Inferred specialty system

Abstract

A system identifies a clinician's specialty by examining procedures performed by that clinician, the diagnoses made by the clinician, and the age and gender of the clinician's patients.

Description

BACKGROUND OF THE INVENTION

[0002] Most health care organizations that supply claims data include clinician specialty as a standard variable in their data sets. This information is important for a variety of analytical products such as norms reports and drug utilization analyses. Accurate specialty listings are, however, not universally available.

SUMMARY OF THE INVENTION

[0003] To provide information about specialists when it is otherwise missing, and to test the validity of assigned specialties, an inference engine, referred to here as the PracticeLogic System (PLS), is used to identify clinician specialty. The PLS identifies a clinician's specialty by examining the procedures performed by that clinician, the diagnoses made by the clinician, and the age and gender of the clinician's patients. Clinicians within each specialty tend to make a distinct set of diagnoses, perform a distinct set of procedures, and see a unique population of patients. For example, the claims submitted by an hematologist/oncologist will likely contain a high proportion of procedures and diagnoses relating to cancer, while those of a pulmonologist will not. As another example, it is expected that a pediatrician sees patients who are, on average, significantly younger than the group of patients seen by an internist.

[0004] The system and methods described herein allow specialty to be automatically inferred based on a set of rules, and thus improve the reporting and analysis of claims data. Other features and advantages will become apparent from the following detailed description and claims.

DETAILED DESCRIPTION

[0005] The PLS can be utilized in a number of circumstances. A specialty listing may not be available. Some datasets do not list specialty information at all, and datasets that generally list specialty often include a significant number (5-20%) of records with missing values in the specialty field.

[0006] The PLS is also used generally for an internal medicine listing because the sub-specialties of physicians certified in internal medicine are generally not available, even though roughly 50% of physicians board certified in internal medicine are also board certified in a sub-specialty (according to data from the American Board of Internal Medicine and the AMA). Using supplied specialty listings in these cases leads to an underestimation of the prevalence of certain specialties, such as cardiology or hematology/oncology.

[0007] An analysis of specialty data also shows that radiation oncologists are commonly listed as radiologists. The PLS is used in order to obtain an accurate estimate of these specialties.

[0008] The system has the following process steps in the development and application of the PLS:

[0009] 1. Determining the list of specialties to be included in the PLS.

[0010] 2. Developing practice pattern measures and specialty identification rules for the PLS.

[0011] 3. Applying the rules to claims where specialty is unknown, or listed as Internal Medicine or Radiology.

[0012] Each data provider may have a unique method for grouping practice areas into a set of listed specialties. In order to bring uniformity to this process the PLS maps each data provider's set into one of 54 categories, although other categories and number of categories could be used. An exemplary set is in Table I, below:

TABLE I
Allergy and Immunology       Facility
Anesthesiology               Gastroenterology
Cardiology                   General Practice/Family
Cardio-Thoracic Surgery      Practice
Chiropractic                 General Surgery
Dentist                      Geriatrics
Dermatology                  Hematology
Emergency Medicine Physician Hematology/Oncology
Endocrinology                Infectious Disease
ENT (Otolaryngology)         Internal Medicine
Medical Genetics             Physical Medicine And
Midwife                      Rehabilitation
Neonatology                  Physical Therapy
Nephrology                   Physician's Assistant
Neurology                    Plastic Surgery
Neurosurgery                 Podiatry
Nurse Anesthetist            Psychiatry
Nurse Practitioner           Psychology
                             Pulmonology
Obstetrics And Gynecology    Radiation Oncology
Occupational Therapy         Radiology
Ophthalmology                Registered Nurse
Optometry                    Rheumatology
Orthopedic Surgery           Social Work
Orthopedics                  Urgent Care Facility
Osteopath                    Urgent Care Medicine
Other Surgery                Urology
Pathology                    Other (Non-Clinician)
Pediatrics

[0013] The PLS identifies the 33 specialty categories that are most prominent in an integrated outcomes database, although more or less of such categories may be used. Clinicians belonging to one of these groups account for roughly 95% of the groupable records in the integrated outcomes database. These categories are in the following Table II:

