2023 Accomplishments Position Industry for Year Ahead
Substantial progress has been made this year on HL7 Da Vinci Project Implementation Guides (IGs), which describe how to use HL7’s Fast Healthcare Interoperability Resources (HL7 FHIR®) standard for exchanging data to support value-based healthcare and implementations of the guides.
Sizing Up Accomplishments
At the December Da Vinci Community Roundtable, Hans Buitendijk, Da Vinci Project Steering Committee Vice Chair, reviewed progress this year and offered an outlook for 2024.
“We have a number of organizations across the spectrum that have adopted one or more of our [FHIR implementation] capabilities. … That's fantastic in the short number of years that this initiative started to look at what is necessary to make it happen,” Buitendijk said.
“We currently have about eight publishing updates that have been accomplished and quite a few ballot processes that are in flight and being planned for, and there is a good amount of commitment to making this happen. So, we really need to be proud of what we have achieved to date, and particularly in the last year.”
In the year ahead, alignment with emerging regulations, including the final CMS Interoperability Rule, will be a top priority, he pointed out.
Interoperability efforts must go beyond a general set of data to ensure adequate support for public health, research, quality measures and more, he added. “We are all going to impact the ability and the opportunity to share more data over time,” he said.
The key to advancing interoperability by leveraging FHIR, he stressed, is to involve many different parties and develop “the same language where we have a minimum set of capabilities that everybody can support, and leaving room … to grow, to explore, to define new things.”
He also pointed out: “We must continuously raise the bar for what we can exchange and determine what is relevant across many different stakeholders that we should all do in the same way … because the data that we have covered so far is still only a part of the variety of data exchanges that are relevant and can benefit from improvements."
The October Roundtable provided a detailed overview of IG progress this year. The following provides a brief summary of each IG discussed at the October event:
Member Attribution (ATR) List
The Member Attribution List (ATR) Implementation Guide describes how to give trading partners the ability to exchange and validate patient/member lists to help support a variety of business needs.
The Standard for Trial Use 2 (STU2) version was balloted in January, with publication anticipated before the end of this year. The most recent update now supports reconciliation of patient lists to add and remove members, and the attribution list profile was generalized so it could support multiple use cases that require patient lists.
“Looking ahead, we expect this profile will eventually be migrated into the HRex IG as a foundational component for use across all IGs,” said Crystal Kallem, Project Manager, HL7 Da Vinci Project and Senior Consultant, Point-of-Care-Partners.
HRex is the Healthcare Record Exchange guide, which serves as the basis for all other guides and will be updated next year.
The STU1 version of the Notifications Implementation Guide was published in October 2020, and an update is planned for the first quarter of 2024 based on feedback from early adopters.
It describes a method for the communication of relevant notifications to support the real-time exchange of information that impacts patient care and value-based or risk-based services. Developers are continuing to assess whether to align this guide with the Direct Trust Event Notifications Implementation Guide to support compliance with the CMS Admission, Discharge and Transfer (ADT) Conditions of Participation, Kallem said.
Data Exchange for Quality Measures (DEQM) and Gaps in Care (GIC)
The DEQM IG describes how to enable the exchange of data needed to close open gaps in care identified by a payer to meet their quality reporting criteria. The guide defines automated data collections to eliminate the need for manual processing.
Version STU4, published in October, added a “guided response resource” to help providers identify what is needed to close an open gap. STU5 is slated to go to ballot in the second quarter of 2024, said Teresa Younkin, Value Based Performance Reporting Lead, HL7 Da Vinci Project PMO and Senior Consultant, Point-of-Care Partners.
The Risk Adjustment Implementation Guide enables standard exchange of risk adjustment coding gaps, documentation and submission status of chronic conditions between payers and providers. It can be used for Medicare Advantage workflows.
STU1 was published in June 2022, and STU2 was balloted in May. Active ballot reconciliation is ongoing. Publication of STU2 is anticipated for the first quarter of 2024, Younkin explained.
Value-Based Performance Reporting (VBPR)
Now in development, the VBPR IG will provide standardization of payer/provider performance reporting for quality and risk contracts. Version STU1 supports a payer sending a provider a VBPR in a standardized format. A later version will standardize a provider returning data to a payer on how they are performing.
