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Chair:  Larry Decelles

Scribe: Dana Marcelonis


Attendees

Present

Name

Affiliation

  •  
Mitre
  •  
George BierOptum
  •  
BCBS AL
  •  
Rush
  •  
Matthew ByrneOptum
  •  
Rush
  •  
Cerner
  •  
Anthem
  •  
Allscripts
  •  
InterSystems
  •  
Allscripts
  •  
Mitre
  •  
Cambia Health
  •  
Cerner
  •  
Enable Care
  •  
Optum
  •  
Aegis
  •  
BCBS FL
  •  
InterSystems
  •  
Anthem
  •  
Mitre
  •  
Allscripts
  •  
Optum
  •  
Jackie HardisonHumana
  •  
Cigna
  •  
Claudia HartmanHighmark Health
  •  
Mark HinghamAnthem
  •  
Optum
  •  
Sheljina Ibrahim KuttyAnthem
  •  
Allscripts
  •  
Point of Care Partners
  •  
Edifecs
  •  
Mitre
  •  
InterSystems
  •  
Anthem
  •  
Tso LukeOptum
  •  
Point of Care Partners
  •  
Optum
  •  
Cognosante
  •  
Optum
  •  
Humana
  •  
Stratametrics
  •  
Casenet
  •  
Allscripts
  •  
Optum
  •  
Optum
  •  
InterSystems
  •  
C SimeoneOptum
  •  
Jeanie SmithBCBS FL
  •  
InterSystems
  •  
Veradigm
  •  
CMS
  •  
Casenet
  •  
Independence Blue Cross
  •  
Anthem
  •  
CentriHealth
  •  
CaseNet
  •  
India DuncanOptum
  •  
Jason Cassidy
  •  
Optum
  •  
Gevity
  •  
Tracy McCutcheonKPMG
  •  
Rashmi MenonKMHP
  •  
Mario JarrinChange healthcare
  •  

  •  
AMA
  •  
Ann GallagherOptum
  •  
Megan Smith-HallingsheadRegence
  •  
Regence
  •  
Anthony SmithUNC Health
  •  
Optum
  •  

  •  

  •  
Jennifer Joe
  •  
Texas Health
  •  

  •  
Cigna
  •  
Labcorp
  •  
Cigna
  •  
Matt DyerVyne
  •  

  •  
Barbara Kramer-ZarinsMITRE
  •  
Centene
  •  
Barbara WoodPNC
  •  
Greta HoneycuttCoverMyMeds
  •  
BCBSA
  •  

  •  
MITRE
  •  
Keya ShahCasenet
  •  
Rich Bloch
  •  
Interpro
  •  
Lauri Shock
  •  
Andrew JohnsonNational Decision Support
  •  
MITRE
  •  
Mark FlemingChange Healthcare
  •  
eClinicalWorks
  •  
Prathima
  •  
Rachel Foerster & Associates
  •  
Heather McComasAMA
  •  
Megan RileyMITRE
  •  
Summer DumanRegence
  •  
Michelle BarryAvaility
  •  
Chris Cera
  •  
Michael FasuloRegence
  •  
Mettle
PresentNameAffiliation
  •  
Peter MuirESAC
  •  

  •  
Ryanne LaurenceOHSU
  •  

  •  
Mitre
  •  
CMS
  •  
Aim Specialty Health
  •  
Christy DodsonMCG
  •  
Tibco
  •  

  •  
Rajesh Godavarthi
  •  
Santosh
  •  
Tom Hartman
  •  
Tori WillowsWellcare
  •  
Alise WidmerLumeris
  •  
Bart CarlsonAzuba
  •  
David BruinsmaColonial Med
  •  
Deepthi ReddyMettle Solutions
  •  
Danny BrennanMA Health Data
  •  
Patrick Edwards
  •  

  •  
Cambia Health
  •  
CMS
  •  
Pallavi TalekarScope Info Tech
  •  
Rajesh GarlapatiRush
  •  
Susan BellileAvaility
  •  
BCBST
  •  
Ralph Saint-Phard
  •  
Kristi CushmanOHSU
  •  
Briana BarnesScope Info Tech
  •  
Didi DavisSequoia Project
  •  
Sreekanth PuramMettle Solutions
  •  
Duane WalkerBCBSM
  •  
EMDI Team
  •  
David HillMitre
  •  
BCBS AL
  •  
Nandini GangulyEMDI
  •  

