Note: Descriptions are shown in the official language in which they were submitted.
SYSTEMS AND METHODS FOR FACILITATING PHARMACEUTICAL PATIENT
ASSESSMENTS
TECHNICAL FIELD
[0001] Aspects of the disclosure relate generally to determining and
communicating
pharmaceutical patient assessments and more particularly, to systems and
methods for
determining and communicating an eligibility of a patient to receive
pharmaceutical patient
assessments.
BACKGROUND
[0002] Today, some healthcare services may be performed by a pharmacist or
other
healthcare professional at a pharmacy. For instance, pharmacists may be able
to perform
medication reviews, vaccination, pharmaceutical opinions, and other services
for eligible
patients. Typically, determining which patients are eligible may be a time-
consuming
process. Additionally, in certain cases, these pharmaceutical patient
assessments may be
paid for by a government entity. One or more forms may be filled out to record
performance
of the pharmaceutical patient assessment to report to the government entity
and also to the
original healthcare provider (e g , prescriber).
SUMMARY OF THE INVENTION
[0002a1 In one aspect of the invention, there is provided a computer-
implemented
method performed by one or more computers comprising at least one memory and a
processor, an application stored in the at least one memory and having
computer code
wherein said computer code is executed by said processor of the one or more
computers; and
the processor configured to access the at least one memory and execute the
computer-
executable instructions comprising instructions for: receiving, by the one or
more computers
an electronic prescription fill request; determining, by the one or more
computers, that the
electronic prescription till request includes at least one patient identifier
for a patient;
determining, by the one or more computers and based at least in part on the
patient identifier,
whether the patient is eligible for a pharmaceutical patient assessment;
generating, by the one
or more computers and upon determination that the patient is eligible for the
pharmaceutical
patient assessment, a notification indicating that the patient is eligible;
via a communications
network, transmitting, by the one or more computers, the notification to a
pharmacy device;
CA 2847761 2019-09-04
via the communications network, receiving, by the one or more computers from
the
pharmacy device, pharmaceutical patient assessment information indicating
performance of
the pharmaceutical patient assessment; generating, by the one or more
computers, an
electronic prescription transaction based at least in part on the
pharmaceutical patient
assessment information; and via the communications network, transmitting, by
the one or
more computers, the electronic prescription transaction to one or more claims
processor
computers for adjudication
[0002b] In another aspect of the invention, there is provided a system,
comprising: at
least one processor; and at least one memory storing computer-executable
instructions, that
when executed by the at least on processor, cause the at least one processor
to: receive an
electronic prescription fill request; determine that the electronic
prescription fill request
includes at least one patient identifier associated with a patient; determine,
based at least in
part on the patient identifier, whether the patient is eligible for a
pharmaceutical patient
assessment; generate, upon determination that the patient is eligible for the
pharmaceutical
patient assessment, a notification indicating that the patient is eligible;
direct communication
of the notification to a pharmacy device via a communications network;
receive, from the
pharmacy computer, pharmaceutical patient assessment information indicating
performance
of the pharmaceutical patient assessment via the communications network;
generate an
electronic prescription transaction based at least in part on the
pharmaceutical patient
assessment information; and via the communications network, direct
communication of the
electronic prescription transaction to one or more claims processor computers
for
adjudication.
[0002c] In yet another aspect to the invention, there is provided a non-
transitory
computer-readable medium storing computer-executable instructions, that when
executed by
at least one processor, cause the at least one processor to: receive, from a
pharmacy computer
associated with a pharmacy, an electronic prescription fill request; determine
that the
electronic prescription fill request includes at least one patient identifier
associated with a
patient; determine, based at least in part on the patient identifier, whether
the patient is
eligible for a pharmaceutical patient assessment; generate, upon determination
that the patient
is eligible for the pharmaceutical patient assessment, a notification
indicating that the patient
is eligible; transmit the notification to a pharmacy device via a
communications network;
receive, from the pharmacy computer, pharmaceutical patient assessment
information
indicating performance of the pharmaceutical patient assessment via
la
CA 2847761 2019-09-04
the communications network; generate an electronic prescription transaction
based at least in
part on the pharmaceutical patient assessment information; and via the
communications
network, direct communication of the electronic prescription transaction to
one or more
claims processor computers for adjudication.
BRIEF DESCRIPTION OF THE DRAWINGS
[0003] Reference will now be made to the accompanying drawings, which are
not
necessarily drawn to scale, and wherein:
[0004] FIG. 1 illustrates an example system for facilitating, among other
things,
pharmaceutical patient assessments, according to one exemplary embodiment.
[0005] FIG. 2 is a block diagram for receiving and communicating a
healthcare
transaction, according to one exemplary embodiment.
[0006] FIG. 3 illustrates a flow chart of an example method for receiving
and
communicating a healthcare transaction, according to one exemplary embodiment.
[0007] FIG. 4 is a block diagram for determining eligibility of patients
for
pharmaceutical patient assessments, according to one exemplary embodiment.
DETAILED DESCRIPTION OF EXEMPLARY EMBODIMENTS
lb
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100081 Exemplary embodiments will now be described more fully hereinafter
with
reference to the accompanying drawings, in which exemplary embodiments are
shown. The
concepts disclosed herein may, however, be embodied in many different forms
and should
not be construed as limited to the exemplary embodiments set forth herein;
rather, these
embodiments are provided so that this disclosure will be thorough and
complete, and will
fully convey the scope of the concepts to those skilled in the art. Like
numbers refer to like,
but not necessarily the same or identical, elements throughout.
