus includes an input adapter, a processor, and an output adapter. The input adapter may receive a first data record from a plurality of data records stored in one or more databases. The processor may generate a first data key from one or more field values in the first data record, compare a second data key associated with a second data record with the first data key associated with the first data record, and identify a match between the first data key and the second data key. In one embodiment, the output adapter may produce an output configured to identify the first data record and the second data record in response to identification of the match.

Abstract: A computer-implemented method for profiling medical claims to assist health care managers in determining the cost-efficiency and service quality of health care providers. The method allows an objective means for measuring and quantifying health care services. An episode treatment group (ETG) is a patient classification unit, which defines groups that are clinically homogenous (similar cause of illness and treatment) and statistically stable. The ETG grouper methodology uses service or segment-level claim data as input data and assigns each service to the appropriate episode. The program identifies concurrent and recurrent episodes, flags records, creates new groupings, shifts groupings for changed conditions, selects the most recent claims, resets windows, makes a determination if the provider is an independent lab and continues to collect information until an absence of treatment is detected.

Abstract: An apparatus, system, and method for rapid cohort analysis. In one embodiment, the apparatus includes an interface and a processor. The interface may receive an identifier of a first index attribute. The processor may search the database for a first group of records associated with the first index attribute, search the database for a second group of records, each record in the second group of records sharing a common second index attribute with a record in the first group of records, but not associated with the first index attribute, and calculate a statistic in response to information associated with the first group of records and the second group of records.

Abstract: In a system and method for processing data, a user interface enables a user to enter mapping data to enable incoming data to be converted to a common data format. A database stores the mapping data and data quality rules, and a receiver receives data from a data source. The processor applies the data quality rules to the common format data to identify any potential errors in the common format data and notifies the user of any potential errors found in the common format data. The data rules may include data structure rules and/or data trending requirements based upon data trends or norms. The data source may be an employer, insurance company or other entity. The data may include insurance claim data, medical data and/or prescription data and/or eligibility and/or occupational and non-occupational data.

Abstract: A method for using claims data to identify high-risk members of a healthcare plan is disclosed. In one embodiment, the present invention includes searching the plurality of claims of members selected by a filtering criteria to identify the presence of an intervention flag, to identify factors influencing care intervention, and identifying a medical episode driving the member's cost. In one embodiment, the intervention flag the medical episode are displayed in association with an identification of the member. In another embodiment, the member selection criteria includes selection based on the member's predicted future health care utilization.

Abstract: A system and method is provided for determining a probability that a member of a health plan has a disease or condition within one or more disease categories, by using data from the member's pharmacy claims. Logistic regression models are generated for each condition category using therapeutic drug categories, provider information, and/or other variables including member demographic information.

Abstract: An apparatus, system, and method are presented for predicting attitudinal segments. In one embodiment, the method includes receiving a set of data elements associated with an individual, calculating a score for one or more attitudinal dimensions to associate with the individual in response to the set of data elements, calculating an attitudinal segment to associate with the individual in response to the score for the one or more attitudinal dimensions, and generating an output configured to associate the attitudinal segment with the individual.

Abstract: An apparatus, system, and method for presentation of a natural history and the progression pathway of a disease is presented. In one embodiment, the apparatus an input/output adapter configured to receive information to generate a health profile for an individual. The apparatus may also include a processor configured to retrieve a disease progression map comprising one or more disease progression states from a data storage device, and determine a disease progression state associated with the individual in response to the health profile. In a further embodiment, the apparatus may include a display adapter coupled to the state determination module, the display module configured to display a graphical representation of the disease progression state with reference to the disease progression map.

Abstract: A method for using claims data to identify high-risk members of a healthcare plan is disclosed. In one embodiment, the present invention includes searching the plurality of claims of members selected by a filtering criteria to identify the presence of an intervention flag, to identify factors influencing care intervention, and identifying a medical episode driving the member's cost. In one embodiment, the intervention flag the medical episode are displayed in association with an identification of the member. In another embodiment, the member selection criteria includes selection based on the member's predicted future health care utilization.

Abstract: An apparatus system and methods are presented for best match search. In one embodiment, the apparatus includes a plurality of functional modules configured to collect user profile information and a service provider criterion, match a service provider profile to at least one of the user profile information and the service provider criterion, calculate a service provider statistic based on service provider data associated with a selected service provider, and generate service provider comparison data in response to the service provider statistic. In the described embodiments, these modules include a profile collection module, a profile match module, a provider analyzer, and a provider comparison module.

Abstract: A computer-implemented method for profiling medical claims to assist health care managers in determining the cost-efficiency and service quality of health care providers. The method allows an objective means for measuring and quantifying health care services. An episode treatment group (ETG) is a patient classification unit, which defines groups that are clinically homogenous (similar cause of illness and treatment) and statistically stable. The ETG grouper methodology uses service or segment-level claim data as input data and assigns each service to the appropriate episode. The program identifies concurrent and recurrent episodes, flags records, creates new groupings, shifts groupings for changed conditions, selects the most recent claims, resets windows, makes a determination if the provider is an independent lab and continues to collect information until an absence of treatment is detected.

Abstract: A computer-implemented system and method for administering a drug registry database generates a display of a plurality of new drug/comparator drug pairings, wherein each new drug is added to the database when a threshold number of healthcare claims for the new drug have been received. Upon receiving a selection of a new drug/comparator drug pairing, and filter parameters input by a user, an analysis engine searches the healthcare claims stored in the database to identify a first and second group of patients satisfying the filter parameters input by the user; wherein the first group includes patients with claim data indicating use of the new drug and the second group includes patients with claim data indicating use of the comparator drug.

Abstract: A system and computer-implemented method for grouping medical records implements a multi-level analysis of the records. The level of analysis for each record is determined based upon the time proximity of each record to the defining medical procedure or service (anchor procedure) to be analyzed. Once an anchor procedure is identified, claim records are processed to determine whether any of the records should be grouped with the anchor procedure into a procedure episode group (PEG). First, the date of service for each claim record is identified to determine whether the claim record falls within time window. The claim records falling within the window then are assessed to determine whether each claim record is sufficiently related to the anchor procedure (for example, by determining whether the diagnostic, procedure, or episode treatment group coding of each claim record is associated with the anchor procedure).

Abstract: A method for transferring health care data between a consumer health care application and a plurality of health care information sources. The method includes requesting a first portion of health care data corresponding to a consumer from a first health care information source of the plurality of health care information sources, receiving the first portion of health care data from the first health care information source, storing the first portion of health care data in a health care data repository, requesting a second portion of health care data corresponding to the consumer from a second health care information source of the plurality of health care information sources, receiving the second portion of health care data from the second health care information source, storing the second portion of health care data in the health care data repository, and accessing the first portion of health care data and the second portion of health care data from the health care data repository.

Abstract: A system and method for modeling healthcare utilization based on usage data from physician claims, hospital claims, and pharmacy claims. The method includes extracting from a claims file the portion of the data from a base period that is relevant to modeling healthcare utilization in a target period by computing a utilization score based on the usage data. The models may be used concurrently by calibrating them with the base period equal to the target period and they may be also be used prospectively by calibrating the models with the target period representing a future time period.