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201701 Attachments

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Attachments

Submitting WG/Project/Implementer Group

Attachments Work Group (AWG)

Justification

Electronic attachments are a high priority for processing claims and other payer/provider interactions. Current thinking has attachment submissions occurring via X12 messaging. However, there is substantial interest in experimenting with FHIR-based messaging for exchanging attachments. This track will explore the feasibility of this approach.

Proposed Track Lead

See Connectathon_Track_Lead_Responsibilities

  • Rick Geimer
    • Email: rick dot geimer at lantanagroup dot com
    • Skype: rgeimer
    • Co-leads, Paul Knapp, Durwin Day

Expected participants

  • BCBS
  • HCSC
  • BCBSAL
  • Anthem
  • Optum
  • A|D Vault
  • ZeOmega
  • Janie Appleseed (powered by MaxMD)

Roles

Please include information here regarding how much advance preparation will be required if creating a client and/or server.

Payer

Plays the role of a payer who may request and receive attachments. This is loosely analogous to the "FHIR Client - Claims Attachment Requestor" and "FHIR Client - Claims Attachment Processor" roles in the Financial Management track, but with a focus on content instead of process.

Provider

Plays the role of a provider who may receive requests for attachments and send attachments (solicited or unsolicited). This is loosely analogous to the FHIR Client - Claims Attachment Submitter role in the Financial Management track, but with a focus on content instead of process.

Clearinghouse

Serves as an intermediary/aggregator between multiple parties (usually payers and providers), and thus needs to play both submitter and processor roles. The clearinghouse will need to change the sender/receiver information in the Communication and CommunicationRequest resources appropriately (i.e. when forwarding a request from a Payer to a Provider, the sender should be changed from the Payer to the Organization resource for the clearinghouse.

Patient (In Patient Voice Scenario)

Plays the role of a system that helps a consumer/patient create a Personal Advance Care Plan to share information about the person's goals, preferences, and priorities for care in case they suffer a medical emergency or health condition and can't communicate this information for his or her self.

Provider (In the Patient Voice Scenario)

Plays the role of a system that allows the Provider to request and receive information from the patient to ensure care planning will be patient-centered and take the patient's goals, preferences, and priorities for care into consideration in a more efficient way. This system generates information requests and shares them directly with the patient using Direct Messaging. This system also accepts solicited and unsolicited non-clinical patient generated health data that improves care planning activities and is used to make Care Plans more patient-centered.

Scenarios

For all scenarios below, the following types of attachments are allowed:

  • PDF attachment
  • Unstructured C-CDA attachment
  • Structured C-CDA attachment
  • C-CDA on FHIR attachment

Below are some sample resources we can use during the Connectathon. Most of these will need to be linked to the CommunicationRequest and Communication resources you will create.

Patient

Clearinghouse

Payer

Provider

Claim

Here is a link to the main Connectathon 14 page with test servers, other tracks, etc.

http://wiki.hl7.org/index.php?title=FHIR_Connectathon_14

Solicited

Action: Payor sends an attachment request to the provider. Onus is on the payer to create the staple between the request and the attachment. Provider must return the payer's electronic staple (i.e. ID) with the attachment.
Here is an example of a request for an attachment from a payer:
http://hl7.org/fhir/2016Sep/communicationrequest-example-fm-solicit-attachment.xml.html
Here is an example of a solicited attachment from a provider (the payload would point to the PDF, C-CDA, or C-CDA on FHIR attachment):
http://hl7.org/fhir/2016Sep/communication-example-fm-solicited-attachment.xml.html
Precondition: None
Success Criteria: Provider receives the request, responds with the attachment, payer receives the attachment and is able to view it in their system.
Bonus point: Send to an adjudication engine in the Financial track.

Basic script for provider:

Basic script for payer:


Unsolicited

Action: Provider sends an attachment to the payer in support of a claim without a request. Onus on the provider to create the electronic staple (i.e. matching IDs) between the claim and the attachment. Here is an example of a Communication resource for an unsolicited attachment from a provider (the payload would point to the PDF, C-CDA, or C-CDA on FHIR attachment):
http://hl7.org/fhir/2016Sep/communication-example-fm-attachment.xml.html
Precondition: Prior agreement in place between payer and provider.
Success Criteria: Payer receives the attachment and is able to view it in their system.
Bonus point: Send to an adjudication engine in the Financial track.


Prior Authorization

Action: Provider creates an attachment and sends it to the payer. Here is an example of a Communication resource for prior authorization (the payload would point to the PDF, C-CDA, or C-CDA on FHIR attachment):
http://hl7.org/fhir/2016Sep/communication-example-fm-attachment.xml.html
Precondition: Prior authorization has occurred, and the provider has an id (i.e. electronic staple) to associate the attachment with the claim.
Success Criteria: Payer receives the attachment and is able to view it.
Bonus point: Send to an adjudication engine in the Financial track.

Patient Voice - Solicited Personal Advance Care Plan

Action: Provider creates a communication request to ask the patient to send his or her current advance care plan information ("advance directives").
Precondition: The patient has created and maintains his or her advance directive information in a system that allows download of the information in a pdf or PACP (CDA). The Patient also has a Direct Secure Messaging address that he or she uses to communicate directly with the provider.
Success Criteria: Provider receives a person's current advance care planning information in a solicited PACP document.

Patient Voice - Unsolicited Personal Advance Care Plan

Action: Patient creates or updates his or her advance care plan information ("advance directives") and proactively shares the information with his or her care provider.
Precondition: The patient has created and maintains his or her advance directive information in a system that allows download of the information in a pdf or PACP (CDA). The Patient also has a Direct Secure Messaging address that he or she uses to communicate directly with the provider.
Success Criteria: Provider receives a person's current advance care planning information in an unsolicited PACP document.


TODO: Paul, how does the payer respond to the provider with an auth number and other info?

TestScript(s)

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