100091 Exemplary embodiments described herein include systems and methods
that
facilitate pharmaceutical patient assessments. In some example
implementations, a
prescription fill request may be received by a pharmacy computer, such as from
a patient
visiting a pharmacy where the pharmacy computer is located. Additionally, the
prescription
fill request may include information that enables the pharmacy computer to
identify the
associated patient. Upon identifying the patient, the pharmacy computer may
access patient
information associated with the patient. The patient information may include,
but is not
limited to, active medication information, medication history information,
visit history
information, location information, patient demographic information (e.g., age,
gender,
zip/postal code, etc.) and/or other types of pharmaceutical information
related to the patient.
The pharmacy computer may compare the patient information with one or more
pharmaceutical patient assessment eligibility thresholds (e.g., medication
review thresholds,
vaccination thresholds, pharmaceutical opinion thresholds, and/or the like).
Based on the
comparison, the pharmacy computer may determine whether the patient is
eligible for any
pharmaceutical patient assessments. If a patient is eligible for a
pharmaceutical patient
assessment, the pharmacy computer may transmit, to a mobile pharmacy device of
a
pharmacy, a notification indicating the patient's eligibility for the
pharmaceutical patient
assessment. The notification may be sent as part of an adjudicated response
from a claims
processor. Alternatively, the notification may be sent as a separate message.
In certain
cases, upon receiving the notification, a pharmacist or other healthcare
professional
associated with the pharmacy may perform the eligible pharmaceutical patient
assessment for
the patient. The pharmacist may record the details of the service with the
pharmacy
computer, which may be stored as pharmaceutical patient assessment
information. The
pharmacy computer may transmit the pharmaceutical patient assessment
information back to
the pharmacy computer. The pharmacy computer may generate one or more
completed
forms based on the pharmaceutical patient assessment information and transmit
the
completed form to the healthcare provider computer. In certain
implementations, the
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pharmacy computer may also generate a prescription transaction based at least
in part on the
pharmaceutical patient assessment information, and transmit the prescriptoin
transaction to a
claims processor computer for adjudication.
100101 System Overview
100111 FIG. 1 illustrates an example system 100 for facilitating, among
other things,
determining whether a patient, who is a consumer of and/or otherwise
associated with a
pharmacy, is eligible for one or more pharmaceutical patient assessments that
may be
provided at the pharmacy. As shown in FIG. 1, the system 100 may include one
or more
pharmacy computers 104, claims processor computers 106, and/or pharmacy mobile
device(s) 108. As desired, each of the pharmacy computer 104, claims processor
computer
106, and/or pharmacy mobile device 108 may include one or more processing
devices that
may be configured for accessing and reading associated computer-readable media
having
stored data thereon and/or computer-executable instructions for implementing
various
embodiments of the disclosure.
100121 Additionally, in one or more example embodiments of the disclosure,
the
pharmacy computers 104 may include or otherwise be in communication with a
pharmaceutical patient assessments module 110. The pharmaceutical patient
assessments
module 110 may include computer-executable instructions operable for
facilitating the
determination of an eligibility of a patient for pharmaceutical patient
assessments at a
pharmacy. For example, the pharmaceutical patient assessments module 110 may
facilitate
creation of a prescription transaction (i.e., a predetermination of benefits
transaction,
healthcare claim transaction, prescription claim or billing request,
healthcare order
transaction, or e-prescription transaction (i.e., electronic prescription
order transaction, e-
script, or e-prescription)). The pharmaceutical patient assessments module 110
may facilitate
storage of information related to the prescription transaction in one or more
suitable
databases and/or data storage devices 112. For example, the pharmaceutical
patient
assessments module 110 may facilitate the storage and/or access of information
including,
but not limited to, patient information (i.e., identifier (e.g., patient
social security number, a
subset of the patient social security number, health insurance claim number
(HICN),
cardholder ID, etc.), name, gender, date of birth), benefits provider
identifier (e.g., Banking
Identification Number (BIN Number), BIN Number and Processor Control Number
(PCN),
or BIN Number and Group ID), benefits provider name, date of service, software
and/or
vendor certification identification, pharmacy identification qualifier,
pharmacy identification
(e.g., store and/or chain name, group ID, BIN Number, or the like), medication
information
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(i.e., medication name(s), National Drug Code (NDC) numbers, RxNorm medication
identifiers, and the like).
100131 Further, the pharmaceutical patient assessments module 110 may
facilitate storage
of patient information including, but not limited to, medication information
(e.g., total
number of medications, medication name(s), NDC numbers, RxNorm medication
identifiers,
quantity of medication to be dispensed, days' supply, dosage), patient
information (i.e.,
identifier (e.g., patient social security number, a subset of the patient
social security number,
health insurance claim number (HICN), cardholder ID, etc.), name, gender, date
of birth),
and prescriber identification number (ie., prescriber ID ((e.g., National
Provider Identifier
(NPI) number and/or a provider identification issued by the Drug Enforcement
Agency
(DEA))), prescriber name, and prescriber ZIP code or other postal zone
identifier for a
prescription.
100141 In addition to receiving and storing information, the pharmaceutical
patient
assessments module 110 may be further operable to access and/or be in
communication with
one or more suitable databases and/or data storage devices 112. In one non-
limiting
example, the pharmaceutical patient assessment module 110 may facilitate
generation of a
prescription transaction in response to receiving a prescription fill request
from a patient.
