WO2010141251A2

WO2010141251A2 - System and methods for sourcing and managing healthcare related resources

Info

Publication number: WO2010141251A2
Application number: PCT/US2010/035933
Authority: WO
Inventors: Thomas Lenz
Original assignee: Creighton University
Priority date: 2009-06-05
Filing date: 2010-05-24
Publication date: 2010-12-09

Description

SYSTEM AND METHODS FOR SOURCING AND MANAGING HEALTHCARE

RELATED RESOURCES

FIELD OF THE INVENTION The present invention relates generally to the delivery of goods and services for healthcare related purposes. More particularly, the present invention relates to the management of the delivery of good and services such that the goods and services are delivered efficiently and in a cost effective manner to produce healthcare related benefits, The system and methods of the present invention permit a care recipient, or another for the care recipient, to source and manage the delivery of the goods and services such that they are provided as needed and for a competitive price. BACKGROUND

The current medical care delivery system places primary responsibility on the provider, such as a primary-care or personal physician, to care for the patient largely throughout the provider's or the patient's life. To discharge this overall responsibility, the provider, when a physician, must satisfy a host of other, not necessarily mutually exclusive obligations. Some of these obligations are inherent to the position that a physician holds within the healthcare system, other obligations are mandated by state and federal laws and regulations, others are imposed by those that are paying for the care given to a patient (such as through Medicare, Medicaid, and insurance company programs), while other obligations are ones that many physicians assume simply to further assist the patient.

More specifically, the current medical care delivery system obligates, the personal physician or provider is required to provide what is conventionally considered to be primary care services directly to the patient. These services include interacting with the patient to determine the condition of the patient, ordering laboratory or other diagnostic tests to more accurately determine the condition of the patient, arriving at a diagnosis, informing the patient of the diagnosis, recommending a course of treatment in line with the diagnosis, rendering treatment - surgical or otherwise - directly to the patient, interacting with the patient during and after the treatment period to determine whether the patient's condition has improved, and providing educational or other informational follow-up as needed such as to lessen the likelihood that the patient's condition will return.

Incidental to the delivery of the services to the patient, the personal physician is subject to a variety of obligations under state and federal laws and regulations. These include those concerning record keeping and reporting.

The current system largely relies on third parties - such as the federal government (the Medicare program, the Medicaid program), state government, and private insurance companies - to pay for the care received by a patient. The current system largely places the onus on the physician to do that which is necessary in order that the physician can be compensated by these third parties for the services rendered to and costs incurred on behalf of the patient. Accordingly, the primary physician is obligated to submit the necessary requests and documentation to the third party payers and continue following up with them until payment is received. The current system also places the responsibility on the personal physician to maintain all relevant records regarding the care delivered to a patient. Information from these records is accessed not only by the physician and physician's staff, but is also the subject of a variety of requests from third parties concerning the details of the service delivered to the patient. Those paying for the care delivered to a patient typically request information from the physician's patient records. As the other service providers or vendors or the third party payers need some or all of the information in the patient's records, the personal physician's office is required to locate the needed information and dispatch it to the requesting party - all the time making sure first that the patient has approved the transfer of the information - quickly and at no charge. Under the current system, the physician also is largely expected to instruct or at least make recommendations to the patient from whom or what the patient should purchase/lease/or otherwise acquire the goods or services prescribed or recommended by the physician. These goods can include drugs or equipment (walker, wheel chair, medical bed, etc.) needed by the patient for treatment or during the recovery stage. The services can be those provided by other healthcare practitioners - including physical therapists, occupational therapists, nutritionists or dietitians - or those not necessarily considered to be healthcare practitioners - such as personal physical trainers. Largely because of the relationship of trust that a patient develops with the physician, the patient looks to the physician to provide recommendations that are appropriate not only for the patient's medical condition but also financial condition and lifestyle.

There are a number of problems associated with the current healthcare system. Many of these problems arise from the simple fact that there are too many patients and too few physicians. Because of the demand, a patient cannot be seen by a physician - particularly, specialists - on short notice; rather, the patient must make an appointment that, in the case of the specialist, may be some 30 to 60 days in the future. As a result, a patient who is experiencing a serious medical condition has the choice of visiting a hospital emergency room or a walk-in clinic. Many of the advantages of having a personal physician - such as continuity in care and maintenance of a complete record of the care delivered to a patient - are thereby lost. A discontinuity often appears in the patient's record. But even if the patient can wait to be seen by his or her personal physician, the patient's time with the personal physician is short - typically some 15 to 20 minutes. The physician is limited to a short period of time because other patients also need to see the physician. As a result, the physician must speed through the discussion with and diagnosis of the condition of the patient and make a treatment recommendation. After the initial visit, the opportunity and time that the physician has available to follow up with the patient are similarly limited because of the physician's busy schedule. Typically, the next time that the physician can discover whether the patient's condition has changed is when the patient comes in for his or her next scheduled appointment. Overall, because of the imbalance between patient demand and physician availability, the system largely gives top priority only to those patients experiencing a medical crisis. Little opportunity is provided to discuss preventive measures or otherwise better educate patients.

