TOOL FOR DETECTING INCONSISTENCIES AND OMISSIONS IN DOCUMENTED JUSTIFICATION FOR MEDICAL SERVICES
A computerized tool to aid health care workers determine whether health care services proposed for a patient are consistent with policies of a health care facility and adequately justified by documentation, reducing the burden on health care workers of obtaining reimbursement for the services. The tool receives information relating to a diagnosis and risk factors, which may be used to justify planned health care services. Potentially omitted information may be identified based on a disparity between documented risk factors and an assessment provided by a health care worker or a to disparity between identified risk factors and a documented diagnosis. Further, the tool may identify a disparity between proposed services and diagnosis and documented risk, prompting a user to provide more documentation of risk, if appropriate. The tool is configurable such that the comparisons can be based on compliance with policies of a specific health care facility where it is used.
1 . A method of operating a computer system, the method comprising:
with at least one processor:
receiving first input indicating a diagnosis of a patient;
assigning one or more first values based on the diagnosis;
receiving second input identifying one or more values of factors indicating risk for the patient;
assigning one or more second values based on the one or more values of the factors indicating risk;
determining a combined score based on the one or more first values and the one or more second values;
receiving third input indicating intended health care services to be provided to the patient;
determining a health care services score based on the intended health care services;
comparing the determined health care services score to the combined score, and, based on the comparison, selectively outputting a warning of an inconsistency between the intended health care services and a documented justification for the intended heath care services.
2 . The method of claim 1 , wherein selectively outputting a warning comprises outputting a warning that the intended health care services are inconsistent in response to the comparing indicating that the determined health care services score exceeds the combined score.
3 . The method of claim 2 , wherein:
determining a health care services score comprises assigning a lower value when the intended health care services involves outpatient services and a higher value when the intended health care services comprises a hospital admission; and
selectively outputting a warning comprises displaying to a user a warning that hospital admission is inconsistent with one or more of a documented diagnosis and documented risks when the intended health care services comprises hospital admission and the health care services score is greater than the combined score.
4 . The method of claim 3 , further comprising:
archiving information indicative of the first input and the second input.
5 . The method of claim 4 , further comprising:
generating an audit report based on the archived information.
6 . The method of claim 4 , further comprising:
identifying based on the second input a clinical indicator of a possible diagnosis;
when the first input does not include the possible diagnosis, prompting a user to consider documenting that the possible diagnosis is applicable to the patient.
7 . The method of claim 4 , further comprising:
receiving fourth input indicating a risk assessment assigned by a user;
comparing the risk assessment to a risk score computed from at least the one or more second values;
when the comparison indicates that the risk assessment is greater than the computed risk score, prompting the user to provide an explanation of the risk assessment; and
including information indicative of the explanation in the archived information.
8 . The method of claim 1 , wherein the second input comprises at least one of values of vital signs for the patient and laboratory results for the patient.
9 . The method of claim 1 , wherein:
the method further comprises receiving customization information for a health care facility, the customization information identifying values associated with diagnoses and values associated with risk factors; and
assigning one or more first values and assigning one or more second values comprises selecting values from the customization information.
10 . A non-transitory computer-readable storage medium comprising computer-executable instructions that, when executed by a processor, perform a method comprising:
receiving diagnosis input indicating a diagnosis of a patient;
receiving risk input indicating risk factors for the patient;
receiving a disposition input indicating a disposition of the patient;
determining whether documented justification for health care services according to the indicated disposition are suitable based on a comparison of the indicated disposition to the diagnosis input and the risk factor input.
11 . The computer-readable medium of claim 10 , wherein:
receiving risk input comprises receiving through a display listing possible risk factors; and
the method further comprises:
selecting a plurality of risk factors associated with the diagnosis;
generating the display for receiving risk input based on the selected risk factors.
12 . The computer-readable medium of claim 10 , wherein the method further comprises:
when the documented justification is determined to be unsuitable, providing a warning to the user.
13 . The computer-readable medium of claim 10 , wherein the method further comprises:
prompting a user to supply further risk input when the documented justification is determined to be unsuitable.
14 . A method of operating a computer system, the method comprising:
with at least one processor:
receiving first input indicating a diagnosis of a patient;
assigning one or more first values based on the diagnosis;
receiving second input identifying one or more factors indicating risk for the patient;
assigning one or more second values based on the one or more factors indicating risk;
comparing a first score computed based on the one or more first values to a second score computed based on the one or more second values;
when the first score is greater than the second score, prompting a user to provide input further identifying factors indicating risk for the patient.
15 . The method of claim 14 , further comprising:
receiving third input indicating a disposition of the patient;
assigning a third score based on the indicated disposition of the patient; and
determining a suitability of the indicated disposition based on a comparison of the third score to a combined score based on the one or more first values and the one or more second values.
16 . The method of claim 15 , wherein:
the combined score comprises a maximum value of the one or more first values and the one or more second values.
17 . The method of claim 16 , wherein:
the method further comprises receiving input representing first scoring criteria, the first scoring criteria associating each of a plurality of diagnoses with a respective value; and
assigning one or more first values comprises selecting the one or more of the respective values of the first scoring criteria based on the diagnosis.
18 . The method of claim 17 , further comprising:
storing in computer memory the first scoring criteria with an association with a health care facility.
19 . The method of claim 18 , wherein:
the at least one processor comprises a processor associated with a server; and
storing the first scoring criteria comprises storing the first scoring criteria in a data store with scoring criteria associated with scoring criteria for each of a plurality of other health care facilities.
20 . The method of claim 16 , wherein:
the method further comprises receiving user input representing second scoring criteria, the second scoring criteria associating each of a plurality of risk factors with a respective value; and
assigning one or more second values comprises selecting one or more of the respective values of the second scoring criteria based on the one or more factors indicating risk for the patient.
21 . The method of claim 14 , wherein:
receiving the first input comprises receiving input through a graphical user interface of a computer.
22 . The method of claim 14 , wherein:
receiving the first input comprises receiving input through an application programming interface from a clinical system.
23 . The method of claim 13 , wherein:
receiving second input comprises receiving input relating to an objective condition of the patient.
24 . The method of claim 23 , wherein:
receiving the second input further comprises presenting a graphical user interface comprising possible risk factors applicable to the indicated diagnosis and control elements, each control element being adapted to receive user input indicating a selection of an associated possible risk factor.
25 . The method of claim 24 , further comprising:
indicating at least a portion of the control elements as selected based on the received user input relating to an objective condition of the patient.