Abstract: A method for adjudicating and reimbursing a care provider for services provided for a clinical event is provided. The method includes referencing an integrated transaction including a number of clinical data elements, wherein the clinical data elements include clinical event details and electronic medical record data elements associated with a patient. Clinical data elements are used to select medical appropriateness criteria from an appropriateness knowledge base. Thereafter, it is determined that an electronic medical record data element affects the selected medical appropriateness criteria. As a result, the medical appropriateness criteria is adjusted in accordance with the electronic medical record data elements determined to affect the medical appropriateness criteria. The adjusted medical appropriateness criteria is used to determine whether the clinical data element(s) satisfy the adjusted medical appropriateness criteria.

Abstract: A method for adjudicating and reimbursing a care provider for services provided for a clinical event is provided. The method includes referencing a transaction including a number of clinical event details electronically documented by a care provider at a point of care for a clinical event for which reimbursement is sought. A first knowledge base comprising a number of quality criterion for assessing quality of health care provided to patients is accessed. Quality criterion are selected based on the clinical event details, and an analysis of the clinical event details against the selected quality criterion is performed to determine the quality of health care provided to a patient.

Abstract: Systems, methods, and graphical user interfaces are provided for identifying, analyzing, and adopting opportunities for optimizing clinical processes within clinical facilities. An optimized practice process model may be defined for a particular clinical procedure, setting forth an optimal clinical process. In addition, critical levers may be identified within the optimal clinical process, representing the activities that have the greatest impact on outcomes. Clinical facilities may collect current measures for the critical levers, and the current measures may be compared against an optimal, benchmark, and/or target measure. Based on the comparison, opportunities for clinical process optimization may be identified. Those opportunities may then be analyzed and prioritized for adoption into a facility's current practice. Clinical processes within healthcare facilities may be further improved by continuously monitoring facility data and identifying further opportunities of optimization.

Abstract: A method for adjudicating and reimbursing a care provider for services provided for a clinical event is provided. The method includes referencing a transaction including a number of clinical event details electronically documented by a care provider at a point of care for a clinical event for which reimbursement is sought. A first knowledge base comprising a number of quality criterion for assessing quality of health care provided to patients is accessed. Quality criterion are selected based on the clinical event details, and an analysis of the clinical event details against the selected quality criterion is performed to determine the quality of health care provided to a patient.

Abstract: A method for adjudicating and reimbursing a care provider for services provided for a clinical event is provided. The method includes the step of receiving a transaction having a number of clinical data elements. The method also includes the steps of accessing a data store including payer information and determining whether the transaction is eligible for reimbursement by at least one payer. The method also includes the steps of accessing a first knowledge base comprising evidence-based standards for providing medically appropriate care and selectively performing analysis of the clinical data elements of the transaction against at least one standard to determine if the care provided is medically appropriate.

Abstract: A method for adjudicating and reimbursing a care provider for services provided for a clinical event is provided. The method includes the step of receiving a transaction having a number of clinical data elements. The method also includes the steps of accessing a data store including payer information and determining whether the transaction is eligible for reimbursement by at least one payer. The method also includes the steps of accessing a first knowledge base comprising evidence-based standards for providing medically appropriate care and selectively performing analysis of the clinical data elements of the transaction against at least one standard to determine if the care provided is medically appropriate.

Abstract: A method for adjudicating and reimbursing a care provider for services provided for a clinical event is provided. The method includes the step of receiving a transaction having a number of clinical data elements. The method also includes the steps of accessing a data store including payer information and determining whether the transaction is eligible for reimbursement by at least one payer. The method also includes the steps of accessing a first knowledge base comprising evidence-based standards for providing medically appropriate care and selectively performing analysis of the clinical data elements of the transaction against at least one standard to determine if the care provided is medically appropriate.

Abstract: A method for adjudicating and reimbursing a care provider for services provided for a clinical event is provided. The method includes the step of receiving a transaction having a number of clinical data elements. The method also includes the steps of accessing a data store including payer information and determining whether the transaction is eligible for reimbursement by at least one payer. The method also includes the steps of accessing a first knowledge base comprising evidence-based standards for providing medically appropriate care and selectively performing analysis of the clinical data elements of the transaction against at least one standard to determine if the care provided is medically appropriate.