Further, the pharmaceutical patient assessments module 110 may be configured
to determine,
based on the prescription fill request, a patient identifier associated with
the patient. The
pharmaceutical patient assessments module 110 may determine, based at least in
part on the
patient identifier, whether the patient is eligible for one or more
pharmaceutical patient
assessments. Pharmaceutical patient assessments may refer to any type of
healthcare
assessments that may be performed by a pharmacist and/or other healthcare
professional
including, but not limited to, medication review, vaccination, pharmaceutical
opinions (e.g.,
data/notes/feedback regarding medication usage, frequency, dosage, effects,
patient age,
patient condition, patient reactions, etc.), and/or the like.
100151 Generally, network devices and systems, including one or more
pharmacy
computers 104, claims processor computers 106, and/or pharmacy mobile devices
108, may
include or otherwise be associated with suitable hardware and/or software for
transmitting
and receiving data and/or computer-executable instructions over one or more
communication
links or networks. These network devices and systems may also include any
number of
processors for processing data and executing computer-executable instructions,
as well as
other internal and peripheral components currently known in the art or which
may be
developed in the future. Further, these network devices and systems may
include or be in
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communication with any number of suitable memory devices operable to store
data and/or
computer-executable instructions. By executing computer-executable
instructions, each of
the network devices may form a special-purpose computer or particular machine.
As used
herein, the term "computer-readable medium" describes any medium for storing
computer-
executable instructions.
100161 As shown in FIG. 1, the one or more pharmacy computers 104, claims
processor
computers 106, and/or pharmacy mobile devices 108 may be in communication with
each
other via one or more networks, such as network 114, which may include one or
more
independent and/or shared private and/or public networks including the
Internet or a publicly
switched telephone network. In other example embodiments, one or more
components of the
system 100 may communicate via direct connections and/or communication links.
Each of
these components ¨ the pharmacy computer 104, claims processor computer 106,
pharmacy
mobile device 108, and the network 114¨ will now be discussed in further
detail. Although
the components are generally discussed as singular components, as may be
implemented in
various example embodiments, in alternative exemplary embodiments each
component may
include any number of suitable computers and/or other components.
100171 The one or more pharmacy computers 104 may be associated with a
pharmacy. A
pharmacy computer 104 may include, but is not limited to, any suitable
processor-driven
device that is configured for receiving, processing, and fulfilling healthcare
transactions
relating to patient prescription information including, but not limited to,
medications,
medication name(s). NDC number(s), RxNorm medication identifiers, quantity of
medication
to be dispensed), patient information (i.e., name, gender, date of birth), and
prescriber
identification number (i.e., prescriber ID ((e.g., National Provider
Identifier (NPI) number
and/or a provider identification issued by the Drug Enforcement Agency
(DEA))), prescriber
name, and prescriber ZIP code or other postal zone identifier for a
prescription. Any number
of claims processor computers 106 and/or pharmacy computers 108 may be in
communication with the pharmacy computer 104 as desired in various example
embodiments.
100181 The pharmacy computer 104 may include any number of special- purpose
computers or other particular machines, application-specific integrated
circuits,
microcontrollers, personal computers, minicomputers, mainframe computers,
servers,
networked computers, and/or other processor-driven devices. In certain
embodiments, the
operations of the pharmacy computer 104 may be controlled by computer-executed
or
computer-implemented instructions that are executed by one or more processors
associated
CA 02847761 2014-03-31
with the pharmacy computer 104 to form a special-purpose computer or other
particular
machine that is operable to facilitate the receipt, routing, and/or processing
of healthcare
requests or healthcare transactions. The one or more processors that control
the operations of
the pharmacy computer 104 may be incorporated into the pharmacy computer 104
and/or
may be in communication with the pharmacy computer 104 via one or more
suitable
networks. In certain example embodiments, the operations and/or control of the
pharmacy
computer 104 may be distributed among several processing components.
100191 The pharmacy computer 104 may include one or more processors 116,
one or
more memory devices 118, one or more input/output ("I/O") interfaces 120, and
one or more
network interfaces 122. The one or more memory devices 118 may be any suitable
memory
device, for example, caches, read-only memory devices, etc. The one or more
memory
devices 118 may store data, executable instructions, and/or various program
modules utilized
by the pharmacy computer 104, for example, data files 124 and an operating
system ("OS")
126. The OS 126 may be any operating system known in the art or which may be
developed
in the future including, but not limited to, Microsoft Windows , Apple OSXTm,
Linux, Unix,
Apple iOSTM, Google AndroidTM, or a mainframe operating system. The OS 126 may
be a
suitable software module that controls the general operation of the pharmacy
computer 104
and/or that facilitates the execution of other software modules.
100201 According to an example embodiment, the data files 124 may store
patient
transaction records associated with communications received from various
patient and/or
pharmacy mobile devices 108, and/or various claims processor computers 106.
The data
files 124 may also store any number of suitable routing tables that facilitate
determining the
destination of communications received from a patient, a claims processor
computer 106,
and/or a pharmacy mobile device 108. In one or more example embodiments of the
disclosure, the pharmacy computer 104 may include or otherwise be in
communication with
one or more suitable databases and/or data storage devices 112.