Another problem with the current system is that it is often not configured to permit the patient to easily obtain additional advice or information so that the patient can easily and efficiently make more fully informed decisions. Most patients rely on the advice provided by their primary care physicians, in part, because of the trust they develop with their physicians but also because it is not easy to obtain the advice of others. A patient that has received the opinion of his or her physician may wish to obtain the advice of one or more other healthcare practitioners in order to place the first opinion in context. The current system does not allow a patient to easily obtain a second opinion or additional advice because the records of the patient are maintained by the physician. To obtain the second opinion or additional advice, the patient typically must notify his or her physician of the desire to obtain a second opinion, request that the physician's office make a copy of the information relevant to the first diagnosis, pick-up or otherwise make arrangements for the transfer of the requested information to the person asked to render the second opinion or advice, then wait. Besides the cost associated with it, the process takes time and simply prevents the patient from obtaining the information that the patient needs to make a more fully informed decision in a timely fashion. The current system is also problematic in that it does not readily ensure that the most cost effective care is being rendered to the patient. At the most basic level, patients continue with their primary care physicians without ever knowing whether the primary care physician's rates are competitive with similarly situated physicians. Separate and apart from what the physician charges are the costs and charges of the goods and services recommended by the physician. Patients do not know whether the goods or services prescribed or suggested by the physician are the most cost effective solutions. At times, incentives are offered to or available to physicians that may sway their judgment as to which product or service to recommend to a patient when the product or service varies only in price. Also, primary care physicians are often contractually obligated to recommend that the patient obtain such additional goods or services from a certain source. Such sources (such as an imaging center in the hospital in which the physician works, or a physical therapist group affiliated with the physician's group), relative to alternatives in the marketplace, may not be the cost effective solution. Additionally, the physician at times makes recommendations with respect to goods or services about which the physician has little first hand information. These recommendations are often based on little more than what others have told the physician.

An additional problem with the current system is that it makes the patient the ultimate decision maker but does not provide the patient with the means by which the patient can become fully informed. It is a time consuming task for most patients to obtain additional information, answers to his or her questions, or additional assistance in making decisions easily. Again, the primary care physician is often too busy to provide advice to the patient regarding every decision that the patient must make regarding his or her care in a timely fashion.

Over the years, many solutions have been proposed to cure the ills in the system. The recent Call to Action: Health Reform 2009 begins the reformation of America's healthcare system by striving to achieve universal coverage while also addressing the underlying problems in the healthcare system. The Commonwealth Fund Commission on a High Performance Health System recognizes the need for national leadership to revamp, revitalize, and retool the healthcare system by promoting a high-performing health system that provides affordable access to high- quality, safe care while maximizing efficiency in its delivery and administration. Of particular concern to the Commission are the most vulnerable groups in society, including low-income families, the uninsured, racial and ethnic minorities, the young and the aged, and people in poor health. Typically, such solutions seek to solve one or a limited number of the problems with the system. No comprehensive solutions have been offered and instituted.

For example, one solution that has been offered is termed a "medical home model". The medical home model is characterized as a "patient-centered team approach". The model places the personal physician at the head of the team that includes not only the primary care physician but also specialist physicians, nurses, dietitians, mental health professionals, and health educators. The personal physician is responsible to provide "continuous, comprehensive care". The patient is said to be a team member and is required to take an active role in his or her own care. The model makes the patient's entire medical history accessible online to all members of the medical team as electronic medical records. A version of the model makes a "medical home page" within the electronic medical records of the patient. In recognition of the statistic that some 45% of the U.S. population has a chronic medical condition and half of that population (that is, some 60 million people) has multiple chronic conditions, this home page is characterized as an "executive summary" of the patient's condition and provides only the information needed for the management of the patient with a chronic condition. The medical home page provides information regarding the medications which have been prescribed to the patient. The information is updated by the pharmacy team member. Medications are ordered electronically to avoid errors in handwritten prescriptions. The pharmacist is required to check for counter indications, drug interactions, and dosages. The medical home page provides information regarding new treatments and changes in therapies. Specialists and other healthcare providers are given access to the medical home page and are allowed to enter their own observations and recommendations. The information is instantly accessible to the entire medical home team. The medical home model considers the patient's own input to be most critical to the performance of the model. The patient is required to monitor their conduct and conduct various tests (e.g., blood pressure, glucose monitoring, etc.) and record this information directly into the electronic medical record - not just send it to the physician's office for entry by someone else. This information is then automatically plotted on the medical home page. Overall, the model is said to allow physicians more time interacting with patients and leading the medical home team than spending time searching for information.

While such a model's use of electronic medical records does facilitate the more efficient care of patients, the model's reliance on the personal physician to guide and manage the larger assembled team of healthcare workers places more time pressures on the member of the team with the least time to spare. The model also does not facilitate the maintenance of the health of a person before the person gets sick and becomes a patient. The model also does not allow the patient to incorporate in the system one or more other people or entities outside the traditional healthcare sphere who can provide goods or services that may ultimately produce an impact on the health of the patient. The model also does not allow the patient to shift some or all of the responsibility to evaluate options and make decisions that can impact the health of the patient to one or more people who may not necessarily be healthcare workers.

