PhilHealthDigital Transformation Journey

September 26, 2017

Jovita V. AragonaChief Information Officer

PhilHealth

- Transformational Leadership- Digital Strategy- Manpower Skills- Client Focus

ISSUES / CONCERNS / PROBLEMS Systems Fragmentation Continuing Demands - New / Updated

Systems Minimal Project Planning, Management,

and Documentation Different Systems Used by Regional Offices Minimal Software Development Control

Mechanisms Problems like errors or bugs

Minimal IT Standards Others …

Transformational LeadershipUnderstand digital trendsLead digital strategy

o Build inspiring visiono Create integrated

business strategyo Set standards and

directiono Guide, coach, motivate

and inspire people

Corporate Strategy MapDigital Strategy

PhilHealth Enterprise Architecture

Digital Strategy

Digital Strategy

A critical instrument for organizational efficiency and effectiveness

Strategic context for evolution of IT

systems in response to changing needs of

the organization

Achieve the right balance between IT

efficiency and innovations

PhilHealth Enterprise Architecture

Digital Strategy

Digital Strategy

Digital Strategy

ICT Implementation• Implementation of Electronic Claims System (eClaims)• Use of Electronic Medical Record / Hospital Information System

for Claims Transmission• Philippine Health Information Exchange (PHIE) – Lite Version

between DOH and PhilHealth : Harmonization of Data Collection• Implementation of PhilHealth Corporate Dashboards• Development of Online Applications/API/e-Services• Software Certification of EMR/HIS for eClaims and Primary Care

Benefits

• Database Build-up/ Updating of Registration of Members and Dependents

• Business Intelligence and Data Warehouse• Integration and Replacement of Legacy Applications• Outsourcing and Adoption of Micro-services• Data Analytics Harmonization Effort between DOH and PhilHealth• Cloud Computing Environment (Hybrid Implementation)• Data Sharing / Data Mining• Implementation of Unified Multi-purpose Identification, Biometrics and

Identity Management System• Collection Efficiency and Services (e.g. Full Implementation of

Electronic Premium Reporting System (EPRS) and auto-generated billing)

• Machine Learning

ICT Current Focus

PhilHealth Corporate Dashboard

Digital Strategy

DOH-PhilHealth Analytics

Digital Strategy

Machine Learning

- Machine learning is a method of data analysisthat automates analytical model building.

- Using algorithms that iteratively learn from data, machine learning allows computers to find hidden insights without being explicitly programmed where to look

- Create software “models” that are trained from huge volumes of data and then used to predict certain patterns, trends, and outcomes.

Digital Strategy

PhilHealth Fraud Analytics Phases (Preliminary)

PhilHealth Fraud Analytics Phases (Preliminary)

Phase 1 Phase 2Phase 2 Phase 3Phase 3

PhilHealth Fraud Analytics Framework

PhilHealth Fraud Analytics Framework

Rules-BasedAnalysis

Rules-BasedAnalysis

Unstructured

Data Analysis

Unstructured

Data Analysis

AIAnalysis

AIAnalysis

BehaviorModelingBehaviorModeling

ModelsModels

Data LinkAnalysisData LinkAnalysis

PredictiveAnalysis

PredictiveAnalysis

Uses a series of simple "if then" rules when fraud patterns are understood.An example of a fraud detection rule is as follows:

IF: • # of claims is

above bed capacity OR

• Average LOS is below confinement thresholds for specific diseases

THEN: • Flag HCI as

suspicious AND • Alert fraud

investigation team

IF: • Claim for a distinct

member, in addition to recent claims, is beyond defined parameters

THEN:

Shows the links between claims, claimant, house address, phone, etc. It shows how the network grows in time. This allows to uncover more complex fraud patterns.

For example:

Assume claimant A shares the same address and phone as claimant B. If claimant A has filed a fraudulent claim, then all claims filed by claimant B should raise an alert since claimant A and claimant B could be the same person.

This will be the process of analyzing data objects that doesn’t follow a predefined data model-architecture and/or is unorganized.

It is the analysis of any without any intent for its orchestration, pattern or categorization It is typically text-heavy with member sentiments, but may contain data such as dates, numbers, and facts.

For example, social media,

Artificial intelligence (AI)will perform tasks that normally require human intelligence, such as visual perception, speech recognition, image analysis, problem solving, and decision-making.

