The initial set of draft workflows are FHIR-based workflows leveraging Health Financing and FHIR workflows and ongoing work on Integrating health financing into the OpenHIE Landscape. The workflows are being documented by the OpenHIE community and will be included in the OpenHIE Specification.  

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 HF Workflows

Other HIE Workflows