JLN Information Technology Track: Collaborating Across Countries - Standards, Opportunities and Strategies

David Lubinski, PATHCees Hesp, PharmAccess FoundationKate Wilson, PATH

24 January 2012Bangkok, Thailand

JLN Information Technology Track Welcome and Introductions

Please take 5 minutes to introduce yourself to someone at your table you don’t already know

Share your top priority and biggest challenge for information systems in 2012

Agenda

ListenLearn

AnalyzeDocument

Share

What is our approach?

What have we done/will do?

Introduce project and hold initial

workshop in Bangkok

Develop process framework with experts;

Build draft process matrix; Draft country level task

flows

Country consultationsThailand May 3-13

India (RSBY) – Jul 13-15India (Aarogyasri) – Jul 18-20

Draft first set of common task flows and requirements for

core work group

Develop health data dictionary paper series

and tool

Requirements Development Work

JLN Information Technology Track Work

Convene core work group with JLN members to review task

flows and agree on global requirements;

Finalize and share requirements.

Develop future plan for IT track based on country feedback

Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Host online survey; Interview JLN country

respondents; Conduct stakeholder

mapping

What is the benefit of shared common functional requirements?

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.

1st

Country 2nd

Multi-Country Solution

Collaborative

The Cost Effectiveness of Common Requirements, Standards and Solutions

Cost

Time

Multi-Country Requirements & StandardsCollaborative

1st

Country 2nd

Shared Common Architecture Tools

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.

Agenda

Joint Learning Network

How Standards Make Life Easier

Harmonize to Interoperate

Cees J. HespChief Technology OfficerPharmAccess Foundation

Contents Definitions Examples How standards make life easier Advantages / challenges Capability-maturity levels Standards needed in healthcare

administration / financing / insurance Call for action

Definitions Standardization

Formulation, publication, and implementation of guidelines, rules, and specifications for common and repeated use, aimed at achieving an optimum degree of order or uniformity in a given context, discipline, or field.

HarmonizationAdjustment of differences and inconsistencies among different measurements, methods, procedures, schedules, specifications, or systems to make them uniform or mutually compatible.

InteroperabilityAbility of computers programs to interact with each other regardless of the underlying architecture and/or operating system(s). Interoperability is feasible through (hardware and software) components that conform to open standards.

From a New Institutional Economics point of view, standardization starts with a social problem known as the “coordination dilemma”. Standards, as “voluntary norms”, serve to facilitate the resolution of coordination dilemmas and to realize mutual gains.

Globally, shipping costs have dropped 70%

Example 1: Physical World (Freight Containers)

First 110 different documents, now 1

Example 2: Administration (European Union Driver’s Licenses)

Example 3: e-claims in the Netherlands

16

Key Figures Description

100,000,000 Claims per year

40,000 Healthcare providers

500 Claims software packages

20 Health insurers (payers)

Key Solution(s)

1 Central claims-routing hub

1 Common set of standards, formats, etc.

1 National registry for patients, providers, and insurers respectively

Savings

€400-600 mio Annually, in administrative cost alone

billions In rationalized purchasing & planning

How Standards Make Life Easier

No Standard(s) Standard(s)

Advantages Reduced complexity & cost Reduced error-rate(s)

Increased predictability & transparency Increased processing speed Increased (data) quality & reliability Increased efficiency & scalability

Enables supply-chain integration Less chances of vendor lock-in Easier to train staff on, easier to find staff trained in

Changes apples and oranges into comparable fruits / smoothies

Challenges

The good thing about standards is that there are so many of them... Joke by former HL7 chairman in the Netherlands

Some standards require a high level of sophistication! ICD-10 ≈ 68,000 diagnoses, 87,000 procedures

Not all standards created are equally practical ISO 3166 country codes (2-letter, 3-letter, 3-digit) Netherlands = “NL”, “NLD”, or “528”

Standardization vs flexibility...?

Choose Standards That Align With Your Ability to Implement Them

Simple Model

Choose standards that solve real needs and problems, not as an academic exercise

Capability Maturity Model

Level 3 Run

Level 2 Walk

Level 1 Crawl

Level 5 Optimizing

Level 4 Managed

Level 3 Defined

Level 2 Repeatable

Level 1 Ad Hoc/Chaotic

Whether you use a simple or sophisticated model to create your standards road map…

?