The adjudication claims can be done through AI models and algorithms that will be trained and refined over time with the vast majority of

This will mine historical data to forecast future events or trends. It hinges upon predictors: a variable or set of variables that can be measured to calculate the statistical likelihood of future occurrences.

For example, PhilHealth can employ predictive analysis can use factors such as age, gender, and driving history as predictors to estimate the

Behavior modeling is when you think of your ideas in terms of states and transitions. Behavior modeling is also referred to as State modeling,

Behavioral models define normal behavior which are then used to flag potentially abnormal behaviors.

For example, The normal behavior of specific classes of providers in the treatment of specific

- Resources / Opportunities – build necessary skills to benefit from digital trends and execute the digital strategy

- Ability to conceptualize, develop, and implement digital technologies to the best advantage of the Corporation

- Strategic / Critical Thinkers

- Resource Investment

Manpower Skills

- Client needs become more pronounced – demands as driver of digital transformation

- Improve delivery of service Client Satisfaction

- Awards/Recognitions Every year, the CSC conducts the Anti-Red Tape Report Card

Survey (RCS), a client feedback survey to check government service offices’ compliance with provisions under the Anti-Red Tape Act (ARTA) of 2007. Among the 10 government agencies surveyed, PhilHealth got the second highest rating for 2015 for its excellence in frontline service delivery, service quality, physical working condition, and overall satisfaction. PhilHealth was also recognized for having excellent ratings in the RCS and was given the ARTA Breakthrough Agency and Seal of Excellence awards during the same year.

Client Focus

- Awards/Recognitions

The Local Health Insurance Offices (LHIOs) of Abra, Baguio, Mountain Province, including the Apayao PhilHealth Business Center, received the CSC’s Seal of Excellence award for rendering exceptional frontline services, as well as obtaining an overall outstanding client satisfaction.

For the second consecutive year, the LHIO in Kabankalan, Negros Occidental was granted the prestigious Seal of Excellence award by the CSC for its adherence to the requirements of the ARTA. According to the ARTA RCS, most clients who visited the LHIO Kabankalan were highly satisfied with its services.

Client Focus

- Awards/Recognitions

The Regional Development Council, headed by the National Economic Development Authority (NEDA), recently named the PhilHealth Regional Office in the National Capital Region (PRO-NCR) as a Regional Competitiveness Committee Partner.

This was given during the Cities and MunicipalitiesCompetitiveness Index (CMCI) Survey held at theTandang Sora Hall of the TESDA Women’s Centerin Taguig City. The CMCI, spearheaded by theNational Competitiveness Council (NCC)Philippines through the Regional CompetitivenessCoordinating Committees (RCCs) and the UnitedStates Agency for International Development(USAID), is an annual

Client Focus

- Awards/Recognitions

PhilHealth received the Customer Service and TransformationExcellence Award for its PhilHealth Customer Assistance,Relations and Empowerment Staff (PCARES) Project during therecently concluded 33rd ASEAN Social Security Association(ASSA) Board Meeting held in Sofitel Philippine Plaza Manila inPasay City. The ASSA is composed of social security agenciesfrom Brunei, Cambodia, Indonesia, Lao PDR, Malaysia, Myanmar,Singapore, Thailand, Vietnam, and the Philippines.

Client Focus

- Expanded Frontline Services for transparency, fastertransactions, and customer satisfaction

- Service Delivery Infrastructure 17 regional offices, 5 branches, and 101 Local Health

Insurance Offices Service desks inside the malls, municipal or city halls,

hospitals, public libraries, and in other areas with high volumeof foot traffic. From 11 PhilHealth Express outlets in 2012, thenumber has already grown to 63.

- Action via offline, online, and social mediaThrough its Corporate Action Center (CAC), PhilHealth is able torespond to member inquiries, comments, suggestions, andcomplaints received.

- Innovations

All Case Rates Search Engine Member Inquiry Facility allows Tie-up with Bayad Center Electronic Premium Remittance System Electronic Claims using EMR/HIS Internet of Things

Digital Transformation is an ongoing process. The journey will never end because technology changes. PhilHealth will

continuously study and understand the impact of new technologies and develop capabilities to respond to the

opportunities.

As we look to the future with the well-being of the Filipino in mind, PhilHealth vows to be responsive in addressing health concerns that are changing with the times. The corporation is

determined to come up with innovative solutions through partnerships and cooperation with local and national

agencies.

Thank You.