Session Name:openIMIS for Universal Health Coverage & National Health Insurance - a valuable use case for the openHIE framework
Time / Room: 12:30 - 1:15 Tembo
Presenter: Alicia Spengler (GIZ), Carl Leitner (Digital Square), Nils Kaiser (GIZ / Digital Square)
Notes:
Introduction
1. few slides on openIMIS
-OpenIMIS is open source
-evolution from IMIS to OpenIMIS (financed by SDC and GDC) - become a global good/open source
-implementations in Nepal, Tanzania
data dashboard
2. Use Cases
- benefit package/scheme design
- mix of paper and mobile app
- eligibility verifications
- done at all points of care (e.g. web based/android)
- photo/ID; balance information
- app captures diagnosis, services, supplies- synchronized
- central reviewing mechanism/filter claims/ payment advice
3. Group Exercise - break OpenIMIS into multiple building blocks/ connections with the systems that you have
- Civil registration and vital statistics (CRVS)
- Claims submission at Points of service
- Data Analysis -data flow needs
- Expectation from analytics
- Transparency/public reporting
- Type of data needed for analysis
- Existing systems that can be queried for analysis
- Hospital management systems/ERP
- Private insurance systems
- Type of analytics to be derived
- How data is collected by existing lists
CRVS & CR intractions with Insurance Management Information System (IMIS)
Civil Registry = Population Register may or may not include non citizens
National Identification Registry
Heath Client/Patient Registry = All people that have inteacted with health system
Social Registry = Vulnerable people that receive social aid, may or may not inlcude aid for health
Birth or first interaction notication propogates from either Health Client/Patient registry or Civil Registry to others
Workflows:
Register beneficiary
Register dependant
Death notification
Beneficiary verification with Patient or Civil Registry
Exchange Insurance enrolment with Social Registry
EMR
what is the use case that we are using
work flows and highest priority workflows, and/or focus on this workflow
moral hazard with checking eligibility prior to the
- what is the logic flow around submitting a claim
- identify patient (CR call)
- query for insurance number
- need for a beneficiary registry
- client registry/terminology service/ MFR/ HWR
- multiple questions that inform the eligibility verification
- enrollment (can be in health facility)
- when does eligibility occur
- check eligibillity- multiple eligibility check
- eligibility and verification check
- multi share mediation claims workflow
- rules engine for benefits/coverage
- submit query for benefits package/ coverage request
- using appropriate terminology standard codes
- either preloaded in the EMR or query a terminology service for this
- asynchornous claims submission-submit claims
- feed back loop for recoding and denial
- submission and subsequent response to the submission
- FHIR/HL7 messaging submission standard
- account, coverage, elibility request and response, enrollment , payment, explanation of benefit resource
- content standard- EDI X12 in the US
Workflows identified:
Level 1 (initial)
- Claim mediation (if there are issues)
- Terminiology and code sync and update
Needs:
- beneficiary registry- stores beneficiaries registered on a specific registry; insurance dB
- multiple beneficiary registries exist
- resolve demographic query for an insurance number