Standards Needed in Healthcare Administration / Financing / Insurance

Unique identifiers Patients, Providers, Facilities, Insurers Diagnoses, Drugs, Procedures, Investigations, Outcomes

Common (electronic/paper) forms Registration, encounter(s) Claims Referral letters

Key Performance Indicators (KPIs) Health metrics, statistical data

Messaging Standards21

Available Standards in Healthcare

Standard Description

HL7 Health Level 7

SNOMED - CT Systematized Nomenclature of Medicine – Clinical Terms

DICOM Digital Imaging and Communications in Medicine

LOINC Logical Observation Identifiers Names and Codes

openEHR Electronic Health Records (ISO 12052:2006)

SDMX-HD Statistical Data and Metadata Exchange – Health Domain

ICD-9/10 Internation Classification of Diseases – WHO

CEN/ISO 13606 Electronic Health Records

Limited standards for health administration, finance & insurance

Call for Action

The Health Data Dictionary (HDD) as the foundation for standardizing data

Continued work in 2012-2013 on an HDD tool Create & share common definitions Collaborative (web-based) platform & community

Countries have heard the call to action!

23

Agenda

Joint Learning Network

Philippine Health Insurance Corporation (PhilHealth)

Alvin B. MarceloChief Information Officer

About PhilHealth

Established by an act of congress in 1995 (Republic Act 7875)

- allocate national resources for health- universality- equity- responsiveness- social solidarity

PhilHealth

together with the Department of Health, works towards assuring universal health coverage to Filipinos

Alvin B. MarceloPresently PHIC senior vice-president and chief information officerFormerly:•associate professor of surgery and health informatics, University of the Philippines Manila•director of the National Telehealth Center•program coordinator for the Master of Science in Health Informatics•program manager for UNDP's International Open Source Network ASEAN+3

-

State of Country Health Information SystemGovernance is emerging but still strugglingMultisectoral approach is underway but still seeking clear directionsSector-wide enterprise architecture is lackingStandards, to a large extent, are still undefinedNo defined curriculum for developing the human resource-base for HIS

State of PhilHealth Information SystemLargely a mix of legacy systems With defined standards (ICD-10, CPT)Discontiguous processes prevent experiencing the full benefit of automation

Standards Needed

Identifiers (person, patient, provider)Health data dictionaryData exchangeSecurity

Standards Implemented

ICD-10 for diagnosisCPT for procedures (with local relative value units)PhilHealth ID (for adults)

Standards in Waiting

Diagnosis related groupsSNOMED for clinical vocabularyopenEHR and/or HL7SNOMED-to-ICD crosswalk

Major Objectives of StandardsConsistently record data about patients (health ID)Ease of transacting with PhilHealth (electronic claims)Consistent statistics across agencies

Challenges

High cost of electronic systems limit adoption among providersLack of standards contribute to higher costsLack of standards introduce "non-interoperable" components into the larger system

Priorities

Define a simple health data dictionary for electronic claimsBuild capability of providers to file claims electronicallyCreate business value for information use - utilization review (for payor)- cost effectiveness (for provider)

2

Next Steps

Define an enterprise architecture to guide transition from old to newDefine standards (identifiers, health data dictionary, schema for electronic claims)Information use (utilization review, quality assurance)

Agenda

24 January 2012

JLN Information Technology Track: Developing Functional Requirements For National Health Insurance Information Systems

Progress to date

Why we think requirements matter?

Where do functional requirements fit?

Enterprise ArchitectureHow everything fits together across the health finance system

TechnicalArchitecture

Information ArchitectureData

Applications

How information systems support the objectives of the health finance system

How the technology fits together and supports the health finance system

Infrastructure ArchitecturePhones & Computers

Networks & Communications

BusinessArchitecture

Vision, Principles, Policy

Functional Requirements

How the health finance system is structured & works to meet its objectives

What benefit do global requirements offer countries?

