Notice C

Promoting the collaborative development of proposals for investments in digital health global goods

Integrating openIMIS with Bahmni: A Nepal-Based Proof-of-Concept Project

Notice C Opportunity: 
Announcement C1: Modular transformation of openIMIS
Proposal Status: 
Approved - Fully Funded

CONCEPT NOTE

Executive Summary

Possible is an innovative, experienced healthcare delivery organization in Nepal working to transform rural healthcare to make it work for underserved populations. Our integrated hospital-to-home healthcare model includes:

  1. improved quality of care at government-owned facilities;
  2. community-based care delivered by a trained professionalized cadre of community health workers (CHWs); and,
  3. an Electronic Health Record (EHR) that includes facility-level and community-level data to enable care continuity, a holistic picture of healthcare needs, and continuous improvement of healthcare delivery.

Our facility-based EHR, NepalEHR, is Nepal’s national EMR system and is built on the OpenMRS platform, Bahmni, with embedded protocols and the ability to track patient, supply, laboratory, radiology, and pharmacy data seamlessly. Following the recent passage of Nepal’s National Health Insurance Act, Possible is beginning to accept health insurance from patients and processing claims for reimbursement. As such, in line with the openIMIS product roadmap, we are working to integrate openIMIS with Bahmni through a proof-of-concept claim submission module. The development of this solution will support the openIMIS Initiative vision of making openIMIS interoperable with national health information architectures and, ultimately, support Nepal’s path to universal health coverage.

Consortium Team

Possible has a dynamic team of experienced technology innovators that support our efforts to transform health systems for underserved populations. Anant Raut, Possible’s Director of Informatics, led the rollout of our EHR system at our hospital hubs and oversees our innovative digital systems design and quality improvement efforts. He helps improve health outcomes and patient experience through innovative digital systems design and quality improvement and leads a robust team of three developers and five implementers who have been working on these open source projects for several years.

Possible will also work closely with the Bahmni Coalition to ensure the interoperability of its solution in contexts outside of Nepal. The Bahmni Coalition is a group of 15 organizations that collaborate in an open source way around the Bahmni hospital information system. Bahmni and its coalition received Digital Square funding through Notice B, and you can read more about the coalition in that proposal: https://open-proposals.ucsf.edu/digital-square/notice-b/proposal/14385.

Bahmni’s Product Architecture Team will participate in the design and review of this Bahmni-openIMIS integration, and core Bahmni product developers will participate via pair programming and code reviews to ensure that this proof of concept is built so that it can be incorporated into the core Bahmni distribution in the future.

Possible is also eager to collaborate with organizations who are working to add the relevant FHIR APIs to openIMIS as a part of this project.

Project Description

In a major step towards achieving Universal Health Coverage, Nepal piloted its national health insurance program in 2016 in a few districts, and is now rolling it out nationwide. Nepal uses openIMIS to manage its national health insurance program. Bahmni is gaining traction at public health facilities around the country as NepalEHR, and this presents an opportunity for synergy between the two interdependent yet separate systems.

a) Technical Approach and Outcomes

Currently, Bahmni does not integrate an insurance workflow. The manual workflow to submit claims for those insured in openIMIS is time-intensive and inefficient. Developing a Bahmni-openIMIS Integration system will streamline processes around checking/validating patients with insurance, submitting claims, and tracking claims status.

Once this module is developed, one will be able to determine the validity and available balance of a person’s insurance account from within Bahmni itself. Users will be able to submit claims and track the status of these claims as “approved” or “rejected” within the system.

Concurrently, billing encounters for each patient will be synced with Odoo (OpenERP) and differentiated either as insurance claims or non-insurance bills. Managers will be able to generate reports on claims/non-claims from Odoo and utilize features like sorting and filtering for improved costing and planning.

To accomplish this, Possible will carry out the following steps:

1. Conduct Bahmni EHR User Interface changes to support collecting and displaying insurance related information of patient.