  •  
Rajesh GodavarthiMCG Health
  •  
Rim Cothren
  •  
Donna CampbellBCBSIL
  •  
Joanna GaskillLumeris
  •  
Edifecs
  •  
Michael CabralCMS
  •  
Sudhir NairAnthem
  •  
Saul KaravitzMitre
  •  
Dawn PerreaultBCBSM
  •  
Brent WoodmanBCBSM
  •  
Yolanda VillanovaCMS
  •  
Deryl Lam
  •  
Edifecs
  •  
Karen TottCMS
  •  
MITRE
  •  
Dacarba
  •  
Carradora
  •  
Rachel Goldstein
  •  
Ric LightHumana
  •  
eClinicalWorks
  •  
Healow
  •  
Wanda Govan-JenkinsHHS
  •  
Cindy MonarchBCBSM
  •  
Edward Yurcisin
  •  
Veradigm
  •  
Hibah QudsiMitre
  •  
Nancy SpectorAMA
  •  
Patrick Leblanc
  •  
Anupam ThakurBCBSFL
  •  
MCG
  •  
Chris KlesgesMitre
  •  
BCBSA
  •  
Gregory MagazuCaseNet
  •  
Isaac VetterEpic
  •  
Kat RuizUNC Health
  •  
Laura Bright
  •  
Humana
  •  
Roland Gamache
  •  
Katherine LuskChildrens
  •  
Anthem
  •  

  •  
Chris JohnsonBCBS AL
  •  
Jim AdamsonArkansas Blue Cross
  •  
Carry Denny
  •  
Infor
  •  

  •  
Anna MeisheidCMS
  •  
Celine LefebvreAMA
  •  
Eshaa DhalleClinicalWorks
  •  
BCBSM
  •  
Express Scripts
  •  
Sandhya
  •  
Christopher GraconIndependent Health
  •  
Candice TitusCrisp Health
  •  
Mariana SinghCAQH
  •  
BC Idaho
  •  
Shilesh NairGdit
  •  

  •  

  •  

  •  
UHC
  •  
Tammy BanksProvidence St. Joseph
  •  
Bob HarringtonAllscripts
  •  
Vishnu
  •  
DanielleSutter Health
  •  
MITRE
  •  
Sonya MayOptum
  •  
Molly MalaveyAMA
  •  
Guidewell
  •  
Angela BublikRegence
  •  


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Minutes Approved as Presented 


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Agenda Topics

Agenda Outline

Agenda Item

Meeting Minutes from Discussion

Decision Link(if not child)
ManagementReview ANSI Anti-Trust Policy




Links

DTR IG: http://hl7.org/fhir/us/davinci-dtr/2019May/

Reference Implementation: https://github.com/HL7-DaVinci/dtr 



Healow/eClinicalWorks Team Implementation Questions

(Mrugen Mehta)

  • Take a clinical example such as ordering a Diagnostic Image of Echocardiogram
    • EMR User selects Echocardiogram
    • Bundle everything that is needed, create CDS Hook (Order Select) and send information to the payer
    • Looking to explore options to either using a SMART on FHIR app for DTR questionnaire and responses, or not using that
    • Once we get the CDS CARD back for Echocardiogram requirements - questionnaire needed, does patient need testing
      • Are we expecting that to be part of CDS CARD because not part of SMART app
  • Intent was, if provider is ordering, you'd send via CRD/CDS Hooks an indication of being ordered - it's up to payer (CDS endpoint) to decide how to respond
    • Respond by saying no requirement, or a documentation requirement, or a prior authorization requirement
    • If latter 2, would send link to the rules that are important to that documentation or prior authorization
    • Prior auth rules - rules required to collect data to support the prior auth
    • At that point the SMART app or native app would connect to that URL/endpoint, pull down the rules (CQL and questionnaire), gather the information via FHIR APIs to 'populate' the questionnaire - if there's something missing, query the provider or someone else in the practice
    • At that point if there's documentation that has been collected it should be written back to the record (observation or document, etc.)
    • If this is going on for prior authorization or post-acute orders... the data that was collected to support necessity determination would flow into the requirements in the PAS IG - at that point assemble info necessary to provider prior authorization FHIR bundle which includes info needed to translate from FHIR to 278
      • You could do that translation, or piece of software outside of EMR, or clearinghouse or business associate could do that translation
      • Documentation could be exchanged via 275 or something else - expectation is that entire FHIR bundle is exchanged
  • Question: does this allow for provider to send info and payer to respond with a question (e.g., does the patient have chest pain? yes/no) - No
  • Question: can payer respond with a 2 part CARD - if chest pain click that URL if not chest pain, click that URL
    • No interactive process inherent in CRD IG
    • You could have 2 CARDS come back each with different actions - consistent with CDS Hooks
    • You can get back multiple hooks
  • Other option is that payer provides the rules for EMR to evaluate the data collected from the record or provider entry
  • Concrete examples based into the Reference Implementation
    • Discussed putting together supplemental examples together on Confluence - interaction diagrams and JSON to go along with it
    • MITRE is currently finishing up IG, but could look at this as next task
    • eClinicalWorks/Healow would be willing to assist from EMR point of view to help putting together examples - Mrugen Mehtaand Larry Decellesto schedule time together offline
    • Sreekanth Puram will share something to test with via email to Mrugen Mehta
    • Offline work will be brought back to the group for review as examples/share learnings
  • Viet Nguyen and Robert Dieterle - possibly use next week's call to define this framework - where are we going to put this information, how do we organize it, and how do we get feedback from HL7 workgroups


