NPAG -- Emerging Technology Initiatives 20190826 · ô l î ò l î ì í õ î 7huplqrorj\ +/ )+,5 ±)dvw +hdowkfduh ,qwhurshudelolw\ 5hvrxufhv edvhg rq lqwhuqhw whfkqrorjlhv ;0

$Page 1: NPAG -- Emerging Technology Initiatives 20190826 · ô l î ò l î ì í õ î 7huplqrorj\ +/ )+,5 ±)dvw +hdowkfduh ,qwhurshudelolw\ 5hvrxufhv edvhg rq lqwhuqhw whfkqrorjlhv ;0$
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Da Vinci – NPAGEmerging Technologies / Initiatives

Gulf Shores, AL

August 26, 2019

ANSI Antitrust Policy

• ANSI neither develops standards nor conducts certification programs but instead accredits standards developers and certification bodies under programs requiring adherence to principles of openness, voluntariness, due process and non-discrimination. ANSI, therefore, brings significant, procompetitive benefits to the standards and conformity assessment community.

• ANSI nevertheless recognizes that it must not be a vehicle for individuals or organizations to reach unlawful agreements regarding prices, terms of sale, customers, or markets or engage in other aspects of anti-competitive behavior. ANSI’s policy, therefore, is to take all appropriate measures to comply with U.S. antitrust laws and foreign competition laws and ANSI expects the same from its members and volunteers when acting on behalf of ANSI.

• Approved by the ANSI Board of Directors May 22, 2014

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Terminology

HL7 FHIR© – Fast Healthcare Interoperability Resources -- (based on internet technologies;

XML, JSON, and RESTful exchanges -- current release is R4)

FHIR Resource – definition of a related set of clinical data elements (e.g. Observation)

CDS Hooks – Clinical Decision Support Hooks (triggers exchange base on clinical workflow events)

SMART – framework developed by MIT and Harvard for adding provider functionality to EHRs

USCDI – ONC’s US Core Data for Interoperability – Meaningful Use required elements

US Core Profiles – Constraints on a version of FHIR to represent the USCDI data set

CQL – Clinical Quality Language (SQL like language for clinical applications)

HL7 Da Vinci Project: An Overview

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To ensure the success of the industry’s shift to Value Based Care, Da Vinci established a rapid multi-stakeholderprocess to identify, exercise and implement initial use cases between payers and provider organizations.

The objective is to minimize the development and deployment of unique solutions with focus on reference architectures that will promote industry wide standards and adoption.

Payer Members:Anthem, BCBSA, BCBSAL, BCBSM, BCBST, BC Idaho, Cambia Health, Cigna, CMS, GuideWell, HCSC, Humana, Independence, United Healthcare

Vendor Members:Allscripts, Athenahealth/Virence(aka GE Centricity), Casenet, Cerner, Cognosante, eCW, Edifecs, Epic, HealthLX, InterSystems, Juxly, Optum, Surescripts, ZeOmega

Project Process Define requirements (clinical,

business, technical and testing Create Implementation Guide (IG) Create and test Reference

Implementation (RI) (prove the IG works)

Pilot the solution Deploy the Solution

Provider Members:Dallas Children's Health, MultiCare, OHSU, Providence St. Joseph Health, Rush University Medical Center, Sutter Health, Texas Health Resources, Weil Cornel Medicine

Partners:HIMSS, NCQA

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Sample Project Timeline

Assemble Team

FHIR Gap Analysis

Build Initial RI

Specify profiles, …

RI Tech Approach

Requirements

IG Development

RI Development Test RI Update Final RI

Project start

Represents 4 weeks2 - 4 sprints

Build Data Set

Week 0 2 4 6 8 10 12 14 16

Build Test Set

Work with appropriate HL7 workgroup for IG sponsorship and input

IG Framework Create Draft IG Revise and Finalize IG

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Documentation Templates and Rules


Gaps in Care & Information


Coverage Requirements

Discovery


Discovery

Performing Laboratory Reporting


Data Exchange for Quality Measures


Prior-Authorization Support


Risk Based Contract Member IdentificationRisk Based Contract

Member Identification

6

Alerts / NotificationsAlerts / Notifications

Patient Cost TransparencyPatient Cost

Transparency

Chronic Illness Documentation for

Risk Adjustment


Risk Adjustment

Payer Data ExchangePayer Data Exchange

Use Case Focus Areas

Patient Data ExchangePatient Data Exchange

Payer Coverage Decision Exchange


Clinical Data Exchange


Payer Data Exchange: Directory


Payer Data Exchange: Formulary


Qu

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Clin

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Co

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Process Improvement


Mem

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May ballot STU and for comment