STU1 was balloted in September, and ballot reconciliation is continuing in anticipation of publishing STU1 in the first quarter of next year, Younkin said. “The VBPR IG has links to a whole lot of other IGs,” she stressed. “It’s the culmination of many other IGs.”
Payer Data Exchange (PDex)
PDex enables a health plan to share key clinical data and patient history with a patient-used application and with other payers.
STU2 was released for ballot in May 2022, and ballot reconciliation is continuing, with publication planned before the end of the year, said Mark Scrimshire, PDex Implementation Guide Lead, HL7 Da Vinci Project, and Chief Interoperability Officer, Onyx Health.
PDex is referenced in the proposed CMS Interoperability Rule, which would require making prior authorization profiles accessible to consumers via apps, Scrimshire said. The latest version of PDex addresses such access.
Developers are also working on payer-provider bulk data exchange, where payers are responding to provider patient data requests, and payer-to-payer bulk data exchange via APIs.
The PDex Formulary IG went through a major restructuring last year, based on feedback from pharmacy benefit managers and others, to make it easier to manage formularies, Scrimshire said.
The PDex Plan Net (provider directory) IG is designed to increase patient transparency about providers available in their plan and provides a standard approach for requesting and receiving provider information based on patients’ insurance plans. Enhancements to the IG are designed to stay in synch with FAST National Healthcare Directory IG.
Prior Authorization/Burden Reduction
The goal of the burden reduction IGs is to reduce the effort for prior authorization and leverage available clinical content from electronic health records, said Michael Gould, Associate Vice President, Interoperability Strategy at ZeOmega and HL7 Da Vinci Project Architectural Group Co-Lead. The three components of this effort are:
- Coverage Requirements Discovery (CRD)
This focuses on the exchange of coverage plan requirements from payers to providers at the time of treatment decisions to answer questions, such as: Is this service covered by the plan? Is prior authorization required?
The STU2 version, with improved clarity and functionality, was published October 20, 2023.
“The purpose is to take the guesswork out of patient-specific coverage by sharing authorization or process requirements right in the provider workflow,” Gould explained.
- Documentation Templates and Rules (DTR)
This builds on CRD to specify how payer documentation rules can be executed in a provider context to ensure that documentation requirements are clear and met. It reduces manual data entry by automatically extracting necessary data from electronic health records. Version STU2 was published November 7.
Gould explained that this guide describes automating the process of assembling clinical documentation to support a prior authorization request for a specific payer.
- Prior Authorization Support (PAS)
This defines FHIR-based services to enable the provider, at the point of service, to request prior authorization and receive immediate authorization from the payer. PAS takes information from CRD and DTR and submits it to the payer. Version STU2 was published November 21.
The three burden-reduction guides, all referenced in the proposed revised federal Interoperability Rule, provide several benefits, Gould said, including:
- Standardizing interactions across all providers and payers
- Creating common workflow expectations
- Minimizing collection of documentation which is necessary to help ensure privacy
- Avoiding duplicate entry of information, such as separate entries via payer portals
Clinical Data Exchange (CDex)
CDex is a utility tool that can be used across Da Vinci use cases. It can be used, for example, for requesting and sending documentation to support claim submission and prior authorization and for supporting clinical data requests by payers, or other interested parties from providers. Version STU2 was published in March. Recent additions include a FHIR approach for requesting attachments for claims and prior authorizations.
Patient Cost Transparency (PCT)
PCT defines a mechanism for providers to request and receive cost information from a payer regarding a service or item, resulting in an Advanced Explanation of Benefits (AEOB) that includes a good faith estimate, which will help inform a clinician and patient cost conversation. The goal is to provide the data in near real-time to allow effective decision making by the patient in consultation with the ‘ordering’ provider. Version STU1 was published in March.
The latest versions of many of the IGs will be tested at the next HL7 Connectathon, to be held online January 16-18, 2024. Meanwhile, those interested in helping to refine data exchange standards to ensure they meet their needs should consider attending development sessions for each IG that are held regularly.