User-Definable Episode of Care Grouping via Graphical Interface
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Solution Overview
Problem
Existing systems for identifying episodes of care in medical claim processing are inflexible, as they rely on predefined rules, making it difficult and costly to modify or deviate from established standards, limiting transparency and efficiency.
Innovation Solution
A method and system that allow users to manually define episodes of care through a graphical user interface, enabling the selection of trigger events, time periods, and claim categories, which are then used to group medical claims, allowing for customization and flexibility in defining episodes.
Engineering Contradictions & Design Principles
Engineering Contradiction Analysis
1Reliability
If predefined rules are used to identify episodes of care, then consistency and standardization are improved, but flexibility and adaptability deteriorate
Solution Approach 1:
The system transitions from static predefined rules to dynamic user-configurable parameters. Users can modify episode definitions, time periods, trigger events, and claim categories through a graphical interface, allowing the system to adapt to changing standards and organizational needs while maintaining structured processing.
Solution Approach 2:
The invention allows changing key parameters of episode definitions including time periods, trigger events, and claim categories. This enables the system to flexibly adjust episode criteria without requiring system redesign, resolving the contradiction between standardized processing and adaptability to new standards.
2Extent of automation
If predefined rules are used for episode identification, then processing automation is improved, but system modifiability and transparency deteriorate
Solution Approach 1:
The system enables users to self-configure episode parameters through an intuitive graphical interface without requiring programming expertise or system developer intervention. Users can independently modify time periods, trigger events, and claim categories, maintaining automation while improving modifiability and transparency.
3Adaptability or versatility
If manual definition of episodes is allowed, then flexibility and adaptability are improved, but system complexity and implementation difficulty increase
Solution Approach 1:
A graphical user interface acts as an intermediary between users and the complex episode definition system. This intermediary layer simplifies interaction by providing visual tools for selecting and configuring parameters, hiding the underlying complexity while enabling flexible manual episode definition.
Solution Approach 2:
The system uses templates and predefined structures that can be copied and customized. Users can start with standard episode definitions and modify them as needed, reducing the complexity of creating new episode types while maintaining flexibility.
Data Source
AI summary
Methods and systems for generating episodes of activity, such as episodes of care. One method includes generating, by a processor, a graphical user interface for display to a user. The method also includes receiving, by a processor, (1) a first selection of a trigger event for an episode of care from the user through the graphical user interface, (2) a second selection of at least one time period for the episode of care from the user through the graphical user interface, and (3) a third selection of at least one claim category for the episode of care from the user through the graphical user interface. The method further includes creating, by the processor, parameters for the episode of care based on the first, second, and third selections, wherein the parameters are applied to a plurality of medical claims to group at least two of the plurality of medical claims.