Additionally, a patient may have the interest to become more actively involved in taking preventive measures or assisting in the management of a current disease or illness. The patient may wish to purchase goods or engage the services of another or others. However, often the patient cannot devote the time to determine who can provide the needed goods or services and at what cost - including because they are trying to recover from the condition that made them a patient. Even if the patient had the time, the patient may not have the training or experience to know the scope of the goods or services that are needed and which of those offering goods or services may be best for the patient. Also, certain goods or services can be obtained only after a physician writes an order. Physicians typically will not write such an order for new goods and services unless the physician has had an opportunity to examine or re-examine the patient. This delays the timely purchase of the needed goods and services and extends the time needed by the patient to accomplish the desired health goals. Overall, placing the responsibility on a patient - particularly a sick patient - to locate goods or services that match well with the patient's needs and financial resources obligates the patient to engage in an inefficient, disjointed process. Keeping an individual well, or treating the individual after he or she has developed a health condition cannot be accomplished solely by the physician. A group of service providers typically must be engaged to perform the complete task. For example, an individual that is trying to stay in good health and avoid common chronic conditions, such as obesity or poor circulation, can easily utilize the services of a dietitian and a trainer. However, an individual that is attempting to overcome an obesity condition can utilize the services of a physical therapist, a chiropractor, a dietitian, a nutritionist and a trainer among others. How such a team is managed and coordinated such that each provides the needed services at the best time and in the most cost effective manner is a time consuming task that needs the advice and assistance of a trained professional. Therefore, there is a demand for a system and methods by which a person can organize and facilitate the workings of a team that can produce benefits for the health of the person but without placing the onus on the person's primary care physician to manage such a team. The present invention satisfies this demand. SUMMARY OF THE INVENTION For purposes of this application, the present invention is discussed in reference to healthcare, but the discussion is merely exemplary. The present invention is applicable to the sourcing and management of any resource including renewable and non-renewable resources, tangible and intanbile resources, and other financial, inventory, manufacturing, distribution and production resources. The system and methods according to the present invention allow resources to be identified, obtained, and managed efficiently and in a cost-effective manner in order to maintain the health of an individual, but if the individual does become sick to assist the patient in his or her recovery.

Numerous environments are contemplated wherein the present invention is applicable, for example, hospitals, assisted living facilities, home health care settings, and university or college environments in order to maintain and assist the health of students, teaching assistants, and professors to name a few.

The system and methods are particularly useful to prevent and manage chronic conditions, which include, for example, diabetes mellitus, hypertension, hypercholesterolemia, and obesity, and other conditions, or to just improve wellness generally. This system and method is also useful to obtain cost-effective and comprehensive healthcare, which benefits the person receiving the healthcare resources and the person or entity paying for those resources. Total care is delivered to meet the healthcare needs efficiently and at the lowest possible cost. One preferred embodiment of the system and methods of the present invention provides a single access point designed to facilitate efficient communication and information access between a group of providers, beneficiaries and coordinators through a communication network centered around a communication inter-hub. For purposes of this application, the following terms have the following identified meanings. The term "provider" designates one or more persons or entities that provide a healthcare related good or service. The term "beneficiary" designates any person, group of persons, or entity that is the recipient of goods and/or services with the goal to produce healthcare related benefits. It is contemplated that the beneficiary may be a person that is not sick but who wishes simply to maintain his or her health. The term beneficiary also includes a person that is afflicted with a condition or who has risk factors to develop a condition or quite simply a person who wants to improve their wellness and efficiently obtain cost-effective and comprehensive healthcare. A beneficiary includes children or sick/elderly persons who require another person such as a parent or one given medical power of attorney to make binding decisions on his or her behalf. The term "condition" includes wellness, chronic and non-chronic conditions as well as diseases and illnesses. The term "coordinator" designates one or more persons or entities that assist at least the beneficiary in any number of ways depending upon the needs and desires of the beneficiary, more specifically, the coordinator assists in the sourcing and management of providers through the communication network. The system and method is focused on prevention, wellness and chronic condition management while providing an inter-professional and collaborative approach to healthcare. The present invention provides a healthcare infrastructure with the widespread availability and use of networks to improve access to healthcare information in order to focus on and specialize in wellness and chronic disease prevention and management. Most importantly, the present invention facilitates efficient communication between beneficiaries and their providers and between the providers themselves thereby producing a fundamental change to the current system of healthcare delivery.

A healthcare team is established that comprise one or more providers or groups of providers termed herein as "squad" - all of which work toward the common goal of delivering care to the beneficiary. Each provider or squad of the team is assigned one or more specific tasks to provide goods and/or services to the beneficiary, for example an ophthalmology provider or squad is assigned to a beneficiary that cannot see well, a weight loss provider or squad is assigned to a beneficiary that is overweight, and an orthopedic provider or squad is assigned to a beneficiary that has a broken foot. The healthcare team may be assembled by one or more of the coordinator, beneficiary, or provider such as an insurance company or even a third party. For purposes of this application, third parties may include an employer such as for the beneficiary or the coordinator, hospital, university, any company such as home health care or agency including profit, non-profit, government, or member benefits organization or association such as alumni club, assisted living, American Association of Retired Persons ("AARP") or even a condo association.

Providers can include, for example, primary care physician, healthcare specialists, vendors, claims administrators, payers, and personal support individuals. It is contemplated that providers may be hired by a third party, as defined above, such as an employer or government agency. The primary care physician may provide both the first contact for a person with an undiagnosed health concern as well as continuing care of varied medical conditions. A primary care physician generally does not, but may, specialize in any medical specialty and can include, for example, a physician, medical doctor, nurse practitioner, clinician, physician assistant, or an alternative medicine practitioner.

