JLN Information Technology Track: Collaborating Across Countries for Health Insurance Information Systems

An example of using a network and common tools

Kate Wilson, PATHOctober 11, 2012

The JLN is growing in membership and drawing on an increasing number of resource countries

Current JLN Countries Ghana India Indonesia The Philippines Thailand Vietnam

New JLN Countries Kenya Nigeria Mali MalaysiaProspective JLN countries• South Africa Rwanda

JLN Resource Countries Colombia Chile Brazil Mexico Taiwan South Korea Estonia Kyrgyzstan Hungary

3

Testing innovative methods for improving the implementation of UHC within member countries

Improving Implementation

What are the JLN’s goals?

Creating CommunityFostering community and increasing shared learning among countries

pursuing universal health coverage.

Increasing KnowledgeIncreasing the understanding of policies and

operational techniques that work best for reaching universal health coverage.

Enabling Country Progress

Translating evidence into actionable reforms at the policy

and operational level. Changing behavior

through knowledge

acquisition

Translating ideas into

action

Creating an

atmosphere for

shared learning

Focus of the JLN

Shared CommonArchitecture

• Requirements• Standards• Guidelines• etc.

Country SpecificArchitecture

• Requirements• Standards• Guidelines• etc.

Shared Common Solutions

• Software• Hardware• Services• etc.

Country SpecificSolutions

• Software• Hardware• Services• etc.

• Health Data Dictionary

• Common E-claims

• Standards selection

• Provider Management

• Support country led deployments with partners like

GIZ

• Coordinate with country led

planning

• Develop Open

HDD • Mobile

Payments• Adapt COTS or

Build FOSS

How does it work in practice

http://player.vimeo.com/video/51764451?badge=0

What is an example of the IT problems?

Claims Backlog in Ghana

*”CFS2” conditions for sustainability and scalability, “SDLC” software development life cycle, “OS” operating systems, “TCO” total cost of ownership.

Deploy Develop Design

ContextProblemsUsersProcessesRequirementsCFS2*

SpecificationsData ModelUser InterfaceDevice TypesInterfacesStandards

SDLC*Dev ToolsData baseOS*NetworkRoad Map

User TrainingMigration PlanInfrastructureTCO*/BudgetSupport StaffMaintenance

1 2 3 4

Analysis

Most people start hereNeed a bit more focus here

What is our approach?

Shared CommonArchitecture

• Requirements• Standards• Guidelines• etc.

Country SpecificArchitecture

• Requirements• Standards• Guidelines• etc.

Shared Common Solutions

• Software• Hardware• Services• etc.

Country SpecificSolutions

• Software• Hardware• Services• etc.

If you want to go fast, go alone.If you want to go far, go together.

African Proverb

1st

Country 2nd

3 4 5

Multi-Country Solution

Collaborative

How this approach leverages resources?

Cost

Time

Multi-Country Requirements & StandardsCollaborative

1st

Country 2nd

3 4 5

What are the steps in CRDM?

1. Domain – set of functions and processes that define the work of a specific area of the larger health system, i.e. health financing

2. Process Framework – set of processes that define the boundaries of a domain and the relationships between them and other systems and domains.

3. Business Process – A set of activities and tasks that logically group together to accomplish a goal or produce something of value for the benefit of the organization, stakeholder, or customer

4. Activity/Task Model – visual representation of a business process in terms of tasks, sets of tasks and decision points in a logical workflow used to enhance communication and collaboration among users, stakeholders, and engineers

5. Requirement – a statement that describes what an information system must do to support a task, activity or decision. These are non-technology statements that usually begin with “the system must or shall…”

What is the process framework?

Scheme PolicyBenefit Package

FormularyProvider Rates

Eligibility RequirementsProvider Policy Setting

Premium Setting Fundamental System

“Factory” 1. Beneficiary

Management2. Provider Management

3. Premium Collection4. Claims Management

5. Accounting

Rules

Data Provides Policy Guidance

Analyzing Performance

6. Care Management7. Utilization Management

8. Provider Quality Management

Fiduciary Fund Management

9. Actuarial Management10. Medical Loss11. Audit/Fraud

Data &

Feedback

Change Mgmt

National policy regarding target population set

by country

What are the steps in CRDM?

1. Domain – set of functions and processes that define the work of a specific area of the larger health system, i.e. health financing

2. Process Framework – set of processes that define the boundaries of a domain and the relationships between them and other systems and domains.

