Pharmacy episodes of care

Abstract

A computer-implemented method for grouping, categorizing, and profiling pharmaceutical claims data to assist health care managers in determining (a) medication treatment experience, outcomes, and medication compliance behaviors of patients and (b) appropriate drug prescribing, medication coordination, and cost-efficiency of health care providers. An objective means is provided for categorizing and quantifying patterns of prescription drug utilization as a health care service within a clinically relevant time frame. A pharmacy episode group (PEG) is a pharmacologically homogenous grouping of drugs with the same therapeutic ingredients used by a patient once or over an extended period of time. The PEG is a patient-centered pharmacy classification unit, which uses script-level pharmacy claim data as input data and assigns each script to the appropriate episode. Pharmacy episodes are categorized based on algorithms linking the pattern of a physician's recommended use (drug supply) and the patient's pattern of compliance (intervals between fill dates). The system also identifies multi-drug and concurrent use drug episodes, flags patients' records where intervals between scripts suggest non-compliance with recommended therapy, selects the most recent claims, resets windows (episode start and end dates), and ultimately assigns all pharmacy claims to episodes.