Jan 2019 HL7 AWG WGM Minutes

HL7 AWG Project Meeting Minutes

Location: San Antonio

Date: 01/15/18 – 01/17/19
Time: 9:00 AM – 5:00 PM  Eastern Time

Facilitator:

Christol Green

Scribe:

Robin Isgett

Attendee Names – Also see "2019 Jan AWG Attendance" on Confluence under "AWG Agenda 2019 January"

Christol Green

Co-chair

Durwin Day

Co-chair

Robin Isgett

Note taker

Joel Bales

Mark Krebs

Mark Scrimshire

Tony Benson

Katrina Keyes

Henry Meyne

Chris Johnson

Laurie Burkhardt

Katie Sullivan

Mary Lynn Bushman

Mary Kay McDaniel

Lorraine Doo

Sherry Wilson

Brian Flynn

Russell Ott

Mike Cabral

Pat Van Dyke

Rachel Foerster

Rick Geimer

Jean Narcisi

Todd Cooper

Carlos Polk

Dresden Maxwell

Sam Rubenstein

Keith Boone

Fahmi Boussetta

Tammy Banks

Lenel James

Nancy Beavin

Megan Soccorso

Bob Dieterle

Marci Maisano

Walter Suarez

Jocelyn Keegan

Quorum Requirements Met:  Yes

Agenda Outline

Agenda Item

Meeting Minutes from Discussion

Decision Link

01/15/19 – Q3

Dental Interoperability Project #1482

CARIN Alliance

• Introductions

• Durwin summarized the Payer User Group summit.  See supporting documents.

• The Patient Care workgroup is co-sponsoring the Dental Interoperability Project #1482.  Todd Cooper’s presentation explained that HL7 and the ADA have initiated a joint Dental Interoperability Investigation Project to develop a white paper that details a representative set of storyboards and use cases.  See supporting documents.

• Mark Scrimshire gave a presentation on the CARIN Alliance.  A group of more than 60 healthcare and other stakeholders, has released the first draft of a voluntary code of conduct that entities not covered by HIPAA can self-attest to in order to access health data on behalf of consumers.  When personally identifiable health information is shared between applications, that information is considered consumer data and falls outside of the industry's current privacy and security practices under HIPAA. The CARIN code of conduct addresses how healthcare data should be handled by consumer-facing applications under Section 5(a) of the Federal Trade Commission Act, which encourages industry to develop consensus for what is meant by "unfair or deceptive acts or practices."  See supporting documents.

01/15/19 – Q4

INDUSTRY UPDATES

• FHIR Connectathon – See Supporting Documents. 

• HL7 updates -  new logo, asking for comments.  Go to HL7 to standard to look like HL7 FHIR logo, plain HL7.  Survey monkey/r/jwgm2019

• ASD Co-chair Meeting - Monday dinner – New Confluence calendar.  PSS deadlines. Changes reminder.   Administrative Steering Division -

• Complete 3 year plan on confluence

• Todd Cooper shared the Dental White Paper on interoperability

• Had a conversation on US vs. Universal Realm.  If marking Universal, there must be a country that will implement PSS (not just interested) and listed on PSS

• Review vote on ePDx – passed ASD

• Complaint from AWG member that there will be 3 Blues as co-chairs for then new workgroup?  We shared with workgroup that this is not true.  We had 3 candidates which one was a Blues, but he withdrew.  The 2 that are candidates are not payers. Russ Ott and Henry Meyne.  Then the discussion around HL7 co-chairs and their affiliations.  It is HL7s guidance that workgroups can vote in whoever they feel appropriate.  They may even be from the same company.  No rules against same entity as co-chairs.

• Group attendance on Confluence.  Updates to confluence.  No more help desk.  Questions with go through Zulip Chat, on-line instant messaging platform.  FHIR has been using it.  Threads are available.  Can be used real-time or mailing list. Follow-up with the TSC.  HL7 home page has a chat/contact us. Also a FHIR chat and Private messages.

• AWG new name and Charter discussion and ASD suggestions.

1. Additional and Supporting Payer/Provider Information (ASPPI)

2. Additional and Supporting Information for Payers/Providers (ASIPP)

Straw poll – 8 for first one 7 for second one.  With hyphen in the second

, 11 to 3 for the second one written as "Additional and Supporting Information – Payers/Providers".

• Mission and charter were approved.

