Method of grouping and analyzing clinical risks

Abstract

A method of creating a classification system for rating the nature and severity of health care requirements, including obtaining a set of medical disease codes, categorizing the medical disease codes into major disease categories, and categorizing the medical disease codes in each major disease category into episode disease categories based on severity.

We claim: 
     
         1 . A method of rating the nature and severity of health care requirements for an individual, including:
 (a) providing a computer system storing a set of medical disease codes, wherein the medical disease codes are categorized into major disease categories, wherein the medical disease codes in each major disease category are categorized into episode disease categories based on severity of health care requirements, wherein at least some of the episode disease categories are sub-divided by severity of illness level by using severity of illness rules, and wherein the computer system further stores overall clinical risk group criteria for assigning an overall clinical risk group to an individual patient, where the overall clinical risk group criteria takes into account the episode disease categories and severity of illness levels;   (b) obtaining historical care data for an individual;   (c) determining the episode disease categories for the individual;   (d) assigning severity levels to the episode disease categories for the individual; and   (e) assigning an overall clinical risk group to an individual based on the overall clinical risk group criteria.   
     
     
         2 . The method of  claim 1  wherein the severity of illness rules take into account other episode disease categories or other information not related to a particular episode disease category being subdivided. 
     
     
         3 . The method of  claim 1  wherein the overall clinical risk group criteria adjusts for the effect of interacting conditions in different episode disease categories. 
     
     
         4 . The method of  claim 1  wherein the step of assigning severity levels to the episode disease categories for the individual is based on the nature and temporal relationships of the episode disease categories experienced by the individual. 
     
     
         5 . The method of  claim 1 , further comprising defining severity of illness levels for each clinical risk group taking into account episode disease categories. 
     
     
         6 . The method of  claim 1 , further comprising defining severity of illness levels for each clinical risk group taking into account prescription drug usage. 
     
     
         7 . The method of  claim 1 , wherein the severity of illness rules adjust the severity of illness level for each episode disease category based on the nature and timing of treatment for each episode disease category. 
     
     
         8 . The method of  claim 8 , wherein the severity of illness rules adjust the severity of illness level for each episode disease category based on the recency of other episode disease categories. 
     
     
         9 . The method of  claim 1 , further comprising:
 a) obtaining a set of medical procedure codes for the individual;   b) categorizing the medical procedure codes into episode procedure categories;   
       wherein the severity of illness rules take account of the episode procedure categories in adjusting the severity of illness level for each episode disease category. 
     
     
         10 . The method of  claim 9  wherein medical procedure codes include prescription drug usage codes. 
     
     
         11 . The method of  claim 9 , further comprising the step of determining episode disease categories for the individual that are indicated by the episode procedure categories. 
     
     
         12 . The method of  claim 1 , further comprising selecting a primary chronic disease or identifying a lack of a primary chronic disease from the episode disease categories for each major disease category based on a set of selection criteria. 
     
     
         13 . The method of  claim 12 , wherein the computer system further stores a risk group criteria for each of a series of risk groups, wherein the series of risk groups are ranked in order of clinical significance, and further comprising the step of comparing the episode disease categories to the risk group criteria for each risk group, and assigning the most severe clinical risk group for which the criteria are met. 
     
     
         14 . The method of  claim 1 , wherein the computer system further stores a criteria for assigning an overall clinical risk group to a group of patients, where the criteria for assigning an overall clinical risk group to a group of patients takes into account the episode disease categories and severity of illness levels. 
     
     
         15 . The method of  claim 1 , further comprising adjusting the episode disease categories for the individual based on the nature and temporal relationships of the episode disease categories experienced by the individual. 
     
     
         16 . The method of  claim 15 , wherein the adjusting step includes deleting episode disease categories when the temporal relationship between events implies that the disease indicated by an episode disease category has likely been eliminated by subsequent treatment. 
     
     
         17 . The method of  claim 16 , further comprising the steps of:
 a) assigning a clinical risk group to the individual based on the adjusted episode disease categories experienced by the individual;   b) identifying from adjusted episode disease categories the primary chronic disease in each major disease categories; and   c) determining the clinical risk group based on the number and type of primary chronic diseases.   
     
     
         18 . The method of  claim 17 , wherein the step of determining the clinical risk group is further based on the presence of catastrophic conditions. 
     
     
         19 . The method of  claim 17 , further comprising the steps:
 a) determining the severity of illness level for each primary chronic disease experienced by the individual;   b) setting a severity of illness level for each primary chronic disease based on the nature, temporal relationships and severity of illness levels of the episode disease categories experienced by the individual; and   c) assigning an overall severity of illness for the individual based on the adjusted severity of illness levels for the primary chronic diseases experienced by the individual.   
     