TABLE II
Allergy And Immunology       Neurosurgery
Cardiology                   Neurology
Chiropractic                 Obstetrics And Gynecology
Cardio-Thoracic Surgery      Ophthalmology
Dentist                      Orthopedic Surgery
Dermatology                  Other Specialist
Endocrinology                Pediatrics
ENT (Otolaryngology)         Podiatry
Emergency Medicine Physician Psychiatry
Facility                     Pulmonology
Gastroenterology             Radiation Oncology
General Practice/Family      Radiology
Practice                     Rheumatology
Hematology/Oncology          General Surgery
Infectious Disease           Urology
Internal Medicine
Neonatology                  Clinician
Nephrology                   N/A

[0014] The PLS provides specialty identification in 53 clinical practice areas and 4 non-clinician or undefined groupings (Facility, Urgent Care Facility, Other (Non-Clinician) and N/A). A number of these categories deserve special explanation.

[0015] N/A: If a listing is unavailable and the PLS cannot identify the provider's practice area, the provider is listed as N/A.

[0016] Clinician: A provider is clearly identified as a clinician, but no other information is available.

[0017] Other Specialist: A provider is identified as a specialist, but is not as a member of one of the other 32 defined specialty categories included in the PLS.

[0018] Other (Non-Clinician): A provider is identified as not being a clinician, but no other information is available.

[0019] Other Surgery: A provider is identified as a surgeon, but is not a member of one of the defined surgery categories listed above.

[0020] Before developing a rule that will identify a specialty, one creates a set of measures that characterize a particular clinician. For example, it is believed that pediatricians tend to see a high proportion of patients under 18, it is useful to know, for each clinician, the percentage of patients they see who are under 18 years of age. The Up PLS rules are based on the following list of measures, each of which is recorded as a percentage. All of a clinician's records are scored on these measures and the percentage that belong to each category is counted.

Percentages Based on Demographics

[0021] Patients Less Than Age One

[0022] Patients Over Age Eighteen

[0023] Patients Less Than or Equal to Age Eighteen

Percentages Based on Procedures (CPT4 and HCPCS Codes)

[0024]

Allergy/Immunology Procedures Hematology/Oncology
Cardiac Surgeries             Procedures
Cardiology Procedures         Infectious Disease Procedures
Chiropractic Procedures       Nephrology Procedures
Dental Procedures             Neurology Procedures
Dermatology Procedures        Neurosurgery Procedures
Emergency Medicine Procedures OB/GYN Procedures
Endocrinological Procedures   Ophthalmological Procedures
ENT (Otolaryngology)          Orthopedic Surgery Procedures
Procedures                    Podiatry Procedures
Gastroenterology Procedures   Psychiatric Procedures
                              Pulmonology Procedures
Radiological Oncology         Surgical (General) Procedures
Procedures                    Thoracic Procedures
Radiological Procedures       Urology Procedures
Rheumatology Procedures

Percentages Based on Diagnoses (ICD-9 Codes)

[0025]

Allergy/Immunology Diagnoses     Neurology Diagnoses
Cardiac Surgery Diagnoses        Neurosurgery Diagnoses
Cardiology Diagnoses             OB/GYN Diagnoses
Chiropractic Diagnoses           Ophthalmological Diagnoses
Chronic Disease Diagnoses        Orthopedic Surgery Diagnoses
Associated with Internal Medicine Podiatry Diagnoses
Critical Care Diagnoses          Psychiatric Diagnoses
Dermatology Diagnoses            Pulmonology Diagnoses
Emergency Medicine Diagnoses     Radiological Diagnoses
Endocrinological Diagnoses       Rheumatology Diagnoses
ENT (Otolaryngology) Diagnoses   Surgical (General) Diagnoses
Gastroenterology Diagnoses       Thoracic Diagnoses
Hematology/Oncology Diagnoses    Urgent Care Diagnoses
Infectious Disease Diagnoses     Urology Diagnoses
Nephrology Diagnoses

[0026] The next step is to write a rule that identifies the specialty of a clinician, based upon the clinician measures described above. For example, a rule might state that if greater than 50% of a clinician's procedures are related to neurology, then identify that clinician as a neurologist. The values for these rules can be determined by experts who draw upon knowledge and expertise, and upon detailed analysis of records within an integrated outcomes database. The rules are then refined so that they result in specialty identifications that best match those of data sets that include specialty listings.

