Kick-Off Workshop openIMIS

13-15 FEB 2018, FRANKFURT/ESCHBORN

Participants:

Caren Althaeuser (Path/JLN), George Atohmbom Yuh (BEPHA, Cameroon), Sosthenes Bagumhe (MOH, Tanzania), Saurav Bhattarai (GIZ Nepal), Sweta Purushotam (Consultant, GIZ Nepal) Patrick Ernst (Consultant), Lucas Gervas (PORALG, Tanzania), Christopher Gideon (HSSP, Tanzania), Sebastian Kuhn (GIZ), Gerald Laezer (KfW), Carl Leitner (Path/Digital Square), Michelle Lessa Nascimento (GIZ), Silvery Mgonza (NHIF, Tanzania), Jiric Neme (Swiss TPH), Alicia Spengler (GIZ), Siddharth Srivastava (Swiss TPH), Michael Stahl (GIZ), Hans van Hoppe (Exact), Alexandre Vanobberghen (Swiss TPH), Franz von Roenne (GIZ), Uwe Wahser (GIZ Kenya), NHIF Kenya

Day 1 (Feb 13): Coordination and Technical Meeting

Agenda:

10:00 - 12:30: Digital Square Technical Proposal

12:30 - 13:30: Lunch

13:30 - 14:30: Preparatory coordination meeting

14:30 - 17:30: Opening of openIMIS system architecture

Preparatory coordination meeting

On the 13th a smaller group of participants from Swiss TPH, GIZ, Digital Square + consultants discussed jointly the work plan of Swiss TPH for the “Maintenance of openIMIS in 2018”. Further details of the work plan for 2018 Q1-Q4 have been discussed and defined.  Focus was laid on (a) community tools and their set up,(b)  the demo version and the main requirements it needs to serve, (c) Implementation Starter Kit and the usefulness of an interaktiv Moodle installation to host corresponding training materials as well as the Release Cycle Management for the Master Version of openIMIS.

Open

OpenIMIS system architecture

SwissTPH as well as Jiric Neme presented the actual system architecture of MS IMIS as well as opportunities and challenges for opening the system under the following topics: (a) possibilities to use external DWHs;(b) HL7 FHIR use case for OpenIMIS and (c)  import/export functionalities.Full presentations available here and here.

Day 2 (Feb 14): Common information basis

Agenda:

08.30 - 09:00: Arrival and coffee

09:00 - 09:30: Welcome

09:30 - 10:30: Current status and system architecture of master

10:30 - 10:45: Coffee break

10:45 - 12:15: Window into the future

12:15 - 13:15: Lunch

13:15 - 14:15: openIMIS governance structure

14:15 - 14:30: Introduction of the overall workplan

14:30 - 17:30: openIMIS workplan 2018

openIMIS Initiative

Alicia Spengler (GIZ) opened the second workshop day by reminding that there is a functioning IMIS implemented in Tanzania, which has been replicated and adapted in Cameroon and Nepal. Swiss and German Development Cooperation respectively, being present in different countries, perceived IMIS as a possible basis for a global system building upon national experiences and expertise. Based on synergies in this thematic area, Germany and Switzerland pushed for a joint initiative aiming at the implementation of such systems in various countries and meeting the high demand for information systems for health insurance and other financing mechanism. The initiatives’ vision is that all countries will have the insurance data they need to effectively manage their social insurance schemes, therefore contributing to Universal Social Protection. As, for now, the project is planned and budgeted for three years and setting up the platform until 2019 will be quite a challenge, the initiative is currently looking for additional funds and business models to be able to extend the time frame.

openIMIS update

Speakers: Alex and Jiri (Swiss TPH, full presentation here)

• Work plan for 2018 for the transition of IMIS to openIMIS and maintainance of the openIMIS product is developed

• Tools selected: Github (data storage), Jira (issue tracking), Confluence (documentation management); should be available soon; Readthedocs hasn’t been picked in the procurement process, but should be easily integratable into Confluence

• Demo server setup (being procured); will make use of live examples

openIMIS master version

There is an openIMIS master version (17.5.4) implemented, and limited customizations can derive from it. Derivations so far, are: CHF-IMIS (Tanzania), NHIF-IMIS (Nepal), BEPHA-IMIS (Cameroon) and some pilot installation in DRC.

