System for Automated Eligibility Determination Improves Health Care Access

As healthcare payers and providers use different information systems, patients can get caught in the middle and forced to bridge the gap with cumbersome processes.

Leumit Health Services, a health maintenance organization (HMO) has eased that burden for its members getting care at Sourasky Medical Center with an automated bridge using InterSystems IRIS for Health™ data platform. This new model for eligibility determination centered around a convenient check-in kiosk improves efficiency while making it easier and quicker for patients to access care.

In Israel, where health insurance is dominated by HMOs, patients needing care at a hospital or outpatient clinic get a Form 17, a paper referral, from their primary care provider confirming that the visit will be covered. They must bring the form with them when they go to the appointment or face cancellation. Once they’ve arrived at the advanced care provider’s office, they check in at an often busy reception desk where the form is validated.

Leumit worked with Outburn – Israel-based experts in business process design and FHIR implementation – and Sourasky to develop a solution that integrates their individual information systems through a FHIR façade. The façade enables information sharing without additional data storage.

When going to Sourasky for a health care visit, Leumit members swipe their insurance card at a check-in kiosk. Once eligibility is confirmed, the kiosk prints a voucher with the queue number and the patient goes directly to the service provider without having to wait in line at the reception desk.

While patients experience a quick and seamless check-in process with the kiosks, behind the scene there is a complex, multi-step process of sharing information across systems.

When the patient swipes their insurance card at the Sourasky hospital check-in kiosk, the hospital system authenticates the patient and sends the insurance ID to an IRIS for Health instance. That instance runs the business logic to bring data from the hospital’s internal system and converts it into FHIR to send the request to Leumit.

At Leumit, InterSystems IRIS for Health acts as a translator through its FHIR Façade architecture. The incoming FHIR request is converted into JSON to fetch the relevant data from Leumit’s internal systems and then back to FHIR to send the response to Sourasky.

Once the patient’s visit and commitment to pay have been validated, InterSystems IRIS for Health updates the hospital systems with the eligibility.

Subsequent steps are tracked to ensure that care was delivered before payment is released, and that the primary care provider is updated.

The new process fits with the Israel Ministry of Health’s national strategy launched in 2021 to improve interoperability and health information sharing using FHIR. Leumit will connect all of its core systems through InterSystems IRIS for Health to enable faster and more standardized information sharing with health care organizations and health applications for members. Leumit will be the first health organization in Israel to report information to the Ministry of Health in accordance with the FHIR standard.

“We chose InterSystems for its deep FHIR expertise and the multiple capabilities of InterSystems IRIS for Health,” Yakovi explained. “InterSystems IRIS for Health simplifies our IT environment, as it’s a single solution with the connectivity we need to get the data and has the ability to work with all aspects of FHIR.”

With the success of the process between Leumit and Sourasky Medical Center, Leumit plans to extend this service to additional hospitals.

The process also will be expanded so that hospitals can request and receive approvals for follow-up visits without involving the patient. While this first project didn’t require storage of data in a FHIR server, future projects could incorporate storage.

“Having chosen InterSystems IRIS for Health means we already have full FHIR server capabilities when needed.” Yakovi said. “It’s enabled us to adopt FHIR faster than we could have otherwise.”