[0027] In addition, if specialty information is unavailable and the practice pattern rules are unable to identify a specialty, then the specialty may be identified by the provider type field of the claim record.

[0028] Having established a set of rules, the PLS then applies this set of rules to all known clinicians within the integrated outcomes database, creating a master record of clinician specialty. The rules are applied to providers in two steps: (1) each clinician is broadly identified as a generalist (e.g. Internal Medicine, Pediatrics, General Practice/Family Practice) or a specialist (e.g. Neurologist, Pulmonologist); and (2) the clinician's measures are then further tested against rules in one of these two broad categories in order to make the final specialty identification.

[0029] All clinicians who have submitted claims for greater than 10 services (regardless of the time period during which those services occurred) are included in the master record of clinician specialties. This limit was set because the measures by which the clinician is characterized cannot be computed to a reasonable level of accuracy if a clinician has submitted fewer claims.

[0030] The vast majority of prescription records list a non-clinician as a provider—usually a pharmacy is listed. In order to link pharmacy records to providers, and hence to a provider specialty, an Episode Treatment Groups (ETG) methodology is used. A key feature of the ETG methodology is its ability to combine seemingly disparate claims records into clinically meaningful disease episodes. The grouper's fundamental task is to group together all claims relating to the treatment of a single episode of a disease.

[0031] Clusters are groups of claims records relating to a single disease episode, for which one clinician is responsible. Each cluster contains one anchor record and any number of linked records. The anchor record is generally a visit to a clinician that diagnoses an illness. The linked records generally refer to tests or procedures ordered and drugs prescribed by that clinician.

[0032] The key property of clusters pertinent to the PLS is the fact that one clinician manages all the service activity in a cluster. Therefore the ETG grouper assigns all pharmacy records in a cluster to the clinician who is the listed provider on the anchor record of the cluster. The grouper records this assignment by creating a variable for each record, called the Cluster Provider ID that lists the managing provider responsible for all activity within the cluster.

[0033] The Cluster Provider ID generated by the ETG grouper allows the PLS to link pharmacy records with clinicians, even when no clinician is listed on the original pharmacy record. Since it is known that the cluster provider is the responsible clinician for all records within a cluster, a specialty can be assigned to a record based upon the clinician listed as the Cluster Provider. By using this method a provider specialty has been assigned to over 95% of records in the assignee's outcomes database (excluding orphan drug records and ungroupable records).

[0034] Where possible, the client-supplied specialty listing is assigned to a particular record. The PLS identified specialty is assigned to a record in one of three cases: (1) no client supplied specialty listing is available; (2) the supplied specialty is Internal Medicine, as noted previously, because the supplied data systematically exclude the sub-specialties of physicians board certified in Internal Medicine; and (3) the supplied specialty is Radiology (supplied data systematically includes the practice of Radiation Oncology under the heading of Radiology, but the PLS, on the other hand, has been designed with the ability to distinguish these two specialties).

[0035] The PLS is tested by measuring the degree to which its output agrees with the listed specialty. This is done by testing the PLS on datasets where specialty listings are provided, and comparing the provided listings with the output of the PLS. (An other way to test the results would be to independently verify the practice specialties of individual clinicians, but this could be difficult, or even not possible if the entity does not possess information that would allow it to know the identity of individual physicians.) Extensive testing and updating of the PLS rules has resulted in an 85% agreement between the PLS with the listed data. Using the listed specialty information along with application of the PLS results the ability to identify specialty on 95% of all groupable records within the outcomes database.

