1. 1 Background Recent years have seen remarkable technological advance in computing, with computer spreading over in usage to various areas of life. The enunciation of a new era in computing as regards to health care has emerged to play a prominent role in the delivery of healthcare. The application and use of machines and computer-based technologies in health care have undergone an evolutionary process.
Advance in information, telecommunication, and network technologies have led to the emergence of a revolutionary new way of health care delivery leading to new experience and knowledge that cross traditional disciplinary boundaries in the fields of information technology and health care, along with emerging knowledge that promote evidence-based medicine, e-medicine and remote e-health service (TAN, 2005) Computer have been employed in healthcare services and its use for healthcare delivery seems noticeable after finding out that it reduces the drudgery of work that characterizes the manual system.
Also the need to monitor population health, insurance level and provide accurate, adequate and timely information for management decision at all level within and outside the health sector were supported to be of importance in providing healthcare delivery service which the computer is known to handle efficiently. Health care provision in Nigeria is a concurrent responsibility of the three tiers of government in the country. However, because Nigeria operates a mixed economy, private providers of health care have a visible role to play in health care delivery.
Health Insurance is designed to pay the costs associated with health care. Health insurance plans pay the bills from physicians, hospitals, and other providers of medical services. Countries with national health insurance generally consider access to health care to be a basic right of citizenship. Historically, health insurance in Nigeria can be applied to a few instances: free health care provided and financed for all citizens, health care provided by government through a special health insurance scheme for government employees and private firms entering contracts with private health care providers.
The National Health Insurance Scheme (NHIS) was launched by the Federal Government on June 6th 2005 as a health welfare scheme aimed at providing quality healthcare at an affordable cost to the general populace. It currently covers the employees of the Federal Government Civil Service (Ministries) and their families. The estimated population size is well over one million beneficiaries. This scheme has already resulted in an increased awareness around the country of health insurance in general.
And the objectives of the scheme are: * To ensure that every Nigerian has access to good health care services * To protect families from the financial hardship of huge medical bills * To limit the rise in the cost of health care services * To ensure equitable distribution of health care costs among different income groups * To maintain high standards of health care delivery services within the Scheme * To ensure efficiency in health care services.
* To improve and harness private sector participation in the provision of health care services * To ensure equitable distribution of health facilities within the Federation * To ensure appropriate patronage of all levels of health care * To ensure the availability of funds to the health sector for improved services. The Computerized Medical Insurance System (CMIS) is a system that links the physician’s office or the hospital administrative office and the provider of insurance coverage by means of a central administration computer.
The system provides up-to-date information to the provider of health care services as to identity of patients, insurance plans and coverage of a patient. The system also allows for real time modification of the information 1. 2 Problem definition It has been observed that health care delivery system witness a high influx of people that need urgent treatment and attention. Hence the need to provide support services which add real value to healthcare delivery is highly required, giving rise to health insurance schemes and policies.
For the masses to benefit from it there must be timely, effective, reliable and efficient healthcare delivery at this level. The available record shows that this has not been achieved yet. The current method used by most hospital in ascertaining insurance information of patient is still manually and inefficient. This makes the operation unnecessarily slow and cumbersome. The problems observed include the following: * Slow tracking of medical insurance information that is needed for urgent decision making and analysis * Lost of vital and important information * Difficulty in retrieving insurance information.v
1. 3Justification of study The idea of computerizing the medical insurance system is to fully computerized the existing insurance scheme at the hospital-end, removing the manual systems which have so many hand downs. The Computerized Medical Insurance System (CMIS) provides: * An accurate and efficient data/information that is well organized and easier to read compared to the traditional paper insurance record. * It improves the efficiency of processes such as data collection, data management, data retrieval and Maintenance of up-to-date medical insurance information for quick and fast decision making.
* Proper patient insurance record maintenance * Production of timely information 1. 4 Aims and objectives of study The computerized health insurance system (CHIS) designed and developed for this work will achieve the following: * Provision of a timely information about the patient insurance policies * Maintain an up-to-date and accurate information system fit for markup decision making * Reduction in the use of paper requisition forms resulting in significant cost saving * Increase productivity.
