IST-Africa 2020 Conference Proceedings

Miriam Cunningham and Paul Cunningham (Eds)
IST-Africa Institute and IIMC, 2020
ISBN: 978-1-905824-64-9 

Identification of the Limitations of

Healthcare Service/Insurance Industry
ERPs on Data Flow using QlikView and MS
Excel
Mwirigi KIULA1, Caroline CHEGE2
Jomo Kenyatta University of Agriculture and Technology, 62000, Nairobi, 00200, Kenya
Tel: +254 067 5870001-4, Email: 1bmkiula@aa.jkuat.ac.ke,
2
caroline.chege@students.jkuat.ac.ke
Abstract: Digital transformation has enterprise benefits at the operational, tactical
and strategic levels of the enterprise. The healthcare service/insurance sector would
benefit from digital transformation. Analysis was done on data drawn from three
healthcare service/insurance industry ERPs available in Kenya: PARAS, eOxegen
and digital medical card system on the efficacy of data exchange/flow. Data was
obtained from the intersection of the three systems for the months of March and
April 2018 based on access to data and month-on-month comparison. Juxtaposition,
comparison and summation was done using functions in QlikView and Microsoft
Excel. Inconsistencies were observed on the data between the three systems with
significant monetary value. Data analytics using common Microsoft Excel and
QlikView tools is recommended for identification of inconsistencies and limitations
in healthcare service/insurance ERPs. The study is beneficial to healthcare
service/insurance players, ERP solution developers and project implementers for
consistent data flow and mitigation of the pursuant risks.
Key words: Digital transformation, claims pipeline, data analytics, digital medical
card, eOxegen, ERPs, PARAS

1. Introduction
Digital transformation has the potential to transform an enterprise at the operational, tactical
and strategic levels of management. It also has the ability to raise the efficacy of an
enterprise leading to improved competitiveness and adjustability to growth in a turbulent
environment [13]. It reinforces digital interaction between organizations, intermediaries and
customers among other stakeholders in the ecosystem. The healthcare ecosystem would be
part of and a beneficiary of digital transformation. Finding the appropriate information
systems for the healthcare service and insurance industry is a key cog in reinforcing digital
transformation in the health care ecosystem.
The healthcare industry needs to mitigate the risk of surpassing budgetary limits,
stabilize the claims pipeline and plan sufficient claims reserves, manage the healthcare
packages offered by the various service providers profitably and help the business to
determine the right strategy: profitability, market share and customer delight. Weaknesses
in the Enterprise Resource Planning (ERP) systems used in the businesses would be a threat
in this pursuit.

Copyright © 2020 The authors www.IST-Africa.org/Conference2020 Page 1 of 9

1.1 ERPs in the Healthcare Sector
The healthcare management systems help in managing inpatients, outpatients, records,
database of treatments, status of illness, billings in the pharmacy and labs as well as
maintain hospital information such as ward identification, doctors in charge and department
administering [3].
Healthcare management systems are built to eliminate redundancy in term of data
storage – data being stored in a computer rather than a heap of files, reduce the time wasted
in retrieving data especially in finding past health records (such as patient history) and
increase efficiency and interactivity in any area of specialization in the hospital [1].
Healthcare management systems also serve as a decision support system [5].
Some of the key challenges of an un-automated healthcare is the lack of immediate
retrievals: - the information is very difficult to retrieve and to find particular information
such as a patient’s history, lack of immediate information storage: - the information
generated by various transactions takes time and efforts to be stored at the right place, lack
of prompt updating: - various changes such patient data are difficult to make because of the
tedious paper work involved, error-prone manual calculation: - manual calculations are
error-prone and time-consuming resulting in incorrect information such wrong patient’s bill
based on various treatments as well as difficulties in the preparation of accurate and prompt
reports [3].
The challenge of manual healthcare management environments in the developing
nations cannot be overemphasized. In Tamil Nadu, with only manual records, getting an
overview of the number of patients visiting the hospital or the nature of problems that need
immediate action such as managing a disease break-out is impossible while healthcare data
collected for analysis is unreliable. No snapshot/dashboard view can be availed to monitor
the performance of the hospitals [5].
Although being a frontrunner in the region, only 25% of Kenyans are covered by a
health insurance scheme. There is an increasing demand for quality healthcare living up to
Western standards and budgets for ‘high-end branded’ equipment - which would include
automation of the healthcare management systems [9].
Implementation of healthcare ERPs reduces revenue leakages and material/financial
mismanagement, brings in huge operational cost reduction and real-time management of
resources and leads to improved patient care conforming to local clinical, administrative,
accreditation and legislative requirements [17]. E-health, the use of information
technologies in healthcare system, improves access, efficiency, effectiveness and quality of
medical business processes with the participation of relevant entities (healthcare facilities,
medical staff, patients, insurance companies and the state). The ultimate goal is to improve
the health condition of a patient [12], the well-being and feel-good of the patient and the
social circle around the patient.
In the absence of legislation to protect the patient in terms of confidentiality, healthcare
providers are hesitant to start telemedicine services, eHealth and mHealth in Kenya. There
are ambitions towards eHealth in the country but practice lags behind. The reasons for the
high ranking of Kenya in comparative eHealth list is because the entrepreneurial energy and
skilled labor in the country is great and pushes people to be innovative [9].
Most healthcare ERPs available in the market (a) lack bi-directional integration and
balance between the ‘business’ and the ‘clinical’ processes, (b) are unable to document
payment of claims as per the ever changing requirements of the policyholder and (c) lack
clinical and administrative tracking for healthcare recipients [17]. It makes it very difficult
to provide reliable data on the number and type of services obtained from the private health
sector [9]. PARAS as a healthcare management system developed with the aim of resolving
these problems had, by 2015, been implemented in more than 130 locations globally, in 10