• Additional discussion - Laurie mentioned that the Financial Management group presented a Project Scope Statement that AWG co-sponsored, but Attachments was left out of the PSS.  The Domain/Steering committee will have to review the PSS and approve for AWG to be added.  Laurie had concerns about the workgroup sponsoring projects without some consistency in the process

• Durwin summarized what we will be going over tomorrow.

ADJOURNED at 4:45 PM.

01/16/19 – Q1

IG Vision on Da Vinci eHealth Record (eCDx/ePDx) for Provider Information Exchange with Payers

• Bob Dieterle gave Da Vinci presentation.  As part of the Da Vinci project, work has begun on creating implementation guides for Clinical Data Exchange (eCDx) and Payer Data Exchange (ePDx).  Work will be done collaboratively with the Financial Management work group.  The scope is to define exchange methods (push, pull, triggers, subscription), use of other interoperability "standards" (e.g. CDS Hooks and SMART on FHIR) and specific use of FHIR resources to effectively exchange payer information regarding the current or previous care, including the provenance of the data, of one or more specific patients/members with a provider responsible for evaluating/specifying/ordering/delivering care for the patient.  The goal is to identify, document and constrain very specific patterns of exchange so that providers and payers can reliably exchange information for patient care (including coordination of care), risk adjustment, quality reporting, identifying that requested services are necessary and appropriate (e.g. should be covered by the payer) and other uses that may be documented as part of this effort.  See supporting documentation.

• Durwin mentioned that Mary Kay took our new name to the TSC this afternoon and ASIPP was approved to be submitted for official name change.

• Laurie asked for a brief overview of CDS hooks.   A capability of an eHR vendor to incorporate that when an interaction takes place, eHR can fire off an alert that is invisible to the user.  Lenel pulled up a video by Josh Madel, that explained by example.  A physician is about to prescribe a medicine: when CDS hooks sees that a prescription is about to be prescribed, the hook may show price of generic vs high dollar med.  BCBS may only pay for the generic.  CDS hooks can go into any FHIR certified eHR.  Separate from vendor solutions.  Walter – eHRs can consume external RULEs from a payer, etc.  Part of the clinical work flow and decisions.  The eHR triggers hooks (specific events) that notify external CDS services that return Cards (or decisions).  Set of hooks, when patient chart is opened, a new med is prescribed, real-time order review.  Responsibilities, respond in real-time, obtain via FHIR any data needed for the decision, then generate cards for display to the user.  Cards are simple JSON.  Cards include an urgency indicator, have 3 basic card types: information, suggestion and app link.  CDS Hooks is a work in progress, the Argonaut project link to SMART app not just a web page and project for clinical decisions.    Asynchronous delivery.  CDS Hooks tracks in FHIR connectathons.  See CDS Hooks.org 2017 demo. 

Break time

01/16/19 – Q2

Orthodontic Reconciliation

Russell Ott gave a recap of the guide.  The goal is to take ADA requirements (1079 structured format) and codify the data into a CDA document, on behalf of DOD as secondary payers. Thirteen outstanding comments put to a block vote.  There was discussion on attachment re-association ID.  We will instruct implementers to do the following:

• For solicited scenario, put the Attachment Control Number in the inFulfillmentOf.order.id, with id@root = OID maintained by the Health Plan requesting the Attachment, and id@extention = Attachment Control Number. 

• For unsolicited scenario, use the ClinicalDocument.id as the Attachment Control Number, and propagate it to the appropriate envelope metadata location.

The reason for the difference of location for Attachment Control Number, is that, the produced Attachment in response to a request from a Health Plan is logically similar to a Report being generated in response to an Order (hence inFulfillmentOf.order.id). The Attachment Control Number in an unsolicited submission represents a unique document identifier for the organization generating the Attachment, which is the purpose of the ClinicalDocument.id.

Block vote for comments 4, 5, 6, 7, 8, 9, 17, 18, 28, 32, 35, 40, and 41.  Laurie motions to approve sherry seconds.  No discussion. No abstentions.  All 14 approve.

Lenel announced that a Prior Auth discussion that was done at payer summit would be in the Live Oaks room during Q3.  The workgroup agreed to attend the discussions. 

Durwin went to Structured Docs discussion about LOINC codes change of "History and Physical" to "Evaluations".  Updates will be made on LOINC database by June 2019.  Determine impact to current guides for the name change.  Document Ontology committee and Structured Docs need to be better coordinated since workgroups were not consulted.

