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Submitting WG/Project/Implementer Group

Financial Management / Da Vinci 

Justification and Objectives

This track will have two primary objectives:

  1. Test the $member-match operation for member matching between payers. This operation is a candidate for promotion to the HRex IG since it is an operation that could be used across multiple IGs. PDex and PCDE are already planning to implement $member-match as a preliminary step in the respective IG workflows for Payer to Payer exchange use cases.
  2. Test Consumer Apps connecting to a server that provides US Core resources that have been generated from Payer Claims information. The primary resources to be focused on for testing are:
    1. Encounter
    2. Condition
    3. Procedure
    4. Observation
    5. Provenance

Track Orientation

Kick-off: Connectathon-24-PDEX_PCDE.pptx'

Zoom Link: https://zoom.us/j/2779458846


PDex Track Orientation Recording_041720.mp4

Presentation: PDexConnectationPrep.pptx

Track Wrap-up

Connectathon-24-PDEX_PCDE-DaVinciReportOut.pptx

Topic: DaVinci PDex Track Leader HL7 FHIR Connectathon's Personal Meeting Room
Start Time : May 15, 2020 12:59 PM

Meeting Recording:
https://zoom.us/rec/share/6P1kH4_J7D1IYZ3s9HGcSukcBabsaaa81nMc__YIxRx3xUfkDL79mPL8XC92vgH0

Coordination

This track will use the following Zulim chat on chat.fhir.orgDa Vinci PDex

Da Vinci Sync up Schedule: HL7 Virtual Connectathon - May 2020

Date

Time (EDT)

Event Type

Track

Thursday, May 14th 10amDa Vinci Track Kick-Off

Payer Data Exchange (PDex) / Payer Coverage Decision Exchange (PCDE)

Thursday, May 14th 4:30pmDa Vinci Track Sync-UpPayer Data Exchange (PDex) / Payer Coverage Decision Exchange (PCDE)
Friday, May 15th 4:30pmDa Vinci Track DemosPayer Data Exchange (PDex) / Payer Coverage Decision Exchange (PCDE)

Overview

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. 

An additional workflow is required to enable a payer to query a prior payer when a member is enrolling on to a Health Plan. 

The new Payer will collect prior coverage information from the enrolling member. This, together with the member's demographic information will be used to compile a bundle of records that will be submitted to a  $member-match operation at the /Patient endpoint.

The details of the bundle can be found on this page: HL7 Da Vinci PDex $member-match

The $member-match operation will use the Coverage information and the Patient profile from the submitted bundle to determine a unique member match. 

If there is a unique member match the Old Health Plan will return a bundle that includes:

  • Patient resource that includes a unique member identifier.
  • A coverage record that reflects the earliest date for which coverage was provided and the latest date for which coverage applies. 

The $member-match operation will return a 404 status code if a unique match is not found.

 

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.

Payer Coverage Decision Exchange Track.

Proposed Track Lead

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

Expected participants

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

  • NewWave/Onyx - Mark Scrimshire
  • Humana - Patrick Murta
VirginiaLorenziNewYork-Presbyterian Hospital
TeepleJasonCigna
DickinsonGaryEHR Standards Consulting
KandurRanjithAnthem Inc.
GouldMichaelBlue Cross Blue Shield Association
LambJoshUPMC
ZapataKarenDiameter Health
SmithAnneNCQA
DeboraSimmonsConsultant
MuirPeterPJM Consulting LLC
JohnsonChrisdBlue Cross and Blue Shield of Alabama
LeePreston
MichaelsenLindaOptum
ReynoldsGuyAlphora
HammondCarieAEGIS.net
MuirPeterPJM Consulting LLC
EisenbergFloyd


DonnellyJohnIntePro Solutions (consultant)

Please email mark.scrimshire@onyxhealth.io if you are volunteering to provide a server or client to participate in testing for this track. You can also add your name to the list above.

Track Orientation


Webinars will be hosted on Friday's from noon - 1:00pm ET as part of the regular PDEX Working Group call on 4/3, 4/10, 4/17, 4/24, 5/1, 5/8 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 

Resources

Sandbox Name: DaVinciPDex-R4-Payer
Sandbox Description: Payer FHIR R4 Endpoint for CDS-Hooks
Sandbox ID: DVPDexR4Payer1
Secured FHIR Server URL: https://api.logicahealth.org/DVPDexR4Payer1/data
Open FHIR Server URL: https://api.logicahealth.org/DVPDexR4Payer1/open
Sandbox FHIR Version: FHIR R4 (v4.0.0)

Organization resource: Organization-diamond-health.json

Bundle of Coverage Resources: Bundle-Coverage.json


System Roles - Member-Match testing

Old Payer

New Payer

Payers (and their in-house or out-sourced data systems). 

Participants have approximately 4 weeks to prepare for the Connectathon (April to early May).

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 a new 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 to select a new Primary Care Provider and a new Health Plan offered by her new Employer.

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 from one health plan to a new health plan. 

During enrollment with the new health plan Lauren provides demographic information and the details of her old health plan, taken from her insurance card.

Lauren also gives the New Health Plan permission to request her health record from her old health plan.

The New Health Plan connects to the Old Health Plan and supplies a coverage record complete with old health plan information and member demographics to a /Patient/$member-match endpoint.

The old health plan performs a member match and returns a Patient resource for the matched member (or a 404 if not found).

The New Health Plan receives the Patient resource and an access Token to enable them to query the old health plans FHIR endpoint for specific clinical resources, or to perform a /Patient/{id}/$everything to get a bundle of records back that represent the member's clinical record.


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.

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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