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the default openIMIS Claim adjudication process should be modified as less as possible
Medical Officers should not be impacted too much by the activation of the openIMIS-AI module
Claim
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AI-based Adjudication System
Use cases
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AI-based Claim Adjudication Status
The following state diagram from Figure 1 corresponds to the Claim fields status with the updated adjudication process.
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Figure 1. Claim state diagram for the updated claim adjudication process
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AI-based Claim Adjudication Process
The following activity diagram proposes the updated adjudication process.
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Contribute to Claim Review Search with Medical Item/Service and Service filtersListening for <<signal_mutation_module_after_mutating>> SubmitClaimsMutation and prepare AI-categorized filters
Prepare the new checked claims for AI categorisation by adding custom fields (i.e.
was_categorized
)Contribute to Claim Review Search based on the custom fields (i.e.
was_categorized
)Push the claims Push Claims to Claim-AI module based on scheduled task and/or event-based activation and update claims Claims based on the response
Reports claim Claim adjudication misclassifications
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Claim.json_ext.claim_ai_quality.was_categorized = true Claim.json_ext.claim_ai_quality.request_time = Claim.ValidityFromReview Claim.json_ext.claim_ai_quality.response_time = Claim.ValidityFromReview ClaimService.json_ext.claim_ai_quality.ai_result = ClaimService.ClaimServiceStatus ClaimItem.json_ext.claim_ai_quality.ai_result = ClaimItem.ClaimItemStatus |
Module Configuration
Claim-AI Module
Claim-AI Responsibilities
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Self containing REST API
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Accepts FHIR R4 Claim and reply with FHIR R4 ClaimResponse
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Clean the data and prepare it for the AI model
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The following module configuration is accepted:
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{
claim_ai_url: string // URL of the openIMIS instance running Claim-AI module. Default: ""
event_based_activation: boolean // True if the checked Claims are sent to Claim-AI module immediatly after check. Default: False
} |
FHIR Contained Resources
FHIR Contained Resources feature (https://www.hl7.org/fhir/references.html#contained) allows to integrate the referred resourced. In our case for FHIR Claim, these are Patient, Condition, Medication, HealthcareService, Practitioner, ActivityDefinition.
Because AI-model is requiring information from other resources referenced by the Claim, these resources must to be accessible in the POST call sent by claim-ai-quality module.
The mechanism to build Claim resource with Contained Resources is to be developed in the openIMIS FHIR R4 module.
The construction based on Contained Resources should be possible based on query variable contained=true/false
. Default false
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Custom Claim Review Search Filters - Frontend
The following contributor filters to claim.ReviewsFilter
are defined:
ClaimFilterMedicalItem
allows Medical Officers to filter the Claims list based on a specific Medical Item (only one from autocomplete list)ClaimFilterMedicalService
allows Medical Officers to filter the Claims list based on a specific Medical Service (only one from autocomplete list)ClaimFilterAIProcessed
allows Medical Officers to display or hide the non AI-processed Claims (checkbox, decision if this is hidden or not )
AI Categorisation Misclassification Report
A report is generated that provides the following information (based on manual reviewed Claims ):
accuracy scores
number of True Positives results
number of True Negative results
number of False Positive results
number of False Negative results
Decision: should this report be a webpage or a PDF
Claim-AI Module
Claim-AI Responsibilities
REST API accepting FHIR Claims to categorize them based on a ML model
AI-model execution
REST API
The Claim-AI module will define one endpoint that will receive the FHIR Claim Bundle to be adjudicated. The base URL for this module is /claim_ai
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Call: POST /claim_ai/Claim
Body: FHIR R4 Claim Bundle with Contained Resources
Response: FHIR R4 ClaimResponse Bundle |