Flow Charts of Clinical process and claim adjudication for the input of the digital system. The database structure of digital development depends upon these process, therefore, the understanding of which is very essential.
- The Ministry of Health or Department of Health must assure that the network of all Basic Health Unit (BHU)/Rural Health Unit (RHU) are functional 24/7. It is a first-level health facility. Every patient must approach to his nearest BHU/RHU in the locality. These are units where patient can get primary health care facility and then may be referred to a Secondary Care Hospital for further treatment. In rural areas, the distance between village and Secondary Care Hospital is concerned. When the patient will get primary health care at BHU/RHU and become some stable can be moved easily with low risk to Secondary Care Hospitals. All Out Patient Disease (OPD) patients may be treated in BHU/RHU. In this way, the un-necessary burden of Secondary and Tertiary Care Hospitals may be reduced. Rural population specially women may prefer BHU/RHU to get maternity treatments than delivering baby birth at home due to nearest to their homes, avoiding transportation cost and ignoring unavailability of male attendant due to sectarian and religious issues. Therefore, the true implementation of UHC is mostly depends up on the full fledge functioning of BHU/RHU 24/7 at root level of the population of a country. Pakistan already has a wide network of this first-level health facility but the need is to be functional.
- Business Rules
- Each visit of the patient to health service must have a unique identity in digital development.
- Each visit of the patient to health service either for medical or non-medical purpose must be recorded in database for future analysis.
- Lookups
- Purpose of visit of the patient or beneficiary must be predefined in lookups table not user defined as per indicators to maintain uniformity and reuse of indicators in analysis.
- At the reception desk, the validity of the patient with the family tree will be checked i.e. either the patient is a valid member of family as per family definition or not and is balance amount is sufficient for this treatment as per family or member specified amount for primary, secondary and tertiary treatment. The purpose of the visit will be selected from available list so that every visit may be recorded with a unique visit ID by the system.
- Business Rules
- The status of the patient to be admitted should be not be Already Admitted in an other hospital.
- Balance amount for such treatment should be sufficient either per family or per member of family basis.
- If balance is insufficient for such treatment and the patient is a valid member of family then the system should adopt the mechanism of payment out of pocket or from UHC Reserve Fund if any because the patient may not be refused to get treatment.
- A long text field/column for user defined patient's history.
- If purpose of visit is non-medical then above checks should be skipped.
- Lookups
- Presenting Complaint.
- If the purpose of the visit is medical then the patient will be referred to a concerned doctor for check-up. If Doctor have an access to the digital system then will directly feedback such as initial diagnosis, suggesting procedure/treatment and its mapping with ICD-10 Codes etc., to the system otherwise the patient will go back to the desk for feedback. In this situation the Doctor appointed in UHC project will map the procedure with ICD-10 Codes. This mapping will be more helpful in future analysis for international purpose.
- Business Rules
- ICD-10 Codes will only be selected by the user for mapping with prevailing practice in hospital (procedure names).
- Access of digital system to the Doctors should also be available on mobile or tablets so that they may map their respective patient's cases with ICD-10 Codes at any time and on any place where they feel easy to do that.
- Lookups
- Initial Diagnosis.
- Line of Treatments
- All Lab Tests
- Type of medicines
- Medicines
- Doses
- How many days the patient should use the medicines.
- Weight of patient
- Hight of patient
- Blood Pressure, Sugar etc.,
- If treatment is covered under UHC as per case history and initial diagnosis then the primary healthcare cases will be treated in BHU/RHU. The secondary and tertiary cases will be referred by the doctor.
- If the balance under UHC is less than the treatment cost then the remaining amount will be paid by the patient through self-finance/out of pocket as mentioned above or debited to the UHC Reserve Fund whatever is decided in the policy of the Government.
- When the above checks are fulfilled, the system will authorize the patient for IPD or OPD.
- Already generated unique visit IDs will be marked as IPD, OPD, Postnatal, Antenatal, Vaccination, or Follow-up, and treatment of patients will be started.
- Business Rules
- Cost of treatment will be of two types.
- Package Cost i.e. all treatments of OPD or IPD will be packaged by one amount.
- Service Cost i.e. each service provided by the hospital will be charged separately.
- Availability of Amount in Patient's Account
- Sufficient Balance Available Ok
- Insufficient Balance for treatment to be done or in case of complication during current treatment of diagnosis or in case of emergency or trauma cases.
- Payment of access amount by out of pocket or
- Payment of access amount by UHC Reserve Fund as per policy.
- The doctor will decide to discharge the IPD patient. He will prepare a discharge plan in the system.
- The concerned unique visit IDs will be marked by discharge type.
- Feedback from patients will also be entered against that unique visit IDs or a video/audio of patient will be recorded in database.
- Business Rules
- Without concerned Doctor no one can discharge the patient.
- Only Doctor would have access for preparation of discharge plan.
- Lookups
- Discharge Types
- Discharge Plan
- Feedback from patient
- When a unique visit ID is marked by any above discharge type, a claim will be generated by the system, and all supporting documents and ICD codes will be checked and verified by the reception desk and doctor.
- After checking and verification by authorized officials, the claim will be intimated or reported to the relevant insurance company office for processing and payment to the service provider.
- The claim will be escalated for approval, preparation of payment voucher, prepayment internal audit, and preparation of cheque for full and final payment.
- Further flowchart for sub-processes may be developed as per the country’s standard.
- Serial numbers represent steps of claims in a paperless environment.
- There should be 5 types of dashboards or roles in Health Management Information System (HMIS) or digital development and artificial intelligence.
- Here the digital envelope (scan copy of all supporting documents) will be prepared at the service provider level at its resources.
- Hospital Dashboard means a Dashboard for Service Provider’s Management.
- Committee Dashboard means a Dashboard for claim approving authorities.
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