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  • Health Financing Workflows
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The initial set of draft workflows are FHIR-based workflows leveraging Health Financing and FHIR workflows and ongoing work on Integrating openIMIS into the OpenHIE Landscape.

Beneficiary Enrollment

Query Beneficiary

//query for beneficiary - should come close to mirror CR workflow.

Check enrollment status


title Check enrollment status

PoS->PoS: [1] Register patient
PoS->IOL: [2] FHIR Coverage resource search
IOL->IOL: [3] Validate FHIR resource
IOL->openIMIS: [4] Search for beneficiary
openIMIS->IOL: [5] Return beneficiary details
IOL->PoS: [6] Return FHIR Coverage resource
PoS->PoS: [7] Add details to patient record


Enrol beneficiary

title Enrol beneficiary

PoS->PoS: [1] Fetch / Register patient
PoS->IOL: [2] Submit FHIR EnrollmentRequest resource
IOL->IOL: [3] Validate FHIR resource
IOL->openIMIS: [4] Submit enrollment details
openIMIS->openIMIS: [5] Process enrollment
openIMIS->IOL: [6] Return enrollment response
IOL->PoS: [7] Return FHIR EnrollmentResponse resource
PoS->PoS: [8] Add details to patient record

Claim Submission

Check beneficiary validity

title Check beneficiary validity

PoS->PoS: [1] Fetch claims data 
PoS->IOL: [2] Submit FHIR EligibilityRequest resource
IOL->IOL: [3] Validate FHIR resource
IOL->openIMIS: [4] Query patient eligibility
openIMIS->IOL: [5] Return patient eligibility details
IOL->PoS: [6] Return FHIR EligibilityResponse resource
PoS->PoS: [7] Process response


Check beneficiary balance/treatment options

title Check beneficiary balance/treatment options

PoS->PoS: [1] Fetch claims data 
PoS->IOL: [2] Submit FHIR Claim {use=exploratory} resource
IOL->IOL: [3] Validate FHIR resource
IOL->openIMIS: [4] Query patient balance/treatment options
openIMIS->IOL: [5] Return treatment options/reimbursement details
IOL->PoS: [6] Return FHIR ClaimResponse resource
PoS->PoS: [7] Process response


Preauthorization of claim

title Preauthorization of claim

PoS->PoS: [1] Fetch claims data 
PoS->IOL: [2] Submit FHIR Claim {use=proposed} resource
IOL->IOL: [3] Validate FHIR resource
IOL->openIMIS: [4] Submit claim to reserve funds
alt Acknowledgement of preauthorization
    openIMIS->IOL: [5] Return acknowledgement of preauthorization
    IOL->PoS: [6] Return FHIR ClaimResponse resource
    PoS->PoS: [7] Process response
else Additional information requested
    openIMIS->IOL: [5] Request for additional information
    IOL->PoS: [6] Return FHIR CommunicationRequest resource
    PoS->PoS: [7] Process response and fetch claims data
    PoS->IOL: [8] Submit FHIR Communication resource
    IOL->IOL: [9] Validate FHIR resource
    IOL->openIMIS: [10] Submit supporting information
    openIMIS->IOL: [11] Return adjudicated response
    IOL->PoS: [12] Return FHIR ClaimResponse resource
    PoS->PoS: [13] Process response
end

Track status of claim

title Track status of claim

PoS->PoS: [1] Fetch claims data 
alt Check claim status
    PoS->IOL: [2] Submit FHIR ProcessRequest {action=status} resource
else Poll on claim status
    loop text
       PoS->IOL: [2] Submit FHIR ProcessRequest {action=poll} resource
    end
end
IOL->IOL: [3] Validate FHIR resource
IOL->openIMIS: [4] Submit claim status check
openIMIS->IOL: [6] Return claim status
IOL->PoS: [7] Return FHIR ProcessResponse resource
PoS->PoS: [8] Process response

Submit claim

title Submit claim

PoS->PoS: [1] Fetch patient visit data 
PoS->IOL: [2] Submit FHIR Claim {use=complete} resource
IOL->IOL: [3] Validate FHIR resource
IOL->openIMIS: [4] Submit patient claim
openIMIS->openIMIS: [5] Process claim
openIMIS->IOL: [6] Return claim outcomes
IOL->PoS: [7] Return FHIR ClaimResponse resource
PoS->PoS: [8] Process response

Indicator Reporting

openIMIS Indicator Reporting

title openIMIS Indicator Reporting

openIMIS->openIMIS: [1] Generate indicators to meet reporting needs
openIMIS->IOL: [2] Submit report
IOL->IOL: [3] Validate report / indicators
IOL->IOL: [4] Transform report (e.g. FHIR Measure Report to ADX)
IOL->HMIS: [5] Submit to HMIS
HMIS->HMIS: [6] Evaluate and persist report / indicators

openIMIS Patient Level Indicator Reporting

title openIMIS Patient Level Indicator Reporting

openIMIS->openIMIS: [1] Generate FHIR resources to meet reporting needs
openIMIS->IOL: [2] Submit FHIR resources
IOL->IOL: [3] Validate FHIR resources
IOL->FHIR Server: [4] Persist FHIR resources
CQL Engine->CQL Engine: [5] Trigger / external request for report
CQL Engine->FHIR Server: [6] Evaluate FHIR Measure(s) / Measure Report(s)
CQL Engine->IOL: [7] Submit to DHIS2
IOL->IOL: [8] Validate FHIR Measure(s) / Measure Report(s)
IOL->IOL: [9] Transform report (e.g. FHIR Measure Report to ADX)
IOL->HMIS: [10] Submit to HMIS
HMIS->HMIS: [11] Evaluate and persist report / indicators

Other HIE Workflows

  • 'Patient leaves treatment setting' workflows
    • Explanation of benefit and payment reconciliation
  • Client Registry (CR) interactions
    • Beneficiary enrolment
    • Beneficiary verification
  • Terminology Services (TS) and Product Registry (PR)
    • Terminology and product code sync
  • ...


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