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Date: July 31, 2020

Time: Noon EDT

Attendees (55)

Action items

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Planned Agenda Topics

Burden Reduction and Prior Authorization

Presenters:

Dr. Viet Nguyen, internist, pediatrician, clinical informaticist and consultant to government and commercial organizations in developing interoperable workflows and technologies. He has nearly two decades of experience in Health IT focused on interoperability standards and product development. Formerly the CMIO for Lockheed-Martin and Leidos Corporation, Dr. Nguyen is a nationally recognized FHIR educator, an HL7 Board Member, a FHIR Foundation Board Member, CMO for Logica, and Technical Director for the HL7 Da Vinci Project.

Gary Gryan, Principal Data Analyst and Prior Authorization SME, MITRE.


Meeting Minutes

Anthony DiDinato, mCODE CodeX Community Lead, kicked off the meeting with an overview of the CoP, mCODE, CodeX and with announcements.

Steve Bratt, the HL7 FHIR CodeX Project Lead, welcomed attendees and provided an update on CodeX. CDC is the newest CodeX member. Public calls are starting for the Integrated Trial Matching for Cancer Patients and Providers use case. CodeX governance and operational structure will soon be launched with the help of Point of Care Partners (POCP). 

Dr. Nguyen:

DaVinci is a collaboration of providers, payers and vendors to address the value based care requirements related to information gaps and information requirements. 

2 deliverables: HL7 FHIR Implementation Guides (IG) and Reference Implementations

2020/2021 Focus: mature the IGs and support moving implementations into production.

Successful testing with multiple payers, health systems and vendors working on the same IG.

DaVinci IGs use US Core as the base for profiles.

Focus on the Coverage Requirements Discovery (CRD), Documentation Templates and Rules (DTR) and Prior Authorization (PA) use cases. Combined, they provide a workflow that can be used to facilitate completion of payer documentation requirements in general, and prior authorization specifically. Moving towards automated adjudication. 

X12 translation is required for payer communication. 

Benefits:

  1. Reduce duplicate data entry
  2. Create possibility of automated adjudication

IGs will be improved through testing experience and careful selection of exemplars. Process = define workflow, clinical/business data requirements, FHIR Gap analysis. 

Gary Gryan:

InterOpathon 2020 Review (held at Michigan University)

Addressing the problem of configuring and maintaining payer endpoints. 

Solution: create a Payer Directory to automate discovery of payer endpoints.  Available at no cost to all payers. Provides automated endpoint discovery - using FHIR resources.

Relies on assumptions:

  1. funding available,
  2. payers will use it
  3. governance will be required
  4. payers require an organization ID (OID)
  5. endpoints have to be live

Supports faster prior authorization leading to faster care, reducing provider burden, and could drive adoption of other provider and payer solutions.


Q&A

Q: Are payers ready to implement the CRD/DTR/PA workflow? 

A: Different parts of the payer ecosystem are maturing at different rates. The ones that participated in the HIMSS connectathon and DaVinci members are ready. Payers are evaluating their environment to determine the best place to start - provider/vendor/payer combination.

Q: Could you elaborate on the use of CQL? How is it used in the Prior Auth use case?

A: CQL = Clinical Quality Language. HL7 Standard used in Clinical Quality Measures (e.g. inclusion and exclusion criteria) and Clinical Decision Support - uses FHIR to query data from EHRs. The PA workflow uses CQL to query the EHR for data to provide to payers, and to populate payer required documentation templates. For example, the CQL may reference a single or a value set of LOINC codes, used to find an observation. 


Increase community understanding of prior authorization; create an examplar for oncology treatment and prior authorization.