GMSPB PICNIC Pharmacy Patient Validation

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GMS(P)B PICNIC Pharmacy Patient Validation
Electronic Claims/Reimbursement Prototoype

• David Piggott, Integrity Consulting
• GMS PICNIC Project Manager
• PICNIC Nordic Portals Conference, Copenhagen
• 13th March 2003

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Pharmacy Pilot Objectives

• To improve the efficiency effectiveness of
  pharmacy reimbursement
• To improve accountability - via the validation of
  a patients identity and eligibility for services
  at the point of service delivery
• To confirm the feasibility of the proposed
  technical solution

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Pilot Business Requirement

• Verify client identity/eligibility at point of
  service delivery (for all schemes)
• Patient-held swipe card/access to central index
• Drugs Payment Scheme
• Access/update family monthly running balance
• Handle reimbursement process more efficiently
• On-line claims
• Automate exception processing
• Incorporate business rules

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GMS Environment

• UNIX/Oracle Applications
• Central Client Eligibility Index
• Claims Payments System
• SeeBeyond eIndex and eGate Integration Broker
• Oracle Datawarehouse
• J2EE selected for GMS infrastructure development

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Pharmacy Environment

• 1,200 sites
• 3 main vendors
• Windows-based systems
• Moving to XML
• Stand-alone systems / small networks
• ISDN/Internet communications

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Pilot Technical Requirement

• Pharmacy systems access GMS CCEI CPS databases
• Online fast dial up secure access
• Batch high volume secure data transmission
• Integrate with Pharmacy application
• Requested by pharmacists
• Access components for pharmacy systems
• PIDS interface for CCEI

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Architecture
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Reimbursement
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PICNIC Components

• PIDS server
• PIDS Access component
• HL7 CDA XML Reimbursement messages
• Open Source Linux/Apache
• PICNIC Services
• PIDS
• Reimbursement
• Clinical Messages

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Common Components
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PIDS Component

• Person Identification Service Specification
• OMG
• CORBA/IDL
• Comprehsive interface for identifying a person
• PIDS interface built to GMS CCEI database
• Accepts UPCI number returns client demographic
  data DPS monthly balance

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PIDS Prototype Implementation

• Simple PIDS conformance
• IdentifyPerson and ProfileAccess interfaces
• EJB rather than CORBA
• CORBA Interface IN and OUT parameters specified
  using XML messages

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HL7 CDA

• HL7 CDA XML Header record
• Based on D6.2 Harmonised Message spec
• CDA XML Body Record based on MEDRUC EDIFACT
  Reimbursement message
• CDA XML messages sent from pharmacies to GMS via
  Access Component
• Middleware at GMS parses message and directs data
  to GMS CPS system

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Questions