Pharmacy Claims Analysis for Chronic Condition Identification
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Solution Overview
Problem
Current methods for identifying patients with chronic medical conditions rely heavily on medical claims, but when these are unavailable, there is a need for alternative solutions to effectively identify such patients.
Innovation Solution
A computer-implemented method and system that analyze pharmacy claims to identify patients as candidates for chronic medical conditions, determine their pharmacy home, and offer relevant services, such as Medication Therapy Management programs, by transmitting patient identifications to associated pharmacy computers.
Engineering Contradictions & Design Principles
Engineering Contradiction Analysis
1Measurement precision
If medical claims are used to identify patients with chronic medical conditions, then identification accuracy is improved, but the system becomes unusable when medical claims are unavailable
Solution Approach 1:
The patent introduces pharmacy claims as an intermediary data source to identify patients with chronic medical conditions when medical claims are unavailable. The system uses pharmacy claim data (prescriptions filled by patients) as a substitute indicator to infer chronic conditions, thereby maintaining system functionality and patient identification capability even when primary medical claims data is inaccessible
2Adaptability or versatility
If pharmacy claims analysis is implemented to identify patients when medical claims are unavailable, then system availability is improved, but identification precision deteriorates compared to medical claims
Solution Approach 1:
The system performs preliminary analysis of pharmacy claims data to identify patients with chronic medical conditions before referring them for further evaluation or intervention. By pre-identifying candidate patients through pharmacy data patterns (such as multiple prescriptions for chronic condition medications), the system prepares a targeted list that maintains reasonable accuracy while enabling timely intervention when medical claims are unavailable
Solution Approach 2:
The patent accepts a broader identification net by analyzing pharmacy claims, which may include some false positives compared to medical claims. The system casts a wider net to ensure no potential patients are missed, then allows for subsequent verification or triage to refine the identified patient list, prioritizing comprehensive coverage over perfect precision in the initial identification phase
Data Source
AI summary
Systems and methods may be provided for pharmacy claims-based condition identification proxies. The systems and methods may include receiving, by a condition identification system, at least one pharmacy claim associated with a patient, where each pharmacy claim is associated with a medication previously filled by the patient, and identifying, by the condition identification system, the patient as a candidate for at least one chronic medical condition by analyzing the at least one pharmacy claim associated with the patient. The systems and methods may also include determining, by the condition identification system, a pharmacy home for the patient, and transmitting, by the condition identification system to a pharmacy computer associated with the pharmacy home, an identification of the patient that is the candidate for at least one chronic medical condition, where the patient is offered at least one service by the pharmacy home based upon the transmitted identification of the patient.