In early September ballot (July) as STU

September ballot as STU

Currently targeted for potential early or regular January 2020 ballot

Use cases in discovery (some may be balloted in January 2020)

Use Case Status



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January ConnectathonHL7

Connectathon

Da VinciConnectathon &Working Session

MAY BALLOT (Mar 29 – Apr 29)

STU Data Exchange for Quality Measures (DEQM)

STU Coverage Requirements Discovery (CRD)

Comment Documentation Templates & Rules (DTR)

HL7 Connectathon

Ballots and Connectathons

EARLY SEPTEMBER BALLOT (June 21 – July 21)

STU Health Record Exchange (HRex)

STU Payer Data Exchange (PDex)

STU PDex Formulary

STU Clinical Data Exchange (CDex)

20202019

7

MAR APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR

JANUARY BALLOT (Dec 27 – Jan 26)

STU Gaps in Care

STU STU Patient Cost Transparency

STU RBC Member ID and Bulk Data

SEPTEMBER BALLOT (Aug 9 - Sept 9)

STU Documentation Templates and Rules (DTR)

STU Payer Coverage Decision Exchange

STU Prior Authorization Support (Prior Auth) HL7 Connectathon

Potential early January ballot (Oct 15 – Nov 15)

STU PDex Payer Directory

STU Alerts / Notifications

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Information Exchanges Supported by Da Vinci IGs

Patient

Provider

Member directed

[3] USCDI[6] Continuity of Treatment

[2] Aggregated Quality Measure Reporting

[2] Gaps in Care[7] Coverage Requirements[8] Documentation Rules[11] Payer Data

[10] Provider Data[12] Alerts/Notifications

[1] Quality Data[10] Provider Data

[9] Prior-Authorization[12] Alerts/Notifications

Quality Measures and Gaps[1] Data Exchange for Quality Measures[2] Gaps in Care and Information

Member Directed Exchange (CMS NPRM)[3] Payer Data Exchange [4] Payer Data Exchange: Directory[5] Payer Data Exchange: Formulary[6] Payer Coverage Decisions (Treatment)

Coverage/Documentation Requirements[7] Coverage Requirements Discovery[8] Documentation Templates and Rule[9] Prior-Authorization Support

Patient Data Exchange[10] Clinical Data Exchange (Provider Data)[11] Payer Data Exchange (Payer Data)[12] Alerts/Notification

Patient Cost Transparency (in discovery)

[3] USCDI [4] Directory[5] Formulary

Provider

PayerPayer


ConsumerApplication

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Coordination with CARIN Alliance

DATA SUB TYPE RESOURCE / PROFILE BUILD IG MEMBER PROVIDER PAYER

Financial EOB CARIN BB 2.0 CARIN

Clinical USCDI / US Core / Da Vinci Da Vinci PDex DV for CARIN Da Vinci Da Vinci

Clinical Data All USCDI / US Core / Da Vinci Da Vinci PDex DV for CARIN Da Vinci Da Vinci

Payer Decisions Treatment USCDI / US Core / Da Vinci Da Vinci PCD Da Vinci

Alerts/Notification Admit/Discharge USCDI / US Core / Da Vinci Da Vinci Alerts Da Vinci

RTBC SCRIPT FHIR R4? CARIN NCPDP RTBC CARIN NCPDP CARIN NCPDP

Medications USCDI / US Core Da Vinci PDex DV for CARIN Da Vinci Da Vinci

Formulary Da Vinci (new Profile) Da Vinci PDex Formulary DV for CARIN Da Vinci Da Vinci

Directory Data Payer & Pharma Network

USCDI / US Core / Da Vinci Da VinciPdex Provider

NetworkDV for CARIN Da Vinci

DV for CARIN CARIN may choose to add additional guidance

Claims Data

Pharma Data

PAYER TO:WORK BREAKDOWN TO SUPPORT CMS NPRM

Activities by the Numbers

Stats

Total practice runs 3

Total public runs 23

Filming runs 1

Total variations 14

Total roles 96

Total role system issues

7

Role availability 92.7%

Each step represents a provider – payer exchange using FHIR IG10

UNLOCKING PAYER INFORMATION TO IMPROVE CAREHIMSS19 Demonstration

CLINICAL SUMMARY

Da Vinci is demonstrating the ability to exchange information between payers and providers using HL7® FHIR® and CDS Hooks® as part of the Interoperability Showcase.

