Computerized Medical Care System for Real-Time Diagnosis Validation
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Solution Overview
Problem
Managed care systems experience delays and inefficiencies due to non-medically trained personnel making decisions, leading to improper denials of medical services and increased costs, as they often lack necessary information for accurate diagnoses and service approvals.
Innovation Solution
A computerized medical care system that receives medical codes, applies filters such as diagnosis and procedure filters to validate medical determinations in real-time, providing feedback to prompt modifications and ensuring that diagnoses and services are medically appropriate before being rendered.
Engineering Contradictions & Design Principles
Engineering Contradiction Analysis
1Loss of energy
If non-physician personnel manage and make decisions in the medical care system, then costs are controlled, but decision accuracy and patient welfare deteriorate due to lack of medical knowledge and information
Solution Approach 1:
The patent introduces a computer-based intermediary system that acts as a bridge between non-physician personnel and medical decision-making. The system includes a database of medical knowledge, diagnostic criteria, and treatment guidelines that the computer uses to evaluate patient cases and provide recommendations to non-physician personnel, thereby improving decision accuracy without requiring them to have medical expertise
Solution Approach 2:
The patent replaces the mechanical system of human medical expertise with an automated computer-based system. The computer processes patient information, applies medical criteria from databases, and generates decisions or recommendations, substituting the need for non-physician personnel to have medical knowledge while maintaining cost control
2Loss of energy
If authorization is required before providing certain medical services, then costs are controlled, but service delivery time increases due to delays of more than two or three days
Solution Approach 1:
The patent implements preliminary action by pre-establishing comprehensive databases containing medical knowledge, diagnostic criteria, treatment protocols, and authorization rules before service delivery is needed. When a patient case arises, the computer system can immediately query these pre-prepared databases and generate authorization decisions without requiring time-consuming manual review processes
Solution Approach 2:
The patent replaces the manual authorization process with an automated computer-based system that processes service requests in real-time. The computer retrieves relevant information from databases, applies authorization criteria, and generates decisions instantly, eliminating the multi-day delays caused by manual administrative processing while maintaining cost control
3Reliability
If manual review of medical charts is performed to verify diagnostic codes, then decision accuracy improves, but processing time increases significantly
Solution Approach 1:
The patent replaces manual review of medical charts with an automated computer-based system. The computer retrieves patient information and diagnostic codes directly from electronic databases, applies verification criteria automatically, and validates codes instantaneously. This substitution maintains thorough verification accuracy while reducing processing time from hours or days to seconds
Solution Approach 2:
The patent implements continuous verification through the computer system that operates without interruption. As diagnostic codes are entered or service requests are made, the system continuously queries databases, applies verification rules, and provides immediate feedback. This continuous automated process eliminates the intermittent, time-consuming nature of manual chart review while maintaining comprehensive verification
Data Source
AI summary
A computerized medical care system provides validation of a diagnosis of a medical condition and requested medical services for treating the medical condition. The medial care system invokes multiple filters to determine the appropriateness of the diagnosis and medical service. Real time feedback is provided based on the determination. If the medical care cannot be validated, the feedback includes the reasons for the failure to validate, and any supporting materials for the lack of validation. The feedback may also prompt the requesting entity to provide additional information to help support the medical provider's position as to why the requested medical care is appropriate.