Key features:

• Regional level of insurance products and operational support (besides district and national levels)

• Capitation

• Catchments areas of health facilities

• Field activity of enrollment

• Mobile app for enrollment officers (Android based)

• Moving of territorial units

• Bilingual – English, French (possibility of switching, but primary language has to be defined)

• Claim management through mobile phone app, online format and offline form

• Other minor enhancements

In the derivations, language is adapted to local terms and, depending on the context, openIMIS can be offered in a second language as well (e.g. Swahili in Tanzania). Other functionalities, such as drop-down menus, communication tools (e.g. SMS gateways for enrollment info), insurance numbers (Tanzania: 9 digits, Cameroon: 12 digits) and escape procedures, can be easily adapted in the resource files.

It is important to make sure that all country specific features are reflected in the master version, as openIMIS will be later maintained on the master version level. Once openIMIS is implemented, it is possible to operate different insurance schemes.

Country specific versions

• CHF-IMIS Tanzania – release 17.5.4 derived from master version

• Implementation in 2012

• Operating 3 community based insurance schemes

• Using mobile phone (2300 users)

• Used in 3 provinces, 25 districts

• BEPHA-IMIS Cameroon – release from 2016 not yet derived from master version – launch of upgraded national version planned for spring 2018

• Will migrate data

• Mobile phone apps not used yet

• Used for the whole insurance scheme

• NHIF–IMIS Nepal – release from 2016, not started yet with the migration to the Master Version

• Mobile phone apps are used

Nepal, IMIS implementation

Speaker: Sarauv  Bhattarai (GIZ Nepal, full presentation here)

• 2013-2014 – introduction of social insurance policy; requirements analysis

• Customized Nepal version (looked at using Cameroon vs Tanzania as base; features are used out of both)

• 2015 – slow down, other country priorities due to earthquake

• 2016 - new push from government

• SHI launched in Nepal

• 4 enrollment cycles per year, started enrolling April

• IMIS used as the MIS of NHI from the beginning

• System is used for voluntary health insurance only

• Set up:

• One central IMIS server at government integrated data center

• One smartphone per enrolment assistant – for enrolment and renewals (2300 with phones)

• Smartphones and computers at health facilities for eligibility check and claim entry. No claims through phones (though functionality exists); faster to use computer at facilities

• IT team in Kathmandu

• Modifications:

• Presentation layer. Design level modifications; documenting in an issue tracking system.  Will upload/share, once Jira is operating.

• Analysis dashboards – dump into a database for visualization/dashboards. Mostly operational

• No changes to business logic. Don’t want to do any forks; supporting master version.

• Use of ICD term field, rather than only code → facilitation for health professionals

• Migration to master version:

• Nepal is willing to do so; want to use opportunity for upgrade and take first steps to get prepared

• Documenting all modifications they’ve made so they can be made in the master version

• Developing test scenarios

• VPS test server secured

• Launch will need to coincide with enrolment cycles. Nepali calendar is constant challenges/requirement; difficulty to fix it in the system.

Window into the future

openIMIS governance structure

Speaker: Carl Leitner (overview available here)

Other successful open source mechanisms:

• OpenMRS: has board of directors & leadership team, as well as OpenMRS community and OpenMRS incorporated (trademark and copyright); ca. 40 country representations; used for management of clinical data

• OpenLMIS: has governance committee (for strategic decisions), product committee (for project management), technical committee (for operating the tasks); used for logistics and operational business flow

• DHIS2: getting started with their governance structure; have advisory board; deployed in 50-70 countries

openIMIS:

• Steering group consists of SDC and BMZ (donors of initiative); other donors, country representatives and others will participate; GIZ acts as the steering group facilitator → strategic decisions

• TAG (technical advisory group): open group, will be called in when needed

• Product Committee: program coordination desk, IT & Product Team (Swiss TPH)

• Community of Practice

It is questioned where the partner countries will be placed in this organigramm, and whether the structure is based on a sustainable business model.