[0021] The pharmacy computer 104 may include additional program modules for
performing other processing methods described herein. Those of ordinary skill
in the art will
appreciate that the pharmacy computer 104 may include alternate and/or
additional
components, hardware, or software without departing from the scope of the
disclosure. The
management module 128 may be an Internet browser or other software, such as a
dedicated
program, for interacting with the healthcare provider device 102, and/or the
claims processor
computers 106, and/or the pharmacy mobile device 108. Alternatively, the
management
module 128 may also be implemented as computer-implemented instructions of a
memory of
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CA 02847761 2014-03-31
a separate computing entity or processor-based system, according to another
example
embodiment of the disclosure.
[00221 With continued reference to the pharmacy computer 104, the one or
more I/O
interfaces 120 may facilitate communication between the pharmacy computer 104
and one or
more input/output devices, for example, one or more user interface devices,
such as a display,
keypad, control panel, touch screen display, remote control, microphone, etc.,
that facilitate
user interaction with the pharmacy computer 104. The one or more network
interfaces 160
may facilitate connection of the pharmacy computer 104 to one or more suitable
networks,
for example, the network 114 illustrated in FIG. 1. In this regard, the
pharmacy computer
104 may communicate with other components of the system 100.
100231 With continued reference to FIG. 1, any number of claims processor
computers
106 may be associated with any number of pharmacy benefit managers and/or
processors.
Each claims processor computer may be any suitable processor-driven devices,
such as, but
not limited to, a server computer, a personal computer, a laptop computer, a
handheld
computer, and the like. In addition to having one or more processors 162, the
claims
processor computer 106 may further include one or more memories 164, one or
more
input/output (I/O) interfaces 166, and one or more network interfaces 168. The
memory 164
may store data files 170 and various program modules, such as an operating
system (OS) 172
and a benefits management module 174. The I/O interface(s) 166 may facilitate
communication between the processors 162 and various 1/0 devices, such as a
keyboard,
mouse, printer, microphone, speaker, monitor, bar code reader/scanner, RFID
reader, and the
like. The network interface(s) 170 each may take any of a number of forms,
such as a
network interface card, a modem, a wireless network card, and the like.
100241 Generally, the claims processor computer 106 may facilitate the
determination of
benefits, coverage, and/or extent of coverage for one or more healthcare claim
transactions,
such as prescription claim transactions or other healthcare service or product
claim
transactions. According to various embodiments, the claims processor computer
106 may be
associated with, without limitation, a PBM, an insurance company, a government
payor
affiliated entity, another third-party payor, or a claims processor processing
healthcare claim
transactions and performing adjudication on behalf of one or more third-party
payors and/or
healthcare providers. In one embodiment, the claims processor computer 106 may
be
operated by, or otherwise included with, the pharmacy computer 104, such as if
the
pharmacy computer operates the benefits management module 174 and provides
adjudication
services.
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100251 The claims processor computer 106 may include the benefits
management module
174. The benefits management module 174 may be an Internet browser or other
software,
such as a dedicated program, for interacting with the pharmacy computer 104
and/or the
pharmacy mobile devices 108. The benefits management module 174 may be
operable to
access one or more databases in database 112. In one non-limiting example, the
claims
processor computer 106 may have a dedicated connection to the database 112.
However, the
claims processor computer 106 may also communicate with the database 112 via
the network
114 shown, or via another network.
100261 With continued reference to FIG. 1, any number of pharmacy mobile
devices 108
may be associated with any number of pharmacies and/or pharmacists. Each
pharmacy
mobile device 108 may be any suitable processor-driven device that facilitates
receiving,
processing, and/or fulfilling healthcare transactions and/or prescription
transactions received
from the pharmacy computers 104. For example, a pharmacy mobile device 108 may
be a
processor-driven device associated with a pharmacy or a pharmacist including,
but not
limited to, a tablet computer ,a mobile phone, a personal digital assistant, a
notebook, a
laptop computer, a wearable device, and/or the like. As desired, the pharmacy
mobile device
108 may include any number of special-purpose computers or other particular
machines,
application-specific integrated circuits, microcontrollers, personal
computers, minicomputers,
mainframe computers, servers, and the like. In certain example embodiments,
the operations
of the pharmacy mobile device 108 may be controlled by computer-executed or
computer-
implemented instructions that are executed by one or more processors
associated with the
pharmacy mobile device 108 to form a special-purpose computer or other
particular machine
that is operable to facilitate the receipt, processing, and/or fulfillment of
healthcare
transactions (e.g., a prescription claim or billing request, healthcare order
transaction, or e-
prescription transaction (i.e., electronic prescription order transaction, e-
script, or e-
prescription)) received from the pharmacy computer 104. The one OT more
processors that
control the operations of a pharmacy mobile device 108 may be incorporated
into the
pharmacy mobile device 108 and/or may be in communication with the pharmacy
mobile
device 108 via one or more suitable networks. In certain example embodiments,
the
operations and/or control of the pharmacy mobile device 108 may be distributed
among
several processing components.
100271 Similar to other components of the system 100, each pharmacy mobile
device 108
may include one or more processors 176, one or more memory devices 178, one or
more I/O
interfaces 180, and one or more network interfaces 182. The one or more memory
devices
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178 may be any suitable memory devices, for example, caches, read-only memory
device,
random access memory devices, magnetic storage devices, removable memory
devices, etc.
