Modeling healthcare authorization and claim submissions using the openEHR dual-model approach

<p>Abstract</p> <p>Background</p> <p>The TISS standard is a set of mandatory forms and electronic messages for healthcare authorization and claim submissions among healthcare plans and providers in Brazil. It is not based on formal models as the new generation of health informatics standards suggests. The objective of this paper is to model the TISS in terms of the openEHR archetype-based approach and integrate it into a patient-centered EHR architecture.</p> <p>Methods</p> <p>Three approaches were adopted to model TISS. In the first approach, a set of archetypes was designed using ENTRY subclasses. In the second one, a set of archetypes was designed using exclusively ADMIN_ENTRY and CLUSTERs as their root classes. In the third approach, the openEHR ADMIN_ENTRY is extended with classes designed for authorization and claim submissions, and an ISM_TRANSITION attribute is added to the COMPOSITION class. Another set of archetypes was designed based on this model. For all three approaches, templates were designed to represent the TISS forms.</p> <p>Results</p> <p>The archetypes based on the openEHR RM (Reference Model) can represent all TISS data structures. The extended model adds subclasses and an attribute to the COMPOSITION class to represent information on authorization and claim submissions. The archetypes based on all three approaches have similar structures, although rooted in different classes. The extended openEHR RM model is more semantically aligned with the concepts involved in a claim submission, but may disrupt interoperability with other systems and the current tools must be adapted to deal with it.</p> <p>Conclusions</p> <p>Modeling the TISS standard by means of the openEHR approach makes it aligned with ISO recommendations and provides a solid foundation on which the TISS can evolve. Although there are few administrative archetypes available, the openEHR RM is expressive enough to represent the TISS standard. This paper focuses on the TISS but its results may be extended to other billing processes. A complete communication architecture to simulate the exchange of TISS data between systems according to the openEHR approach still needs to be designed and implemented.</p

Climate, Ticks and Disease

This book brings together expert opinions from scientists to consider the evidence for climate change and its impacts on ticks and tick-borne infections. It considers what is meant by 'climate change', how effective climate models are in relation to ecosystems, and provides predictions for changes in climate at global, regional and local scales relevant for ticks and tick-borne infections. It examines changes to tick distribution and the evidence that climate change is responsible. The effect of climate on the physiology and behaviour of ticks is stressed, including potentially critical impacts on the tick microbiome. Given that the notoriety of ticks derives from pathogens they transmit, the book considers whether changes in climate affect vector capacity. Ticks transmit a remarkable range of micro- and macro-parasites many of which are pathogens of humans and domesticated animals. The intimacy between a tick-borne agent and a tick vector means that any impacts of climate on a tick vector will impact tick-borne pathogens. Most obviously, such impacts will be apparent as changes in disease incidence and prevalence. The evidence that climate change is affecting diseases caused by tick-borne pathogens is considered, along with the potential to make robust predictions of future events. This book contains: Expert opinions and predictions. Global coverage of trends in ticks and disease. In-depth examination of climate change and tick distribution links.This book is suitable for researchers and students studying zoology, biological sciences, medical entomology, animal health, veterinary medicine, epidemiology, parasitology, and climate change impacts; and for those concerned with public health planning or livestock management where ticks and tick-borne pathogens pose a threat