This page is part of the Da Vinci Clinical Documentation Exchange (v1.0.0: STU1) based on FHIR R4. The current version which supercedes this version is 1.1.0. For a full list of available versions, see the Directory of published versions

Background

About the Da Vinci Project

Da Vinci is a private sector initiative that addresses the needs of the Value Based Care Community by leveraging the HL7 FHIR platform. For more information about the Da Vinci Project, its use cases, members and updates, see the Da Vinci Overview

What Do Payers Do with Clinical Information?

Payers require clinical data from providers who order or provide services. They use this data to document prior authorization, process and audit claims, and to confirm medical necessity and appropriateness. Clinical data is used by Payers to create risk profiles for members for value-based care contracts and population health adjustments. Quality reporting requirements and quality care scoring all require clinical data for evaluating clinical performance and outcomes. Payers also want to create a clinical record of their members to improve care coordination and provide optimum medical care. For example with this information they can reduce redundant care, shift to more proactive and timely care, and make better informed and more accurate medical treatment and care planning recommendations. Payers may use this clinical record to give providers information that may assist in care coordination.

Example Scenarios

• Payer requests attachments to support a claim submission.
• Payer requests attachments to support medical necessity or a coverage rule.
• Payer requests attachments to support a claims audit.
• Payer requests additional information for prior authorization. (See the Da Vinci - Prior Authorization Support for more information)
• Payer requests patient health record information to support their Risk Adjustment submissions to Centers for Medicare and Medicaid Services (CMS).
• Payer requests patient health record information to support a HEDIS or CMS Five-Star Quality Measure Rating quality program.
• Payer requests patient health record information to support their member records.
• Payers requests patient health record information to meet new regulatory requirements (for example, promoting patient access).

Provider to Provider Data Exchange

Providers commonly need and request information from other providers about their patients. Although this guide focuses on payor to provider to interactions, the technical exchange is no different than a provider to provider interaction.

Example Scenarios

• Referred-to provider solicits additional clinical information from referring provider to support performing the requested service.
• Referring provider needs the results from the Referred-to provider.

What Information is Needed?

A sampling of the type of information needed by Payers includes:

• Medical records - for example, a progress note or visit summary
• C-CDA’s of various types
• Medications
• Laboratory results
• Clinical Assessments for Diagnoses
• Vital Signs - for example Blood Pressure measurements
• Narrative - such as written or transcribed clinical notes

For Security and Privacy considerations refer to the Security and Privacy page.

Where Does CDEX Fit in the Da Vinci Project?

There are over a dozen use cases and corresponding Implementation guides being developed by the Da Vinci Project. Figure 2 illustrates how the Clinical Data Exchange (CDex) use case fits in the family of Da Vinci Use Cases/Implementation Guides. There are many areas of functional overlap between this guide and other Da Vinci guides which are summarized in this table. CDex is not intended to supersede these guides which focus on a particular use case and define how to share clinical information. However, CDex may be used to request clinical data from a provider when:

• An alternative is needed to cover some aspect of an exchange. For example, in Da Vinci - Coverage Requirements Discovery, if a CDS hook client refuses prefetch requests, the CDS service could use CDex to request the data instead.
• There is a specific exchange is not already addressed by one of the other IGs For example, in Da Vinci Prior Authorization Support (PAS) FHIR IG, the Payer could requests additional information for prior authorization using CDex.
• The other IG has not been or can not be implemented for the use case. For example, the Data Exchange For Quality Measures (DEQM) Implementation Guide provides a standard method for automating the reporting of Quality Measures. CDex can be used when:
  1. The measure is not yet implementable using DEQM
  2. A Provider has not implemented DEQM
  3. Additional information is required for an audit of the Quality Measure.

Workflow Overview

FHIR offers numerous architectural approaches for sharing data between systems. This guide focuses on three FHIR transaction approaches for exchanging clincal data:

1. Direct Query (preferred): Payer directly queries EHR for specific data using the standard FHIR RESTful search.
2. Task Based Approach: Payer requests the information desired using the FHIR Task resource and the EHR supplies the data possibly with human involvement to find/aggregate/filter/approve it.
3. Attachments Based on pre-defined payor rules or business needs the EHR sends supporting information for claims or prior authorization directly to Payer using a “push” based FHIR operation.

See the Specification pages for a detailed description of the technical workflow and API guidance.

Direct Query and Task-Based Workflow

Figure 3 below illustrates the exchange of clinical data between a Payer (or Provider) system and a Provider system using the Direct Query and Task-Based workflows.

Actors and Roles

• The Payer or External Provider System acts in the role of a data consumer.
• The Provider system acts in the role of a data source.*
• A human practitioner involved in approving/filtering the information provided.
  • A pre-existing agreement could be in place that allows data to be shared without human intervention.

* For most payer use-cases, payers can not use the data if they cannot identify who is responsible for the clinical event (for example an observation, diagnosis, order, etc). Therefore, payer’s health records needs to identify the provider who is making the assertion. This information is typically supplied by provider systems. An Electronic Health Information Exchange (HIE) that has the ability to validate the authorship of the information would also be an acceptable data source. However, not all HIEs do this (and not for all records) and they would not be acceptable data sources.

Steps

1. The data consumer initiates a request for information.
2. The data source retrieves the requested data.
3. The data may be reviewed by a human practitioner prior to sending it back to the data consumer.
4. The data is sent back to the data consumer.

Attachments Workflow

Figure 4 below illustrates the exchange of clinical data between a Payer system and a Provider system using the Attachments workflow.

Actors and Roles

• The Payer acts in the role of a data consumer.
• The Provider system acts in the role of a data source.

Steps

1. The data source sends attachments to the data consumer.
   • Supporting information for a claim or prior authorization
   • Data Elements for association to a claim or prior authorization. (for example, member id and claim id)
2. Payer accepts attachments
3. Out of Scope: Payer processes the claim or prior authorization.