For purposes of this application, healthcare specialists specialize in a medical specialty, such as neurology, cardiology, pulmonology. Healthcare specialists include, for example, dentists, pharmacists, therapists such as occupational therapists and physical therapists, psychologists, psychiatrists, chiropractors, optometrists, paramedics, specialists such as health behavior specialists and tobacco cessation specialists, surgeons, fitness trainers, dietitians, nutritionists, yoga instructors, safety specialists, health educators, and a wide variety of other individuals or entities such as hospitals and laboratories such as medical or research laboratories.

Vendors include suppliers such as medical device suppliers, safety suppliers, pharmaceutical suppliers, food suppliers, and others. Medical device suppliers could supply devices such as walkers, wheelchairs, medical beds, crutches, diabetic needles, blood pressure equipment, scales, pedometers, or exercise equipment. Safety suppliers could include those that supply fire extinguishers, smoke detectors, carbon-monoxide detectors, radon testing, pest eradication, mold detection, home maintenance, cleaning supplies, or cleaning services. Pharmaceutical suppliers could include individuals or entities that supply prescriptions, over-the-counter treatments, vitamins, or supplements, for example. Food suppliers could include grocery stores, online grocers, and diet food delivery services. It is also contemplated that the term vendor could additionally include individuals or entities that provide goods and/or services such as child care services, pet care services, and landscaping services. .

A claims administrator is a person or organization who processes claims and may perform other administrative services. More specifically, a claims administrator processes claims on behalf of the payer described below. Services may include processing claims including audits, adjusting, and negotiating settlements, record keeping, self-insurance certification, and notification of excess insurers.

A payer is an employer or entity - such as an insurance company, Medicare, Medicaid - that indemnifies for losses or pays the cost for the goods and/or services received by the beneficiary.

A personal support individual is any person or entity that assists the beneficiary with their emotional, mental and physiological state associated with any behavioral changes. The personal support individual may help the beneficiary in a variety of ways including organizing its medications, shopping for groceries, helping make medical or other decision, and interpreting health information to name a few. Personal support individuals include for example, a social worker, a human resources employee, or a co-worker. The personal support individual may additionally include the beneficiary's child, sibling, parent, grandparent, friend, neighbor, or walking partner. The coordinator is one or more persons or an entity that assists the beneficiary in coordinating its care within the healthcare system. The coordinator may have many roles and responsibilities according to the present invention, some of which include: acting as an advocate for the specific and individual medical needs of a patient and that patient's family; designing and implementing individualized chronic disease management/prevention programs for patients that include, but are not limited to, comprehensive lifestyle modifications, health behavior change strategies, and immunizations; acting as a liaison to facilitate effective communication regarding the health conditions and concerns of the patent with all of the patient's providers; facilitating inter-professional healthcare on behalf of an individual patient; educating the patient about their specific health conditions, drug therapy, disease prevention/disease management strategies; ensuring coordination occurs for all of the patient's disease prevention and disease treatment strategies between all of the patient's providers as well as ensuring patient adherence; maintaining a current and accurate listing of the patient's medications; referring the patient to specialists when needed; and acting as a legal entity such as power of attorney to make decisions on behalf of the beneficiary.

The objective of the system and methods of the present invention is to empower the coordinators so that they are likely to be more accessible to the beneficiary than healthcare providers and may meet or contact the beneficiary on a regular basis, upon request of the beneficiary, upon the need of the beneficiary, or upon the request of a healthcare provider, for example.

The coordinator is selected by the beneficiary. However, it is also contemplated that the coordinator may be selected by a third party such as an employer of the beneficiary such that the coordinator owes a duty to the beneficiary and a duty to the person/entity that employs the beneficiary. As another example, the coordinator may be selected by a payer such as an insurance company such that the coordinator owes a duty to the beneficiary and a duty to the person/entity paying for the services rendered to the beneficiary.

The coordinator may be a healthcare provider whom the beneficiary feels most comfortable with such as the primary care physician. It is also contemplated that the coordinator may be a payer such as an insurance company or even a third party such as an employer, company, agency, member benefits organization or association.

It is also contemplated that a coordinator can hire other respondent coordinators - which can be one or more persons or an entity. For example, a coordinator can be a person designated by beneficiary to have the medical power of attorney - the person may know about the beneficiary's health condition and financial resources - but may have to engage a respondent coordinator for health purposes, a respondent coordinator for financial purposes, etc. All the respondent coordinators hired by the coordinator form a respondent team of individuals or entities that respond to the needs of a beneficiary as identified by a coordinator.

The coordinator helps to manage the beneficiary's needs - one result of which is that the beneficiary's health is maintained or restored. A beneficiary may receive or potentially receive healthcare service and/or goods from many sources - a podiatrist, a dentist, a pharmacist, a surgeon, a physical therapist, a psychiatrist, a fitness trainer - such that the coordinator could source and manage the healthcare related resources for the beneficiary. The coordinator can help the beneficiary establish a schedule in which all of the treatments or recommendations from different healthcare providers are integrated.

More specifically, the coordinator may provide assistance in carrying out the treatment or regimen recommended or prescribed by each provider of the healthcare team. For example, if a healthcare provider such as an occupational therapist recommends that the beneficiary engage in certain exercises for two hours a day, the coordinator could ensure that the beneficiary has a way to get to the exercise facility or arrange for the exercises to be performed at a convenient location for the beneficiary. Additionally, the coordinator may help the beneficiary in choosing the occupational therapist, follow up after therapy appointments to identify the results of the therapy and ensure the satisfaction of the beneficiary with the occupational therapy experience.