* Production of a detailed report that can be used to follow up claims submission * High security of stored information 1. 5 Scope of the Study This report is divided into the following five chapters: Chapter one gives the background to the study, its scope, justification and objectives. It also states the problems of the study, methodology and the expected result.
Chapter two reviews the previous work or literature on the study including some theoretical techniques that can be applied to the operations of the information system Chapter three gives an in-depth description of the methodology used and the methods employed in carrying it out. Chapter four highlights the systems analysis, design, documentation and implementation. Here the file and modules used in the prototype are described and tested Chapter five is the conclusion and recommendation. It gives a brief summary to the entire project work and also made recommendations on how to further improve on the study.
1. 6 Methodology In order to design and develop this system, the following activities will be carried out: * Existing methods of generating patient insurance details will be studied via survey and case study * Hypertex Processor programming language will be used to develop the interfaces for the proposed system * Implementation of the proposed system using acquired data and information. 1. 7 Limitation of Study The research is limited to production of a computerized medical insurance system only for the hospital-end. CHAPTER TWO LITERATURE REVIEW 2. 1 Health.
It is defined as a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity (WHO). 2. 2 Medical health This is the science and act of preventing disease, prolonging life and efficiency through organized community effort for the sanitation of the environment, the control of communicable disease, education of the individual in personal hygiene, the organization of medical and nursing services for early diagnosis and preventive treatment of disease and the development of social machinery of health so organizing these benefit as to enable every citizen to realize the birth right of health and longevity (Zajac, 2003).
2. 2. 1Health care provision in Nigeria Health care provision in Nigeria is a concurrent responsibility of the three tiers of government in the country. However, because Nigeria operates a mixed economy, private providers of health care have a visible role to play in health care delivery.
The federal government’s role is mostly limited to coordinating the affairs of the university teaching hospitals, while the state government manages the various general hospitals and the local government focus on dispensaries, (which are regulated by the federal government through NAFDAC). The total expenditure on health care as % of GDP is 4. 6, while the percentage of federal government expenditure on health care is about 1. 5% (WHO). 2. 3Insurance In law and economics, Insurance, is a form of risk management primarily used to hedge against the risk of a contingent loss.
Insurance is defined as the equitable transfer of the risk of a loss, from one entity to another, in exchange for a premium. An insurer is a company selling the insurance. The insurance rate is a factor used to determine the amount, called the premium, to be charged for a certain amount of insurance coverage. Risk management, the practice of appraising and controlling risk, has evolved as a discrete field of study and practice. 2. 3 Health Insurance The term health insurance is generally used to describe a form of insurance that pays for medical expenses.
It is sometimes used more broadly to include insurance covering disability or long-term nursing or custodial care needs. It may be provided through a government-sponsored social insurance program, or from private insurance companies. It may be purchased on a group basis (e. g. , by a firm to cover its employees) or purchased by individual consumers. In each case, the covered groups or individuals pay premiums or taxes to help protect themselves from high or unexpected healthcare expenses.
Similar benefits paying for medical expenses may also be provided through social welfare programs funded by the government. Health insurance works by estimating the overall risk of healthcare expenses and developing a routine finance structure (such as a monthly premium or annual tax) that will ensure that money is available to pay for the healthcare benefits specified in the insurance agreement. The benefit is administered by a central organization, most often either a government agency or a private or not-for-profit entity operating a health plan 2.
5Introduction to National Health Insurance Scheme (NHIS) in Nigeria The National Health Insurance Scheme (NHIS) was launched by the Federal Government on June 6th 2005 as a health welfare scheme aimed at providing quality healthcare at an affordable cost to the general populace. It currently covers the employees of the Federal Government Civil Service (Ministries) and their families. The estimated population size is well over one million beneficiaries. This scheme has already resulted in an increased awareness around the country of health insurance in general.