Copyright © 2020 The authors www.IST-Africa.org/Conference2020 Page 2 of 9

countries, serving over 12,000 users and handling over 7 million records across the
platform [18].
ERPs are prone to technical issues (uncertain quality, functionality, usage, lack of
integration with other applications); financial issues (initial costs of hardware and software,
maintenance, upgrades, replacement, investment reimbursement); resource issues, training
and retraining; resistance from potential users, due to the changes in working practice; and
certification, security, ethics, privacy and confidentiality [12].
PARAS healthcare solution is a patient centric comprehensive and integrated healthcare
delivery platform built to conform with best clinical and administrative practices. It covers
the complete spectrum of patient care and fully integrated enterprise class solution and is
designed to suit the needs of diverse healthcare providers including hospitals, clinics,
laboratories, day-care centres and diagnostics centres among others. It supports paper-less
and film-less healthcare environments [19].
PARAS operates on the healthcare provision or the clinical side of the healthcare
service provision sector – focused on the patients, healthcare staff and hospital operations.
1.2 ERPs in the Healthcare Insurance Sector
Besides the healthcare service provision segment, the healthcare insurance sector also
requires digital transformation. Most healthcare insurance management solutions apply two
filters, underwriting and accounting, in the medical claim adjudication process. A third
filter, the medical filter, is also necessary and essential [4].
The strengths and the weakness of healthcare insurance sector ERPs will almost always
be most visible at the underwriting, medical and accounting filter. Underwriting is the
process that an insurance company uses to decide, based on your medical history, whether
to take your application for insurance, whether to add a waiting period for pre-existing
conditions (depending on the local legal frameworks), and how much to charge for that
insurance [6]. Simplification, digital channel use, and the application of advanced analytics
to large data sets hold the potential to dramatically improve straight-through-processing
rates [15].
Underwriting is the gateway to the medical insurance for the policyholders – whether
individuals or corporates. The medical filter, among other variables, (a) helps in controlling
overbooking of inpatient cases in the same admission period for inpatients, (b) ensures that
all inpatient cases are booked to the correct benefits and (c) helps in matching the ailments
with their benefit categories. The accounting filter is the checklist for all. If all the filters are
positive and all the appropriate documentation is complete, the claim is cleared for
payment.
The role of ERPs in the underwriting, medical and accounting/transaction processing
steps is to ensure that the correct underwriting is done on all incoming and existing clients,
ailments are correctly mapped to their relevant benefits according to the company policies
and WHO ICD 10 classification and claims are effectively settled.
eOxegen as a healthcare insurance sector ERP includes the underwriting, accounting
and medical filters in the medical claim adjudication process.
1.3 Patient Digital Medical Card System
The application of digital medical cards has grown in the healthcare industry. Smart cards
help first responders with vital medical data at the scene or en-route to the hospital. They
enable immediate identification of a patient and access to the patient's medical record, even
when the patient is unconscious or too flustered to convey the entire medical picture
accurately or when language barriers impede effective communication. Patients benefit
from more immediate and improved treatment [16].

