Pharmacy Intervention Eligibility Determination System
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Solution Overview
Problem
Current pharmacy computer systems face challenges in processing and tracking patient intervention information associated with interventions like medication therapy management, particularly in notifying pharmacies about eligible services during medication fills or refills, and in timely communication of service information to providers.
Innovation Solution
A system and method that facilitate determining and communicating intervention services, such as medication therapy management, by using a network of computers including sponsor, service provider, and pharmacy computers, which process healthcare transactions, generate patient intervention service forms, and capture intervention information for reporting, ensuring timely notification and storage of intervention data.
Engineering Contradictions & Design Principles
Engineering Contradiction Analysis
1Adaptability or versatility
If traditional pharmacy computer systems are used for processing healthcare transactions, then basic prescription processing is maintained, but the system cannot effectively determine and communicate patient eligibility for intervention services during medication fills or refills
Solution Approach 1:
The system is divided into distinct modular components: a determination module that identifies eligible patients during transaction processing, a communication module that notifies pharmacies, and a tracking module that monitors service delivery. This segmentation allows traditional pharmacy systems to gain intervention service capabilities without complete system replacement, resolving the contradiction between enhanced adaptability and system complexity.
Solution Approach 2:
The determination module is designed to work within existing healthcare transaction processing frameworks while simultaneously identifying patients eligible for multiple types of intervention services (Medication Therapy Management, Pharmaceutical Care, etc.). This multi-functionality enables a single system addition to serve diverse intervention needs without proportionally increasing complexity.
2Loss of time
If intervention service eligibility is determined during healthcare transaction processing, then timely notification of eligible services is achieved, but additional processing steps increase system complexity
Solution Approach 1:
The determination module performs eligibility assessment during the existing healthcare transaction processing workflow, identifying eligible patients before the transaction is completed. By embedding the determination logic within the established transaction flow rather than adding separate post-processing steps, the system achieves timely notification without proportionally increasing processing complexity.
Solution Approach 2:
The system introduces an intermediary determination module that sits between the transaction processing system and the pharmacy notification system. This intermediary captures transaction data, performs eligibility determination, and triggers notifications, thereby adding the necessary processing steps while maintaining a clean separation of concerns and manageable system architecture.
3Loss of information
If service information is captured and communicated to pharmacy ownership and service providers, then complete tracking of intervention services is achieved, but communication delays occur in traditional systems
Solution Approach 1:
The tracking module establishes continuous electronic communication channels between the determination module, pharmacy systems, and service provider systems. Service information is transmitted and updated in real-time or near-real-time throughout the intervention service delivery process, eliminating the communication delays and information gaps that occur with traditional batch processing or manual reporting methods.
Solution Approach 2:
The system implements feedback loops where service provider communications about delivered interventions are automatically captured and transmitted back to the determination module and pharmacy systems. This continuous feedback mechanism ensures all stakeholders have access to current service status information, achieving complete information tracking without manual intervention or delays.
Data Source
AI summary
Systems and methods are provided for determining and communicating intervention service opportunities, such as medication therapy management services, that may be available for a patient, as part of processing a healthcare claim transaction. A healthcare claim transaction, such as a prescription benefit request transaction, may be received by the service provider computer from a healthcare provider computer. The service provider computer may determine if an intervention service is available for the patient and if an available intervention service notification has been transmitted to the pharmacy computer prior to the service provider computer receiving the healthcare claim transaction. The service provider computer may receive an approved adjudicated response and generate a patient intervention service form corresponding to the available intervention service for the patient. The service provider computer may transmit the patient intervention service form to the pharmacy computer and receive a completed patient intervention service form from the pharmacy computer.