Provider assessment system, methods for assessing provider performance, methods for curating provider networks based on provider performance, and methods for defining a provider network based on provider performance

1 . A method of generating a performance measure, comprising:

first mapping at least one clinical priority area and at least one candidate measure concept to one or more coding fields of claims data;

wherein the at least one candidate measure concept is identified based, at least in part, on an identified key-clinical decision point, the identified key-clinical decision point based, at least in part, on a decision by a provider represented in the claims data by a set of claim codes associated with a date occurring chronologically before a further date associated with a further set of claim codes representing, in the claims data, an initial diagnosis of a condition of a patient;

defining at least one first performance measure based on the one or more coding fields of claims data mapped to the at least one clinical priority area and the at least one candidate measure concept;

performing one or more validation processes using the at least one first performance measure;

obtaining a validation result responsive to the one or more validation processes;

second mapping the at least one clinical priority area and the at least one candidate measure concept to one or more coding fields of claims data responsive to the validation result; and

obtaining at least one final performance measure responsive to the second mapping.

2 . The method of claim 1 , further comprising obtaining the at least one final performance measure responsive to the second mapping.

3 . The method of claim 1 , further comprising, responsive to the validation result, adjusting one or more specifications of the at least one first performance measure based on obtained patient risk.

4 . The method of claim 1 , wherein first mapping at least one clinical priority area and at least one candidate measure concept to one or more coding fields of claims data comprises first mapping at least one clinical priority area and at least one candidate measure concept to coding fields of claims data via one or more of field mapping or field value mapping methodologies.

5 . The method of claim 1 , further comprising obtaining the at least one clinical priority area, wherein the at least one clinical priority area comprises one or more of low-risk obstetrics, orthopedic joint surgery, orthopedic spinal surgery, cardiology, primary care, gastroenterology, or pulmonology.

6 . The method of claim 1 , further comprising obtaining the at least one candidate measure concept, wherein the at least one candidate measure concept comprises an existing measure from existing measure inventories of a provider assessment system.

7 . The method of claim 6 , wherein obtaining the at least one candidate measure concept comprises:

analyzing claims data to identify a plurality of patients' journeys indicated in the claims data within a given clinical area;

identifying areas within the plurality of patients' journeys where measurable variation occurs between journeys of different patients; and

identifying the measurable areas of variation as the at least one candidate measure concept.

8 . The method of claim 1 , further comprising, upon defining the at least one first performance measure based on the one or more coding fields of the claims data mapped to at least one clinical priority area and at least one candidate measure concept, refining specifications of the at least one first performance measure based on a patient population, numerators, and denominators reflected in the claims data.

9 . The method of claim 1 , wherein performing one or more validation processes comprises performing an external validation process by:

providing specifications of the at least one first performance measure to a third-party system; and

receiving feedback data from the third-party system regarding the specifications of the at least one first performance measure.

10 . The method of claim 9 , upon receiving the feedback data, second mapping the first performance measure to one or more coding fields of claims data based on the feedback data.

11 . The method of claim 1 , wherein performing one or more validation processes comprises performing an internal validation process.

12 . The method of claim 1 , further comprising determining at least one performance score of a provider utilizing the at least one final performance measure.

13 . The method of claim 12 , wherein determining at least one performance score of a provider comprises:

receiving, from a third-party system, claims data;

applying the at least one final performance measure to the claims data to determine measure scores of the provider, the measure scores being related to key-clinical decision points within condition-based patient journeys represented in the claims data;

outputting one or more data packages representing the determined measure scores;

applying a principal components analysis to the one or more data packages to determine composite performance scores of the provider based on the determined measure scores; and

generating a performance data package including the determined composite performance scores.

14 . A system comprising:

at least one processor; and

at least one non-transitory computer-readable storage medium storing instructions thereon that, when executed by the at least one processor, cause the system to:

upon obtaining at least one clinical priority area and at least one candidate measure concept, first map the at least one clinical priority area and the at least one candidate measure concept to one or more coding fields of claims data;

wherein the at least one candidate measure concept is identified based, at least in part, on an identified key-clinical decision point, the identified key-clinical decision point based, at least in part, on a decision by a provider represented in the claims data by a set of claim codes associated with a date occurring chronologically before a further date associated with a further set of claim codes representing, in the claims data, an initial diagnosis of a condition of a patient;

define at least one first performance measure based on the one or more mapped coding fields of claims data;

validate the at least one first performance measure via at least one validation process;

second map the at least one clinical priority area and the at least one candidate measure concept to one or more coding fields of claims data based on an obtained validation result; and

obtaining at least one final performance measure responsive to the second mapping.

15 . The system of claim 14 , further comprising instructions that, when executed by the at least one processor, cause the system to: store the at least one final performance measure within a library of performance measures within a database.

16 . The system of claim 14 , wherein first mapping the at least one clinical priority area and the at least one candidate measure concept to one or more coding fields of claims data comprises first mapping via one or more of field mapping or field value mapping methodologies.

17 . The system of claim 14 , further comprising instructions that, when executed by the at least one processor, cause the system to: determine at least one performance score of a provider utilizing the at least one final performance measure.

18 . The system of claim 14 , wherein the at least one validation process comprises one or more of an internal validation process and an external validation process.

19 . The system of claim 17 , wherein determining at least one performance score of a provider comprises:

receiving, from a third-party system, claims data;

applying the at least one final performance measure to the claims data to determine measure scores of the provider, the measure scores being related to key-clinical decision points within condition-based patient journeys represented in the claims data;

outputting one or more data packages representing the determined measure scores;

applying a principal components analysis to the one or more data packages to determine composite performance scores of the provider based on the determined measure scores; and

generating a performance data package including the determined composite performance scores.

20 . A method of determining a performance score of a provider, comprising:

first mapping at least one clinical priority area and at least one candidate measure concept to one or more coding fields of claims data;

wherein the at least one candidate measure concept is identified based, at least in part, on an identified key-clinical decision point, the identified key-clinical decision point based, at least in part, on a decision by a provider represented in the claims data by a set of claim codes associated with a date occurring chronologically before a further date associated with a further set of claim codes representing, in the claims data, an initial diagnosis of a condition of a patient;

defining at least one first performance measure based on the one or more coding fields of claims data mapped to the at least one clinical priority area and the at least one candidate measure concept;

performing one or more validation processes using the at least one first performance measure;

obtaining a validation result responsive to the one or more validation processes;

second mapping the at least one clinical priority area and the at least one candidate measure concept to one or more coding fields of claims data responsive to the validation result;

obtaining at least one final performance measure responsive to the second mapping;

obtaining, from a third-party, claims data include data specific to the provider; and

applying the at least one final performance measure to the claims data to determine at least one composite performance score of the provider.

21 . The method of claim 20 , wherein performing the first mapping comprises performing in first mapping process, and wherein performing the second mapping comprises performing the first mapping process.

22 . The method of claim 20 , wherein performing the first mapping comprises performing in first mapping process, and wherein performing the second mapping comprises performing a second, different mapping process.