The one or more memory devices 178 may store data, executable instructions,
and/or various
program modules utilized by the pharmacy mobile device 108, for example, data
files 184, an
OS 186, and a pharmacy management module 188. The data files 184 may include
any
suitable information that is utilized by the pharmacy mobile device 108. The
OS 186 may be
a suitable software module that controls the general operation of the pharmacy
mobile device
108. The OS 186 may also facilitate the execution of other software modules by
the one or
more processors 176. The OS 186 may be any operating system known in the art
or which
may be developed in the future including, but not limited to, Microsoft
Windows , Apple
OSXTM, Linux, Unix, Apple iOSTm, Google AndroidTM, or a mainframe operating
system.
100281 The one or more I/0 interfaces 180 may facilitate communication
between the
pharmacy mobile device 108 and one or more input/output devices, for example,
one or more
user interface devices, such as a display, keypad, control panel, touch screen
display, remote
control, microphone, etc., that facilitate user interaction with the pharmacy
mobile device
108. The one or more network interfaces 182 may facilitate connection of the
pharmacy
mobile device 108 to one or more suitable networks, for example, the network
114 illustrated
in FIG. I. In this regard, the pharmacy 108 may receive healthcare
transactions and/or other
communications from the pharmacy computer 104 and the pharmacy mobile device
108 may
communicate information associated with processing healthcare transactions to
the pharmacy
computer 104.
[0029] The phainiacy management module 188 may be a software
application(s),
including a dedicated program, for fulfilling healthcare transaction orders,
reading and/or
updating medical records (e.g., prescription records), facilitating patient
billing, etc.,
receiving and/or transmitting pharmaceutical patient assessment information
associated with
performance of pharmaceutical patient assessments, as well as interacting with
the pharmacy
computer 104. For example, a pharmacist or other pharmacy employee, may
utilize the
pharmacy management module 188 in filling a prescription, recording and/or
updating a
patient's medical prescription history, billing, and preparing and providing a
healthcare
transaction request for information to the pharmacy computer 104. As another
example, a
pharmacist or other pharmacy employee may utilize the pharmacy management
module 188
to enter and/or update pharmaceutical patient assessment information. For
instance, if the
pharmacist were to perform a medication review, the pharmacist may utilize the
pharmacy
management module 188 to enter information associated with the medication
review (e.g.,
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patient reaction, patient age, medication dosage, medication frequency,
medication effects,
patient health conditions etc.). If the pharmacist were generate a
pharmaceutical opinion, the
pharmacist may utilize the pharmacy management module 188 to enter the
opinion. It will
be appreciated that various types of information associated with various types
of
pharmaceutical patient assessments may be entered via the pharmacy management
module
188. Such information may be stored and associated with a patient (e.g., a
patient identifier),
such as in a database 112, and/or may be provided to the pharmacy computer
104, such as to
the pharmaceutical patient assessments module 110. Furthermore, the pharmacy
mobile
device 108 may utilize the pharmacy management module 188 to retrieve or
otherwise
receive data, messages, or responses from the pharmacy computer 104 and/or
other
components of the system 100.
[0030] It will be appreciated that the pharmacy management module 188 may
also be
configured to facilitate various other operations of the pharmacy mobile
device 108,
including, but not limited to, receiving/storing electronic signatures,
scheduling appointments
with patients, scan and/or attach documents provided by a pharmacist or other
employee,
access medication history information for patients, updating medication
information of
patients with the pharmacy computer 104 such as the dosage, activation, and/or
deactivation
of medication, and/or generating billing information related to fulfilling a
prescription or
performing a pharmaceutical patient assessment. As such, a pharmacist and/or
other
employee of the pharmacy may be able to take the pharmacy mobile device 108 to
locations
outside of the pharmacy (e.g., to a long-term care facility, a patient's home,
and/or the like)
in order to collection the information described above. The pharmacy mobile
device 108
may be configured to communicate the collected information back to the
pharmacy
computer(s) 104 (e.g., via the pharmacy management module 188) or the claims
processor
computer 106. In certain implementations, the collected information may be
stored by the
pharmacy computer(s) 104, such as in the database 112, such that other
pharmacy computers
104 and/or other pharmacy mobile device(s) 108 may have access to the
collected
information.
[0031] The network 114 may include any telecommunication and/or data
network,
whether public, private, or a combination thereof, including a local area
network, a wide area
network, an intranet, the Internet, intermediate handheld data transfer
devices, and/or any
combination thereof and may be wired and/or wireless, or any combination
thereof. The
network 114 may also allow for real time, offline, and/or batch transactions
to be transmitted
between or among the pharmacy computer 104, the claims processor computer 106,
and the
CA 02847761 2014-03-31
pharmacy mobile device 108. Various methodologies as described herein, may be
practiced
in the context of distributed computing environments. Although the pharmacy
computer 104
is shown for simplicity as being in communication with the healthcare provider
device 102,
the claims processor computer 106, or the pharmacy mobile device 108 via one
intervening
network 114, it is to be understood that any other network configurations are
possible. For
example, intervening network 114 may include a plurality of networks, each
with devices
such as gateways and routers for providing connectivity between or among the
components
of the system 100. Instead of or in addition to the network 114, dedicated
communication
links may be used to connect various devices in accordance with an example
embodiment.
For example, the pharmacy computer 104 may form the basis of network 114 that
interconnects the healthcare provider device 102, the pharmacy computer 104,
the claims
processor computer 106, and the pharmacy mobile device 108.