     
         20 . A computer system for rating the nature and severity of health care requirements for an individual, including:
 (a) a storage device storing:
 (i) a set of medical disease codes, wherein the medical disease codes are categorized into major disease categories, wherein the medical disease codes in each major disease category are categorized into episode disease categories based on severity of health care requirements, wherein at least some of the episode disease categories are sub-divided by severity of illness level by using severity of illness rules, and wherein the computer system further stores overall clinical risk group criteria for assigning an overall clinical risk group to an individual patient, where the overall clinical risk group criteria takes into account the episode disease categories and severity of illness levels; and 
 (ii) historical care data for an individual; and 
   (b) a processing unit configured for:
 (i) determining the episode disease categories for the individual; 
 (ii) assigning severity levels to the episode disease categories for the individual; and 
 (iii) assigning an overall clinical risk group to an individual based on the overall clinical risk group criteria. 
   
     
     
         21 . The system of  claim 20  wherein the severity of illness rules take into account other episode disease categories or other information not related to a particular episode disease category being subdivided. 
     
     
         22 . The system of  claim 20  wherein the overall clinical risk group criteria adjusts for the effect of interacting conditions in different episode disease categories. 
     
     
         23 . The system of  claim 20  wherein assigning severity levels to the episode disease categories for the individual is based on the nature and temporal relationships of the episode disease categories experienced by the individual. 
     
     
         24 . The system of  claim 20 , wherein the processing unit is further configured for defining severity of illness levels for each clinical risk group taking into account episode disease categories. 
     
     
         25 . The system of  claim 20 , wherein the processing unit is further configured for defining severity of illness levels for each clinical risk group taking into account prescription drug usage. 
     
     
         26 . The system of  claim 20 , wherein the severity of illness rules adjust the severity of illness level for each episode disease category based on the nature and timing of treatment for each episode disease category. 
     
     
         27 . The system of  claim 26 , wherein the severity of illness rules adjust the severity of illness level for each episode disease category based on the recency of other episode disease categories. 
     
     
         28 . The system of  claim 20 , further comprising:
 a) obtaining a set of medical procedure codes for the individual;   b) categorizing the medical procedure codes into episode procedure categories;   
       wherein the severity of illness rules take account of the episode procedure categories in adjusting the severity of illness level for each episode disease category. 
     
     
         29 . The system of  claim 28  wherein medical procedure codes include prescription drug usage codes. 
     
     
         30 . The system of  claim 28 , wherein the processing unit is further configured for determining episode disease categories for the individual that are indicated by the episode procedure categories. 
     
     
         31 . The system of  claim 20 , wherein the processing unit is further configured for selecting a primary chronic disease or identifying a lack of a primary chronic disease from the episode disease categories for each major disease category based on a set of selection criteria. 
     
     
         32 . The system of  claim 31 , wherein the storage device further stores a risk group criteria for each of a series of risk groups, wherein the series of risk groups are ranked in order of clinical significance, and wherein the processing unit is further configured for comparing the episode disease categories to the risk group criteria for each risk group, and assigning the most severe clinical risk group for which the criteria are met. 
     
     
         33 . The system of  claim 20 , wherein the storage device further stores a criteria for assigning an overall clinical risk group to a group of patients, where the criteria for assigning an overall clinical risk group to a group of patients takes into account the episode disease categories and severity of illness levels. 
     
     
         34 . The system of  claim 20 , wherein the processing unit is further configured for adjusting the episode disease categories for the individual based on the nature and temporal relationships of the episode disease categories experienced by the individual. 
     
     
         35 . The system of  claim 34 , wherein the processing unit is configured for, when adjusting the episode disease categories, deleting episode disease categories when the temporal relationship between events implies that the disease indicated by an episode disease category has likely been eliminated by subsequent treatment. 
     
     
         36 . The system of  claim 35 , wherein the processing unit is further configured for:
 a) assigning a clinical risk group to the individual based on the adjusted episode disease categories experienced by the individual;   b) identifying from adjusted episode disease categories the primary chronic disease in each major disease categories; and   c) determining the clinical risk group based on the number and type of primary chronic diseases.   
     
     
         37 . The system of  claim 35 , wherein the processing unit is further configured for determining the clinical risk group further based on the presence of catastrophic conditions. 
     
     
         38 . The system of  claim 35 , wherein the processing unit is further configured for:
 a) determining the severity of illness level for each primary chronic disease experienced by the individual;   b) setting a severity of illness level for each primary chronic disease based on the nature, temporal relationships and severity of illness levels of the episode disease categories experienced by the individual; and   c) assigning an overall severity of illness for the individual based on the adjusted severity of illness levels for the primary chronic diseases experienced by the individual.