2020-06-24 DTR Meeting

Chair:  Larry Decelles

Scribe: Dana Marcelonis

AttendeesPresent Name Affiliation

 Nalini Ambrose Mitre

 George Bier Optum

 Tony Benson BCBS AL

 Michael Brady Rush

 Matthew Byrne Optum

 Modi Boutrs Rush

 Hans Buitendijk Cerner

 Chris Cioffi Anthem

 Jeffrey Danford Allscripts

 Jeremy Davis Davis InterSystems

 Stephen Dean Allscripts

 Larry Decelles Mitre

 David DeGandi Cambia Health

 Raymond Delano Cerner

 Robert Dieterle Enable Care

 Kristen Edsall Optum

 Richard Ettema Aegis

 Beth Galt-Salsamendi BCBS FL

 Daniel Gottlieb InterSystems

 Christol Green Anthem

 Andy Gregorowicz Mitre

 Kenneth Hall Hall Allscripts

 Roxanne Hanson Optum

 Jackie Hardison Humana

 Patrick Haren Cigna

 Claudia Hartman Highmark Health

 Mark Hingham Anthem

 Wendy Hofner Optum

 Sheljina Ibrahim Kutty Anthem

 Emma Jones Allscripts

 Jocelyn Keegan Point of Care Partners

 Geeta Krishnan Edifecs

 Patrick LaRocque Mitre

 Russell Leftwich InterSystems

 Alberto S. Llanes Anthem

 Tso Luke Optum

 Dana Marcelonis Point of Care Partners

 Timothy McCrimmon Optum

 Mary Kay McDaniel Cognosante

 Linda Michaelsen Optum

 Patrick Murta Humana

 Viet Nguyen Stratametrics

 Henry Pham Casenet

 Unknown User (rpena2) Allscripts

 Nick Radov Optum

 John Romza Optum

 Lynda Rowe InterSystems

 C Simeone Optum

 Jeanie Smith BCBS FL

 Julie Smith InterSystems

 Grace Stambaugh Veradigm

 Ashley Stedding CMS

 Jay Taylor Casenet

 Tiffanny Welch Independence Blue Cross

 Karen L. Zapata Anthem

 Gary Dickinson CentriHealth

 Henry Pham CaseNet

 India Duncan Optum

 Jason Cassidy

 Joseph Quinn Optum

 Lloyd McKenzie Gevity

 Tracy McCutcheon KPMG

 Rashmi Menon KMHP

 Mario Jarrin Change healthcare

 Luis Maas

 Terrence Cunningham AMA

 Ann Gallagher Optum

 Megan Smith-Hallingshead Regence

 Holly Weeks Regence

 Anthony Smith UNC Health

 Sonja Ziegler Optum

 John Moehrke

 Unknown User (estonner)

