Development of an electronic claim system based on an integrated electronic health record platform to guarantee interoperability

Abstract

Objectives: We design and develop an electronic claim system based on an integrated electronic health record (EHR) platform. This system is designed to be used for ambulatory care by office-based physicians in the United States. This is achieved by integrating various medical standard technologies for interoperability between heterogeneous information systems.

Methods: The developed system serves as a simple clinical data repository, it automatically fills out the Centers for Medicare and Medicaid Services (CMS)-1500 form based on information regarding the patients and physicians' clinical activities. It supports electronic insurance claims by creating reimbursement charges. It also contains an HL7 interface engine to exchange clinical messages between heterogeneous devices.

Results: The system partially prevents physician malpractice by suggesting proper treatments according to patient diagnoses and supports physicians by easily preparing documents for reimbursement and submitting claim documents to insurance organizations electronically, without additional effort by the user. To show the usability of the developed system, we performed an experiment that compares the time spent filling out the CMS-1500 form directly and time required create electronic claim data using the developed system. From the experimental results, we conclude that the system could save considerable time for physicians in making claim documents.

Conclusions: The developed system might be particularly useful for those who need a reimbursement-specialized EHR system, even though the proposed system does not completely satisfy all criteria requested by the CMS and Office of the National Coordinator for Health Information Technology (ONC). This is because the criteria are not sufficient but necessary condition for the implementation of EHR systems. The system will be upgraded continuously to implement the criteria and to offer more stable and transparent transmission of electronic claim data.

Keywords: Electronic Health Records; Health Level Seven; Reimbursement; Relative Value Scales.

Figure 1

Architecture of SeniCare. CDA: clinical document architecture, CMS: Centers for Medicare and Medicaid Services. UI: user interface, EMR: electronic medical record, PHR: personal health record, HL7 I.E.: Health Level Seven interface engine, App.: application program, XMLDBC: eXtensible Markup Language database connectivity, DB: database.

Figure 2

(A) Calculation procedure for reimbursement charge, based on (CPT) code set. (B) Calculation procedure for reimbursement charge based on NIC and CCC code sets. ICD: International Classification of Diseases, CPT: Current Procedural Terminology, RVU: Relative Value Unit, CF: conversion factor, GPCI: Geographic Practice Cost Indices, NIC: Nursing Intervention Classification, ABC: alternative billing codes, CCC: Clinical Care Classification, UV: unit value, NANDA: North American Nursing Diagnosis Association, NOC: Nursing Outcomes Classification, NIC: Nursing Interventions Classification.

Figure 3

Centers for Medicare and Medicaid Services (CMS)-1500.

Figure 4

Fragment of HL7-based clinical document architecture (CDA) schema for Centers for Medicare and Medicaid Services (CMS)-1500 document.

Figure 5

Summary view of a patient's personal and health information.

Figure 6

(A) Searching diagnoses with International Classification of Diseases (ICD) code. (B) Suggested Current Procedural Terminology (CPT) list related to an indicated ICD code.

Figure 7

Mapping system adopted in SeniCare.