INTRODUCTION TO THE NATIONAL HEALTH INSURANCE INFORMATION SYSTEM

INTRODUCTION TO THE NATIONAL HEALTH INSURANCE INFORMATION SYSTEM OF TAIWAN Presenter：Sun, Hau-Chuen Information Management Division, Bureau of National Health Insurance, DOH, Taiwan 2013/05/16 http: //www. nhi. gov. tw 1

AGENDA u Overview u Automated Data Collection u Data Warehouse (Decision Support) u Information Sharing & e-Services u Smart Card http: //www. nhi. gov. tw 2

OVERVIEW - BNHI IT STATUS IT responsibilities： - Support Business demands - Plan, Develop and Operate BNHI Information system IT people： 155（about 5. 5% of BNHI employees） Annual IT budget of 2012： 0. 3 billion NTD（10 million USD） http: //www. nhi. gov. tw

NHI System Framework (Data Flow) BNHI Claim data Smart Card Premiums Payments Healthcare Services Insured Copayment Providers 4

NHI DATA PROFILE l l l THE NUMBER OF GROUP INSURANCE APPLICANTS： 700, 000 THE NUMBER OF BENEFICIARIES： 23 million the rate of enrollment switching per month： 8%-10% THE NUMBER OF HEALTHCARE PROVIDERS： 25, 000 THE NUMBER OF CLAIMS FOR OUTPATIENT VISITS PER MONTH： 31 million l the number of medical orders per month ： 116 million THE NUMBER OF CLAIMS FOR INPATIENT CARE PER MONTH： 260, 000 the number of medical orders per month ： 16 million http: //www. nhi. gov. tw 5

NHI NETWORK ARCHITECTURE DOH Government Service Network BNHI Administrative enforcement agency BNHI VPN Branches Government agency Internet Group insurance applicants District administration office Providers KIDC Insured http: //www. nhi. gov. tw 6

UTILIZING INFORMATION SYSTEM FOR BUSINESS EFFICIENCY IT people Health care providers Developing , Maintaining Medical Claims Payment Group Insurance Applicants Information System Internal users Office Automation / Decision Support System Enrollment underwriting Electronic data exchange Internet The Public External outsiders http: //www. nhi. gov. tw 7

BNHI APPLICATION SYSTEMS BNHI Information System Revenue Payment Integration Administration • Underwriting • Medical affairs • Human resource • Financial management • Fee schedules • Data warehouse system • Community insurance • Drug formularies • Smart card system • Information • On-line enrollment data • Medical reimbursement Security/Auditing exchange system • Global budget • Statistics system monitoring • Office automation • IT request management • Official document management • Utilization analysis & Provider profiling http: //www. nhi. gov. tw 8

AUTOMATED DATA COLLECTION – BENEFITS • Reduce administration costs • Better data quality • Fast Data processing Success Tip: Make Standard Ø Ø Ø Single-payer payment system Unified claim form (data format) Standard coding table http: //www. nhi. gov. tw 9

ENROLLMENT DATA FLOW Channels of Premium payment： • Bank account • ATM • Online network • Convenience store Enrollment data Premium calculation • Electronic Data media • Network • Paper Subsidy or waive premium Pay premium Overdue payment 10 Update enrollment data Data warehouse system

CLAIM DATA FLOW （ days） 60 Global budget （ 15/30 days） Claim reception channel : Network Media Paper (few!) Provisional payment Based on previous deduction rate Claim review • Automatic adjudication rules • Profile analysis • Professional Peer Review 11 Approval & payment Data Warehous e system Calculate point value

METHODS TO IMPROVE CLAIM DATA QUALITY Fast payment remittance for electronic claim Provide various data claims & exchange e-service ü the rate of electronic medical claims is almost 100% (since 2001) Provide data pre-check services Early error reported, providers can re-check and modify data before claim. Help Hospital Information System detect possible system malfunction. Phased-in policy to accept only 100% correct claim data to proceed the following payment procedure. http: //www. nhi. gov. tw 12

