This page presents the analysis of AI algorithm’s input data model. First, we analyse the openIMIS data structure and fields representing the information used by the Medical Officer to adjudicate a claim. Second, we look at the openIMIS-FHIR mapping and extract the minimal required FHIR resources and fields to feed the AI algorithm during the learning, development and test processes. Because the openIMIS FHIR module do not map all openIMIS fields to FHIR resources, we are limited by the current FHIR-openIMIS R4 mapping.
Claim adjudication - openIMIS entities and fields
Based on the openIMIS claim adjudication process, we are interested to identify the entities/tables and their fields that are used by the Medical Officers to review and categorise the items and services present in a claim.
openIMIS Claim Review Web Page
openIMIS Database Tables
Diagram
The following database diagram displays openIMIS tables and their relations. The analysis is centred on Claim and identifies other entities in relation to a Claim and used in the adjudication process.
Fields definition
From all the fields that the Medical Officers are using when reviewing claims, we mainly need to identify entities in relation to the Claim. From some entities (Diagnosis, HF), we might not require more than the identification fields.
The fields that will be taken into consideration from openIMIS database will be limited by the current openIMIS to FHIR mapping.
In the following tables, we list only the identified information/fields that we will consider as the input data model for the development of the AI algorithm and model.
tblClaim (includes tblClaimServices and tblClaimItems) | Claim
openIMIS Field | FHIR Field | Type | Description |
|---|---|---|---|
ClaimUUID / ClaimID | identifier | uniqueidentifier | Unique identifier of the Claim |
DateFrom | billablePeriod.start | smalldatetime | |
DateTo | billablePeriod.end | smalldatetime | |
DateClaimed | created | date | |
ClaimStatus | status | tinyint | |
Claimed | total | decimal(18, 2) | |
VisitType | type | char(1) | Emergency, Referral, Other |
tblClaimItems.ItemUUID / tblClaimServices.ServiceUUID | item.extension.productOrServiceReference | uniqueidentifier | Reference to Item/Service |
tblClaimItems.QtyProvided / tblClaimServices.QtyProvided | item.quantity.value | decimal | |
tblClaimItems.PriceAsked / tblClaimServices.PriceAsked | item.unitPrice.value | decimal | |
last visit to the same hospital (how many days) | Displayed on Nepal Claim review interface |
tblClaim → tblClaimServices → tblServices | Claim → ActivityDefinition
openIMIS Field | FHIR Field | Type | Description |
|---|---|---|---|
ServiceUUID | identifier | uniqueidentifier | |
ServPatCat | useContext.code | char(1) | decomposed in “gender” and “age” |
ServCategory | useContext.code | char(1) | “workflow” code |
ServCareType | useContext.code | char(1) | “venue” code |
ServType | topic | char(1) | |
ServPrice | unitPrice | decimal | |
ServFrequency | frequency | integer |
tblClaim → tblHF | Claim → HealthcareService
openIMIS Field | FHIR Field | Type | Description |
|---|---|---|---|
HfUUID / HfId | identifier | uniqueidentifier | |
HFLevel | category | char(1) | |
HFCareType | type | char(1) | |
HFSublevel | specialty | char(1) |
tblClaim → tblClaimAdmin | Claim → Practitioner
openIMIS Field | FHIR Field | Type | Description |
|---|---|---|---|
ClaimAdminUUID | identifier | uniqueidentifier |
tblClaim → tblClaimItems
Field | Type | Description |
|---|---|---|
ClaimItemStatus | tinyint | Item accepted or rejected |
QtyProvided | decimal(18, 2) | |
PriceAsked | decimal(18, 2) |
tblClaim → tblClaimItems→ tblItems
Field | Type | Description |
|---|---|---|
ItemUUID | uniqueidentifier |
tblClaim → tblICDCodes (Main and Secondary Diagnosis)
Field | Type | Description |
|---|---|---|
ICDUUID | uniqueidentifier |
tblClaim → tblInsuree | Claim.Patient
Field | Type | Description |
|---|---|---|
InsureeUUID | uniqueidentifier | |
DOB | date | Date of birth |
Gender | char(1) | Gender in codded format: e.g. M/F, 0/1 |
HFID | int | First Point of Contact |
tblClaim → tblInsuree → tblFamilies
Field | Type | Description |
|---|---|---|
FamilyUUID | uniqueidentifier |
tblClaim → tblInsuree → tblInsureePolicy → tblPolicies
Field | Type | Description |
|---|---|---|
PolicyUUID | uniqueidentifier |