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Submitting WG/Project/Implementer Group

Financial Management / Da Vinci 

Justification and Objectives

This track will enable Payers and Providers to share claims and clinical data using FHIR API guidance specified in the PDex and HRex implementation guides that will be balloted in July (Early September Ballot). 

This track will use 4.0 version of FHIR.

Clinical input requested (if any)

The track requires clinical input to assess the value and priority of payer data to be added to a patient's record.

Related tracks

This track is a part of the larger Da Vinci Program. It also is related to the Financial Management track.

Proposed Track Lead

Mark Scrimshire, mark@ekivemark.com. Track leads must be registered users on http://chat.fhir.org

Expected participants

Who do you expect to be present? TBD

How many do you expect to attend? To be confirmed: 4-6 people.

Track Orientation

Webinars will be hosted on Friday's from noon - 1:00pm ET on 3/29, 4/5, 4/12, 4/19, 4/26, 5/3 to share further participation information about this track.  Visit the HL7.org Conference Call page for the dial-in information. Look for the call titled: Payer Data Exchange (PDex) (for Da Vinci Project). Once participants have been established separate calls will be established 

System Roles

Provider and their EMR.

Payer and their in-house or out-sourced data system. 

Participants have approximately 4 weeks to prepare for the Connectathon (end of March to the end of April).

Role 1 Name

Scenarios

Lauren Dent is a 62-year-old female, living in Wisconsin but she spends winters in Tampa Bay, FL.

Lauren works on a seasonal basis and has just accepted a new position with her employer and has moved to Madison, WI to live with her daughter, leaving her previous home in La Crosse, WI. As a result of the move she has selected a new Primary Care Provider.

Lauren is in reasonable health but is managing a number of conditions:
* She has been diagnosed as Pre-Diabetic and is being treated with medications.
* She is taking medication for hypertension.
* She had a knee replacement 5 years ago.
* She had a procedure seven years ago to correct a problem with a disc in her lower back.
* A history of a normal colonoscopy 5 years earlier
* A history of a pneumovax and zostavax 4 years earlier.

Example 1:

The subject is switching to a new provider as a result of moving for their job. 

The provider collects the subject's coverage information and makes a query to the payer providing health coverage. 

Provider requests data from Payer/Health Plan via CDS- Hooks. 

The query to the payer can be triggered by an "appointment-book" CDS-Hook. See the Reference Implementation Page for details of the payload provided to the hook.

Provider supplies subscriberId as part of a Coverage record. 

Payer responds with Encounter, Procedure and/or MedicationDispense records built from claims information. Additional information may be provided from other clinical sources.


Example 2:

Arthur Dent is a 68 year old Male. He has recently switched from Medicare Advantage Plan A and enrolled in Medicare Advantage Plan B.

In this scenario, Arthur has signed up for a new  Medicare advantage plan with payer C during the open enrollment period. Before the initiation of his coverage beginning January 1, payer C has established communication with the patient and has provided the patient with a secure log in to the payer C patient portal. Patient continues to have an active login to payer B patient portal.

Patient-mediated Payer to Payer Exchange.

The Member moves to a new health plan and initiates a request to their old health plan via OAuth2.0 to request their information be passed to their new plan.

Scenario Steps:

Use USCDI to represent payer data derived from claims, laboratory testing, diagnostic reports, immunization registries, data extracted from C-CDA documents and other sources.

Write records to the Provider's EMR for resources that have a write capability (as defined in EMR CapabilityStatement).

Create a DocumentReference to write supplemental information from the payer-supplied data.

bonus points: Use a Smart on FHIR App to enable provider to select payer supplied data that is delivered via CDS Hooks and enables a provider to select data to import into their EMR.

TestScript(s)

Aegis will develop specific test scripts in addition to their standard test scripts for R4 US Core.

Security and Privacy Considerations

We are considering Security and Privacy topics out of scope for Connectathon. These issues are discussed in the Health Record Exchange (HRex) implementation guide.

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