3. Business Process – A set of activities and tasks that logically group together to accomplish a goal or produce something of value for the benefit of the organization, stakeholder, or customer

4. Activity/Task Model – visual representation of a business process in terms of tasks, sets of tasks and decision points in a logical workflow used to enhance communication and collaboration among users, stakeholders, and engineers

5. Requirement – a statement that describes what an information system must do to support a task, activity or decision. These are non-technology statements that usually begin with “the system must or shall…”

What is the business process matrix?

REFERENCE NUMBER

PROCESS GROUP

PROCESS OBJECTIVE(S) INPUTS OUTPUTS TASK SETS MEASUREABLE

OUTCOMES 2.1 Beneficiary

Management

Enroll beneficiary or insured

Verify identity and eligibility in a timely manner of persons seeking access to benefits plan services

Demographics Financial information Geographic information Qualifying criteria (see

qualifying conditions) Proof of identity (e.g.,

national identification card, personal identification number, biometrics information, photo)

Medical history Current medical condition

Time-based eligibility determination

Insured identifier Benefits plan number Benefits class Benefits plan detail Proof of coverage Feed into data repository

Validate identity documents

Record information in data repository

Eligibility is determined as approved or rejected

Approved person receives proof of coverage (e.g., identification card)

Assign benefits class Benefits plan Accurate list of

insured

Illustration of all possible inputs, outputs and tasks a system may need to perform for consideration purposes

What are the steps in CRDM?

1. Domain – set of functions and processes that define the work of a specific area of the larger health system, i.e. health financing

2. Process Framework – set of processes that define the boundaries of a domain and the relationships between them and other systems and domains.

3. Business Process – A set of activities and tasks that logically group together to accomplish a goal or produce something of value for the benefit of the organization, stakeholder, or customer

4. Activity/Task Model – visual representation of a business process in terms of tasks, sets of tasks and decision points in a logical workflow used to enhance communication and collaboration among users, stakeholders, and engineers

5. Requirement – a statement that describes what an information system must do to support a task, activity or decision. These are non-technology statements that usually begin with “the system must or shall…”

Discrete work activity or task

Person who does the work

Decision point in

the work flow Critical

clarification or annotation

Capture rules,

comments and

feedback

What is common task flow?Where the work takes

place

What are the steps in CRDM?

1. Domain – set of functions and processes that define the work of a specific area of the larger health system, i.e. health financing

2. Process Framework – set of processes that define the boundaries of a domain and the relationships between them and other systems and domains.

3. Business Process – A set of activities and tasks that logically group together to accomplish a goal or produce something of value for the benefit of the organization, stakeholder, or customer

4. Activity/Task Model – visual representation of a business process in terms of tasks, sets of tasks and decision points in a logical workflow used to enhance communication and collaboration among users, stakeholders, and engineers

5. Requirement – a statement that describes what an information system must do to support a task, activity or decision. These are non-technology statements that usually begin with “the system must or shall…”

What is a draft requirement catalog?

ID BUSINESS PROCESS

ACTIVITY REQUIREMENT (The system must or should…)

1 ELIGIBILITY Search for insurance detail with alternate ID

allow provider to search for beneficiary's insurance detail with alternate identifier (i.e. name, DOB…..)

2 ELIGIBILITY Search for insurance detail with alternate ID

allow provider to visibly see prompt for alternate identification method if ID presented is not valid

3 ELIGIBILITY Capture insurance detail allow provider to enter identification detail

4 ELIGIBILITY Capture insurance detail allow provider to enter proof of insurance detail

5 ELIGIBILITY Capture insurance detail allow provider to enter biometric detail

6 ELIGIBILITY Capture insurance detail allow provider to capture referral details

7 ELIGIBILITY Validate Insurance allow provider to validate identification

8 ELIGIBILITY Validate Insurance allow provider to authenticate biometric detail

9 ELIGIBILITY Validate Insurance allow provider to visibly see benefits plan assigned to the beneficiary

10 ELIGIBILITY Validate Insurance allow provider to visibly see beneficiary eligibility status

11 ELIGIBILITY Validate Insurance allow provider to clearly see the beneficiary's benefits plan details

12 ELIGIBILITY Validate Insuranceallow provider to visibly see enrollee benefit plan statistical data (i.e. amount of money remaining…….)