Copyright © 2020 The authors www.IST-Africa.org/Conference2020 Page 3 of 9

 Smart cards play a key role in sharing patient specific information [11]. According to
the World Health Organization, healthcare service providers need to know a patient’s
identity to access relevant medical and treatment histories and ensure that they are giving
consistent and appropriate care. Patients, on the other hand, need documentation to prove
enrollment in insurance programs or other safety nets that cover medical expenses.
Administrators and researchers need a unique patient identifier to be able to aggregate
records and share data between separate health databases (such as health information
systems). This is useful to generate statistics and other data for planning, evaluation,
emergency response, and improved treatments and disease management. Healthcare
insurers need to be able to identify patients to ensure that those for whom claims are
submitted are actually insured and to facilitate the adjudication of claims based on the
patient’s history. A secure, inclusive, and responsible method of uniquely identifying and
authenticating healthcare users over time and across facilities is central to each of these
needs and the goal of achieving universal healthcare [8].
The PARAS healthcare management ERP operates on the clinical side of the business
while the healthcare insurance uses eOxegen as the ERP. The digital medical card is on the
customer relationship management side of the business. The three communicate through an
electronic data interchange based on a set of standards and policies.
Usually, data flows from the healthcare management ERP (PARAS) to the healthcare
insurance ERP (eOxegen) through an electronic data interchange. It is then harvested at the
application programming interface between PARAS and eOxegen side and compared with
the digital medical card (smart card) data.
The ambit of this paper is the utilization of data analytics using QlikView and Microsoft
Excel to identify and quantify the gaps in the ERPs (PARAS, eOxegen and digital medical
card) through the underwriting, medical and accounting segments of the healthcare
insurance management process.

2. Problem Statement
ERPs and related solutions in the healthcare sector have fairly developed in recent years.
Like any other sector, ERPs in the medical field are prone to technical issues (uncertain
quality, functionality, usage, lack of integration with other applications); financial issues
(initial costs of hardware and software, maintenance, upgrades, replacement, investment
reimbursement); resource issues, training and retraining; resistance from potential users,
due to the changes in working practice; and certification, security, ethics, privacy and
confidentiality [12]. The ERPs prevalent in the healthcare sector in Kenya, both in the
clinical and the insurance side are not exempt from these issues.
It is noteworthy that the complaints received in the Republic of Kenya in 2018 included
delayed settlement, declined claims, erroneous deductions and unsatisfactory
offers/compensation [7]. Acknowledging these problems in the insurance industry,
recommendations were made to create, organize and maintain company records in a single,
reliable and accessible repository and automate the verification of coverage, and streamline
claims settlement to improve operational efficiency and remove costs [10]. One of the
opportunities identified in the insurance industry is investment in infrastructure and
improved technology [2].
The observations and the recommendations by the KPMG, General Insurance Industry
Review of 2018 and the Insurance Regulatory Authority of Kenya Report of 2019 point to
the need to study the existing healthcare service/insurance ERPs and analyse their ability to
address the gaps.
This paper seeks to identify and quantify the limitations in PARAS, eOxegen and digital
medical cards system from a data analytics perspective using QlikView and Microsoft

Copyright © 2020 The authors www.IST-Africa.org/Conference2020 Page 4 of 9

Excel. QlikView and Microsoft Excel are simple and easy to use data analytics platforms
that are available in the productivity environment.
The focus of this study is on the quantitative aspects of the business, looking at the
number of transactions and the monetary impact of any anomalies in the transactions. The
comparative analysis is on the data harvested from the eOxegen and the digital smart card
system.

3. Objective
The objective of this study is to apply data analytics to identify and quantify the limitations
in the ERP systems used in the healthcare service/insurance sector on the completeness of
data at the point of service, system integration, operating procedures and the
implementation of business rules.