In another example, the coordinator could collect data including observations on treatment such as side effects from a prescription medication or adherence to a lifestyle modification plan. The coordinator could contact the proper healthcare provider on behalf of the beneficiary.

The coordinator could also organize price comparisons for goods and/or services for the beneficiary review and selection. Where the coordinator services more than one beneficiary, it may be possible for the coordinator to obtain discounts on the same or similar goods and/or services for the beneficiaries.

In one embodiment, the coordinator is an "ambulatist". An "ambulatist" is a professional that requires a license such as a state license. The ambulatist may optimize the health and wellness of an ambulatory beneficiary, with the primary goal of preventing the progression of a beneficiary's current and potential medical conditions and the incidence of hospitalization. The ambulatist may be (but is not required to be) a current healthcare provider for the patient. Ideally, the patient may choose one of their healthcare providers whom they feel most comfortable with to act as their ambulatist. In some cases, patients may be assigned an ambulatist by the payer. Healthcare providers who wish to be an ambulatist must receive specific post-graduate training on how to provide care as an ambulatist. It is contemplated that this post-graduate training consists of a certificate training program that may take place on a campus or via a distance education technology. Because the ambulatist has specialized training, they may make detailed and personalized suggestions based on, for example, the beneficiary's risk factors, current habits, and/or goals. The ambulatist may further provide suggestions to help the beneficiary implement preventive habits, for example, lifestyle modifications, health behavior changes, immunizations, etc. The ambulatist may also provide assistance in understanding an ailment or condition and recommendation or directions of a member of the healthcare team.

The coordinator would also facilitate the set-up and use of the communication inter-hub. The coordinator could provide continued support and assistance to the beneficiary in the use of the communication inter-hub.

The communication inter-hub is part of a communication network that facilitates information sharing and interaction between beneficiaries, coordinators and providers. The communication inter-hub allows for private, confidential, secure and Health Insurance Portability and Accountability Act ("HIPAA") compliant communication

The communication inter-hub is capable of using the "World Wide Web" accessed via an internet or intranet based and works in conjunction with clients such as pagers, mobile phones, wireless personal digital assistants, faxes, smart phones and any Bluetooth® enabled device. The communication inter-hub may be hosted and administered by any individual or entity, for example, a coordinator, a provider, payer such as an insurance company or third parties such as an employer, hospital, or university.

Besides communication via the inter-hub, direct communication still takes place between anyone within the communication network such as through regularly scheduled face-to-face visits between a beneficiary and the coordinator, primary care provider or other healthcare providers.

Although the beneficiary's primary point of contact is the coordinator, or ambulatist, they can also communicate directly with their primary care provider or any other healthcare provider within the team.

The beneficiary, coordinator and providers within the healthcare team access the communication inter-hub using interfaces. One example of an interface is a personalized webpage that may be customizable to each user. For example, the beneficiary webpage may be customized by the coordinator based on their specific medical conditions and needs and further include links to social networking sites or blogs. It is also contemplated that the beneficiary may customize their own webpage. Additionally, the interfaces accommodate selective access to information on the communication inter-hub discussed more fully below.

The interfaces provide the ability to access and view combined information. As an example, it is conceivable that a coordinator may have several beneficiaries including those that work for different employers. The coordinator interface allows the coordinator to access and view simultaneously all beneficiary files of beneficiaries that the coordinator represents. This alleviates the coordinator from logging into each beneficiary file separately. It is also contemplated that a provider can access and view all beneficiary files that the provider is affiliated. It is also contemplated that a user may have access to more than one user interface, for example, a coordinator may have access to the coordinator interface as well as the beneficiary interface. Furthermore, the beneficiary interface may be the same as the coordinator interface. The communication inter-hub includes a database element, bidding forum element and a general information element. The database element includes files for each beneficiary of the network. Each beneficiary file includes a personal medical records component, a tracking component, a messaging component and a lifestyle modification component. In other embodiments, the beneficiary file further includes a reward component. The beneficiary file of the database element allows the beneficiary to actively participate in their own care.

The personal medical records component includes a variety of information such as: beneficiary profile including name, address, contact information, insurance information; health profile including health history, family history, symptoms, treatment, medication, prescriptions, charts, graphs, and diagnoses; and payment profile including insurance claims, payment and provider invoices - current, outstanding and historical.

The beneficiary can monitor and log vital information in the personal medical records component. For example, they can log blood pressure, glucose level, heart rate, insulin shot administrations, and medication consumption. The personal medical records component may complement or be integrated with the beneficiary's other electronic medical records that may reside with other providers such as their primary care provider.

The personal medical records component summarizes the care of a beneficiary. For example, past, current and new prescriptions and dosages are recorded. Side effects, counter indication and interactions may also be recorded. It is also contemplated that prescriptions can be ordered electronically through the personal medical records components.

The messaging component of the beneficiary file is used for the electronic transfer of information including notifications. It is contemplated that the messaging component not only transfers information to the beneficiary, but also the coordinator and/or any provider or squad of the healthcare team. The messaging component can transfer information from any of the interfaces described more fully below in addition to any component within the communication inter-hub.