 Jennifer Joe

 Diann Smith Texas Health

 Kathleen Connor

 Jeff Brown Cigna

 Laurie Woodrome Labcorp

 Jay Johnstone Cigna

 Matt Dyer Vyne

 Paul Knapp

 Barbara Kramer-Zarins MITRE

 Sai Tumuluru Centene

 Barbara Wood PNC

 Greta Honeycutt CoverMyMeds

 Lenel James BCBSA

 Reed Gelzer

 Yunwei Wang MITRE

 Keya Shah Casenet

 Rich Bloch

 John Donnelly Interpro

 Lauri Shock

 Andrew Johnson National Decision Support

 Benjamin Langley MITRE

 Mark Fleming Change Healthcare

 Mrugen Mehta eClinicalWorks

 Prathima

 Rachel E. Foerster Rachel Foerster & Associates

 Heather McComas AMA

 Megan Riley MITRE

 Summer Duman Regence

 Michelle Barry Availity

 Chris Cera

 Michael Fasulo Regence

 Melanie Combs-Dyer Mettle

Present Name Affiliation

 Peter Muir ESAC

 Rachel E. Foerster

 Ryanne Laurence OHSU

 Serafina Versaggi

 Cole Springate-Combs Mitre

 Susan Billet CMS

 Barbara Antuna Aim Specialty Health

 Christy Dodson MCG

 Jim Taylor Tibco

 Laurie Burckhardt

 Rajesh Godavarthi

 Santosh

 Tom Hartman

 Tori Willows Wellcare

 Alise Widmer Lumeris

 Bart Carlson Azuba

 David Bruinsma Colonial Med

 Deepthi Reddy Mettle Solutions

 Danny Brennan MA Health Data

 Patrick Edwards

 Gay Dolin

 Jodie Zellerhoff Cambia Health

 Lorraine Doo CMS

 Pallavi Talekar Scope Info Tech

 Rajesh Garlapati Rush

 Susan Bellile Availity

 Susan Langford BCBST

 Ralph Saint-Phard

 Kristi Cushman OHSU

 Briana Barnes Scope Info Tech

 Didi Davis Sequoia Project

 Sreekanth Puram Mettle Solutions

 Duane Walker BCBSM

 EMDI Team

 David Hill Mitre

 Kevin Lambert BCBS AL

 Nandini Ganguly EMDI

 Rachel E. Foerster

 Rajesh Godavarthi MCG Health

 Rim Cothren

 Donna Campbell BCBSIL

 Joanna Gaskill Lumeris

 Lindee Chin Edifecs

 Michael Cabral CMS

 Sudhir Nair Anthem

 Saul Karavitz Mitre

 Dawn Perreault BCBSM

 Brent Woodman BCBSM

 Yolanda Villanova CMS

 Deryl Lam

 John Kelly Edifecs

 Karen Tott CMS

 Keeyan Ghoreshi MITRE

 Luis Sayago Dacarba

 Michael Flanigan Carradora

 Rachel Goldstein

 Ric Light Humana

 Rohit Shinde eClinicalWorks

 Seth Paradis Healow

 Wanda Govan-Jenkins HHS

 Cindy Monarch BCBSM

 Edward Yurcisin

 Frank Hone Veradigm

 Hibah Qudsi Mitre

 Nancy Spector AMA

 Patrick Leblanc

 Anupam Thakur BCBSFL

 Sreenivas Mallipeddi MCG

 Chris Klesges Mitre

 Michael Gould BCBSA

 Gregory Magazu CaseNet

 Isaac Vetter Epic

 Kat Ruiz UNC Health

 Laura Bright

 Nancy Beavin Humana

 Roland Gamache

 Katherine Lusk Childrens

 Brandon Raab Anthem

 Reed D. Gelzer

 Chris Johnson BCBS AL

 Jim Adamson Arkansas Blue Cross

 Carry Denny

 Corey Spears Infor

 Karen Iapoce

 Anna Meisheid CMS

 Celine Lefebvre AMA

 Eshaa Dhall eClinicalWorks

 Evan Currie BCBSM

 Unknown User (harvey_kuang) Express Scripts

 Sandhya

 Christopher Gracon Independent Health

 Candice Titus Crisp Health

 Mariana Singh CAQH

 Troy Bergstrand BC Idaho

 Shilesh Nair Gdit

 Kensaku Kawamoto

 Jason Teeple

 Vipul Kashyap

 Srinivas Posinasetty UHC

 Tammy Banks Providence St. Joseph

 Bob Harrington Allscripts

 Vishnu

 Danielle Sutter Health

 Gary P. Gryan MITRE

 Sonya May Optum

 Molly Malavey AMA

 Amit Shah Guidewell

 Angela Bublik Regence

 Mona Chandrapal

Create Decision from template

Minutes Approved as Presented 

Agenda Topics

Agenda Outline

Agenda Item Meeting Minutes from Discussion Decision Link(if not child)

Management

Review ANSI Anti-Trust Policy

Links DTR IG: http://hl7.org/fhir/us/davinci-dtr/2019May/

Reference Implementation:   https://github.com/HL7-DaVinci/dtr

This is to approve minutes via general consent. "You have received the minutes. Are there any corrections to the minutes? (pause) Hearing none, if there are no objections, the minutes are approved as printed."

Healow/eClinicalWorks Team Implementation Questions

( )Mrugen Mehta

Take a clinical example such as ordering a Diagnostic Image of EchocardiogramEMR User selects EchocardiogramBundle everything that is needed, create CDS Hook (Order Select) and send information to the payerLooking to explore options to either using a SMART on FHIR app for DTR questionnaire and responses, or not using thatOnce we get the CDS CARD back for Echocardiogram requirements - questionnaire needed, does patient need testing

Are we expecting that to be part of CDS CARD because not part of SMART appIntent was, if provider is ordering, you'd send via CRD/CDS Hooks an indication of being ordered - it's up to payer (CDS endpoint) to decide how to respond

Respond by saying no requirement, or a documentation requirement, or a prior authorization requirementIf latter 2, would send link to the rules that are important to that documentation or prior authorizationPrior auth rules - rules required to collect data to support the prior authAt that point the SMART app or native app would connect to that URL/endpoint, pull down the rules (CQL and questionnaire), gather the information via FHIR APIs to 'populate' the questionnaire - if there's something missing, query the provider or someone else in the practiceAt that point if there's documentation that has been collected it should be written back to the record (observation or document, etc.)If this is going on for prior authorization or post-acute orders... the data that was collected to support necessity determination would flow into the requirements in the PAS IG - at that point assemble info necessary to provider prior authorization FHIR bundle which includes info needed to translate from FHIR to 278

You could do that translation, or piece of software outside of EMR, or clearinghouse or business associate could do that translationDocumentation could be exchanged via 275 or something else - expectation is that entire FHIR bundle is exchanged

Question: does this allow for provider to send info and payer to respond with a question (e.g., does the patient have chest pain? yes/no) - NoQuestion: can payer respond with a 2 part CARD - if chest pain click that URL if not chest pain, click that URL

