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Use Case Scenarios

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This implementation guide addresses a Provider-to-Payer use case:

• Patient at Primary Care Provider

The other use case is for Member/Patient-mediated Payer-to-Payer Exchange:

• A consumer enrolls with a new health plan and accesses their prior health plan to authorize sharing of the health history that the prior health plan holds on the consumer.

The examples used in this guide are based on Payers providing claims from events where a member visits an ambulatory provider or when a member switches health plan.

Three example data requests from Providers to Health Plans are covered in this IG and the associated Reference Implementation:

1. What Encounters has the patient had since mm/dd/yyyy, excluding encounters at my organization.
2. What procedures has the patient had?
3. What medications has the patient received (i.e., A claim for a medication has been settled by the health plan)

Reference Implementations can be found in the Da Vinci GitHub account:

• PDex SMART-on-FHIR+CDS-Hook Patient Import App
• PDex Payer-to-Payer Patient Import App

Patient Persona

Provider to Health Plan scenario:

Lauren Dent is a 62-year-old female, living in Wisconsin but she spends winters in Tampa Bay, FL.

Lauren works on a seasonal basis and has just accepted a new position with her employer and has moved to Madison, WI to live with her daughter, leaving her previous home in La Crosse, WI. As a result of the move, she has selected a new Primary Care Provider.

Lauren is in reasonable health but is managing a number of conditions:

• She has been diagnosed as Pre-Diabetic and is being treated with medications.
• She is taking medication for hypertension.
• She had a knee replacement 5 years ago.
• She had a procedure seven years ago to correct a problem with a disc in her lower back.
• A history of a normal colonoscopy 5 years earlier
• A history of a pneumovax and zostavax 4 years earlier.

Member/Patient-mediated Payer-to-Payer Exchange:

Arthur Dent is a 68-year-old Male.

He has recently switched from Medicare Advantage Plan A and enrolled in Medicare Advantage Plan B.

In this scenario, Arthur has signed up for a new Medicare advantage plan with payer C during the open enrollment period. Before the initiation of his coverage beginning January 1, payer C has established communication with the patient and has provided the patient with a secure log in to the payer C patient portal. Patient continues to have an active login to payer B patient portal.

Useful Patient History for Providers

When providers are building a health history for a new patient the information they are interested in MAY include:

• Ambulatory events
• In-patient events
• Medications
• Procedures

This Guide will focus on a method to enable a provider to query the health record of a health plan member they are treating for the information that is of interest to them in relation to the care of the member. The CDS-Hooks method that is described in a later section enables a provider to query for information in the member’s health record at the health plan using US Core profiles and search parameters and subsequently select, either manually or by pre-defined automated tools, the records they want to commit to the patient’s health record in the provider’s EMR.

For example, as part of an event or episode of care the provider MAY be interested in the following types of data:

• Consultations/Encounters
• Practitioners who the patient has seen
• Care Plans
• Laboratory test results
• Image Studies
• Medical Devices
• Procedures
• Diagnoses
• Vital Signs
• Medications
• Immunizations
• Allergies
• Notes
• Family History

These types of data SHALL be mapped to FHIR clinical resources as follows:

It must be recognized that Payers may not have in-depth health history for a health plan member since the majority of the information may be derived from claims information which lacks the depth of clinical content that supports a claim.

Versioning of FHIR Data

A payer SHOULD provide the most recent version of the Patient, Practitioner, Organization and Location resources.

A payer MAY choose to support FHIR resource data versioning in their API including Patient, Practitioner, Organization and Location resources. In such cases resources should follow the vread guidance in the HTTP section of the FHIR specification.

If a payer chooses to support FHIR resource data versioning of related resource references in the referring resource SHALL use the vread format of reference:

[type]/[id]/_history/[vid]

Supporting versioning of FHIR data implies supporting the vread and history interactions in the FHIR specification.

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