Data Warehouse System - Different People use Different Data Informational Data Operational Data Year Pharmacy claim underwriting Month Day Medical claim Integrated data sets Application Oriented Limited Integration Constantly Updated Current Values Only • Supports Day-to-Day Operations • • DW ：a large-scale database • Subject Oriented used for reporting • Integrated analysis. • Non-Volatile • Values Over Time • Supports Management Decisions Operational and Informational Data are Fundamentally Different!! 13

DATA WAREHOUSE SYSTEM FLOW • Data Dictionary • Common Application Data Warehouse Database Analytic Tools ETL Tool Payment Data Revenue Data Detail Data • Data cleansing • Transformation • Consistence Subject-oriented Data Model External Data Source Information Supply Gateway System (ISGS), Data Process Data Warehouse • Application Program • Stastics tools, eg. SAS, SPSS, …etc • Bi tools Access Approach Enterprise Information Analysis System (EIS) : Query & Report Information Output 14

EIS APPLICATIONS SAMPLE Medical utilization-(AGE-SPECIFIC UTILIZATION OF MEDICAL SERVICES) patient Age group Treatment fee Year/Q Medical utilization-disease Provider’s type Gender Service type Treatment #

INFORMATION SHARING & E-SERVICES – FOR DIFFERENT GROUPS Portal for the providers http: //www. nhi. gov. tw 16

E-services for Healthcare Providers u An integrated web portal for providers u Only VPN accessible Secure login mechanism Query for medical claim rules and laws Systems operation manuals download services Data exchange (under authentication for security and privacy) Medical claim data files upload Query for medical claim related business status Query for smart card data / PACS processing status Fast link to other DOH organizations/applications 17

Web Portal for the Public http: //www. nhi. gov. tw

E-SERVICES FOR THE PUBLIC For general NHI business Internet accessible Query for medical providers and treatment info. Query for BNHI related laws, regulations and statistical tables/figures. Sign up for BNHI’s front desk service Apply for smart card issuance Update premium paid status Query for BNHI internal processing status of reimbursement of the self -paid medical expenses Android and i. OS app for smart devices users On-Line query (under authentication for security and privacy) Provide personal enrollment update data information Provide summarized personal medical visit data 19

Query for Medical Providers http: //www. nhi. gov. tw

Query for Paid Medicines http: //www. nhi. gov. tw

Smart Card System – Project Infrastructure Healthcare smartcard Healthcare professional card SAM CARD ds ar C Re ad ers Co mpu S oftw ter & are vices Ser Operation Component Networking Project Launched in 2004! 22

HEALTHCARE SMART CARD Explicit Data Anti-counterfeit printings 邱文達 Name ID number Date of birth Photograph (optional) G 123456789 89/12/31 1234 5678 9012 Basic data：name, ID, birth date, expired date data Insurance data：hospital ID, inpatient /outpatient expenditure, co-payments, data exemption status, medical visit data Medical care data：major examinations, chronic disease/outpatient prescriptions, data allergic medicines Public health data：childhood vaccination records, organ donation, DNR data 23 http: //www. nhi. gov. tw

SAM & HPC Security Access Module Health Professional Card (free for every hospital and clinic) (Health Certification Authentication) 24

SMARTCARD DATA FLOW Hospital IDC Patient Reader’s SAM Authentication (on-line) Card renew Daily upload (medical visit records) Medical Visit Rewrite Medical visit record 25

MEDICAL TREATMENT WITH SMART CARD 邱文達 HIS http: //www. nhi. gov. tw

BENEFITS Different paper cards consolidated into one card Significant social costs savings (administrative, time, commuting costs…) Simplify administration/management process A simple and portable personal electronic medical record summary Provide instant information on “where and when” patient received services Promote hospitals and clinics to further computerization and upgrade to better information system Keep medical visit data on real-time basis to prevent fraud and abuse 27

Thank You for attention From the website of Tourism Bureau, Republic of China (Taiwan) http: //www. nhi. gov. tw 28