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Difference between revisions of "CARIN RTPBC FHIR IG Proposal"

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(CARIN Real-time Pharmacy Benefit Check (RTPBC) FHIR IG Proposal)
 
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=Breast Radiology Profiles=
+
=CARIN Real-time Pharmacy Benefit Check=
  
 
==Owning Workgroup==
 
==Owning Workgroup==
HL7 Clinical Interoperability Council (CIC)
+
HL7 Pharmacy WG
  
 
==Committee Approval Date:==
 
==Committee Approval Date:==
May 2019
+
November 2019
  
 
==Publishing Lead==
 
==Publishing Lead==
Richard Esmond (richard.esmond@gmail.com)
+
Frank McKinney (fm@frankmckinney.com)
  
 
==Contributing or Reviewing Work Groups==
 
==Contributing or Reviewing Work Groups==
   HL7 Clinical Information Modeling Initiative (CIMI)
+
   HL7 Financial Management WG
  HL7 Imaging Integration / DICOM
 
  
 
==FHIR Development Project Insight ID==
 
==FHIR Development Project Insight ID==
1363
+
''To be added''
  
 
==Scope of coverage==
 
==Scope of coverage==
The breast radiology implementation guide intends to formalize the radiology-specific data-elements sufficient to support breast cancer diagnosis, treatment and research, focusing on the key data necessary to facilitate clinical decision-making for medical and surgical oncologists, pathologists and the referring physician community of general practices Obstetrics and gynecology (OB/GYN) clinicians who order the vast majority of screening mammography procedures.
+
This is a guide for implementing the consumer-focused real-time pharmacy benefit check (consumer RTPBC) using FHIR R4.  
  
The implementation guide is expected to incrementally cover a wide variety breast radiology use cases, while supporting secondary data use in for clinical research, cancer registry reporting.</span>
+
The process is limited to medications that are covered under the pharmacy benefit portion of the patient’s health insurance, which typically excludes medications administered during hospital care or as part of medical procedures. Is is further limited to commercially available medication products that are not compounded at the pharmacy.
 +
 
 +
The guide is for use in the United States only.
  
 
==Content location==
 
==Content location==
<i><span>https://github.com/HL7/fhir-breast-radiology-ig</span></i>
+
''To be updated''
  
 
==Proposed IG realm and code==
 
==Proposed IG realm and code==
us/breast-radiology
+
us/pharmacy
  
 
==Maintenance Plan==
 
==Maintenance Plan==
The CIC WG is aware and willing to maintain the content in the future. Among participants, at least MITRE, MRS and PenRad are committed to the maintenance of the content.
+
The CARIN Alliance is committed to the maintenance of the content.
 +
 
 +
The Pharmacy and Financial Management Workgroups are engaged and will continue to provide guidance and review through completion of the guide.
 +
 
 +
==Short Description==
 +
CARIN RTPBC FHIR Implementation Guide
  
This IG comprises FHIR Profiles for breast radiology core data elements long established to be critical for breast cancer diagnosis and staging within the scope of radiology.
+
==Long Description==
 +
With consumer RTPBC, a patient can learn how their medications will be covered at the pharmacy, including out of pocket costs, prior authorization requirements and any limits that might apply.
  
In the first 'For Comment' cycle the terminology bindings are preliminary, and in some cases, defined in terms of local codes only.
+
The communication flow consists of...
  
Our team is collaborating with the VA SOLOR groups, RSNA RadLex and Regenstrief (LOINC) to organize and fund the required unique concept authoring efforts that will be necessary to sufficiently define the data-elements and value-sets represented in the 'For Comment' and 'Informative' breast-radiology draft ballot cycles.
+
* a request submitted by a consumer application that contains information about the patient, the prescription and their insurance coverage
 +
* a response from the patient's insurer that contains cost and coverage information for the requested product, alternative products, and different pharmacy options.
  
==Short Description==
+
This IG defines FHIR profiles for resources representing...
Breast Radiology CIMI Logical Models and FHIR Profiles.
 
  
==Long Description==
+
* the set of information provided in the RTPBC request that enables the insurer to locate the patient's membership details and determine coverage for the requested product. This includes profiles of Claim, Patient, Practitioner, Organization and MedicationRequest resources
The first iteration of the CIMI logical models and FHIR Profiles for breast radiology reporting will be focused on the core modeling structures, patterns and informational relationships between these architectural elements. Our group has works extensively with the HL7 Orders and Observations workgroup to investigate the numerous 'cross cutting' concerns that confront many similar projects.
+
* the pricing and coverage information returned in the RTPBC response, using a profile of the ClaimResponse.
  
This IG defines FHIR profiles for data elements that are either directly or indirectly used in the reporting of breast radiology.
+
In addition, the guide identifies terminology to identify the referenced entities and aspects of insurance coverage.
  
 
==Involved parties==
 
==Involved parties==
The breast-radiology IG is being authored through a formal collaboration under the HL7-CIC workgroup with a wide range of organizations and individual contributors that informally refer the themselves as the 'Cancer Interoperability' Group, which includes representatives from the FDA, NIH, CCO, SBI, HSPC, CiiC, ACS, various health IT vendors and interested solution vendors.
+
The RTPBC IG is being authored by the CARIN Alliance in collaboration with the National Council for Prescription Drug Programs (NCPDP), HL7 Pharmacy and Financial Management workgroups.
  