Meeting adjourned at 12:20

01/16/19 – Q3

Q3 – The Da Vinci Project:  Authorization Support

Bob Dieterle gave a presentation from the Da Vinci project for authorization support which is one of the use cases.  How to make it work in a clinical workflow.  Constraints are that it is done by phone, fax, or online

. Anticipating attachment regulation.  Per HIPAA, between provider and payer must be x12.  No requirement on communication.  EMRs do not use x12.  Use FHIR to extract data from the eHR and get it to the payer.  Make sure that what x12 needs is provided.  Use CDS Hooks to provide a card.  Make a provision to interact with the provider using SMART on FHIR.  Package it up and go into the 275 to give an immediate answer.  The medical record verifies that the service is medically necessary.  The conversion to the 278 can be done by different methods.  Project scope statement for Authorization Support – see PSS under Financial Management in Confluence.  See section3.b - Trying to automate the prior auth.  By using the 278, attachment regulations are not needed.  The 275 is not necessary.  Mary Kay says issue with mapping to the 278 cannot come from Financial Management workgroup.  There is a reasonable expectation that the attachment regs will come out to support the 275.  Is X12 and HL7 coordinating efforts.  Viet suggested adding a note that no x12 mapping not to be done by these workgroups.  Timeline puts this to 2022.  STU to normative.  Bob made verbiage changes to the document in the workgroup meeting. 

Motion to accept the PSS and second.  Passed with 26 approved.

Lenel makes motion and Durwin seconds to vote to co

-sponsor the Da Vinci PSS auth.  No further discussion, no abstentions and none opposed.  10 approved.

Mary Lynn submitted list of LOINC codes that could possibly be included in the 277RFI transaction, but it was the wrong list.  Workgroup will look at the HIPAA tab and review to see if Dan, with Regenstref needs to be consulted.  Will continue the discussion in Q4.

01/16/19 – Q4

277 RFI mapping of LOINC codes

277 RFI mapping of LOINC codes.  More than 2000 codes.  Some are valid LOINC codes but are not on the Relma tab.  Request will be generic to ask for a medical record.  A business decision on what is needed.  When attachments gets approached regarding LOINC, the workgroup should ask for business justification.  Durwin pulled up Regenstref….Documents without imp guides ( like for unstructured) – medical records,

Relma, HIPAA tab with 4 tabs.  Documents with imp guides drop down menu with US realm header.  Look in CDP1 for the LOINC codes Mary Lynn was looking for.  Mary Lynn did not look for the LOINC codes here.  Used LOINC code 11503-0  for "medical records" as an example.  Not in the HIPAA tab.19002-5 for rehab physical therapy is on the tab. Compared the two. Same attachments class.  Ask Dan about this tomorrow.  Ask if the search can include all drop downs.  Has no HL7 Attachment structure.  18842-5 for discharge summary. Also has an HL7 Attachment structure field. 18682-5 ambulance date was included on the claim so they were not displayed on the HIPAA tab.  They have a type 3. 11514-7 chiropractic records total encounter. 

Should be able to request these LOINC codes that are not on the HIPAA tab to do the mapping.  11485-0 CMS mapped all codes to LOINC codes, but some were not on the HIPAA tab.  11526-1 pathology study.  19004-1, skilled nursing is for rehab. Motion to ask Dan to add no IG on these.  Laurie motion to move forward, Mary Lynn second.  Discussion – Laurie requests that we have a work instruction for them to have a business reason/justification and be prepared.  None abstain

, all in favor - 14 approved.  Follow-up with Tony to see if he also has some codes. Lorraine left NCVHS update.  Interoperability predictability roadmap hearing to create a letter that will go to CMS.  Regulation and standards recommendations Feb 6 & 7.  Present to the full committee at NCVHS.  Mentioned being innovative using standards you must have trading partner agreements is allowed with BAA mutually agreed upon.  There will be clarification in the letter to what will be allowed.

Discussion about APIs being adopted by top eHR vendors and payers.  However, there are so many providers that do not go through the top eHR vendors.  

Medicare Attachments - Mary Lynn has implemented 180 providers set up for using 275.  Receiving 275s every day.  Over 900 275s in Dec. that include structured OP notes and unstructured documents.

Lenel - Allscripts e-charts H & P.

Keith – No news on the attachment regulation, but heard that it was sitting in OMB and is in process.

Rescinding the health plan ID (HPID).  Open for comment period.

ADJOURNED at 4:41 PM.