[0032] Those of ordinary skill in the art will appreciate that the system
100 shown in and
described with respect to FIG. I is provided by way of example only. Numerous
other
operating environments, system architectures, and device and network
configurations are
possible. Other system embodiments can include fewer or greater numbers of
components
and may incorporate some or all of the functionality described with respect to
the system
components shown in FIG. 1. For example, in an exemplary embodiment, the
pharmacy
computer 104 (or other computer) may be implemented as a specialized
processing machine
that includes hardware and/or software for performing the methods described
herein.
Accordingly, embodiments of the disclosure should not be construed as being
limited to any
particular operating environment, system architecture, or device or network
configuration.
[0033] Operational Overview
[0034] Certain portions of the exemplary methods below will be described
with reference
to determining and communicating a benefits response message generated during
an
adjudication or pre-adjudication process of a healthcare transaction. In one
example
implementation, the healthcare transaction may include a prescription, a
predetermination of
benefits request; a prescription claim or billing request, or a healthcare
order transaction.
While the methods described below are in reference to a healthcare
transaction, each form of
healthcare transaction should be individually read as being used in the
methods described
below.
[0035] FIG. 2 illustrates an example block diagram 200 for receiving and
communicating
a healthcare transaction, according to an example embodiment of the
disclosure. FIG. 3
illustrates an example method 300 for receiving and communicating a healthcare
transaction,
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according to an example embodiment of the disclosure. The block diagram 200 of
FIG. 2
will be discussed in conjunction with the method of 300 of FIG. 3.
100361 Referring now to FIGs. 1, 2, and 3, the exemplary method 300 begins
at the
START step and continues to step 302, where a pharmacy computer, such as the
pharmacy
computer 104, may be utilized to receive a prescription fill request 202 from
a patient 201.
In one example implementation, the pharmacy computer 104 determine, from the
prescription fill request 202, patient information associated with the
patient. For example,
the pharmacy computer 104 may provide the prescription fill request 202,
and/or information
included in the prescription fill request 202, to the pharmaceutical patient
assessment module
I 10. For example, the management module 128 may parse the prescription fill
request 202
to determine a patient identifier associated with the prescription till
request 202. In some
implementations, the patient identifier may include, without limitation, a
first name, a last
name, a Personal Identification Number (PIN), a social security number, and/or
the like. The
management module 128 may communicate the patient identifier to the
pharmaceutical
patient assessments module 110. In step 304, the pharmaceutical patient
assessment module
110 may utilize patient identifier and/or other information included in the
prescription fill
request 202 to perform a lookup in the database 112.
10037] In step 306, upon receipt of the patient identifier, the
pharmaceutical patient
assessments module 110 may utilize the patient identifier to access patient
information. For
instance, the patient information may be stored in the database 112, and the
patient
information may be indexed by, correspond to, and/or otherwise associated with
the patient
identifier. As an example, the patient information may include one or more of
the following
information:
Payer ID / Routing Information
o Transaction Payer Identifier(s) that designates a destination for payment
(e.g.,
Bank Information Number (BIN), BIN and PCN, or BIN Number and Group
ID)
Patient Personal Information
o Name (e.g. Patient Last Name, Patient First Name, etc.)
o Date of Birth of Patient
o Age of Patient
o Patient Gender Code
o Patient Address (e.g. Street Address, City, State/Province, Zip Code,
etc.)
o Patient Contact Information (e.g. patient telephone number, email
address, etc.)
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o Patient Health Condition Information (e.g., pregnant, diabetic, under
long-
term care, in a nursing home, chronic issues, other demographic information)
o Patient Identifier (such as, but not limited to, patient social security
number, a
subset of the patient social security number, health insurance claim number
(HICN), cardholder ID, etc.)
Benefits Information
o Cardholder Name (e.g. Cardholder First Name, Cardholder Last Name)
o Cardholder ID and/or other identifier (e.g. person code)
o Group ID and/or Group Information
Prescriber Information
o Primary Care Provider ID or other identifier (e.g. National Provider
Identifier
(NPI) code)
o Primary Care Provider Name (e.g. Last Name, First Name)
o Prescriber ID or other identifier (e.g. NPI code, Drug Enforcement Agency
(DEA) number)
o Prescriber Name (e.g. Last Name, First Name)
o Prescriber Contact Information (e.g. Telephone Number)
o Pharmacy or other Healthcare Provider Information (e.g. store name, chain
identifier, etc.)
o Pharmacy or other Healthcare Provider ID (e.g. NPI code)
Medication Information
o Active drugs, services, or product information
o Inactive drugs, services, or product information
o Medication history of drugs, services, or product information
o Pharmacy visit history information
o Prescription/Service Reference Number
o Date Prescription Written
o Quantity Dispensed
o Days' Supply
o Diagnosis/Condition
o Pricing information for the drug/service/product (e.g. network price,
Usual &
Customary price)
o Number of Refills Authorized
o One or more Drug Utilization (DUR) Codes
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o Date of Service.
[0038] At step 308, the pharmaceutical patient assessment module 110 may
compare the
patient information with one or more pharmaceutical patient assessment
eligibility
thresholds. The eligibility thresholds may include various types of thresholds
which may
determine the eligibility of the patient for various types of pharmaceutical
patient
assessments. For instance, the eligibility thresholds may include, but are not
limited to, visit
frequency thresholds, medication review thresholds, vaccination thresholds,
pharmaceutical
opinion thresholds, patient condition thresholds, and/or the like.