The messaging component may include blogging, internet chat sessions, web or video conferencing, online education, email, texting, instant messaging, picture messaging, and alert messaging such as an emergency or urgency. The messaging component in conjunction with the other components provides easy, organized and convenient access to the beneficiary file. For instance, if a beneficiary emails a question about their diabetes condition, a provider could access the beneficiary's health history of the personal medical records component before providing an answer.

The lifestyle modification component includes plans tailored to the beneficiary. It is contemplated that the plans are created by the beneficiary, coordinator, and/or one or more providers or squads of the healthcare team. Plans include, for example, a health improvement plan, a prescription plan, a treatment plan, an eating plan, an exercise program, a behavioral strategy plan, weight control plan, and tobacco cessation plan.

In one embodiment, the present invention includes a reward component. The reward component could facilitate rewards to the coordinator or the beneficiary. For example, the coordinator or beneficiary may be rewarded for various results or goals achieved by the beneficiary such as when the beneficiary arrives at a benchmark for their condition, meets a goal such as achieving a particular weight, or attains a result in a particular time period. The coordinator could also be rewarded for obtaining budgetary goals such as financial savings on goods or services. Rewards include anything offered as an incentive such as money, coupons, discounts, or prizes. The reward component motivates the coordinator to be attentive, encouraging, and responsive to the beneficiary while motivating the beneficiary to achieve their goals.

It is also contemplated that the reward component could facilitate rewards to the provider. The rewards could be based on quality such as a quality benchmark reward. Quality benchmark rewards would allow reimbursement to providers at a rate that is linear to the beneficiary's achievement of clinical benchmarks specific to their condition thereby stimulating value-based care. The tracking component allows a measure of progress or completion of treatment by the beneficiary. Progress or completion of treatment may include assessing adherence to the plans such as taking medication or participating in lifestyle modification of the lifestyle modification component. The tracking component reviews progress towards a goal, determines the rate of progress, and compares rate of progress or adherence to benchmarks. The tracking component could also be used to measure the effectiveness of the coordinator, specifically ambulatist, as well as one or more of the providers, squads, or even the entire healthcare team.

It is further contemplated that the tracking component could analyze data and generate reports. For example, the tracking component could allow for the plot of data such as lab results, cholesterol levels, and heart rate over time. This allows a provider to visually assess the beneficiary's condition and identify a trend or necessary change in treatment. The tracking component could also allow analyze data to measure direct medical claims of payers as well as compare medical claim data to determine financial benefits of the present invention.

In addition to the database element, the communication inter-hub includes a general information element. The general information element includes a variety of information for review and comment and various organizations for participation. Examples of information and organizations include health news, support group for interacting with other people with similar conditions, discussion group, debate group, advice group, pricing information, etc.

A bidding forum element of the communication inter-hub provides a comparison shopping center for buying and selling goods and/or services. Potential providers submit bids to provide goods or services to a beneficiary thereby allowing the beneficiary to obtain the best goods or services at the most competitive levels. The beneficiary, coordinator, or provider could place a bid or offer for a good or service on the communication inter-hub. Besides goods and/or services, it is also contemplated that bids or offers could be placed for a coordinator. The bidding forum element could have forms with drop-down menus for selection of the good or service although a free-form is also contemplated.

It is also contemplated that the bidding forum element may be organized by condition, good, service. For example, a medical supply bidding forum for goods such as walker, wheelchair, medical bed, crutches, diabetic needles, blood pressure equipment, scale, pedometer, exercise equipment; a pharmaceutical supply bidding forum for goods such as prescriptions, over-the-counter treatments, vitamins, supplements; a fitness forum for services such as an exercise facility, yoga instructor, fitness trainer, dancing coach; a diabetes bidding forum for all goods and/or services related to a diabetic condition. A beneficiary or coordinator could request bids for medical services including treatment plans recommended for a specific condition. Providers of squads access the bidding forum element to post bids including any terms to the bid such as availability or shipping. The beneficiary or coordinator acting on behalf of the beneficiary is able to select the best possible bid. It is also contemplated that the beneficiary or coordinator could offer a cost that they were willing and able to pay along with any terms for a particular good or service. Providers access the bidding forum element to accept offers.

The bidding forum element could also provide additional information about providers, coordinators, goods and services. For example, the bidding forum element could provide a preferred list of providers such as vendors, a pre-approved provider list, or a list of certified providers. The bidding forum could also include a ranking system whereby providers are rated. This additional information would further assist the beneficiary or the coordinator in making a decision to accept or post a bid. It is also contemplated that a coordinator who services more than one beneficiary could bid or offer on goods or services in bulk.

As mentioned above, the communication inter-hub is selectively accessible. The beneficiary, coordinator or healthcare team can determine the access to the information through the interface. For example, a beneficiary will be able to view and edit the entirety of his or her own personal medical records component, but not be given access to other beneficiary files. Additionally, the beneficiary may control which other users can see which parts of his or her file. For instance, the beneficiary may choose to give a vendor access to the messaging component of his or her file, while giving a personal support individual access to the tracking component and personal medical records component.

Likewise, provider interfaces allow a provider of squad of the healthcare team to access to all or a portion of beneficiary files for each beneficiary they serve. As an example, a claims administrator may be able to access a partial view of the tracking component and a partial view of the personal medical records component such as recent provider invoices. The present invention may be implemented in a variety of ways including, for example, a payer driven model, a third party driven model or a beneficiary driven model. The following are merely examples for each model.