There is a need for further discussion on the governance structure.

openIMIS work plan 2018

The work plan has been developed according to the TOR of Swiss TPH as service provider to the OpenIMIS Initiative:

• Part 1.1: tools are purchased, Github will be accessible under GIZ’s organization with different logins

• Part 1.2: Saurav is in charge for procurement; the uploaded demo version should be tested

• Part 2.1: the implementation consultants are preparing the documentation

• Part 2.2: there are discussions on the choice of license for creative commons; documentation material will be uploaded on an online tool; more information from the countries is needed

• Part 2.3: information will be compiled as a reference point for other countries

• Part 2.6: Transition to the master version is not very advanced yet. TPH will clarify open queries, but migration itself will be done by the country teams

• Part 3.2: There are some recurring activities for every release cycle

Due to time matters, the discussion on the openIMIS work plan has been postponed.

Day 3 (Feb 15): Technical design

Agenda:

08.30 - 09:00: Arrival and coffee

09:00 - 09:15: Welcome and reflection of day 1

09:15 - 09:45: The importance of global networks

09:45 - 10:30: OpenHIE and Digital Square: opportunities

10:30 - 10:45: Coffee break

10:45 - 12:30: National system architecture

12:30 - 13:30: Lunch

13:30 - 16:00: Two parallel sessions: Session A (Technical) and Session B (Functional)

16:00 - 17:00: Wrap up and closing

Two more participants joined the workshop: Franz von Rönne (GIZ) & Gerald Laezer (KfW)

The importance of global networks

Speaker: Caren Althaeuser (Path, full presentation here)

• Joint Learning Network

• Composed of 23 member countries and country core teams

• Steering Committee decides on annual goals

• Supported by Rockefeller, Gates, Wipro

• IT Team is facilitated by Path

• Existing Tools

•  

  •  

    • Common Requirements for health insurance information systems - developed in 2011 using CRDM (common requirement development methodology) for creating a business matrix

    • Using Health Information Systems

    • Chicken & Egg

• Proposed activity for 2018 = Community of Practice for Health Insurance Information System for learning and sharing purposes

•  

  •  

    • Vendor/software tool neutral

    • Could be used for further developing requirements to feed into release cycles of openIMIS

Speaker: Franz von Roenne (GIZ)

• Providing 4 Health (P4H)

• Exits for 10 years, active on the country level & part of a network working towards UHC2030 as a specific form of health coverage foreseen in the SDGs; there are contact persons located in the countries and staff is going to be deployed to the World Bank as well

• openIMIS needs to be systematically linked with the broader digitization of the countries;

• Key network areas:

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  •  

    • Service Provision (UHC2030 working group on fragility)

    • Legislation + Regulation (Health Governance Collaborative)

    • Data Exchange (Health Data Collaborative, in particular Digital Health & Interoperability WG; OpenHIE)

    • Risk Assessment

    • Early Warning (WHO, CDC)

    • Risk Protection (P4H)

    • Quality Control

    • Research

    • Financing (P4H - support countries in developing health financing strategies)

National Systems - eHealth strategy

Nepal:

Speaker: Saurav Bhattarai

• Endorsed eHealth strategy in 2017; until the end of the Nepali fiscal year (July 2017), they want to focus on structuring their eHealth architecture / roadmap and developing standards and interoperability

• IMIS is using own codes for claims, ICD-10 for diagnostics

• This year have contracts to develop Health Facility Registry (unique ID/code) .  

•  

  •  

    • will cover both public and private

    • will be mandatory - not yet endorsed with policy/regulation for financing

    • Health Unit wants to make it mandatory for any Health Information System component must use the same unique codes for the FR

• WHO supports development of health workforce registry.  Starting with councils - using iHRIS.