2. Develop IMIS-Connect java based rest application which can be plugged in as a service on existing Bahmni environment and acts as a gateway for communication with insurance system (openIMIS), with Bahmni. Major functions include:

  • Validity check
  • Balance check
  • Submit claims
  • Track status of the claims
  • Resubmit the rejected claims

3. Build IMIS-ERP module to tag the billing encounters of the insurance-eligible patient as  claimables or billables.

4. Change Odoo UI as required for claims processing features.

5. Change Odoo UI for generating reports for claims and non-claims

 

Figure 1: Bahmni-openIMIS Integration system


b) Anticipated Timeline

Possible anticipates completing the integration of openIMIS with Bahmni by August 2019.


c) Monitoring and Evaluation

We will carry out the integration of openIMIS with Bahmni in phases, using an agile development approach. We will work closely with the Bahmni coalition and its various implementers across many countries to ensure this module is of global relevance.

d) Interoperability with National Health Information Architectures

Possible’s Bahmni product (NepalEHR) serves as Nepal’s national EMR system. As a result, once we are able to successfully develop the openIMIS module within Bahmni, it will immediately interoperable with Nepal’s national health information architectures.

Additionally, as an open source platform used globally, Bahmni is already embedded within national health systems. As such, developing our solution will allow for other Bahmni implementing partners to begin submitting and tracking insurance claims in countries that have insurance products. For example openIMIS is also in use in Tanzania, and we would expect that the University of Dar es Salaam Computing Center would soon adopt this integration for their national rollout of Bahmni.

e) Furthering the development of openIMIS

Possible’s solution firmly fits within the openIMIS Initiative’s priorities as outlined in Section 3.5: Build on existing software in the openIMIS roadmap. By building on existing tools, Possible is contributing to the global knowledge base to ensure widespread adoption of openIMIS as countries begin to offer insurance products for their citizens.


Tagging

  • Interoperability

  • Bahmni

  • OpenMRS

  • OpenIMIS

  • Insurance

  • Integration

  • Bahmni Coalition

  • Possible

  • Nepal

 
________________________________________________________________________________________
 

PROPOSAL

Executive Summary

See response in Concept Note section above.

Consortium Team

Possible will serve as the lead organization for the proposed project. With a ten-year history of operating in Nepal, Possible has a dynamic team of experienced technology innovators that support our efforts to transform health systems for underserved populations. Anant Raut, Possible’s Director of Informatics, led the rollout of our EHR system at our hospital hubs and oversees our innovative digital systems design and quality improvement efforts. He helps improve health outcomes and patient experience through innovative digital systems design and quality improvement. Before joining Possible, Anant led various projects innovating user-centered solutions for Hospira, P&G and Samsung, and was previously as an analyst at Zurich Financial Services. He completed his M.A. in Engineering Design & Innovation from Northwestern University, and has a B.A in Mechanical Engineering from Trinity College (CT). Anant leads a robust team of three developers and five implementers who have been working on these open source projects for several years.

Possible’s EHR team has significant expertise in designing architecture for complicated systems that require interoperability between various interfacing components (see CVs, attached). Our team has customized our EHR to meet the needs of our hospital staff and optimize the use of data for improved decision-making. For instance, earlier this year, we successfully integrated the Nepal Ministry of Health’s District Health Information System (DHIS2) with NepalEHR, allowing for seamless and automatic reporting of facility data to the central government health database. Direct integration of facility-based OpenMRS and national DHIS2 is the first of its kind anywhere in the world. DHIS 2 is the open-source information system with dynamic visualization features including mapping of diseases and customized dashboards that allow clinicians to look for trends and scan for epidemics in real time. It is also the preferred health management information system in 46 countries and helps governments better manage healthcare delivery efforts. This integration greatly simplifies the data management process, eliminating the burden of reporting on the clinicians whose time is better spent on patient care.

The Director of Informatics will lead Possible’s Nepal-based EHR team in the development and implementation of the Bahmni-openIMIS integration system. The two Java developers will lead the development and testing of the application, incorporating user feedback in further refinements throughout the project. Possible’s two systems engineers, Sr. EHR Associate, and Sr. Data Registration Assistant will work together to lead the deployment of the integration application at two public hospitals over the course of the year-long project. They will also support the training of users and administrators and conduct ongoing maintenance and support for the application.

Our team of technology innovators will work closely with Possible’s finance team who will support claims status tracking and help develop relevant reports to track reimbursements for claims. Finally, Possible’s medical staff will provide valuable input and feedback into the workflow from checking patients’ insurance enrollment to submitting and tracking claims.

Possible will also work closely with the Bahmni Coalition to ensure the interoperability of its solution in contexts outside of Nepal. The Bahmni Coalition is a group of 15 organizations that collaborate in an open source way around the Bahmni hospital information system. Bahmni and its coalition received Digital Square funding through Notice B, and you can read more about the coalition in that proposal: https://open-proposals.ucsf.edu/digital-square/notice-b/proposal/14385.