With a payer driven model, specifically an insurance driven model, the payer initiates the prevention and care of beneficiaries with specified chronic conditions. The payer can either ask the beneficiary to choose a coordinator such as an ambulatist or in some cases, the coordinator may be assigned to the beneficiary by the payer. The coordinator drives the beneficiary-centered care approach by assembling the healthcare team including a personal support individual. These providers are mutually agreed upon by the beneficiary and the coordinator. Payment is made to the coordinator by the payer on a per member per month ("PM/PM") basis and a base payment can be leveled to the number of chronic conditions that the beneficiary possesses. Rewards may be offered to the coordinator if the beneficiary achieves established clinical benchmarks specific to the condition of the beneficiary. Benchmarks may differ based on the condition. In one embodiment, reimbursement may only be provided to the coordinator and not to the other healthcare providers. In another embodiment, the other healthcare providers may be reimbursed via traditional means.

In a third party driven model, specifically an employer driven model, the beneficiary's employer initiates the prevention and care of beneficiaries with specified chronic conditions. The employer can either ask the beneficiary to choose a coordinator or the coordinator may be assigned to the beneficiary by the employer. The coordinator drives the beneficiary-centered care approach by assembling the healthcare team including a personal support individual. The healthcare providers of the team are mutually agreed upon by the beneficiary and the coordinator. The coordinator could either work for the employer for a salary, contracted on a flat monthly rate, or contracted on a PM/PM basis. Rewards could be offered to the coordinator if the beneficiary achieves established clinical benchmarks specific to the condition of the beneficiary. In one embodiment, reimbursement may only be provided to the coordinator and not to the other healthcare providers. In another embodiment, the other healthcare providers may be reimbursed via traditional means.

In a beneficiary driven model, the beneficiary initiates contact with a coordinator such as an ambulatist to set up his/her own care plan. The coordinator drives the beneficiary-centered care approach by assembling the healthcare team including a personal support individual. These providers are mutually agreed upon by the beneficiary and the coordinator and payment is made on a fee-for-service basis.

These and other aspects, features, and advantages of the present invention will become more readily apparent from the attached drawings and the detailed description of the preferred embodiments, which follow. BRIEF DESCRIPTION OF THE DRAWINGS

The preferred embodiments of the invention will be described in conjunction with the appended drawings provided to illustrate and not to the limit the invention, where like designations denote like elements, and in which: Fig. 1 is an embodiment of a communication network according to the present invention;

Fig. 2 is an embodiment of a communication inter-hub of the network according to the present invention;

Fig. 3 is an embodiment of a database element of the network according to the present invention; and Fig. 4 is an embodiment of the first beneficiary file of the network according to the present invention. DETAILED DESCRIPTION OF THE INVENTION

The system and methods according to the present invention allow resources to be identified, obtained, and managed efficiently and in a cost-effective manner in order to maintain the health of an individual, but if the individual does become sick to assist the patient in his or her recovery. This system and method is also useful to obtain cost-effective and comprehensive healthcare, which benefits the person receiving the healthcare resources and the person or entity paying for those resources. Total care is delivered to meet the healthcare needs efficiently and at the lowest possible cost.

As shown in Fig. 1 , a communication network 100 is centered around a single access point, or communication inter-hub 300 designed to facilitate efficient communication and information access between a healthcare team 200, beneficiaries 400 and coordinators 500.

A healthcare team 200 is established that comprise one or more providers

201 or groups of providers known as squads 202 - all of which work toward the common goal of delivering care to the beneficiary 400. Each provider 201 or squad

202 of the team 200 is assigned one or more specific tasks to provide goods and/or services to the beneficiary. Providers 201 can include, for example, primary care physician 211 , healthcare specialists 212, 213, vendors 214, claims administrators 215, payers 216, and personal support individuals 217.

The coordinator 500 is one or more persons or an entity that assists the beneficiary 400 in coordinating its care within the healthcare system and helps to manage the needs of the beneficiary 400. The beneficiary 400, coordinator 500 and providers 201 or squads 202 within the healthcare team 200 access the communication inter-hub 300 using interfaces 250, 450, 550 such as a personalized webpage customizable to each user. The interfaces 250, 450, 550 accommodate selective access to information on the communication inter-hub discussed more fully below.

The interfaces 250, 450, 550 provide the ability to access and view combined information such that a coordinator 500 can access and view simultaneously all beneficiary files of beneficiaries 400 that the coordinator 500 represents. This alleviates the coordinator from logging into each beneficiary file separately.

As shown in Fig. 2, the communication inter-hub 300 includes a database element 600, bidding forum element 700 and a general information element 800. The database element 600 includes files for each beneficiary of the network as shown in Fig. 3. In addition to the database element 600, the communication inter- hub 300 includes a bidding forum element 700. The bidding forum element 700 of the communication inter-hub 300 provides a comparison shopping center for buying and selling goods and/or services and may be organized by condition, good, or service.

In one embodiment, a beneficiary 400 or coordinator 500 could request bids for medical services including treatment plans recommended for a specific condition. Providers 201 or squads 202 access the bidding forum element to post bids including any terms to the bid such as availability or shipping. The beneficiary 400 or coordinator 500 is able to select the best possible bid. It is also contemplated that the beneficiary 400 or coordinator 500 could offer a cost that they were willing and able to pay along with any terms for a particular good or service. Providers 201 access the bidding forum element 700 to accept offers. The general information element 800 includes a variety of information for review and comment and various organizations for participation such as health news, support group for interacting with other people with similar conditions, discussion group, debate group, advice group, pricing information, etc. As shown in Fig. 4, each beneficiary file - here first beneficiary file 610 - includes a medical records component 611 , a tracking component 612, a messaging component 613 and a lifestyle modification component 614. In other embodiments, the beneficiary file 610 further includes a reward component 615.