Payer Uniformity in Documentation Efforts

(Melanie Combs-Dyer)

  • Call with CMS to find out if someone from Medicare FFS program wanted to join the team to encourage payer uniformity in documentation elements
    • CMS wanted to clarify that role of team was to put together a superset of data elements from which payers could choose - goal is not to agree on unique set of data elements
    • PAS team realized assumptions were made re: superset vs. distinct set of documentation elements that all payers agreed to for each item and service
    • PAS call consensus/direction toward superset approach
  • CMS press release - new org change - office of burden reduction and health informatics that combines Dr. Mary Green's area and Alex Mugge's area under Dr. Mary Green
  • CMS believes effort will move faster if we head in superset direction
  • Jay Johnstone volunteered to be co-chair with Melanie Combs-Dyer on this team
  • Are we saying every possible data element that a payer could ask for depending upon what the prior authorization is on the clinical side?
    • We know what this is from an administrative perspective
    • Documentation elements = medical record
    • For example if Medicare FFS program is looking for PO2 test - 5 data elements would be on the list. If Cigna says we need all of those things plus 1 more, then all 6 of those data elements would be on the list.
    • Are we using words for this or clinical coding?
      • Start out looking at words, but after agree on superset, will do gap analysis to make sure every one of those items has a corresponding LOINC code or USCDI code or US Core code 
  • Are you thinking of creating a PSS and doing a project around this?
    • PSS - yes
    • Haven't landed on whether this is under Da Vinci or HL7 - likely broader HL7 effort with support from Da Vinci community
    • Need to get a PSS built and decide which HL7 workgroups are going to be addressed as sponsors/co-sponsors
  • Meetings will be open
  • Need payer and provider participants
  • Also a terminology problem - ultimately will have to go back to LOINC or SNOMED if there's something that hasn't been coded
  • Need to design output of this group - if we understand what you're going to produce, we can understand how we're going to get there
  • Melanie and Jay are going to work on example of what end-output/structure would look like to bring back to this group for feedback
  • Should reach out to Medicaid Medical Directors to request participation - Mary Kay McDaniel will try to find out who's running their association
  •  Payers should reach out to melanie.combs-dyer@mettles.com if interested in participating



  • No way to extract data from DTR Questionnaire Response to generate PAS bundle?
    • Can have a questionnaire where expectation is to extract info from questionnaire and fill in elements in the prior authorization itself - wouldn't be common, but possible
    • For most questionnaires coming back from DTR, expectation is that Questionnaire Response would be included as attachment with prior authorization request
    • Example: need primary and secondary diagnosis - expectation is that it will always be available, but what if provider enters this data - primary diagnosis needs to be put in the claim/278 at a later stage right?
      • If information needs to be in the prior authorization/X12 instance you would have to do extraction
    • Intent has been that when done with DTR we have a questionnaire response that is populated and the resources that were used to populate it
      • Those are the elements that go into the PAS bundle as documentation
    • If somebody needs to fill in the form manually, and not pulled in directly from EHR - where can we insert that data?
      • Application itself can manage that 
      • That data needs to be in the record
    • If provider gets a questionnaire and it's prefilled, but needs to complete the 10th data element because not in the medical record - where does that 10th question go? Does it get inserted in the medical record?
      • Yes, but how depends on EHR capability
      • If there's data you collect, intended to be written back to EHR
    • If you have to type in data, how does that get communicated to payer as a FHIR resource
      • Only reliable way is in questionnaire response itself
    • Required fields to create prior auth - there should be a way for someone to input that information - not only clinical data, where do you put in data mandatory for prior auth request itself?
      • Basic demographics will be required every time do a prior auth, so needs to be part of the record
      • 3 sets of data: 
        • Data collected from EMR via DTR
        • Data required for 278
        • Data specific to the request itself that is not reasonably expected to be available in the medical record?
          • Assuming most of it would be
    • Assumption is that all PAS request data elements are in the medical record/EMR or associated coverage information
    • Pick this up again next week or on PAS call this Friday

Next Agenda


 Adjournment
Adjourned at 12:03pm ET

Supporting Documents

Outline Reference

Supporting Document

Minute Approval


Action items

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