[0036] The physical system that is used to implement the present invention includes a programmed computer or group of computers with an appropriate database interface to obtain the data that is processed to determine the inferred specialty, and may also include a user interface as well. The system can be used with a general purpose computer or may include some specific purpose hardware. Thus the means used to carry out the present invention includes any kind of known programmable computational computer system. The system may further include the database of records in the outcomes database.

EXAMPLE OF MORE DETAILED METHODOLOGY

[0037] A specialty is assigned to a provider according to the following steps:

[0038] 1. The provider shall

[0039] a. have more then 10 service records in the database;

[0040] b. be listed as a clinician; and

[0041] c. have greater then 65% of the provider's records containing procedure codes

[0042] If the provider does not meet these criteria their specialty is listed as not-available and steps 2 and 3 are skipped. If other information indicates that such a provider is lisp known to be a clinician or a facility, the specialty is listed as such.

[0043] 2. If all of the following are true:

[0044] (NOTE 1: crit_diag_percentage may be read as, ‘The percentage of this provider's diagnoses that fall into the critical care category’. Emerg_proc_percentage may be read as, ‘The percentage of this provider's procedures that fall into the emergency care category’)

[0045] (NOTE 2: The meaning of the specialty identifying code used below, such as “endo” or “card”, may be looked up on the attached SPEC_LIST_THRESHOLD.xls table in the column labeled CODE. When the code is used without a ‘diag’ or ‘diagnosis’ identifier it refers to procedures performed by the specialty.)

[0046] (crit_diag_percentage+urg_diag_percentage)>0.23)

[0047] AND (endo_diag_percentage<0.4)

[0048] AND (card_diag_percentage<0.35)

[0049] AND (emerg_proc_percentage<0.2) AND (ent_proc percentage<0.1)

[0050] AND (pulm_diag_percentage<0.2)

[0051] AND (gast_diag_percentage<0.5)

[0052] AND (neph_diag_percentage<0.2)

[0053] AND (all_diag_percentage<0.5)

[0054] AND (inf_diag_percentage<0.2)

[0055] Then select the first of the following statements that is true. If none is true, assign specialty as “othr_spc”:

[0056] IF (average age of patients<1.0) THEN specialty=‘NEONAT’.

[0057] IF (greater than 90% of patients are 18 or under) THEN specialty=‘PED’.

[0058] IF (greater than 50% of patients are over 18 OR pimch_diagnosis) THEN specialty=‘INTERN’.

[0059] IF (neither of the previous two age criteria is true) THEN specialty=‘GP_FP’.

[0060] 3. If the conditions under step 2 are not met then assign specialty according to the first of the following statements that is true. If none is true, assign specialty as “othr_spc.”

[0061] (NOTE 3: A statement such as ‘IF (all OR all_diagnosis)’ may be read as: ‘IF either the percentage of ALLERGY related procedures or the percentage of ALLERGY related diagnoses surpasses the threshold listed in the attached SPEC_LIST_THRESHOLD.xls table, then the statement is true.’ If a number is included in the statement such as. ‘IF (pod<0.002)’, the statement may be read as ‘IF the percentage of PODIATRY related procedures is less than 0.002’.)

[0062] NEONAT:

[0063] IF (average age of patients<1.0)

[0064] ALLERGY:

[0065] IF (all OR all_diagnosis) AND NOT(ent OR ent_diagnosis)

[0066] CARDIOL:

[0067] IF (card OR card_diagnosis) AND NOT(crdsrg OR crdsrg_diagnosis OR crdend_diagnosis OR emerg OR emerg_diagnosis OR neph OR neph_diagnosis OR pulm OR pulm_diagnosis OR thor OR thor_diagnosis)

[0068] SURGERY:

[0069] IF (surg AND surg_diagnosis) AND NOT(crdsrg OR crdsrg_diagnosis OR thor OR thor_diagnosis)

[0070] CT_SURG:

[0071] IF (crdsrg OR crdsrg_diagnosis) AND NOT(derm OR derm_diagnosis OR ent OR ent_diagnosis OR emerg OR emerg_diagnosis OR nesg OR nesg_diagnosis)

