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Health systems and payers need to exchange clinical data and administrative communication (e.g. prior authorization messages). Currently such exchanges are not common and those that exist use a proprietary interface. There is national interest, both in industry and the federal government, for such automated exchanges. The goal is reduction of provider burden for administrative tasks, such as prior authorization. Clinical data exchange also provides key healthcare data for population health and risk stratification for payers.
This clinical data exchange use case involves transmitting the treatment recommendation from an oncology clinical pathway to the payer via a FHIR-based interface. The content of these exchange messages is mCODE plus new CodeX elements, acceptance or denial of the recommendation, and free text entered by the oncologist.
This clinical data exchange use case will provide the key step of transmission of oncology information that drives both prior authorization and population health analytics. This use case is unique in using an emerging oncology national standard (mCODE and its CodeX extensions) that is interoperable and can scale across health systems and payers.
mCODE+ data is transferred from an oncologist to a payer with the intent of enabling alternative payment methods and/or providing information for a payer to enhance the payer's analytics repository.
Oncologist has accepted or denied a treatment recommendation.
Pathway has successfully been navigated to recommend a treatment.
Oncologist receives response that the message was received.
A functioning mCODE, clinical data element pathway branch point, FHIR enabled pathway platform exists. Patient must have mCODE elements populated to enable pathway navigation.
Intent: Provide model to enable clinical data exchange for communication between an oncology practice and payers.
Inclusion: Clinical concepts and decision support for oncology diseases.
Exclusion: Clinical concepts and decision support for non-oncology diseases.
Clinical data exchange greatly improves payer coordination with health system, enabling value-based payment models.
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