•  

  •  

    • Developing electronic attendance system

    • Electronic grievance handling system for citizens to report on quality

    • Want to build out eHealth/informatics capacity within MOH (trainings, certifications, stand alone courses, modules in MPH/BPH programs)

    • National ID and CRVS is trying to get started

Tanzania:

Speaker: Sosthenes Bagumhe (MOH Tanzania, full presentation here)

• eHealth Initiative - national integrated health information system (NHIS)

•  

  •  

    • Avoid fragmented / pilot systems and number HIS silos

    • Problem with pilots - what happens when money runs out?

    • Have 2013-2018 National eHealth Strategy

• Established eHealth Steering Committee to:

•  

  •  

    • control donors and implementing partners

    • evaluate proposed projects to see if it is a worthwhile investment

    • Governance to ensure that projects are really needed and not based on political demands

    • Establish eHealth standards rules and protocols for information exchange

• Have 128 digital health systems across the sector - not a good situation

• Health Sector Strategic Plan 2015-2020

•  

  •  

    • Says to embrace ICT

    • MOHCDGEC will stimulate development and guide interoperability of systems

• Interoperability - using HealthELink for interoperability layer

• Want to avoid peer-to-peer data exchange  

• DHIS2 is integrated with RBF, VIMS, eLMIS, IDSR systems- currently Peer-to-Peer

• HealthELink - is an Enterprise Service Bus

•  

  •  

    • Aim to link to systems such as Plan Rep, LGA Epicor, NHIF/CHF, NIDA, RITA CRVS, Logistics (eLMIS, MSDE9, IHFeMS), Immunization (VIMS, TimR), HMIS (DHIS2), Hospital Management.   Links to OpenHIE architectural components (e.g. HRHIS, HFR)

    • Multiple data transport methods are supported

• Current implementation use cases

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  •  

    • Clinical level data exchange for hospitals (medical services received, death by disease, bed occupancy, hospital revenue)

    • Aggregate data exchange to DHIS2

    •  

      • Link to HFR

      • eLMIS: count of stock received, consumed, stock on hand at facility level

      • VIMS: monthly counts of children vaccinated

      • E9: count of stock received, consumed(distributed), stock on hand at MSD

• Have Developed Investment Roadmap with Data Use Partnership

Kenya:

Speaker: Uwe Wahser (GIZ) and colleague (NHIF Kenya)

• 2014-16 GIZ program health financing, support

• 2015-16 GIZ program to do statistical database on top of NHIF database for aggregate data warehouse

• 2017-19 limited support to data warehouse

• 2018-  KfW investments starts

• Not looking at openIMIS directly, but perhaps an option for the future

• GIZ current work

•  

  •  

    • supporting 10 health facilities in each of 4 counties

    • Did a health facility assessment

    • Sophisticated curricula and many local implementers

    • Has 2015-2030 eHealth Strategy

    • Facilities have donor driven implementations

    • Very diverse b/c of donor and health verticals - multiple systems in same hospital which are not connected.

    • Have guidelines for eHealth interoperability

    • NHIF is national provider for health insurance. Current mandate is for in-hospital, out-patient and informal sector

    • NHIF has mandate for insuring every Kenyan in next 4-5 year; NHIF shall become a law

    • NHIF has centralized database (IBM) w/

    •  

      • thin application layer for UI,

      • reports.  

      • DB is accessible from all NHIF branches

      • Powerful but needs better structure

      • Hospitals can do eligibility verification

      • Allow mobile payment of insurance fees

      • Have biometric identification

      • Have ID cards

    • Looking at how they can better use high volume of data

    • Updating eClaims process?

    • Trying to automate all their systems

    • Mandate:

    •  

      • Registration

      • Receiving of fees -  already automated (mobile, online)

      • Filing Claims - hospitals can file

      • Payment of claims - current work for mPayment

    • Have issues with member retention, especially after receiving the funds

    • There is also a National Hospital Insurance plan (not integrated yet with the MOH’s strategic plan)

OpenHIE & Digital Square

Speaker: Carl Leitner (Digital Square); complete slides are here.