The vignette describes a clinical encounter for 78-year-old Asian women named Dara that starts with her primary care physician, proceeds to a cardiologist who admits Dara to the hospital for an angiogram and observation where it is determined that her chronic obstructive pulmonary disease has progressed to the point that she needs supplemental oxygen.

As Dara returns to her primary care physician, her previous medications are reconciled with those prescribed at discharge, the PCP reports the medication reconciliation, in support of a quality measure the Medicare Advantage program is following for its members.

Activities by the Numbers

Stats

AEGIS Touchstone available

100%

Total MCs 6

Total EHRs 2

Total Payer/Partner 4

Total Payer only 5

Total Sponsors 16

Number of visitors (approx.) 500

Percent that left during vignette

< 10 %

Patient Patient Patient Patient Patient1

2

3

4

PCP

Schedule Appt with

Payer

Admitted for Angioplasty

Discharged with O2

Therapy

PCPCardiologist Hospital

PayerMed Rec

PayerPayerPatient Data

The visual describes the interactions demonstrated at HIMSS Interoperability Showcase, direction of each exchange, the FHIR standards

used, the setting where the interaction is occurring and the participants.

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CMS NPRM Member Access

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CMS NPRM for Payer Data Exchange – to Member

1) Must implement and maintain an open API that permits third-party applications to retrieve, with the approval and at the direction of an individual MA enrollee, data specified below through the use of common technologies and without special effort from the enrollee.

a) Accessible content – all plansi) Standardized data concerning adjudicated claims, including claims …

ii) Standardized encounter data, …iii) Provider directory data on the MA organization’s network of contracted providers, including

names, addresses, phone numbers, and specialties, … andiv) Clinical data, including laboratory results, if the MA organization manages any such data …

b) Accessible content – for plans that offer an MA-PD plansi) Standardized data concerning adjudicated claims for covered Part D drugs …

ii) Pharmacy directory data …, andiii) Formulary data that includes covered Part D drugs, and any tiered formulary structure or

utilization management procedure which pertains to those drugs.

Notes: a) applies to other plans covered by the CMS NPRM – see specific language for eachb) applies in part to some other covered plans – see specific language for each

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CMS NPRM for Payer Data Exchange – to Payer

2) Coordination among payers.

a) MA organizations must maintain a process for the electronic exchange of, at a minimum, the data classes and elements included in the regulations regarding the content standard adopted at 45 CFR 170.213 (USCDI). Such information received by an MA organization must be incorporated into the MA organization’s records about the enrollee. At the request of an enrollee, the MA organization must:

i) Receive such data from any other health care plan that has provided coverage to the enrollee within the preceding 5 years;

ii) At any time an enrollee is currently enrolled in the MA plan and up to 5 years after disenrollment, send such data to any other health care plan that currently covers the enrollee;

Notes: a) applies to other plans covered by the CMS NPRM – see specific language for each






Discovery


Discovery







Risk Based Contract Member Identification

(Bulk Data)


(Bulk Data)

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Transparency


Risk Adjustment


Risk Adjustment

Payer Data Exchange









Qu

ality Imp

rovem

ent

Clin

ical Data E

xchan

ge

Co

verage

/ Prio

r Au

tho

rization

Process Improvement


Mem

ber A

ccess




In early September Ballot (July) all STU


Currently targeted for early or regular January 2020 ballot


Use Case Status

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CMS NPRM Information Exchanges

Supported by Da Vinci IGs

Patient

Provider

Member authorization













Provider

PayerPayer


ConsumerApplication

Health Record Exchange

Payer Data Exchange (PDex)

Provider to Payer Exchange (CDex)

PAYERPROVIDER16

Health Record Exchange Framework

Interactions & Profiles

Provider can receive relevant Payer Sourced Data about a patient

Provider can share relevant Provider Sourced Data to Payer and/or other Providers

