David Lubinski, PATH Cees Hesp, PharmAccess Foundation Kate Wilson, PATH 24 January 2012

1. JLN Information Technology Track: Collaborating Across Countries - Standards, Opportunities and Strategies David Lubinski, PATH Cees Hesp, PharmAccess Foundation Kate Wilson, PATH 24 January 2012 Bangkok, Thailand

2. 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

3. Agenda

5. What is our approach? Listen Learn Analyze Document Share

6. What have we done/will do? JLN Information Technology Track Work Host online survey; Interview JLN country respondents; Conduct stakeholder mapping Develop future plan for IT track based on country feedback Develop health data dictionary paper series and tool Introduce project and hold initial workshop in Bangkok Apr May Jun Dec Jan Feb Mar Jul Aug Sep Oct Nov Dec Develop process framework with experts; Build draft process matrix; Draft country level task flows Convene core work group with JLN members to review task flows and agree on global requirements; Finalize and share requirements. Country consultations Thailand May 3-13 India (RSBY) – Jul 13-15 India (Aarogyasri) – Jul 18-20 Draft first set of common task flows and requirements for core work group Requirements Development Work

7. What is the benefit of shared common functional requirements?

8. The Cost Effectiveness of Common Requirements, Standards and Solutions Multi-Country Requirements & Standards Collaborative Multi-Country Solution Collaborative Cost 1st Country 1st Country 2nd 2nd 3 4 5 3 4 5 Time

9. Shared Common Architecture Tools

10. Agenda

11. Joint Learning Network How Standards Make Life EasierHarmonize to Interoperate Cees J. HespChief Technology OfficerPharmAccess Foundation

12. Contents • Definitions • Examples • How standards make life easier • Advantages / challenges • Capability-maturity levels • Standards needed in healthcareadministration / financing / insurance • Call for action

13. Definitions • StandardizationFormulation, 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.

14. Example 1: Physical World (Freight Containers) Globally, shipping costs have dropped 70%

15. Example 2: Administration (European Union Driver’s Licenses) First 110 different documents, now 1

16. Example 3: e-claims in the Netherlands

17. How Standards Make Life Easier No Standard(s) Standard(s)

18. 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

19. 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...?

20. Choose Standards That Align With Your Ability to Implement Them • Whether you use a simple or sophisticated model to create your standards road map… Simple Model Capability Maturity Model ? • Choose standards that solve real needs and problems, not as an academic exercise

21. 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 Standards

22. Available Standards in Healthcare • Limited standards for health administration, finance & insurance

23. 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!

24. Agenda

25. Joint Learning Network Philippine Health Insurance Corporation (PhilHealth) Alvin B. Marcelo Chief Information Officer

26. About PhilHealth Established by an act of congress in 1995 (Republic Act 7875) - allocate national resources for health - universality - equity - responsiveness - social solidarity

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

28. Alvin B. Marcelo Presently PHIC senior vice-president and chief information officer Formerly: • 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 -

29. State of Country Health Information System Governance is emerging but still struggling Multisectoral approach is underway but still seeking clear directions Sector-wide enterprise architecture is lacking Standards, to a large extent, are still undefined No defined curriculum for developing the human resource-base for HIS

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

31. Standards Needed Identifiers (person, patient, provider) Health data dictionary Data exchange Security

32. Standards Implemented ICD-10 for diagnosis CPT for procedures (with local relative value units) PhilHealth ID (for adults)

33. Standards in Waiting Diagnosis related groups SNOMED for clinical vocabulary openEHR and/or HL7 SNOMED-to-ICD crosswalk

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

35. Challenges High cost of electronic systems limit adoption among providers Lack of standards contribute to higher costs Lack of standards introduce "non-interoperable" components into the larger system

36. Priorities Define a simple health data dictionary for electronic claims Build capability of providers to file claims electronically Create business value for information use - utilization review (for payor) - cost effectiveness (for provider)

37. Next Steps Define an enterprise architecture to guide transition from old to new Define standards (identifiers, health data dictionary, schema for electronic claims) Information use (utilization review, quality assurance) 2

38. Agenda

39. JLN Information Technology Track: Developing Functional Requirements For National Health Insurance Information SystemsProgress to date 24 January 2012

40. Why we think requirements matter?

41. Where do functional requirements fit? Enterprise Architecture How everything fits together across the health finance system Business Architecture Vision, Principles, Policy How the health finance system is structured & works to meet its objectives Functional Requirements Information Architecture Data Technical Architecture How information systems support the objectives of the health finance system Applications Infrastructure Architecture How the technology fits together and supports the health finance system Phones & Computers Networks & Communications

42. What benefit do global requirements offer countries? First Phase of IT Project Focused Here India Aarogyasri 24x7 integrated call center Thailand National ID smart cards JLN Members Focus Here Nigeria Voluntary contributors SW Program India RSBY Biometric ID smart cards

43. Isn’t the Future Mobile Phones & Smart Cards?

44. What may be common in insurance?

45. What may not be common?

46. CRDM – Building functional common requirements together

47. What are the steps in CRDM? • Domain – set of functions and processes that define the work of a specific area of the larger health system, i.e. health financing • Process Framework– set of processes that define the boundaries of a domain and the relationships between them and other systems and domains. • 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 • 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 • 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…”

48. What is the process framework? National policy regarding target population set by country Rules Scheme Policy Benefit Package Formulary Provider Rates Eligibility Requirements Provider Policy Setting Premium Setting Fundamental System “Factory” Beneficiary Management Provider Management Premium Collection Claims Management Accounting Data Provides Policy Guidance Analyzing Performance Care Management Utilization Management Provider Quality Management Fiduciary Fund Management Actuarial Management Medical Loss Audit/Fraud Data & FeedbackChange Mgmt

49. What are the steps in CRDM? • Domain – set of functions and processes that define the work of a specific area of the larger health system, i.e. health financing • Process Framework– set of processes that define the boundaries of a domain and the relationships between them and other systems and domains. • 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 • 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 • 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…”