Bahmni’s Product Architecture Team will participate in the design and review of this Bahmni-openIMIS integration, and core Bahmni product developers will participate via pair programming and code reviews to ensure that this proof of concept is built so that it can be incorporated into the core Bahmni distribution in the future.

Project Description

In a major step towards achieving Universal Health Coverage, Nepal piloted its national health insurance program in 2016 in a few districts, and is now rolling it out nationwide. Nepal uses openIMIS to manage its national health insurance program. At the same time, Possible’s NepalEHR is gaining traction within public sector health facilities throughout the country, and this presents an opportunity for synergy between the two interdependent yet separate systems.

In 2017, Nepal’s Ministry of Health released their National e-Health Strategy that outlined their goal of harnessing the potential of Information and Communication Technology (ICT) technologies to improve health services, health governance and management. With the government’s expressed commitment to digitizing healthcare, the demand for cost-effective and easy to implement and use products is increasing among private and public healthcare providers. As the developer of the first integrated EHR in Nepal with a demonstrated track record of delivering technology-enabled longitudinal care, system efficiencies and quality improvement, we are uniquely positioned to respond to the growing interest in digitization and partner with the Government to expand the use of NepalEHR within the public health sector.

Along with refinements to NepalEHR, promoting implementation of the EHR in the public sector will be a priority for Possible over the next three years. We have already taken steps in this direction. For instance, beginning in December 2017, Possible, in collaboration with the German development agency, GIZ, began the process of implementing our EHR product at Nepal’s Trishuli District Hospital in Nuwakot District. This is an important milestone since it allows us to demonstrate the use and uptake of the EHR in government hospitals that are not under Possible’s management. We are also currently considering other similar opportunities to scale use of our EHR within the public health system. With this fertile environment for innovation and potential for national scale, the integration of openIMIS with NepalEHR presents an exciting opportunity to accelerate Nepal’s progress towards universal health coverage through a seamless system for public sector health facilities to accept insurance and receive reimbursements. Furthermore, the integration of the two open source systems will have global implications for other countries attempting to launch new national health insurance schemes.

a) Technical Approach

Currently, Bahmni does not integrate an insurance workflow. The manual workflow to submit claims for those insured in openIMIS is time-intensive and inefficient. Developing a Bahmni-openIMIS integration system will streamline processes around checking and validating patients with insurance, submitting claims, and tracking claims status.

Possible’s proposed solution is an integration of openIMIS with the existing Bahmni EHR to support a seamless and unobtrusive insurance workflow. Possible will install the application, a REST-based API service, within the existing Bahmni EHR system. The Bahmni EHR will interact with this application through the API, and the application will then connect with IMIS-APIs for processing the claims.

As a component of Bahmni EHR, the application will interface directly with openIMIS for processing claims through the claim life cycle. Possible will also execute UI changes within its Bahmni EHR platform to display relevant insurance details of patients. In addition, we will add insurance TAGs on the Odoo (OpenERP) UI for invoices and process buttons.

Once this module is developed, one will be able to determine the validity and available balance of a person’s insurance account from within Bahmni. Users will be able to submit claims and track the status of these claims as “approved” or “rejected” within the system. Possible will be able to generate reports for the insurance-tagged Bills/invoices from Odoo and send claimable invoices to the openIMIS system.

Concurrently, billing encounters for each patient will be synced with Odoo and differentiated either as insurance claims or non-insurance bills. Managers will be able to generate reports on claims/non-claims from Odoo and utilize features like sorting and filtering for improved costing and planning.


b) Use of Digital Health Technologies

Figure 1 (below) shows the overall interactions between the IMIS-connect application, the EHR system and the openIMIS System. The IMIS-Connect application will act like a gateway to the openIMIS system.  


Figure 1: Bahmni-openIMIS Integration system



The application is targeted for Linux/CentOs Machines and will be an RPM-based installation. It will be built as a component service for Bahmni EHR. The existing server for Bahmni EHR will be capable of running this service in terms of memory, CPU utilization, and database space.

c) Workplan and Schedule

Possible anticipates completing and implementing the integration of openIMIS with Bahmni within 12 months of project commencement. To date, Possible has completed several activities in preparation of this integration project. We have conducted an initial requirement analysis in collaboration with Nepal’s Ministry of Health and GIZ. In addition, we have observed the current insurance and hospital workflow at one of our implementation sites, Bayalpata Hospital in Nepal’s Achham district, and interviewed users to understand their technical needs. Finally, we have drafted a systems requirement specification document that was shared with the broader Bahmni/OpenMRS community.