Payer Data Exchange (PDex): Directory

Payer tData Exchange (PDex): Formulary

PATIENT/ MEMBER

Provider can access Plan Network Directory information

Provider can access Plan Formulary information

Patient can access Plan Network Directory information

Patient can access Plan Formulary information

Provider can receive their Payer Sourced Data

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MEMBER DIRECTEDAPPLICATION

Member Direction

USCDI* -- Da Vinci PDex

Blue Button 2.0 -- CARIN

Directory: Da Vinci Payer Network

Formulary: Da Vinci Formulary

*Supports bulk data exchange for USCDI

1

1

22

PAYER 1

3

3

44

PAYER 2

1

2

3

4

CMS NPRM Member Access for Covered Payers

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USCDI – US Core Profiles on FHIR R4

Examples of Payer Data Sources

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Continuity of CarePayer – Payer Exchange

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Member Direction

USCDI* -- Da Vinci PDex

Continuity: Da Vinci PCD

*Supports bulk data exchange for USCDI

2

PAYER 1

5

5PAYER 2

2

CMS NPRM Requirement for Covered Payers

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21

Goal: To address the portability of care/treatment as a member moves from one covered plan to another

Regulatory: CMS NPRM for member directed payer to payer exchange of USCDI data

Immediate Requirement: Support for information regarding ongoing treatmenta) Relevant diagnosesb) Current treatments (including start date, end date (if any), …)c) Guidelines for prior-authorization (e.g. specific Milliman guideline)d) Current prior-authorizations (service, duration, remaining)e) Clinical information that went into the decision for treatment coverage


CMS NPRM Care Team Alerts

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CMS NPRM Information Exchanges

Supported by Da Vinci IGs

Patient

Provider

Member authorization













Provider

PayerPayer


ConsumerApplication

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Alerts/Notification

Site of where notifiable event

occurred

Primary Care

Specialty Care

Inpatient Services

Payer

HIE / HIN

Potential Interactions:1) Subscribe to event directly (no intermediary)2) Subscribe to event via intermediary3) Push to “registered” member (perhaps via payer care team information)4) Push to intermediary

Any care team member can be connected directly or via an intermediary (e.g. HIE)

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Prior Authorization Support

Current Prior-Authorization Environment

Payers

Providers

Telephone

Portals

Electronic Transactions

PA Request

Medical Records

Currently providers and payer exchange prior authorization requests and supporting medical recordsusing a number of methods: telephone, fax, portals, and electronic transactions

Fax

r5r6

Slide 26

r5 same physiican, add [email protected], 8/17/2018

r6 add bunch of payers on right sycn graphic for physiican with mel's favorite [email protected], 8/17/2018

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Current HIPAA / Anticipated Attachment Approach

Must be ASC X12N 278 (PA request) / 275 (attachment with CDA)

May be any method (including ASC X12N)

BA

Any Method

ASC X12N 278/275

Any Method1a

2

1bASC X12N 278/275 Any Method

Virtual (within same CH)

Per the reqs (i.e. §162.923 Requirements for covered entities), if the Clearinghouse services both payer and provider, they must act as two virtual clearinghouses and must provide the transaction as a HIPAA compliant standard transaction internally – not currently enforced by CMS

Payer 1

Payer 2

Any Method

ASC X12N 278/275

Any Method1a

2

1bASC X12N 278/275

Any Method

Virtual (within same CH)

Payer 1

Payer 2

FHIR FHIR

FHIR

Future FHIR Enabled SolutionMust be ASC X12N 278 (PA request) / 275 (attachment with CDA)

May be any method (including ASC X12N)

HL7 FHIR

FHIR FHIR

ASC X12N 278/275

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Discovery


Discovery







Risk Based Contract Member IdentificationRisk Based Contract

Member Identification

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Transparency


Risk Adjustment


Risk Adjustment












Qu

ality Imp

rovem

ent

Clin

ical Data E

xchan

ge

Co

verage

/ Bu

rden

Red

uctio

n

Process Improvement


Mem

ber A

ccess




In early September ballot (July) as STU




Use Case Status



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Prior Authorization Workflow (X12 processing at Health Plan)

Integrating FHIR and X12

1) Create FHIR bundle with required X12 information and supporting clinical documentation

