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…….)