4. Methodology
Data was harvested from the database of the purposively selected healthcare insurance
service provider for the months of March and April 2018. The two months were selected on
the basis of access to data and the need for month-on-month comparison. The data was
loaded onto QlikView for Windows Personal Edition, Version 11.20.13405.0.SR15 [14]
and Microsoft Excel 2016.
Data flows from the healthcare management ERP (PARAS) to the healthcare insurance
ERP (eOxegen) through an electronic data interchange, harvested at the application
programming interface between PARAS and eOxegen side and compared with the digital
medical card (smart card) data. For the purpose of this study, the data was harvested from
the application programming interface and the digital medical card system. Data analysis
was done using QlikView and MS Excel.
Data clean-up was carried out to remove blank records (including confirmation of the
root-cause of the blanks) and flag spurious records. A unique key was created for every
record in the two datasets. The names of clients were completed and matched. The claims
that did not flow into the eOxegen System through the electronic data interchange from
PARAS were isolated and summarized. The rejection count and amount were obtained.
Consolidation of the amounts of transactions per visit where a client visits more than
one time per day, was done using Microsoft Excel pivot tables. The specific columns of
interest for further analysis were fetched from the raw data using the VLOOKUP function.
This process was carried out for the data from the eOxegen System and the digital smart
card system. The values relating to each visit from the eOxegen System and the digital
smart card were juxtaposed using the VLOOKUP function. Visits in one system but
missing in the other were marked.
A comparative formula was used to compare the amounts from the two systems with the
aim of identifying the presence of overpayments (when the value from the eOxegen is
greater than the value from the smart card system). The difference between the values from
the two systems were computed. The sum total of the overpayments was computed and
summarized in a table. The number of visits not captured in the digital smart card system
were then computed and summed. The summaries were obtained using appropriate
Microsoft Excel functions.
The data harvested at the PARAS-eOxegen application programming interface but
rejected through the claim processing was analyzed using QlikView to identify claims
rejected on underwriting and medical issues. The results are demonstrated and discussed.

Copyright © 2020 The authors www.IST-Africa.org/Conference2020 Page 5 of 9

5. Results
Instances of transactions missing in one of the systems (either the digital medical card was
not used or the record was not captured). The results are shown in Table 1.
Table 1: Discrepancies in Data between the ERPs
Description March 2018 April 2018
On eOxegen & not on Smart Card System 305 437
On Smart Card System & not on eOxegen System 281 275
Overpayments 2,511 3,493
On both eOxegen System & Smart Card System 8,464 7,880
Total on eOxegen System 8,952 8,317
Total on Smart Card System 8,745 8,155
Rejections 2,295 8,385
The results indicate that for the month of March and April 2018 there were significant
discrepancies in the data in the eOxegen System and the Smart Card System. In April 2018,
the 437 records on the eOxegen System but missing on the Smart Card System were worth,
monetarily, 2.1 million Kenya Shillings (equivalent to USD 20,000). The 275 records
missing on the eOxegen were worth 1.2 million Kenya Shillings (equivalent to USD
12,000).
Similarly, in March 2018, there were 305 missing records worth 1.54 million Kenya
Shillings (equivalent to USD 15,000). The 281 missing records in March 2018, in the
reverse, were worth 1.3 million Kenya Shillings (equivalent to USD 13,000).
Projected for one year these discrepancies would translate to a sizeable part of the
business in the tune of hundreds of US Dollars. These results would attract the attention of
the internal audit and external audit function and probably affect stakeholder confidence in
the business. Repetitions were noted in the data such as a member having two membership
numbers.
The 2,295 and 8,385 records, in March and April respectively, under rejections are
explained in Table 2.
Table 2: Summary of Errors on Rejected Claims