The evolution of the National Health Insurance Scheme dates back to 1962, when the need for health insurance in the provision of healthcare to Nigerian citizens was first recognized. The Government had initially provided ‘free healthcare’ for its citizens funded by its earnings from oil exports and general tax revenue. However, the global slum [ in oil prices in the 1980s greatly affected Nigeria’s major source of income. Government could therefore no longer afford to provide free health, and subsequently introduced several cost recovery mechanism like user charges and Drug Revolving Funds.
Furthermore the introduction of the Structural Adjustment Programme in 1986 adversely affected the health sector allocation. These amongst other factors outlined below informed the establishment of the Scheme: * The general poor state of the nation’s healthcare services * The excessive dependence and pressure on government-provided health facilities * Dwindling funding of health care in the face of rising costs * Poor integration of private health facilities in the nation’s health care delivery system The objectives of the NHIS are:
* To ensure that every Nigerian has access to good health care services * To protect families from the financial hardship of huge medical bills * To limit the rise in the cost of health care services * To ensure equitable distribution of health care costs among different income groups * To maintain high standards of health care delivery services within the Scheme * To ensure efficiency in health care services.
* To improve and harness private sector participation in the provision of health care services * To ensure equitable distribution of health facilities within the Federation * To ensure appropriate patronage of all levels of health care * To ensure the availability of funds to the health sector for improved services. In order to ensure that every Nigerian has access to good healthcare services, the National Health Insurance Scheme continuously improves the way it works. The information and diagram below shows you how the NHIS structure works. Fig 2. 0: A diagram showing the structure of NHIS and how it operat.
Patients Patients have been getting excellent care in the NHIS since its inception, but this excellence has been patchy. Now patients are being encouraged to become actively involved in their own care and are helping to shape local services: * They are making real choices about when and where to be treated. * They are being recognized by health professionals as equal partners in their care and are being empowered to manage their own symptoms and medications more effectively. * They are making decisions about local services through Patient Forums and Foundation Trusts.
* They are being asked for their views routinely and listened to, as part of every local service’s effort to achieve the best performance ratings. Amongst many issues concerning patients, Safety is uppermost in the NHIS agenda. Achieving a high quality health service which is responsive to people’s needs, means giving organizations and front-line professionals the freedom and support they need to work more effectively; encouraging staff to develop new skills and think radically and flexibly about how to improve local services.
Throughout all this change, patients need to know that the care they receive is safe as well as of a high standard. Staff too needs to know they are working within a system which protects the patient and, where mistakes are made, they can report these to benefit others without the fear of being unduly blamed or punished. Primary Healthcare Providers Primary Health Care Providers will serve as the first contact within the health care system, and they include; Private clinics/hospitals, Primary Health Care Centers, Nursing and Maternity homes, and Out-patient departments of Hospitals/Clinics.
Primary Health Care Providers is mostly concerned with a patient’s general health needs, but increasingly more specialist treatments and services are becoming available to primary care settings. Health Maintenance Organizations (HMOs) These are limited liability companies which may be formed by private or public establishments or individuals for the sole purpose of participating in the Scheme. They are registered by the Scheme to facilitate the provision of health care benefits to contributors in the Formal Sector Social Health Insurance Programme. Their functions include the following:-
* Receive/collect contributions from eligible employers and employees * Collection of contributions from voluntary contributors * Payment of Health Care Providers for services rendered * Maintenance of quality assurance in the delivery of healthcare benefits in the Formal Sector Social Health Insurance Programme. Secondary and Tertiary Health Care Providers Secondary Health Care Providers provide health services on referral from Primary Providers, while Tertiary Health Care Providers provide health services on referral from primary and secondary levels.
Referrals are undertaken essentially to ensure cost-effectiveness and efficiency in patients’ management under the NHIS. A patient may be referred from a Primary to a Secondary Service Provider due to need for specialized investigations, for medical/ surgical reasons or other services diagnostic, physiotherapy etc, or from secondary to tertiary level.
