Documentation Templates and Rules FHIR IG Proposal

Da Vinci Documentation Templates and Rules (DTR)

Owning work group name

Clinical Decision Support Workgroup

Committee Approval Date:

2019-02-27

Contributing or Reviewing Work Groups

Financial Management

FHIR Development Project Insight ID

1493

Scope of coverage

The IG is specific to the US Human financial claims process across all healthcare disciplines, though the primary focus is inpatient and outpatient primary care. The content is developed by a mix of payor and EHR representatives.

IG Purpose

One of the challenges in the US Healthcare environment is that clinicians are often unaware of the expectations of payer organizations around the delivery of care, requirements for pre-authorizations and other processes. The result is that payment can be delayed, changes must be made to therapy after initiation and/or additional overhead costs are incurred. Coverage Requirements Discovery FHIR IG Proposal (CRD) defines a standardized mechanism by which care delivery organizations and providers can query payers to find relevant guidance prior to care delivery.

While the CRD IG specifies the mechanism for querying the payer, it does not describe the format or guidance of the rules being returned by the payer. Many of the documentation requirements may be satisfied by retrieving information that already exists in a provider's EHR system. Providing a standardized mechanism for evaluating documentation requirements against known information for a patient has the ability to reduce burden on providers and office staff who currently must manually interpret this information.

Content location

https://github.com/HL7/davinci-dtr

Proposed IG realm and code

us/davinci-dtr

Maintenance Plan

This specification will be maintained by Da Vinci working with the CDS workgroup.

Short Description

Provides a mechanism for delivering and executing payer rules related to documentation requirements for a proposed medication, procedure or other service associated with a patient's insurance coverage.

Long Description

This implementation guide specifies how payer rules can be executed in a provider context to ensure that documentation requirements are met. The IG is a companion to the Coverage Requirements Discovery (CRD) IG, which uses CDS Hooks to query payers to determine if there are documentation requirements for a proposed medication, procedure or other service. When those requirements exist, CDS Hooks Cards will be returned with information about the requirements. This IG leverages the ability of CDS Hooks to link to a SMART on FHIR app to launch and execute payer rules. The IG will specify how to maintain the transaction state as the workflow transitions from CDS Hooks to a SMART on FHIR app. It will then describe how the app will contact the payer to retrieve documentation requirements, in the form of CQL and a FHIR Questionnaire resource. The use of CQL will allow payers to inspect a patient's record for the necessary information related to the required documentation for the proposed item. The guide will then describe how to use the payer Questionnaire and results from CQL execution to generate a QuestionnaireResponse containing the necessary information. Finally, the guide will show how this information can be sent to the payer or persisted in the provider's EHR.

Involved parties

This implementation guide has been developed by U.S. EHR, Payer and Provider organizations as part of the Da Vinci project

Expected implementations

A open source reference implementation (RI) will be developed by The MITRE Corporation in support of Da Vinci. It is expected that this RI will be tested at the May 2019 WGM. Several EHR, Payer and Provider organizations are expected to implement this implementation guide or leverage the provided RI.

Content sources

Requirements are drawn from EHR vendors, provider organizations and payer organizations as part of Da Vinci discussions.

Example Scenarios

• EHR performs coverage requirements discovery specifying a patient's insurance coverage and a device request for oxygen therapy. Payer returns a card with a link to a SMART app that can ensure that the necessary rules are met for ordering of oxygen therapy. The provider launches that app, which executes the CQL and examines that patient's record by accessing the EHR's FHIR server to find a condition of hypoxia and other necessary information. The provider is presented with a screen that shows all of the discovered information and asks for confirmation. The provider confirms and the supporting documentation is transmitted to the payer.
• EHR performs coverage requirements discovery specifying a patient's insurance coverage and a device request for Continuous Positive Airway Pressure (CPAP) device. Payer returns a card with a link to a SMART app that can ensure that the necessary rules are met for ordering of CPAP. The provider launches that app, which executes the CQL and examines that patient's record by accessing the EHR's FHIR server to and cannot find a procedure that indicates that a sleep study has been performed. The provider is alerted and can create a task to schedule a sleep study for the patient.

IG Relationships

This guide will use the US Core, Structured Data Capture, Da Vinci Coverage Requirements Discovery and SMART Application Launch Framework Implementation Guides.

Timelines

The intention is to perform initial balloting of the IG in the May 2019 ballot cycle.

When IG Proposal Is Complete

When you have completed your proposal, please send an email to FMGcontact@HL7.org