The personal medical records component 611 includes a variety of information such as: beneficiary profile including name, address, contact information, insurance information; health profile including health history, family history, symptoms, treatment, medication, prescriptions, charts, graphs, and diagnoses; and payment profile including insurance claims, payment and provider invoices - current, outstanding and historical. The beneficiary can monitor and log vital information such as blood pressure and glucose level in the personal medical records component 611 through the beneficiary interface 450 shown in Fig. 1.

The messaging component 613 of the beneficiary file 610 is used for the electronic transfer of information including notifications. It is contemplated that the messaging component 613 not only transfers information to the beneficiary 400, but also the coordinator 500 and/or any provider 201 or squad 202 of the healthcare team 200. The messaging component 613 can transfer information from any of the interfaces 250, 450, 550 described more fully below in addition to any component 611 , 612, 614, 615 within the communication inter-hub 300. The lifestyle modification component 614 includes plans tailored to the beneficiary. It is contemplated that the plans such as a health improvement plan or eating plan are created by the beneficiary 400, coordinator 500, and/or providers 201 or squads 202 of the healthcare team 200.

The reward component 615 could facilitate rewards to the beneficiary 400 or coordinator 500 or even a provider 201 or squad 202 of the healthcare team 200. Rewards include anything offered as an incentive such as money, coupons, discounts, or prizes.

The tracking component 612 of the beneficiary file 610 allows a measure of progress or completion of treatment by the beneficiary. Progress or completion of treatment may include assessing adherence to the plans such as taking medication or participating in lifestyle modification of the lifestyle modification component 614. The tracking component 612 reviews progress towards a goal, determines the rate of progress, compares rate of progress or adherence to benchmarks as well as measures the effectiveness of the coordinator 500 or providers 201 or squads 202 or entire healthcare team 200. The tracking component 612 also analyzes data and generates reports.

The communication inter-hub 300 is selectively accessible. The beneficiary 400, coordinator 500 or healthcare team 200 can determine the access to the information through the interface 450, 550, 250 respectively. A beneficiary 400 will be able to view and edit the entirety of his or her own personal medical records component 611 of their beneficiary file 610 through the beneficiary interface 450, but not be given access to other beneficiary files 630, 650, 670. Additionally, the beneficiary 400 may control which other users can see which parts of his or her file such that the beneficiary 400 may choose to give a vendor 214 access to the messaging component 613 of the beneficiary file 610, while giving a personal support individual 217 access to the tracking component 612 of the beneficiary file 610. Likewise, the provider interface 250 allows access to all or a portion of beneficiary files 610, 630, 650, 670 for each beneficiary 400 they serve, for example, a claims administrator 215 may be able to access a partial view of the tracking component 612 and a partial view of the personal medical records 611 component.

While the present invention has been described with reference to particular embodiments, those skilled in the art will recognize that many changes may be made thereto without departing from the scope of the present invention. Each of these embodiments and variants thereof is contemplated as falling with the scope of the claimed invention, as set forth in the following claims.

Claims

WHAT IS CLAIMED IS:

1. A communication network for sourcing and managing healthcare related resources, comprising: a communication inter-hub including a database element; one or more beneficiary files stored on said communication inter-hub wherein said one or more beneficiary files includes one or more components selected from the group of: a personal medical records component, a tracking component, a messaging component, a lifestyle modification component and a reward component; a provider interface such that one or more providers access said communication inter-hub; a beneficiary interface such that one or more beneficiaries access said communication inter-hub; and a coordinator interface such that one or more coordinators access said communication inter-hub.

2. The communication network for sourcing and managing healthcare related resources according to claim 1 , wherein said coordinator is an ambulatist.

3. The communication network for sourcing and managing healthcare related resources according to claim 1 , wherein said communication inter-hub further comprises a general information element.

4. The communication network for sourcing and managing healthcare related resources according to claim 1 , wherein said communication inter-hub further comprises a bidding forum element.

5. A method for sourcing and managing healthcare related resources, comprising the steps of: establishing a communication network including a communication inter-hub, wherein the communication inter-hub includes a database element with one or more beneficiary files stored thereon; assembling a healthcare team including one or more providers, wherein said assembling step further includes the step of supplying a provider interface for accessing the communication inter-hub; selecting a coordinator, wherein said selecting step further includes the step of furnishing a coordinator interface for accessing the communication inter-hub; and providing a beneficiary interface for accessing the communication inter-hub by one or more beneficiaries.

6. The method for sourcing and managing healthcare related resources of claim 5, wherein the one or more beneficiary files includes one or more components selected from the group of: a personal medical records component, a tracking component, a messaging component, a lifestyle modification component and a reward component.

7. The method for sourcing and managing healthcare related resources of claim 5, wherein the coordinator is an ambulatist.

8. The method for sourcing and managing healthcare related resources of claim 5, wherein the communication inter-hub further comprises a general information element.

9. The method for sourcing and managing healthcare related resources of claim 5, wherein the communication inter-hub further comprises a bidding forum element.