Date: 5/26/2021

Quarter: Q5

CQI Hosted CDS

Chair: Yan Heras

Scribe: Patty Craig

Chairs present - Floyd Eisenberg

Agenda

  • Risk Adjustment Project

Meeting Minutes

  • Risk Adjustment is a new Da Vinci Use Case that was moved to the public space this year
    • Community kick off call held on 3/25/2021
    • Weekly project community call on Thursdays 3PM-4PM ET
    • Primary Sponsoring Work Group - Clinical Quality Information (CQI) Work Group
    • Risk Adjustment Use Case Confluence Page
  • Good representation from payor, providers, and Health IT 


  • Use Case
    • Patients may have one or more chronic conditions that need to be addressed. Communication of chronic or suspected conditions assures that providers are aware of these conditions so that the patient receives comprehensive care that can lead to improved care, follow up and outcomes
    • The provider needs to be aware of all the patient’s chronic conditions in order to address them at least annually. The provider should also recognize that addressing these conditions will result in more accurate risk-based payments to the payers with whom they have contracted, and that usually their contract provides for financial incentives for accurate risk adjustment coding
    • The payers are dependent on providers to submit complete and accurate diagnoses and documentation to assure that appropriate premium is received timely from government managed care programs
    • Communication of risk-based coding gaps will facilitate more efficient partnerships between payers and providers and align incentives
    • A standard for sharing this information will reduce the administrative burdens associated with the current processes


  • HL7 Project Scope Statement for Risk Adjustment
    • The risk adjustment use case acknowledges the importance of risk-adjusted premium calculations to government managed care and seeks to
      • better inform clinicians of opportunities to address risk adjusted conditions,
      • better enable payers to communicate risk adjustment information, and
      • enhance government sponsors’ ability to allocate funding accurately.
    • To accomplish this:
      • Payers need a standard protocol to share and receive clinical data related to risk adjustment with responsible providers.
      • Providers need a standard protocol to share and receive clinical data related to risk adjustment with responsible payers.
      • Payers and providers need a standard methodology to communicate risk based coding, documentation and submission status of chronic illnesses.
        • The resulting bi-directional, real-time, FHIR-based communication will connect payer intelligence with EHR data at the point of care, facilitating providers documentation of relevant chronic illnesses. This model ensures accurate and complete patient assessment to support Value-Based Care programs.


  • CQI and CDS discussed the difference between payor risk coding vs risk adjustment for quality measurement purposes.

    • Quality measurement risk adjustment is used to identify and adjust for variation in patient outcomes that stem from differences in patient characteristics (or risk factors) across health care organizations to facilitate a more fair and accurate inter-organizational comparison.
    • Payor risk coding is about ensuring providers are aware of chronic or suspected conditions so that the patient receives comprehensive care that can lead to improved care, follow up and outcomes.


  • Other discussion focused on whether or not clinical decision support could be used in conjunction with the payor risk coding or quality measurement risk adjustment so as to assist providers in giving the proper care instead of just being an after the fact analysis of the care.

Action Items

  • CQI will meet with Imaging during the Sept WGM by sending representatives.