[0039] At step 310, the pharmaceutical patient assessment module 110 may
determine,
based at least in part on the comparison between the patient information and
the eligibility
thresholds, whether the patient is eligible for one or more pharmaceutical
patient
assessments. For instance, an example pharmaceutical patient assessment may be
a
medication review, and an example eligibility threshold may include a
medication review
threshold that includes one or more medications that would qualify the patient
for a
medication review. If the patient information (e.g., the information accessed
by the
pharmaceutical patient assessments module 110 using the patient identifier
derived from the
prescription fill request 202) indicates that the patient is taking at least
one of the included
medications in the medication review threshold (e.g., one or more of the
active medications
of the patient 201 match the included medications in the medication review
threshold), the
pharmaceutical patient assessment module 110 may determine that the patient is
eligible for a
medication review. Another non-limiting example of an eligibility threshold
may be a
pharmaceutical opinion threshold, which may indicate whether the patient
and/or a
medication being taken by the patient is eligible to receive a pharmaceutical
opinion, such as
by a pharmacist or other healthcare professional. Regardless, if the
pharmaceutical patient
assessments module 110 determines that the patient is eligible for a
pharmaceutical patient
assessment, then the YES branch is followed and processing may proceed to step
312. If the
pharmaceutical patient assessments module 110 determines that the patient is
not eligible for
a pharmaceutical patient assessment, then the NO branch is followed and
processing may
proceed to step 324.
[0040] At step 312, the pharmaceutical patient assessment module 110 may
transmit, to
the pharmacy computer(s) 104, a notification 204 indicating the eligible
service(s). For
instance, the notification 204 may be transmitted as an email, simple
messaging service
(SMS) text, a web page pop-up, and/or the like. In certain implementations,
upon receipt of
the notification 204, the pharmaceutical computer(s) 104 may be configured to
display the
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notification 204. Furthermore, the notification 204 may also be transmitted to
one or more of
the pharmacy mobile devices 108 (e.g., via the pharmacy computer 104 and/or
the
pharmaceutical patient assessment module 110).
[0041] Upon
and/or after receipt of the notification 204, a pharmacist and/or another
healthcare professional may elect to perform the eligible pharmaceutical
patient
assessment(s) for the patient 201. During and/or upon completion of the
pharmaceutical
patient assessment(s), the pharmacist may enter pharmaceutical patient
assessment
information 206 (e.g., via the pharmacy management module(s) 188) into the
pharmacy
mobile device 108. For example, the pharmaceutical patient assessments
information 206
may include details of the assessments performed, and may include, but is not
limited to,
information such-as medication review information, vaccination information,
pharmaceutical
opinion information, patient condition information, and/or the like. The
pharmaceutical
patient assessment information 206 may then be transmitted back to the service
provider.
[00421 At step
314, the service provider may receive the pharmaceutical patient
assessment information 206, which may indicate that one or more of the
eligible
pharmaceutical patient assessment(s) has been performed.
[0043] At step
316, the pharmaceutical patient assessment module 110 may generate one
or more completed form(s) based on the pharmaceutical patient assessments
information. In
other words, the forms may record the pharmaceutical patient assessment
information
indicating the details of the pharmaceutical patient assessments performed by
the pharmacy.
Such forms may be completed a format that adheres to standards used by the
healthcare
provider and/or healthcare provider device(s) 102. In certain implementations,
the forms
may also adhere to a government issued format.
[0044] At step
318, the pharmacy computer 104 may transmit the completed form to one
or more healthcare provider device(s), such as devices associated with a
healthcare provider
(e.g., a doctor's office, a hospital, and/or any other type of medication
prescriber). For
instance, the complete form(s) may be transmitted via email, SMS text, fax,
mail, and/or any
other communications method.
[0045] At step
320, the pharmacy computer 104 may utilize the pharmaceutical patient
assessment information 206 to generate a prescription transaction 208. In
certain
implementations, the pharmacy computer 104 may be configured to store the
pharmaceutical
patient assessment information 206 in the prescription transaction 208.
[0046] At step
322, the phatinacy computer 104 may be configured to communicate the
prescription transaction 208 to the claims processor computer(s) 106 for
adjudication. Upon
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adjudicating the prescription transaction 208, the claims processor
computer(s) 106 may
communicate the adjudicated prescription transaction 210, and/or the results
thereof, back to
the pharmacy computer(s) 104.
100471 At step 324, if the pharmaceutical patient assessment module 110
determines that
the patient is not eligible for pharmaceutical patient assessments, the
pharmaceutical patient
assessment module 110 may communicate, to the pharmacy computer(s) 104 and/or
the
pharmacy mobile devices 108, an indication that the patient is ineligible. The
method 300
may end after step 324.
[0048] FIG. 4 illustrates an example method 400 for determining patient
eligibility for
pharmaceutical patient assessments, according to an example embodiment of the
disclosure.
100491 The exemplary method 400 begins at the START step and continues to
step 402,
where the pharmacy computer 104 may determine and/or identify one or more
patients
associated with a pharmacy and/or the pharmacy computer(s). For instance, the
identified
patients may be patients that have visited the pharmacy or are scheduled to
visit the
pharmacy. In certain implementations, and as described above with reference to
FIGS. 1-3,
the identified patients may be associated with respective patient information.
Additionally,
associations(s) between the pharmacy, the identified patients, and the
respective patient
information may be stored in the database 112.
