The experts have discussed business processes and the mechanism of collection of analytical data on medical service providers of Social Medical Insurance Fund (SMIF) NJSC.

"When implementing the Mandatory Social Medical Insurance (MSMI), a new system of relations between the SMIF, medical service providers and the population should be created, where it is necessary to pay attention to the creation of a more effective mechanism for providing medical care to the population by improving the quality of medical care. The purpose of providing medical care should be either a complete recovery of a citizen or a long remission for chronic patients without repeated similar appeals. In this regard, it will be very important to conduct quality monitoring," Alyona Romanova, Deputy Chairman of the Board of the Atameken NCE RK, said.

As part of the implementation of the MSMI system, the Fund plans to introduce an improved quality management model, in which the Fund itself will be the patient's guarantor.

"When we see a complaint, we do not automatically blame the service provider but study the information and patient stories carefully. Since we reimburse all services provided by the supplier, we have to carry out qualitative monitoring. When we have data from clinics, we will automatically receive information. Therefore, we need automation. Now we are building complex logical chains. For example, if a patient was discharged in an unsatisfactory condition and was brought to another institution in an ambulance in a serious condition, it means that the service provided was of poor quality,” Lyazzat Shomanova, Director of the Department for Monitoring the Quality of Medical Care at the Social Medical Insurance Fund NJSC said.

At present, the Fund has already established regional expert councils, which are responsible for quality issues. It is planned to introduce a three-level model of quality to work with suppliers in 2020. These are three categories of experts who will conduct multi-level monitoring. Thus, the category of the highest expert will be involved at the level of expert councils. The second stage includes monitoring with the visiting of suppliers, the third - system monitoring of availability and quality. The MSMI also plans to increase the number of permanent experts and attract independent professionals. 

"We have a register of independent experts of the highest category, which will be used for auditing in disputed situations. We also plan to introduce a directory of defects, which will be a detailed explanation of violations. We plan to work proactively, identify risk areas and apply penalties in case of failure to implement the recommendation on proper compliance. We have already developed questionnaires on types and profiles of medical care for patients. At the moment, the fund is developing indicators to assess the service provider," Lyazzat Shomanova said.

 "The problem of protecting the rights of patients and medical workers will become more acute from 2020. In this regard, the issue of attracting independent experts to consider appeals, both in pre-trial and in court, is acute. It is necessary to start training experts who know the mechanisms of social health insurance, mediation, civil administrative and criminal legislation," Aizhan Sadykova, Vice President of the Zdrav Atameken, Healthcare Entities Associations, said.

So far, the main problem is the fragmentation of integration systems, the Director of the Department of Medical Centers Management of Mediker LLP Oryntay Kasymova said.

"We have supervision, but the fund needs a single platform to get accurate data. We face integration problems ourselves when a patient changes one clinic to another one. Until we merge the platform into one quality monitoring site," Oryntay Kasymova said.

In turn, the director of the IT department of Akgun LLP Zhulduz Dakhimbayeva noted that when concluding contracts with suppliers, developers sign an agreement on the non-disclosure of information to third parties.

"We cannot provide the Fund with information because its owners are clinics. We have no guarantee that the employee of the fund, who received the information, will not distribute it further. There is no legal Act to regulate access," Zhuldyz Dakhymbaeva said.

The issue of data verification remains important. As Director-General of iDos, Technical Support Center LLP Anuar Zhusupov noted, the data of the Ministry of Health of the Republic of Kazakhstan and the real picture in medical institutions are often different. Therefore, it is necessary to work out the issues of data verification, as well as access to patient histories. 

Besides, Yulia Yakupbayeva, Advisor to the Chairman of the Presidium of the Atameken NCE RK, proposed to introduce the assessment of medical care by the patient to improve the quality.

"It should be announced that the Fund is the only platform for the collection of complaints on medical care. Feedback from patients should be provided on an ongoing basis. It is also necessary to introduce the rating of physicians and clinics within the framework of the SMIF online in the public domain through a special web resource," she added.

Director of Sunkar LLP Kuanysh Kerimkulov suggested outsourcing the consideration of patients' complaints to a competitive environment. In the expert's opinion, this will preserve the elements of independence and security.

Summing up, Yuliya Yakupbayeva noted that for further work on improving the Medical information systems, the business community should have a clear understanding of what we have today and what we should strive for.

"The first thing we need to do is to work with the Ministry of Health and understand where we are staying with eHealth. We should develop a joint Roadmap to address point issues as soon as possible. Concerning the work of the Fund, we need to understand how to build a relationship between the patient, doctor, and foundation. The SMIF should be able to analyze the information after the complaint. To do this, it is necessary to determine how to prescribe the norm in law. The norm should stipulate such issues as data collection using clinical protocols, which should be automatically collected in the database. Medical information systems should collect and synchronize statistics. Only then the Fund will be able to rate the medical organizations. There is a lot of work to be done in terms of digitalization and systematization, and we need to work on all these issues," Yuliya Yakupbayeva concluded.