2) Convert FHIR bundle to X12 278, X12 275 and X12 278 I

3) Process by payers as X12 278 with unsolicited attachments

4) Convert X12 278 tresponse o FHIR bundle

5) Present results to provider

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Disclaimer 31

FHIR Prior Authorization Endpoint Interactions

FHIR PA endpoint requirements

1) Receive and process PA bundle

• Respond in <15 seconds

2) Receive and process Subscription request for “PENDED” PA

• Reply on change in PA status

3) Receive and reply to PA status query

4) Receive and process cancel

5) Receive and process update

6) Support Status, Cancel, Update from both ordering and performing provider

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FHIR Prior Authorization Components

Coverage Requirements1) Initiates process

using CDS hooks2) As if PA is required

Templates and Rules1) If PA is required start

SMART app and retrieve Payer Rules and Template

2) Prepopulate 3) Solicit missing info

PA Support1) Package clinical data

and request/response2) Manage exchanges

with payer

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Summary

• Using new technologies (FHIR , CDS Hooks, SMART on FHIR, CQL) it is possible to integrate previously time intensive tasks into the clinical workflow to achieve significant efficiencies

• We can substantially reduce provider burden by1. Acquiring critical patient information while the patient is available2. Obtain prior-authorizations in real-time for certain common services3. Minimize rework by “getting it right the first time”

• One critical impact of improving the prior-authorization workflow is the improvement on patient care and experience.

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Bulk Data Access

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Pipelines can support many scenarios

Encryption Transformation EHR

EHRRESTful

Exchange Pop Health

Large volume of data for one patient:

RESTfulExchange

Population based Data

Bulk Data API

Bulk Data APIEHR

Bulk Data API

Encryption Transformation

Bulk Data API

Design Goals

● Focus on enabling automated communication between backend services and EHRs/clinical systems● Use mature, stable technologies wherever possible● Small API surface area

○ Limit number of query parameters○ Limit number of serialization formats

● Reuse as much of existing FHIR semantics as possible○ Data models○ API format and data types○ Implementation guide structure

● Use existing standards based authentication and authorization○ Base on widely used OAuth (SMART) standard

● Structure for efficiently generating and loading large datasets○ Asynchronous operation○ One data type per file○ Streaming data

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File RequestKickoff Request

Content Location

GET Content Location

File Generation Status (e.g. 20% complete)

GET Content Location

File Links

GET File (eg. 0001.Observation.ndjson)

FHIR Resources File

Bulk Data Client

(destination)

Bulk Data Server

(source)

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Blue Button 2.0 API

BB 2.0 FHIR Server

1

ACOApplication

Claims

CMS Blue Button 2.0

OAuthToken

Adjudicated Claims

Integrated Data

Repository

StoreSubmitted

Claims

Weekly Load

ACO Attribution

List

Chronic Condition

Data Warehouse

Blue Button 2.0

Data Repository

Data At Point of Care

Application

BeneficiaryApplication

DPC Roster

ACO processing

Bulk Data Access

DPCprocessing

Authentication Process

Authentication Process

Bulk Data Access

BB 2.0 1) Based on FHIR STU 3.02) Custom Extensions3) Resources

• Patient• Coverage• EOB (8)

Integrated Data

Repository

ACO Attribution

List

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Discovery


Discovery






(Bulk Data)

39



Transparency


Risk Adjustment

Payer Data Exchange








Qu

ality Imp

rovem

ent

Clin

ical Data E

xchan

ge

Co

verage / P

rior A

uth

orizatio

n

Process Improvement

Payer Data Exchange

Mem

ber A

ccess



In early September Ballot (July) all STU




Use Case Status

Da Vinci Founder and PMO Member:

Bob Dieterle, EnableCare LLC

[email protected]

Da Vinci Program Manager:

Jocelyn Keegan, Point of Care Partners

[email protected]

Da Vinci Technical Director:

Dr. Viet Nguyen, Stratametrics LLC

[email protected]

Documents

NPAG -- Emerging Technology Initiatives 20190826 · ô l î ò l î ì í õ î 7huplqrorj\ +/ )+,5 ±)dvw +hdowkfduh ,qwhurshudelolw\ 5hvrxufhv edvhg rq lqwhuqhw whfkqrorjlhv ;0