Errors Resulting in Rejection of Claims from PARAS into eOxegen March April
Invoice Amount & Item Amount not Matching 3,435
Another claim exist in the same admission 339
Claim is already registered 266
Claimed amount is more than the member balance 1,943
Diagnosis code/ICD does not exist 132 116
Diagnosis information not found 18 15
Duplicate provider invoice 7
Invalid member policy/Claim outside cover period 64
Member Balance not Available 261 187
Membership No. not valid.. 1,416 1,374
Provider/clinic code does not exist 454 538
TPA/insurance/policy information not found 14 2
Member suspended 3
Claimed amount cannot be zero 1
Member not in the system. 53
Blank (rejected but no reason given - human intervention required) 42
Grand Total 2,295 8,385
Copyright © 2020 The authors www.IST-Africa.org/Conference2020 Page 6 of 9
 March and April respectively recorded a significant 1,416 and 1,374 membership
numbers that were not valid. There were 53 members not in the healthcare insurance system
in April 2018. In the case of an ailment or an emergency, this would present a very
significant concern on the patient and the social circle around the patient. It would also
affect the speed of clinical attendance or even present a life threat to the patient.
The total of amount under the rejections was Kenya Shillings 3.1 million (USD 31,000)
and 10.7 million (USD 107,000) for March and April 2018 respectively. In the operations
this is sent to the respective departments concerned for further investigation of each
category of rejections for resolution.
For all the data from PARAS to eOxegen where claims were rejected due to
contravention of business policy – arising from underwriting and the medical filter – 7
transactions from 6 claimants were observed in April 2018. These were found to have
arisen in circumstances where waivers were granted but were not effected in the eOxegen
System or the root cause of the ailment is not payable under the medical policy.

6. Business Benefits
The results are expected to benefit players in the healthcare service/insurance sector on the
limitations of the ERPs, flag out the risks in the data flow, operations and monetary value,
inform ERP developers and digital transformation champions on the potential pitfalls on the
development, implementation and business rules as well as reinforcement of standard
operating procedures.
This study also calls to attention and scrutiny the implementation, integration and
customization of business rules in ERPs and management information systems as well as
the training of the front-office staff in the healthcare industry.
The quality assurance process (internal audits, external audits and the continual
improvement mechanisms) herein also obtain pointers to flashpoints in the ERPs and
operations which is beneficial to the sustainability of the healthcare service/insurance
industry in particular and all enterprises in general.

7. Conclusions
Data analytics revealed various discrepancies in the data pipeline from the clinical side of
the business (PARAS) to the insurance side of the business (eOxegen) and the customer
side of the business (digital smart card system). This represents the end-to-end flow of
transactions from the data captured at the point of treatment to the payment of the claim.
The most outstanding discrepancies were the differences in the number of records in the
eOxegen and the digital smart card system, the rejections at the data interchange between
PARAS and eOxegen as well as the transaction processing stages.
The discrepancies in the data were very significant with significant impact on the
healthcare service provision, claims settlement on the healthcare insurance segment,
monetary loss or confusion as well as business confidence (decision-makers, oversight
institutions, shareholders and the general population). These would also impact the national
Big 4 Agenda of Kenya on universal healthcare coverage.
These results call to attention the management of customer desk at the healthcare
service provider (where smart cards were swiped on digital smart card system but not
swiped on the PARAS or vice versa). Secondly, attention is called to the underwriting
section of the business to countercheck customer entitlement against business rules
enforced in the system (eOxegen) and the application of the rules to individual or the
corporate clients.
The results obtained will be used to inform implementation, integration and
customization of business rules in ERPs and management information systems as well as

Copyright © 2020 The authors www.IST-Africa.org/Conference2020 Page 7 of 9

establishment of standard operating procedures and the training of the front-office staff in
the healthcare industry.

8. Recommendations
It is observed that there were significant discrepancies between the data from the three
complementary ERPs; PARAS on the healthcare service provision or clinical side, eOxegen
on the healthcare insurance or insurance benefits and claims side as well as the customer
relations or smart card system.
It is noted that the discrepancies arise due to, among others, deficiencies in the standard
operating procedures (smart cards swiped on one system and not swiped on the other),
configuration of business rules (waivers), dropped records and management of data
integration. The monetary value and the operational, tactical and strategic impact of the
discrepancies are very significant. Recommendations are made as follows:
 The customer desk at the healthcare service provider needs to establish standard
operating procedures to mitigate the risk of smarts cards swiped on digital medical card
system but not swiped on the healthcare management system or vice versa – where the
two are separate.
 The development, implementation and deployment of healthcare ERPs need to fill the
data integration gaps/loopholes where records are dropped by the ERPs; PARAS,
eOxegen and the digital card system.
 The configuration of business rules in the ERPs need to be customizable to the needs of
the various policies; medical, company rules and regulatory frameworks.
 Where ailment root causes have an impact on the claims and the management of
waivers (such as discounts) apply this should be reflected in the systems – codified into
business rules and customized into the systems.
 Further scrutiny, by the respective audit and regulatory agencies, of the operations and
the oversight thereof of the systems and the organizations to rule out the possibility of
fraud-related data discrepancies and enactment/reinforcement of appropriate measures
for the well-being of the healthcare service industry.