Global CommonArchitecture

•Requirements

•Standards

•Guidelines

•etc.

Country SpecificArchitecture

Global Common Solutions

Country SpecificSolutions

•Software

•Hardware

•Services

•etc.

First Phase of IT Project Focused

Here

JLN Members Focus Here

India AarogyasriIndia Aarogyasri24x7 integrated call center24x7 integrated call center

India RSBY India RSBY Biometric ID smart cardsBiometric ID smart cards

NigeriaNigeriaVoluntary contributors SW ProgramVoluntary contributors SW Program

ThailandThailandNational ID smart cardsNational ID smart cards

Isn’t the Future Mobile Phones & Smart Cards?

Page 43

What may be common in insurance?

What may not be common?

CRDM – Building functional common requirements together

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 Management

2.Provider Management3.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

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…”

What is common task flow?

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…….)

Future plan requested by Core Work Group

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.

Focus on new requirements,HDD

tools, & policy/tech

evidence

Informed by JLN member

deployments

Support national HDD and

requirements efforts

Compare solutions against

requirements

How do we plan the future together? Questions to consider

What tools – (these or others?) would be the most useful products that could emerge from the JLN

How could your country contribute to the development of these tools ( i.e. prototype, pilot, design, etc.)

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

African Proverb

“What if we go together?”

Agenda

Agenda

Agenda

Thank youขอบคุ�ณAsante

Merci

لك شكرا

Thank You

Gracias

謝謝您

Shukran

Danke

Grazie

Cảm ơn bạn

Dank je

What happens in 2012/2013 determined by 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.

Finalize draft requirements and do new processes

Support JLN member

deployments

Take global requirements and apply in some JLN

countries

Compare solutions against

requirements

Agenda

Agenda

Agenda

Thank youขอบคุ�ณAsante

Merci

لك شكرا

Thank You

Gracias

謝謝您

Shukran

Danke

Grazie

Cảm ơn bạn

Dank je

24 January 2012

JLN Joint Session of the Information Technology & Quality Tracks

A Systematic Architected and Rational Approach for Understanding and Improving Quality

Capability Maturity Model

Typically undocumented and in a state of dynamic change, tending to be driven in an ad hoc, uncontrolled and reactive manner by users or events. This provides a chaotic or unstable environment for the processes.

Level 1Initial

(Chaotic)

Some processes are repeatable, possibly with consistent results. Process discipline is unlikely to be rigorous, but where it exists it may help to ensure that existing processes are maintained during times of stress.

Level 2Repeatable

Sets of defined and documented standard processes established and subject to some degree of improvement over time. These standard processes are in place (i.e., they are the AS-IS processes) and used to establish consistency of process performance across the organization.

Level 3Defined

Using process metrics, management can effectively control the AS-IS process. Management can identify ways to adjust and adapt the process to particular projects without measurable losses of quality or deviations from specifications. Process Capability is established from this level.

Level 4Managed

The focus is on continually improving process performance through both incremental and innovative technological changes/improvements towards clear TO-BE targets.

Level 5Optimizing

1st

Country 2nd

Multi-Country Solution

Collaborative

The Cost Effectiveness of Common Requirements, Standards and Solutions

Cost

Time

Multi-Country Requirements & StandardsCollaborative

1st

Country 2nd

Shared Common Architecture Tools

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.

Boneyard

Developing Scalable Solutions

Page 77

*”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 the benefit of shared common functional requirements?

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.

First Phase of IT Project Focused

Here

JLN Members Focus Here

What have we done?

Introduce project and hold initial

workshop in Bangkok

Develop process framework with experts;

Build draft process matrix; Draft country level task

flows

Country consultationsThailand May 3-13

India (RSBY) – Jul 13-15India (Aarogyasri) – Jul 18-20

Draft first set of common task flows and requirements for

core work group

Develop health data dictionary paper series

and tool

Requirements Development Work

JLN Information Technology Track Work

Convene core work group with JLN members to review task

flows and agree on global requirements;

Finalize and share requirements.

Develop future plan for IT track based on country feedback

Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Host online survey; Interview JLN country

respondents; Conduct stakeholder

mapping