The American College of Radiology (ACR) has will established and long standing guidelines that have been in common and broad use for almost two decades. The Radiological Society of North America (RSNA) and the Society of Breast Imaging (SBI) which the breast focused arm of the ACR are all represented on the subject matter expert team that is reviewing all content and will be used as the definitive source of truth for all our near-term deliverables.
+
The aim of the CARIN Alliance is to advance the ability for consumers and their authorized caregivers to easily get, use, and share their digital health information when, where, and how they want to achieve their goals.
  
 
==Expected implementations==
 
==Expected implementations==
  MITRE's Standard Health Record Collaborative
+
CARIN Alliance members including health plans, pharmacy benefit managers and consumer application vendors.
  PenRad, Inc.
 
  Mammography Reporting System, inc (MRS).
 
 
 
  PenRad and MRS represent well over fifty percent of the almost forty million screening mammography studies performed each year. PenRad and MRS are also committed to participating in FHIR Connectathons to proof the draft profiles.
 
  
 
==Content sources==
 
==Content sources==
  American College of Radiology Breast Reporting Guidelines
+
The CARIN consumer RTPBC process is an adaptation of the NCPDP provider-focused Real-time Pharmacy Benefit Check transactions. The CARIN Alliance is consulting NCPDP in addition the HL7 Pharmacy and Financial Management workgroups in process of developing this guide.
  College of American Pathology (CAP) Breast Reporting SDC Forms
 
  Society of Breast Imaging Reporting Guidelines
 
  In addition to sources specifically providing clinical content related to cancer and breast cancer, from a modeling perspective, CIMI models were also used as a source.</span>
 
  
 
==Example Scenarios==
 
==Example Scenarios==
  Capture and delivery of breast radiology reports to EHR systems
+
Retrieve patient-specific cost and coverage information for a medication product
  Reporting to cancer registries
 
  Reporting for clinical trials
 
  
 
==IG Relationships==
 
==IG Relationships==
The breast-radiology project is intended to target compliance with US Core v4.
+
The IG is based on FHIR R4.  
  
 
==Timelines==
 
==Timelines==
  For Comment September 2019 Ballot
+
''TO BE REVIEWED / ADJUSTED:''
  Informative Jan 2020 Ballot
+
Informative Jan 2020 Ballot
  STU May 2020 Ballot
+
STU May 2020 Ballot
  
  
 
==FMG Notes==
 
==FMG Notes==

Revision as of 16:41, 29 October 2019



CARIN Real-time Pharmacy Benefit Check

Owning Workgroup

HL7 Pharmacy WG

Committee Approval Date:

November 2019

Publishing Lead

Frank McKinney (fm@frankmckinney.com)

Contributing or Reviewing Work Groups

  HL7 Financial Management WG

FHIR Development Project Insight ID

To be added

Scope of coverage

This is a guide for implementing the consumer-focused real-time pharmacy benefit check (consumer RTPBC) using FHIR R4.

The process is limited to medications that are covered under the pharmacy benefit portion of the patient’s health insurance, which typically excludes medications administered during hospital care or as part of medical procedures. Is is further limited to commercially available medication products that are not compounded at the pharmacy.

The guide is for use in the United States only.

Content location

To be updated

Proposed IG realm and code

us/pharmacy

Maintenance Plan

The CARIN Alliance is committed to the maintenance of the content.

The Pharmacy and Financial Management Workgroups are engaged and will continue to provide guidance and review through completion of the guide.

Short Description

CARIN RTPBC FHIR Implementation Guide

Long Description

With consumer RTPBC, a patient can learn how their medications will be covered at the pharmacy, including out of pocket costs, prior authorization requirements and any limits that might apply.

The communication flow consists of...

  • a request submitted by a consumer application that contains information about the patient, the prescription and their insurance coverage
  • a response from the patient's insurer that contains cost and coverage information for the requested product, alternative products, and different pharmacy options.

This IG defines FHIR profiles for resources representing...

  • the set of information provided in the RTPBC request that enables the insurer to locate the patient's membership details and determine coverage for the requested product. This includes profiles of Claim, Patient, Practitioner, Organization and MedicationRequest resources
  • the pricing and coverage information returned in the RTPBC response, using a profile of the ClaimResponse.

In addition, the guide identifies terminology to identify the referenced entities and aspects of insurance coverage.

Involved parties

The RTPBC IG is being authored by the CARIN Alliance in collaboration with the National Council for Prescription Drug Programs (NCPDP), HL7 Pharmacy and Financial Management workgroups.

The aim of the CARIN Alliance is to advance the ability for consumers and their authorized caregivers to easily get, use, and share their digital health information when, where, and how they want to achieve their goals.

Expected implementations

CARIN Alliance members including health plans, pharmacy benefit managers and consumer application vendors.

Content sources

The CARIN consumer RTPBC process is an adaptation of the NCPDP provider-focused Real-time Pharmacy Benefit Check transactions. The CARIN Alliance is consulting NCPDP in addition the HL7 Pharmacy and Financial Management workgroups in process of developing this guide.

Example Scenarios

Retrieve patient-specific cost and coverage information for a medication product

IG Relationships

The IG is based on FHIR R4.

Timelines

TO BE REVIEWED / ADJUSTED: 
Informative Jan 2020 Ballot
STU May 2020 Ballot


FMG Notes