[0072] OR

[0073] IF (thor OR thor_diagnosis) AND NOT(derm OR derm_diagnosis OR ent OR ent_diagnosis OR emerg OR emerg_diagnosis)

[0074] CHIRO:

[0075] IF (chiro OR chiro_diagnosis) AND NOT(neur OR neur_diagnosis)

[0076] DENTIST:

[0077] IF (dent)

[0078] DERMATOL:

[0079] IF (derm OR derm_diagnosis) AND NOT(pod OR pod_diagnosis OR surg OR surg_diagnosis)

[0080] ENDOCRIN:

[0081] IF (endo OR endo_diagnosis) AND NOT(ent OR neph OR neph_diagnosis)

[0082] ENT:

[0083] IF (ent OR ent_diagnosis) AND NOT(rad OR rad_diagnosis OR ane OR ane_diagnosis OR surg OR surg_diagnosis OR emerg OR emerg_diagnosis OR rado)

[0084] ER_PHYS:

[0085] IF (emerg OR emerg_diagnosis)

[0086] GASTRO:

[0087] IF (gast OR gast_diagnosis) AND NOT(rad OR rad_diagnosis)

[0088] INF_DIS:

[0089] IF (inf OR inf_diagnosis) AND NOT(emerg OR emerg_diagnosis OR ane OR ane_diagnosis)

[0090] NEPHROL:

[0091] IF (neph OR neph_diagnosis)

[0092] NEUROL:

[0093] IF (neur OR neur_diagnosis) AND NOT(nesg OR nesg_diagnosis OR chiro OR chiro_diagnosis OR psyc OR psyc_diagnosis OR rad OR rad_diagnosis OR orsg OR orsg_diagnosis OR ((orsg+rad)>0.04))

[0094] NEUR_SRG:

[0095] IF (nesg OR nesg_diagnosis) AND (pod<0.002)

[0096] OB_GYN:

[0097] IF (ob OR ob_diagnosis) AND NOT(endo OR endo_diagnosis OR gast OR gast_diagnosis OR rad OR rad_diagnosis OR ane OR ane_diagnosis OR surg OR surg_diagnosis OR pulm OR pulm_diagnosis OR (avg_age<1.0))

[0098] OR

[0099] IF (gyn OR gyn_diagnosis) AND NOT(endo OR endo_diagnosis OR gast OR gast_diagnosis OR rad OR rad_diagnosis OR ane OR ane_diagnosis OR surg OR surg_diagnosis OR pulm OR pulm_diagnosis OR (avg_age<1.0))

[0100] HEM_ONC:

[0101] IF (hemonc OR hemonc_diagnosis ) AND NOT(ob OR ob_diagnosis OR gyn OR gyn_diagnosis OR rad OR rad_diagnosis OR rado)

[0102] OPHTHAL:

[0103] IF (ophth OR ophth_diagnosis) AND NOT(ent OR ent_diagnosis)

[0104] ORTH_SRG:

[0105] IF (orsg+rad)>0.04) AND (allsurg>0.1)) AND (rad>pod_diag_percentage) AND (rad<0.5) AND (ob<0.01) AND (gyn<0.01) AND NOT(urol OR urol9) AND (orsg>0.02)

[0106] PODIATRY:

[0107] IF (pod OR pod_diagnosis) AND (pod_diag_percentage>rad)

[0108] PSYCHIAT:

[0109] IF (psyc OR psyc_diagnosis)

[0110] PULMONAR:

[0111] IF (pulm OR pulm_diagnosis) AND NOT(rad OR rad_diagnosis OR hemonc OR hemonc_diagnosis OR surg OR surg_diagnosis OR card OR card_diagnosis OR emerg OR emerg_diagnosis OR (avg_age<1.0))

[0112] RAD_ONC:

[0113] IF (rado)

[0114] RADIOL:

[0115] IF (rad OR rad_diagnosis) AND NOT(ob OR ob_diagnosis OR gyn OR gyn_diagnosis)