2. 5. 1 Features of the Health Insurance Scheme Embedded in the Health insurance scheme are health insurance policies. A Health insurance policy is a contract between an insurance company and an individual that covers the types of insurance coverage, level and class of insurance. The contract can be renewable annually or monthly.
The type and amount of health care costs that will be covered by the health plan are specified in advance, in the member contract or Evidence of Coverage booklet. 2. 5. 5. 1Forms of Insurance policy The various forms of Insurance plan policies include: * The Indemnity plans * Management Care Plans 2. 5. 5. 1. 1 The indemnity plans Under this type of plan, the patient may visit any health care provider, in a PHC or General Hospital. The patient or the medical provider then sends the bill to the insurance company, which typically pays a certain percentage of the fee after the patient, meets the policy’s annual deductible.
2. 5. 5. 1. 2 Management Care Plans The management care plans includes the Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), Point of Service Plans (POS) 2. 5. 5. 1. 3. 1 Health Maintenance Organization (HMO) A health maintenance organization (HMO) is a type of managed care organization (MCO) that provides a form of health care coverage that is fulfilled through hospitals, doctors, and other providers with which the HMO has a contract. The Health Maintenance Organization Act of 1973 required employers with 25 or more employees to offer federally certified HMO options.
Unlike traditional indemnity insurance, care provided in an HMO generally follows a set of care guidelines and is provided through the HMO’s network of providers. Under this model, providers contract with an HMO to receive more patients and in return usually agree to provide services at a discount. This arrangement allows the HMO to charge a lower monthly premium, which is an advantage over indemnity insurance, provided that its members are willing to abide by the additional restrictions. (Peter R.Kongstved, 2001).
In addition to using their contracts with providers for services at a lower price, HMOs hope to gain an advantage over traditional insurance plans by managing their patients’ health care and reducing unnecessary services. To achieve this, most HMOs require members to select a primary care physician (PCP), a doctor who acts as a “gatekeeper” to medical services. PCPs are usually internists, pediatricians, family doctors, or general practitioners. In a typical HMO, most medical needs must first go through the PCP, who authorizes referrals to specialists or other doctors if deemed necessary.
Emergency medical care does not require prior authorization from a PCP, and many plans allow women to select an OB/GYN in addition to a PCP, whom they may see without a referral. In some cases, a chronically ill patient may be allowed to select a specialist in the field of their illness as a PCP. Open access” HMOs do not use primary care physicians as gatekeepers – there is no requirement to obtain a referral before seeing a specialist. The beneficiary cost sharing (e. g. , co-payment or coinsurance) may be higher for specialist care. As with most health insurance plans in the United States, HMOs also manage care through utilization review.
The amount of utilization is usually expressed as a number of visits or services or a dollar amount per member per month (PMPM). Utilization review is intended to identify providers providing an unusually high amount of services, in which case some services may not be medically necessary, or an unusually low amount of services, in which case patients may not be receiving appropriate care and are in danger of worsening a condition. HMOs often provide preventive care for a lower copayment or for free, in order to keep members from developing a preventable condition that would require a great deal of medical services.
When HMOs were coming into existence, indemnity plans often did not cover preventive services, such as immunizations, well-baby checkups, mammograms, or physicals. It is this inclusion of services intended to maintain a member’s health that gave the HMO its name. Some services, such as outpatient mental health care, are often provided on a limited basis, and more costly forms of care, diagnosis, or treatment may not be covered. Experimental treatments and elective services that are not medically necessary (such as elective plastic surgery) are almost never covered.
2. 5. 5. 1. 2. 2Preferred Provider Organization (PPO) Preferred provider organizations (PPOs) combine characteristics of traditional insurance plans and HMOs. PPOs establish contractual agreements with health care providers, who accept lower fees for services rendered to PPO members. The PPOs distribute lists of these participating providers to their members, who then select a primary care provider. This primary care provider is the patient’s first contact for health care, providing health care services as well as referrals to specialists.