10050] At step 404, the pharmacy computer 104 may access the respective
patient
information associated with the identified patients. For instance, in certain
implementations,
each of the identified patients may be associated with patient identifiers.
The pharmaceutical
patient assessments module 110 may utilize the patient identifiers to access
the respective
patient information.
100511 At step 406, the pharmaceutical patient assessments module 110 of
the pharmacy
computer 104 may compare the respective patient information with one or more
pharmaceutical patient assessment eligibility thresholds.
100521 At step 408, the pharmaceutical patient assessments module 110 may
determine
for each patient, based at least in part on the comparison, whether the
patient is eligible for a
pharmaceutical patient assessment. For instance, the pharmaceutical patient
assessments
module 110 may determine for each patient, whether any of the pharmaceutical
patient
assessments thresholds are met. If the pharmaceutical patient assessments
module 110
determines that a patient is eligible for one or more pharmaceutical patient
assessments, then
the YES branch is followed and processing may proceed to step 410. If the
pharmaceutical
patient assessments module 110 determines that a patient is not eligible for
one or more
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pharmaceutical patient assessments, then the NO branch is followed, and the
method may
end.
[0053] At step 410, the pharmaceutical patient assessments module 110 may
store one or
more indications of the eligible services for the patient. For instance, the
pharmaceutical
patient assessments module 110 may associate a flag, value, and/or any other
type of
indicator with the patient identifier of the patient. The indicator may
indicate the type of
pharmaceutical patient assessments the patient is eligible to receive.
Furthermore, the
association between the patient identifier and the indicator may be stored in
the database 112
and/or any other storage device in communication with the pharmacy computer
104.
100541 In step 412, the pharmacy computer 104 may transmit a notification
of the eligible
service(s) for the patient to the pharmacy mobile devices 1 08. For instance,
the notification
may be transmitted via email, SMS text, fax, instant message, and/or any other
type of
communication method. In certain cases, the pharmacy mobile device 108 may be
configured to display the notification, thereby providing an indication that a
pharmacist
and/or other healthcare professional employee of the pharmacy may perform the
eligible
service(s) for the patient. The method 400 may end after step 412.
[0055] It will be appreciated that the method 400 illustrated in FIG. 4 may
be performed
periodically by the pharmacy computer 104. For instance, in certain
implementations, the
pharmacy mobile device 108 may periodically request the pharmacy computer 104
to poll
and/or identify which patients may be eligible for certain pharmaceutical
patient assessments.
In other implementations, the method 400 may be performed in response to one
or more
prescription fill requests provided by one or more patients. In yet other
implementations, the
method 400 may be performed in response to a reporting request (e.g., from a
pharmacist
and/or other employee of a pharmacy) to determine which patients may be
eligible for
pharmaceutical patient assessments.
[0056] Various block and/or flow diagrams of systems, methods, apparatus,
and/or
computer program products according to example embodiments of the disclosure
are
described above. It will be understood that one or more blocks of the block
diagrams and
steps of the flow diagrams, and combinations of blocks in the block diagrams
and
combinations of steps in the flow diagrams, respectively, can be implemented
by computer-
executable program instructions. Likewise, some blocks of the block diagrams
and steps of
the flow diagrams may not necessarily need to be perfoinied in the order
presented, or may
not necessarily need to be performed at all, according to some embodiments.
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[0057] These computer-executable program instructions may be loaded onto a
special-
purpose computer or other particular machine, one or more processors, or other
programmable data processing apparatus to produce a particular machine, such
that the
instructions that execute on the computer, processor, or other programmable
data processing
apparatus create means for implementing one or more functions specified in the
flow
diagram step or steps. These computer program instructions may also be stored
in a
computer-readable memory that can direct a computer or other programmable data
processing apparatus to function in a particular manner, such that the
instructions stored in
the computer-readable memory produce an article of manufacture including
instruction
means that implement one or more functions specified in the flow diagram step
or steps. As
an example, various embodiments of the disclosure may provide for a computer
program
product including a computer-usable medium having a computer-readable program
code or
program instructions embodied therein, said computer-readable program code
adapted to be
executed to implement one or more functions specified in the flow diagram step
or steps.
The computer program instructions may also be loaded onto a computer or other
programmable data processing apparatus to cause a series of operational
elements or steps to
be performed on the computer or other programmable apparatus to produce a
computer-
implemented process such that the instructions that execute on the computer or
other
programmable apparatus provide elements or steps for implementing the
functions specified
in the flow diagram step or steps.
[0058] Accordingly, blocks of the block diagrams and steps of the flow
diagrams support
combinations of means for performing the specified functions, combinations of
elements or
steps for performing the specified functions, and program instruction means
for performing
the specified functions. It will also be understood that each block of the
block diagrams and
step of the flow diagrams, and combinations of blocks in the block diagrams
and steps of the
flow diagrams, can be implemented by special-purpose, hardware-based computer
systems
that perform the specified functions, elements or steps, or combinations of
special-purpose
hardware and computer instructions.
[0059] Many modifications and other embodiments of the disclosure set forth
herein will
be apparent having the benefit of the teachings presented in the foregoing
descriptions and
the associated drawings. Therefore, it is to be understood that the invention
is not to be
limited to the specific embodiments disclosed and that modifications and other
embodiments
are intended to be included within the scope of the appended claims. Although
specific terms
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are employed herein, they are used in a generic and descriptive sense only and
not for
purposes of limitation.
,
19
