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A Digital Interface for payment commitment request between HMO's and Hospitals

Digital Health division in MOH, Government Hospitals Division, Callit’s Hospitals Division, Assuta Ashdod Hospital, The Holy Family Hospital Nazareth, Shaare Zedek Medical Center, Clalit HMO, Meuhedet HMO, Leumit HMO, Outburn Ltd.


Developing a digital interface to request payment commitment for ambulatory services between HMOs and hospitals, upon consensual service areas, aimed to reduce today’s bureaucracy’s burden on patients, and improve their continuity of care.


About the Project 

  • Project’s objective: to establish a FHIR based standard digital interface to administrate the process of requesting a payment commitment and receiving the commitment (Form 17) between hospitals to HMOs in consensual areas of service, aimed to reduce today’s bureaucracy’s burden on patients, and improve their continuity of care.

  • Today, when a patient is expected to receive treatment or perform an examination at the hospital, they are required to proactively request a payment commitment from the HMO, to scan it, to attach further relevant documentation, and when the commitment is approved - to print it and bring it to the reception desk at the hospital.

This process produces a great strain of bureaucracy on patients, sometimes causing mistakes in the service codes approved in the commitment form. Also, this process causes a load of  bureaucracy inside the hospitals and imposes payments on patients who choose to get the treatment even if the commitment was not approved.

  • As part of the project, a data share interface is created in accordance with FHIR standard, to administrate the request for payment commitment directly between the hospital in which the patient has it’s appointment, and the insuring HMO, while continuously updating the patient on the status of request. 

  • As a first step, we focus on administrating commitments for a scenario in which a patient is revisiting the hospital to get a continuing treatment.

  • This project is carried out as part of a support test, published by the Digital health division in MOH in December 2022 for general hospitals, and is done in cooperation with the HMO’s.

  • The project also includes the process of receiving the commitments at the hospital’s Kiosk - which was initially implemented by TLV Medical Center (Ichilov) and Meuhedet HMO at 2021 as a study case of the FHIR IL community, and is extended nowadays with great success to the rest of the HMO’s (to the project’s page).


The project’s world of content

  • A Payment commitment for medical service

  • A medical service appointment


Solution's Architecture

  • Data share processes in this project will be aligned with the FHIR standard.

  • The hospital serves as the client component  in this process, the HMO is the server component.

  • Hospitals will send a message of request for commitment to the HMOs, the message will also include the patient’s scheduled appointment details.

  • The HMO will reply regarding the status of approval of the request for commitment.

  • Upon the patient’s arrival to the hospital for the appointment, the commitment’s details will be transferred from the HMO through the Kiosk. 

  • The patient will be constantly updated during the process on the status of the request submitted for her. An elaborated description and a diagram of the process is appended in this page.


Profiles to be characterized in the project

  • CoverageEligibilityRequest

  • CoverageEligibilityResponse

  • Appointment

  • DocumentReference

  • Coverage

  • Location

  • Patient

  • Bundle


Terminology to be used

MOH service codes

Health organizations codes - Organization Profile


Project Status

  • Business process mapping, together with all organizations was completed.

  • Characterizing of data share interfaces solution, with accordance to FHIR standard - in progress.

  • Characterizing the architecture of data streaming - in progress

  • Expected to go On Air - beginning of 20242024


Meetings

  • Work meeting - presenting organizational processes - 9.3.23

  • Presentation and discussion of the business process - 18.5.23

  • Presentation and discussion of the first version of the full solution specification = 29.6.23

  • 26.7.23 - Q&A Meeting - Recording

  • 9.8.23 - Q&A Meeting - Presentation

  • 6.9.23 - Q&A Meeting - Recording

  • 20.9.23 - Q&A Meeting - Recording and Presentation

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