01/17/19 – Q1

Financial Management

Reminder to check in Confluence and do attendance.

Russ Ott is the new co-chair.

Joint meeting with Financial Management workgroup.  Mary Kay is a TSC liaison to Da Vinci.  There are 7 implementation guides coming up for ballot in May.  Two are co-sponsored by Attachments.  Reconciliation and quality of the guides will take time to review.  Content is still being added.  By 03/25/19, we have to approve the guides in a short deal of time.  Combine the Financial Management and Attachment calls to review imp guides for ePDx, Auth and CRD.  Do not map to x12 278 because it is not widely used.  The FHIR auth resource should match the business needs.  The state of Virginia is using Standardized Episodes of Care (SEOC) codes that are specific to them.  Discussion of FHIR can adapt to business needs as they become known, such as in Virginia.  There is a challenge when something is done during the encounter that was not on the auth.  US Realm auths are specific to what was approved on the auth.  No matter the use case, FHIR will try to support it. 

Mary kay met with the TSC and submitted the form for the name change.  After 30 days, they then give approval.

FHIR R4 is the current version web and imp guide.  List of resources; eligibility, claims, predetermination, if a person is not eligible, then other resources response back will let you know if person is not covered.  You do not have to do a separate eligibility. Discussion of FHIR transactions providing only what is available in internal systems.  Pre-auths are normally required for more complicated procedures than is common.  May not be automated as easily as claims.  Pharmacies and vision would have different perspectives than dental and medical regarding when a pre-auth is needed.  FHIR restful API resources can be used behind the scenes using PUT or GET commands.  The FHIR resources between entities, ensures that you will get a response.  Paul talked about differences in US vs other countries.  Relative order of use section.  Overview of claim resource.  UML diagram of a claim model. Paul suggested separate pre-auths for inpatient, dental, vision, pharmacy and what would go into a profile.  The US uses DRG codes, but for global there may be a package code. The structure is there to make the rules you will need.  Service type codes will be used in an auth.  Have a fundamental base that can handle most business needs to do a pre-auth.  The claim must contain the preauthorization code.  The detail line items do not work well for pharmacy or vision.  The detail, then sub detail for compound drugs is an example.  One pre-auth guide with multiple profiles to handle the multiple claim types (dental, vision, inpatient, ambulance, pharmacy, etc.).  Must align business with technical.   Everything requires maintenance.  First timer question.  Paul showed the model.  Where to go to get your business need into a profile.  Go to Financial Management workgroup.  HL7 has events she can join.  Da Vinci can put some of that together.  Weekly calls with FM at 11 EST.  Meeting in Montreal would be best to discuss/finalize the imp guides for ballot:  Mon 1-4, Tues  3-4, W 3-4, TH 3-4.

01/17/19 – Q2

Value Based Health Story

Cross-Paradigm Story Board Artifact:  Payer Perspective, Value-Based Care reconciliation. 

AWG Confluence Page updates and training

• Lenel presented four remaining negative votes that had not been reconciled. He explained how the reconciliation process works.  Group agreed with the wording of the dispositions that will be added to the document.   The block vote was for # 50 (not persuasive w/mod), # 51 (persuasive),   #52 (persuasive w mod) and #55 (persuasive).

• CONFLUENCE – josh made a change to make sure the delete function was working for the attachments workgroup.  Christol was not previously able to delete persons from attendance.  Can drag and drop using Space Tools and drop down details.  Go to workgroup parent page.  Can use a "listening" macro or Watch to see what other workgroups are doing.  Edit page layout and a section {children display, then update subpages.  Create 2019 folder use left bracket again, child,space tools, reorder.  Put all into 2019 folder.  Meeting Index is the parent, conference calls, workgroup meetings, children.  Create 2018 folder in Space Tools by clicking in the body of the document you are working on.  Hit Create button|…| dots.  Can use 3-year Plan template and put under Documents/Presentations.  Create folder for Da Vinci, etc.  Each page has a front side for viewing and a back side for documents.

• Megan asked about free conference call

Adjourned at 12:00

Next Meeting

29 Jan 2019　

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Actions:

• Attachment Control Number - attachment implementation guide.5.3.3 Attachment Control number. Verify that it should only be used in the metadata appendix F transport and payload.

• We will need to update the C-CDAR2 Attachments IG

• Schedule weekly calls with FM Workgroup

• 277 RFI LOINC code research

• Need to complete a 3 year plan for our new work group