• OpenHIE is a blue print, an initial sketch to make systems interoperable (component layer, services layer and external systems)

•  

  • Client registry (storing all information centrally)

  • Shared repository for all clinical information

  • HMIS as basic indicators for public health sectors

  • Facility registry (master list of all facilities, identified by an ID)

  • Health worker registry (who the health workers are? Are they properly trained?)

• Interoperability layer (authentication, ILR, entity matching)

• There is a lot of consensus on the value of OpenHIE among the user countries:

•  

  • A community of communities (exchange among users)

  • Standards

  • Software

• OpenHIE is a architectural reference model. Countries are free to choose their applications for each described system role. Tanzania is not using OpenHIE (the reference application of openHIE) as interoperability layer, but: http://www.wnyhealthelink.com/

• Could openIMIS become the “reference system” for Health Insurance in openHIE?

Example of a health insurance architecture compared to openHIE.  The goal will be to have the openHIE community develop a view that incorporates both together so that insurance will be represented in the openHIE.

Digital Square: in the midst of its current funding phase (funded by Gates Foundation & USAID); when openIMIS gets to a point where it can be applied to different countries, it is more available for financing.

Technical Roadmap

Speaker: Patrick Ernst (Consultant, GIZ)

To-dos as follow-Up to roadmap discussion:

1. Upload current Nepal version to GitHub, identify differences

2. Get requirements from Nepal and Tanzania on the issue queue

Principles for the transition:

• Collect orientation on strategic direction: openness for the needs of the users & broad sounding board (partners JLN/OpenHIE)

• Prioritize current customer base

• Carefully transition technology; not starting with the core of the system, but the satellites; changes coming from the outside

• Re-use existing modules, libraries, standards; benefit from development happening in openHIE.

Session A: Technical group

We do currently use a Microsoft IMIS version, there are discussions whether it should be replaced in the future with another technology. What are possible solutions/restrictions/complexities? Is all this reflected in the business rules?

Understanding the current complexity in the business rules, e.g. in:

• Initial configuration

• Member registration

• Pre-authorization

• Claims processing

• Post claims-processing analysis

Data management system:

Client registry (demographic info) → ID number → data transferred to openIMIS

Business rules are going to be preserved, but we open the system architecture! → expanding the schemes goes along with complexity

Some key points to consider (for flexibility):

• Custom defined attributes

• Custom defined workflows

• Custom defined business rules

Session B: “Non-technical” group

Key points:

• Cost / Training of users, for interoperability → often underestimated; Capacity Building

• Regulation on which system should be used

• Marketing strategy needs to be clear how product can be used

• openIMIS being part of UHC package

• Identify needs for the system (awareness raising)

• P4H can support this process

• Is the product looking for the market or the market looking for the product

• Have more functionalities to make product more visible; Which are the functionalities which make the product attractive, being looked for

• Integrating IMIS and other systems (HMIS, Epicor,...)

• Establish partnership with Mobile company  - USSD technology (to check status of the insurees, e.g. on enquiry, enrollment); SMS Gateway integrated with IMIS

• Have a strong system support (24/7)

• Improve system performance

• Figuring out the funding model

• Partnership with universities and research (analytics of insurance data, how is the data used?)

• Support for policy / scheme design → need of an overall eHealth strategy

• How to set up the secondary market of implementing partners (certification, who does implementations, bad implementations lead to bad reputation)

• Reliability of IT solution (if insurer has faith in it) → does the system deliver what it is needed for?

• Make a business case (Canvas)

• Benefits instead of revenue

• The download is free, but still you need to make investment happen so it can be run

• Comprehensive e-payment solution

• Make openIMIS usable for other insurance/finance products (e.g. microinsurances) → increasing the potential customer base, not only national insurers; defining user profiles

Additional Resources

• List of national ehealth strategies

• IMIS bulk upload

• openIMIS database and data warehousing