Da Vinci CDex FHIR IG Proposal

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Da Vinci Clinical Data Exchange

Owning work group name (Sponsor)

Patient Care Work Group

Committee Approval Date:

Please enter the date that the committee approved this IGproposal

Contributing or Reviewing Work Groups

Structured Documents

Scope of coverage

This Implementation Guide (IG) will define how to utilize exchange methods (push, pull, triggers, subscription) and other interoperability "standards" (e.g. CDS Hooks and SMART on FHIR) to effectively exchange clinical information captured by care providers in electronic health record (EHR) systems with payers responsible for the health plan used by a specific patient or a set of patients or with other providers where a patient has been referred for additional services. The IG defines specific use of FHIR resources to represent the information being exchanged, including the provenance of the data.

IG Purpose

To transform and accelerate the shift in care delivery models toward a focus on health outcomes and value, provider and payer systems need standard ways to bi-directionally share electronic clinical, payer, and quality measure information.

The goal of this project is to rapidly improve available computer processing methods that can be used between payers, providers, and service supplier systems. The project will accelerate the shift toward value-based care and support value-based reimbursement models. More efficient and effective exchange of health record information will improve coordinated care and network performance, increase operational efficiencies, improve delivery of patient care and care outcomes, and reduce the burden of quality reporting.

Content location

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

Proposed IG realm and code

US/Davinci-CDex

Maintenance Plan

The Da Vinci project intends to provide ongoing support of this implementation guide.

Short Description

Provider data exchange with Payers and other Providers to improve care coordination, support risk adjustment, ease quality management, facilitate claims auditing and confirm medical necessity, improve member experience, and support orders and referrals.

Long Description

This IG provides detailed guidance that helps implementers use FHIR-based interactions and resources relevant to scenarios associated with Provider exchange of clinical information with Payers and other Providers. The IG covers six specific use cases that demonstrate how to exchange clinical data generated by Providers with Payers and other Providers to improve care coordination, support risk adjustment, ease quality management, facilitate claims auditing and confirm medical necessity, improve member experience, and support orders and referrals. It supplies guidance on how to reuse existing profiles fit for this type of exchange and provides additional profiles and guidance, where needed, to specifically address the requirements not covered by existing Implementation Guides and profiles.

For these six use cases, the IG describes how to exchange required data as individual FHIR resources, data extracted together as a meaningful collection of information, or data shared in the form of a clinical document such as an encounter summary or patient summary. An encounter summary document includes a predefined collection of data that tells the story of an encounter where services were provided to a patient. A patient summary document includes a predefined collection of data that provides and overview of the provision of care services provided to a patient over a range of time. The IG clarifies exchange requirements for metadata that establishes the context (provenance) for documents, collections of resources, and individual informational resources as well.

Involved parties

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

Content sources

Source Specifications that will be used in this IG include: Argonaut, US Core, C-CDA on FHIR

The subject matter experts engaged in the Da Vinci Project have sufficient expertise to make use of these source specifications.

Example Scenarios

1. Create a complete clinical record to improve care coordination and provide optimum medical care (e.g. reduce redundant care, in order to shift to more proactive/timely care, make better informed, more accurate medical treatment recommendations).
2. Create complete, accurate risk profiles for members for value-based care contracts and population health adjustments.
3. Augment claims data to satisfy quality reporting requirements and improve quality care scores, and to reduce preventable medical errors.
4. Provide documentation to support prior authorization, claims processing, audit submitted claims, to confirm medical necessity and appropriateness.
5. Improve member experience by improve processes between the payer and provider so member has fewer issues-less waiting, better planning/cost information and to allow the payer to have a more informed conversation with the member.
6. Support provider to provider orders and referrals.

IG Relationships

This project will reference, where possible, standards defined by the Health Record exchange (HRex) Framework Implementation Guide which in turn will utilize prior work from Argonaut, US Core and QI Core effort for FHIR DSTU2, STU3, and R4, and C-CDA on FHIR.

When IG Proposal Is Complete

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