The Gantt chart below outlines the phases, activities, and timeline for achieving each activity over the course of the 12-month project.



d) Digital Health Atlas
Possible has registered 
NepalEHR in the Digital Health Atlas, as shown here: https://digitalhealthatlas.org/public/180/assessment.

e) Project Deliverables

Over the two phases of the project, Possible will achieve the following key deliverables:

Phase I: Outpatient workflow

  1. Registration billing feature in Bahmni complete;

  2. openIMIS integration module for OPD workflow developed;

  3. Training and deployment at Bayalpata Hospital in Achham complete;

  4. Technical documentation of OPD insurance integration including product architecture and installation guide for implementers complete.

Phase II: Inpatient and Emergency workflow

  1. Billing feature developed in Bahmni;

  2. openIMIS integration module for IPD and ER workflow complete;

  3. Technical documentation of OPD insurance integration including product architecture and installation guide for implementers complete;

  4. User Training Manual complete.

Two-Sentence Overview

  1. In Nepal, where the government recently passed a National Health Insurance Act, citizens and healthcare providers require novel systems to efficiently process insurance claims, reimburse providers, and, ultimately, achieve the country’s vision of universal healthcare coverage. Possible is developing an application that will seamlessly integrate the leading open source EHR (Bahmni) and the openIMIS insurance system to improve access to healthcare for the insured and reimbursement funds for providers. Once developed and tested, this application can be utilized to scale up insurance uptake nationally within Nepal and easily adapted to additional countries where Bahmni and openIMIS are currently in use.

  2. The investment will go towards the design and development of the application. It will also go towards the implementation and refinement of the application at two public hospitals in Nepal.

Community Feedback

Possible will engage with the broader digital health community through the Bahmni Coalition, a network of 15 organizations from numerous countries that collaborate around the Bahmni hospital information system. We will work with the Bahmni Coalition to obtain feedback and input, especially with regard to the architecture and design of our application prior to starting development. Once we develop the application, much of the architecture and components should be universally applicable in other settings where Bahmni and openIMIS are being implemented.

We will continue to incorporate feedback from the broader community following development and implementation of our application. In collaboration with the Coalition, we will identify other organizations and national governments that are attempting to utilize openIMIS for insurance enrollment, reimbursement, and claims processing. We will share any lessons learned with partners and continue to iterate on our application based on the insights gained by other organizations implementing the application.

Use Cases, User Stories

There are three types of users that will interact with the system: Registration desk staff at our hospitals, finance staff and claims submitting users. Each of these three types of users will use the application differently; as such, each will have their own requirements.

Registration desk staff will use the Bahmni UI to collect NHIS numbers from patients, check for the validity of the insurance account, and determine the balance left in the account, if valid. They will use the Bahmni UI to do the same for revisiting patients if their insurance details have not already been collected.

The claim submitter (a to-be-identified staff member at each hospital location) will use Odoo to submit the insurance-tagged invoices for further processing. They will also be responsible for the tracking the status of claims and resubmitting the rejected claims after correction (in case of known mistakes in claims). The UI in Odoo will be modified for supporting these actions.

Finance staff will be able to check the reports from Odoo for the claimed and billed amounts. They will be able to generate different periodic reports based on the requirements such as total claim reports, non-claims and not-claimable reports.

Figure 2 below shows the actions of the various players and openIMIS in the new workflow post implementation.

Figure 2: Insurance Workflow

The appendix includes a figure (Figure 3) detailing the step-by-step decision-making process from assessing a patient’s insurance status to processing a claim and tracking the status.

Self-Assessment on the Global Goods Maturity Model

Possible has completed the self-assessment here: https://docs.google.com/spreadsheets/d/1iCb0BZ0Ni8ihS1JVXAxg938E62cW86vgEFpSJXpw0HE/edit?usp=sharing

Tagging

See response in Concept Note section above.

 

Comments

Hi Anand,

Thanks for your submission. I would encourage you to reach out to some of the other submissions around OpenMRS and openIMIS. Maybe there are ways to create to collaborate on a proposal and split in a way that makes sense regarding the respective strengths of the different partners?

Cheers,

Nils