Acknowledgement
Special acknowledgement to the management of VizAfrica Symposium 2018 that stirred
the thinking and the engagement to write this paper and the Innovation Centre for
Computing and Technological Solutions (iCCATS) Sub Taskforce of the Africa-ai-Japan
Project for the urgency to advance the research, innovation and entrepreneurial outputs of
JKUAT.

References
[1] Adebisi, O. A., Oladosu, D. A., Busari, O. A., & Oyewola, Y. V. (2015). Design and Implementation of
Hospital Management System. International Journal of Engineering and Innovative Technology, 31-34.
[2] AIB Capital Research. (2018). Insurance Industry Report: Growth on Life Premiums. Nairobi: AIB
Capital Ltd.
[3] Bishwakarma, P. K., Upreti, M., Yadav, R. K., & Acharya, S. (2014). A Proposal on Hospital
Management System. Locus.
[4] CIO Review. (2017). 20 Most Promising Insurance Technology Solution Providers. Retrieved August
15th, 2018, from http://track4infotec.com/
[5] Government of Tamil Nadu. (2011). Health Management Information System by Tamil Nadu Health
Systems Project Department of Health & Family Welfare, Government of Tamil Nadu. Chennai:
Department of Administrative Reforms and Public Grievances, Government of India.
[6] Health Markets. (2014). Medical Underwriting. Retrieved August 15th, 2018, from Health Markets:
https://www.healthmarkets.com/glossary/medical-underwriting/

Copyright © 2020 The authors www.IST-Africa.org/Conference2020 Page 8 of 9

[7] Insurance Regulatory Authority. (2019). Insurance Industry Annual Report 2018. Nairobi: Insurance
Regulatory Authority.
[8] International Bank for Reconstitution and Development/The World Bank. (2018). The Role of Digital
Identification for Healthcare: The Emerging Use Cases. Washington, D.C.: International Bank for
Reconstitution and Development/The World Bank.
[9] Kenya Healthcare Federation, & Task Force Health Care. (2016). Kenyan Healthcare Sector:
Opportunities for the Dutch Life Sciences & Health Sector. Nairobi: Embassy of the Kingdom of the
Netherlands in Nairobi.
[10] KPMG. (2018). General Insurance Industry Review 2018: With the top 10 trends impacting the sector.
Adelaide: KPMG.
[11] Latha, N. A., Murthy, B. R., & Sunitha, U. (2012). Smart Card Based Integrated Electronic Health
Record System for Clinical Practice. International Journal of Advanced Computer Science and
Applications, Vol. 3, No. 10, 123-127.
[12] Milenkovic, D., Milenkovic, M. J., Vujin, V., Aleksic, A., & Radojicic, Z. (2012). Electronic health
system – development and implementation into the health system of the Republic of Serbia.
Vojnosanitetski Pregled, 880-890.
[13] Pashkov, P., & Moshegova, A. (2019). Value Model-based Digital Transformation of Business
Processes in Enterprises. XXII International Conference “Enterprise Engineering and Knowledge.
Moscow: CEUR.org.
[14] QlikView. (2016). Working with QlikView. Lund: QlikTech International AB.
[15] Schaudel, F., Niedermann, F., Kumar, S., & Reinecke, K. (2018). Underwriting excellence: The
foundation for sustainable growth in health insurance. Frankfurt: McKinsey & Company.
[16] Smart Card Alliance. (2013). Smart Cards and Healthcare Providers. New Jersey: Smart Card Alliance.
[17] Srishti. (2013). PARAS-Laboratory Information System. Bangalore: Srishti Software Applications Pvt.
Ltd.
[18] Srishti. (2015). PARAS HMIS: A Patient Centric Comprehensive & Integrated Healthcare Delivery
Platform. Bangalore: Srishti Software Applications Pvt. Ltd.
[19] Srishti Software. (2017). Home. Retrieved from Srishti Software: http://srishtisoft.com/

Copyright © 2020 The authors www.IST-Africa.org/Conference2020 Page 9 of 9