Abstract: The invention provides a computer implemented method for constructing a patient-specific evidence-informed case rate (ECR) for an episode of medical care spanning a defined period of time for a particular payer-provider-patient triad to create a patient-specific, severity adjusted prospective budget for the patient. ECR Analytics is a tool that constructs episodes of care using administrative claims data, both medical and pharmacy. It calculates the cost of care of patient-specific episodes by assigning relevant services to each episode and further distinguishing those services as typical or routine versus those associated with a complication. The episodes calculated within ECR Analytics can be attributed to specific providers, risk adjusted for performance measurement, and can also be used to construct prospective budgets for payment purposes, such as episode of care payment or reference pricing.

Abstract: The Episode Builder according to exemplary embodiments of the present invention is a web-based computer application and its associated architecture that allows health care professionals to define and describe episodes of care. The Episode Builder provides a unique tool for these purposes. Using industry-standard code sets, the Episode Builder describes and defines an episode of care so that the health care professional can create and modify episodes for a variety of purposes. The three main components of the Episode Builder are a configurable and extensive code set management system, a suite of display panels that define the episodes themselves based upon the code sets, and a means to export the episode definition tables thus created to be used as inputs into an analytic program or a claims adjudication engine.