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
- Policy lookup and query – know who is associated to which policy | Stems from a use case in India where 1 family gets a single card / policy number and all members are associated to that policy.
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
- ...