No interactive process inherent in CRD IGYou could have 2 CARDS come back each with different actions - consistent with CDS HooksYou can get back multiple hooks

Other option is that payer provides the rules for EMR to evaluate the data collected from the record or provider entryConcrete examples based into the Reference Implementation

Discussed putting together supplemental examples together on Confluence - interaction diagrams and JSON to go along with itMITRE is currently finishing up IG, but could look at this as next taskeClinicalWorks/Healow would be willing to assist from EMR point of view to help putting together examples - 

and  to schedule time together offlineMrugen Mehta Larry DecellesSreekanth Puram will share something to test with via email to Mrugen MehtaOffline work will be brought back to the group for review as examples/share learnings

Viet Nguyen and  - possibly use next week's call to define this framework - where are we going to Robert Dieterleput this information, how do we organize it, and how do we get feedback from HL7 workgroups

Payer Uniformity in Documentation Efforts

(Melanie Combs-)Dyer

Call with CMS to find out if someone from Medicare FFS program wanted to join the team to encourage payer uniformity in documentation elements

CMS wanted to clarify that role of team was to put together a superset of data elements from which payers could choose - goal is not to agree on unique set of data elementsPAS team realized assumptions were made re: superset vs. distinct set of documentation elements that all payers agreed to for each item and servicePAS call consensus/direction toward superset approach

CMS press release - new org change - office of burden reduction and health informatics that combines Dr. Mary Green's area and Alex Mugge's area under Dr. Mary GreenCMS believes effort will move faster if we head in superset directionJay Johnstone volunteered to be co-chair with   on this teamMelanie Combs-Dyer

Jeff Brown as support from HL7/FHIR perspectiveAre we saying every possible data element that a payer could ask for depending upon what the prior authorization is on the clinical side?

We know what this is from an administrative perspectiveDocumentation elements = medical recordFor example if Medicare FFS program is looking for PO2 test - 5 data elements would be on the list. If Cigna says we need all of those things plus 1 more, then all 6 of those data elements would be on the list.Are we using words for this or clinical coding?

Start out looking at words, but after agree on superset, will do gap analysis to make sure every one of those items has a corresponding LOINC code or USCDI code or US Core code 

Are you thinking of creating a PSS and doing a project around this?PSS - yesHaven't landed on whether this is under Da Vinci or HL7 - likely broader HL7 effort with support from Da Vinci communityNeed to get a PSS built and decide which HL7 workgroups are going to be addressed as sponsors/co-sponsors

Meetings will be openNeed payer and provider participantsAlso a terminology problem - ultimately will have to go back to LOINC or SNOMED if there's something that hasn't been codedNeed to design output of this group - if we understand what you're going to produce, we can understand how we're going to get thereMelanie and Jay are going to work on example of what end-output/structure would look like to bring back to this group for feedbackShould reach out to Medicaid Medical Directors to request participation -   will try to find out Mary Kay McDanielwho's running their association Payers should reach out to   if interested in participatingmelanie.combs-dyer@mettles.com

No way to extract data from DTR Questionnaire Response to generate PAS bundle?Can have a questionnaire where expectation is to extract info from questionnaire and fill in elements in the prior authorization itself - wouldn't be common, but possibleFor most questionnaires coming back from DTR, expectation is that Questionnaire Response would be included as attachment with prior authorization requestExample: need primary and secondary diagnosis - expectation is that it will always be available, but what if provider enters this data - primary diagnosis needs to be put in the claim/278 at a later stage right?

If information needs to be in the prior authorization/X12 instance you would have to do extractionIntent has been that when done with DTR we have a questionnaire response that is populated and the resources that were used to populate it

Those are the elements that go into the PAS bundle as documentationIf somebody needs to fill in the form manually, and not pulled in directly from EHR - where can we insert that data?

Application itself can manage that That data needs to be in the record

If provider gets a questionnaire and it's prefilled, but needs to complete the 10th data element because not in the medical record - where does that 10th question go? Does it get inserted in the medical record?

Yes, but how depends on EHR capabilityIf there's data you collect, intended to be written back to EHR

If you have to type in data, how does that get communicated to payer as a FHIR resourceOnly reliable way is in questionnaire response itself

Required fields to create prior auth - there should be a way for someone to input that information - not only clinical data, where do you put in data mandatory for prior auth request itself?

Basic demographics will be required every time do a prior auth, so needs to be part of the record3 sets of data: 

Data collected from EMR via DTRData required for 278Data specific to the request itself that is not reasonably expected to be available in the medical record?

Assuming most of it would beAssumption is that all PAS request data elements are in the medical record/EMR or associated coverage informationPick this up again next week or on PAS call this Friday

Next Agenda

 Adjournment

Adjourned at 12:03pm ET

Supporting Documents

Outline Reference Supporting Document

Minute Approval

Action items