PPO members who use the services of participating providers will generally receive more generous benefits than those who choose the services of health care providers not on the preferred list. Essentially, a PPO offers its participants some coverage for any doctor or hospital they choose, but participants’ costs will be higher if they go outside the network of preferred providers 2. 5. 5. 1. 2. 3Point of Service Plans (POS) Point-of-service (POS) plans combine aspects of indemnity health insurance policies with some elements of PPOs.
Like PPOs, point-of-service plans establish contracts with health care providers who agree to offer services to plan members. Unlike PPOs, which require participants to select a preferred provider in advance, point-of-service plans allow participants to choose at the time they need health care whether to seek treatment within the plan’s network of health care providers or outside the network. Expenses for services received outside the network are reimbursed, usually after the patient pays a specified deductible amount and a coinsurance percentage.
The benefits are exactly the same as in a PPO plan if the services are provided by a health care provider on the preferred list. The benefits are exactly the same as an indemnity policy if the health care provider is not on the preferred list 2. 5. 5. 1 Class of Coverage Also included in the CHIS is the Class of coverage, which includes * Group and Employee plan * Individual plans 2. 5. 5. 2. 1Group and Employee plan Groups of people who have something in common other than their need for insurance often can join forces to purchase group health insurance.
For example, individuals who all work for the same employer may join a group health insurance plan sponsored by their employer. Group plans typically have lower administrative costs than do individual health insurance plans, so they are able to charge individual subscribers lower monthly premiums. 2. 5. 5. 2. 2Individual plans Individuals who do not have access to less expensive group plans can buy policies directly from health insurance companies. 2. 5. 5. 2 Level of coverage The various level of insurance coverage includes the: * Comprehensive coverage * Hospital-Surgical coverage.
* Catastrophic coverage * Specified Disease Policies * Long-Term Care Policies 2. 5. 5. 3. 1Comprehensive coverage Comprehensive medical insurance is a single plan that combines coverage for both doctor and hospital charges. Most medical services are covered by comprehensive policies, although even comprehensive plans limit benefits for certain specific conditions. They also may not cover services associated with preexisting conditions. 2. 5. 5. 3. 2Hospital-Surgical coverage Hospital-Surgical policies provide separate limits for hospital charges and for physician charges associated with a hospital stay.
A hospital-surgical plan usually limits its benefits to cover a relatively low amount of medical costs, so most people consider it only in conjunction with a more comprehensive policy. 2. 5. 5. 3. 3Catastrophic coverage Catastrophic health insurance—also known as major medical insurance—is a policy of health insurance with a relatively high deductible, Although catastrophic health insurance policies offer coverage only beyond this high deductible amount, they can help people avoid bankruptcy in the event of a catastrophic illness or injury that requires expensive medical treatments.
Because catastrophic health insurance policies have a high deductible, they typically charge policyholders relatively low monthly premiums. 2. 5. 5. 3. 4 Specified Disease Policies Some insurance companies offer specified disease policies that cover only one illness, such as cancer. These plans offer no benefits at all for medical costs associated with any disease other than that specified in the policy. Therefore, most people who purchase these policies also need to be covered by a more comprehensive policy.
Some of these policies provide only for the treatment of the specified illness and exclude from their benefits package the costs of diagnosing the disease. 2. 5. 5. 3. 5Long-Term Care Policies Medicare and most private medical insurance policies cover medically necessary services such as care while recuperating from surgery. 2. 6Health Information System Health information System is the intersection of information science, medicine and health care. It deals with the resources, devices and methods required to optimize the acquisition, storage, retrieval, and use of information in health and biomedicine.
Health informatics tools include not only computers but also clinical guidelines, formal medical terminologies, and information and communication systems. (Wikipedia, 2002). The introduction of information system to healthcare delivery has been a major leap frog into the practice of health care delivery system. Before the advent of information system in healthcare, inadequate and sometimes inaccurate decisions were being made by the health policy makers as a result of inadequate information.
For instance the World Health Organization (WHO) in its 2003 annual reports, “Shortage of adequate health information as well as shortage of personnel contribute to the potential collapse of some health care systems and threaten the long-term viability of others”. The introduction of information system to healthcare delivery has been a major leap frog into the practice of health care delivery system. Before the advent of information system in healthcare, inadequate and sometimes inaccurate decisions were being made by the health policy makers as a result of inadequate information.