[0116] RHEUM:

[0117] IF (rheu OR rheu_diagnosis) AND NOT(chiro OR chiro_diagnosis)

[0118] UROLOGY:

[0119] IF (urol OR urol_diagnosis)

		Procedure	Diagnosis
Code	Description	Threshold	Threshold
ALL	ALLERGY AND	60%	60%
	IMMUNOLOGY
CARD	CARDIOLOGY	20%	35%
CHIRO	CHIROPRACTIC	2%	2%
CRDSRG	CARDIAC SURGERY	5%	5%
CRIT	CRITICAL CARE
THOR	THORACIC SURGERY	5%	5%
DENT	DENTIST	1%
DERM	DERMATOLOGY	20%	20%
ENDO	ENDOCRINOLOGY	30%	30%
ENT	ENT	10%	10%
EMERG	EMERGENCY MEDICINE	10%	10%
	PHYSICIAN
GAST	GASTROENTEROLOGY	5%	20%
GPFP	GENERAL PRACTICE/FAMILY		30%
	PRACTICE
GYN	GYNECOLOGY	5%	5%
HEMONC	HEMATOLOGY/ONCOLOGY	20%	20%
INF	INFECTIOUS DISEASE	20%	20%
IM	INTERNAL MEDICINE		30%
NEPH	NEPHROLOGY	10%	20%
NESG	NEUROSURGERY	5%	5%
NEUR	NEUROLOGY	10%	10%
OB	OBSTETRICS	5%	5%
OPHTHAL	OPHTHALMOLOGY	15%	10%
ORSG	ORTHOPEDIC SURGERY	10%	10%
POD	PODIATRY	5%	5%
PSYC	PSYCHIATRY	80%	80%
PULM	PULMONOLOGY	10%	10%
RADO	RADIATION ONCOLOGY	65%
RAD	RADIOLOGY	20%	20%
RHEU	RHEUMATOLOGY	10%	10%
SURG	GENERAL SURGERY	2%	2%
UROL	UROLOGY	30%	30%
URG	URGENT CARE MEDICINE	30%	30%
VASC	VASCULAR DISEASE	30%	30%

Claims

1. A method comprising: receiving records of medical procedures; in an automated manner, using a set of expert rules to determine the specialty of physicians by applying the rules to the records of medical procedures.

2. The method of claim 1, wherein the method includes determining a list of specialties.

3. The method of claim 1, wherein the method includes determining a specialty and substituting the determined specialty when the records listed a specialty as internal medicine.

4. The method of claim 1, wherein the method includes determining a specialty other than radiology when a specialty in the records is listed as radiology.

5. The method of claim 1, wherein the determining includes using the ages of patients.

6. The method of claim 1, wherein the determining includes using procedures.

7. The method of claim 6, wherein the procedures are determined by CPT4 and/or HCPCS codes.

8. The method of claim 1, wherein the determining includes using diagnoses.

9. The method of claim 6, wherein the diagnoses are determined by ICD-9 codes.

10. The method of claim 1, wherein the determining includes using a combination of patient ages, procedures, and diagnoses.

11. A system comprising: a database for storing records of medical procedures; a processor programmed to use a set of rules to determine the specialties of physicians by applying the rules to the records of medical procedures.

12. The system of claim 11, wherein the processor determines a specialty and substitutes the determined specialty when the records listed a specialty as internal medicine.

13. The system of claim 11, wherein the processor determines a specialty other than radiology when a specialty in the records is listed as radiology.

14. The system of claim 11, wherein the processor determines a specialty includes using the ages of patients.

15. The system of claim 11, wherein the processor determines a specialty using procedures.

16. The system of claim 15, wherein the procedures are determined by CPT4 and/or HCPCS codes.

17. The system of claim 11, wherein the processor determines a specialty using diagnoses.

18. The method of claim 17, wherein the diagnoses are determined by ICD-9 codes.

19. The system of claim 11, wherein the processor determines a specialty includes using a combination of patient ages, procedures, and diagnoses.