For instance the World Health Organization (WHO) in its 2003 annual reports, “Shortage of adequate health information as well as shortage of personnel contribute to the potential collapse of some health care systems and threaten the long-term viability of others”. 2. 6. 1History of Health Care Management Information System The genesis of health care computing can be traced as far back as the early 1950s, when only mainframes were available and only the major hospital of G7 countries could afford to house and use these machines.
In that period, even the processing of a routine batch of health-related information took a consideration amount of coordinated effort among various health professionals and computer experts. Despite the demand on expertise, the end results were mostly fraught with mechanical and programming errors. The failures of this first era of computing in health care were due mainly to the lack of active support from hospital administrators and top management. The lack of continuing funding, and the lack of knowledge and skill in the design and use of automated systems.
From the early 1960s through the 1970s, a new era of computing in health care emerged. A growing group of hospital, including Akron Children’s Baptist, Charlotte Memorial, Deaconess, El Camino, Henry Ford, Latter Day Saint, Mary’s Help, Monmouth Medical Center, St. Francis, Washington Veteran’s Administration, and others throughout the United State as well as Sweden’s Danderyd Hospital and Karolinka Hospital, England’s London Hospital and Kings Hospital, Germany’s Hanover Hospital, and others in Europe began to agree on the need to advance a patient information management system prototype.
Despite the risk of major system failures, these pioneering hospitals invested large amounts of money, time, and effort to move toward computerization. Seeing the sudden surge of interest among these hospitals and the potential market opportunities, large computer vendors such as Burroughs, Control Data, Honeywell, IBM, and NCR joined in an effort to support patient information systems. Lockheed Information System Division, McDonnell-Douglas, General Electric (GE), Technicon Corporation, and several other companies with a reputation for effective management of complex systems also collaborated.
Nonetheless, many of the early projects were almost complete failures: the complexity of the information requirements of a patient management system was gravely underestimated. Companies such as GE and Lockheed had to withdraw their participation due to lack of continuing funding, interest, and management support. Many pioneering hospitals also had to fall back on their manual systems to keep their facility operating smoothly, and several of the hospital administrators had to make the difficult choice to abandon their hospital information systems project at a huge loss.
The Technicon system was the light that was eventually found at the end of the long tunnel of hospital-based patient information system failures. This particular system initiated by Lockheed for El Camino Hospital in Mountain View, California, and later acquired and improved by Technicon Corporation under the leadership of Edwin Whitehead, became the successful prototype that laid the foundation for all future hospital patient information management systems throughout North America and Europe.
The major lessons learned in the EI Camino project were the importance of focusing on user information needs and the need to change user attitudes, particularly to overcome resistance from physicians and nurses. Owing to the success of this project, large-scale data processing applications in medicine and health records systems also began to take hold during the early and mid-1970s as the use of computers began to result in continuing gains in productivity and evidence of increased efficiency.
Nonetheless, these early successes were achieved at very high costs. John Hopkins Oncology Center, for example, acquired their first computer system in 1976 for two hundred and fifty thousand dollars; its processing power was only a fraction of today’s desktop computers. Other successful early patient record systems include the Computer Stored Ambulatory Record System (COSTAR), the Regenstrief Medical Record System (RMRS) and The Medical Record (TMR).
COSTAR, a patient record system developed at Massachusetts General Hospital by Octo Barnett in the 1960s, was later extended to record patient data relating to different types of ailment (for example, multiple sclerosis [MS-COSTAR] and is used even today in several teaching hospitals and research universities across the globe. RMRS was a physical-designed integrated inpatient and outpatient information system implemented in 1972, and TMR is an evolving medical record system that was developed in the mid-1970s at Duke University Medical Center.
Together with the success of the Technicon system, the efficiencies of these automated record systems soon provided consideration motivation for the integration of computing into health care systems.