The Standard

Those of us who have been in healthcare a long time know that prior authorization can been a challenge for both payers, providers, and patients. One might think it’s time to remove prior authorization altogether, but until we have consistent clinical practice across the entire US healthcare system, it’s very hard to justify.

The current processes create a huge burden for providers and payers, and cause delays – sometimes critical – in patient care.

Why is prior authorization such a thorny problem[i]?

• Prior authorization issues contribute to 92% of care delays
• Nearly all of provider care delays are associated with inefficiencies and administrative issues with current prior authorization
• Providers take 6 hours on average to complete these requests, which is the equivalent of two business days. Thirty-four percent of providers have staff dedicated exclusively to completing prior authorizations.
• The prior authorization process costs $23 to $31 billion per year in the US, according to a 2009 study published in Health Affairs.
• The health plan cost per manual prior authorization is $3.68, compared to $0.04 per electronic prior authorization, according to a 2017 Chilmark Research report.

Whether Attendees are Novices or Experts on Implementation Guides, Education Will Increase Knowledge and Build Community

Communicating the value of HL7’s Fast Healthcare Interoperability Resource (FHIR®) in healthcare isn’t always easy. Do you tell the story in purely technical terms? Describe the problems it’s intended to solve? Or offer examples of where it’s providing benefits?

The upcoming Da Vinci Education & HL7 FHIR Implementation Event addresses all of those questions for a variety of audiences.

The presenters at the virtual event, scheduled for the week of April 26 to 30, will explain the sense of urgency that underscores the need to accelerate adoption of FHIR-based use cases. They will also provide real-world context to show that these use cases are not just a theoretical construct, but are providing immediate benefits to those organizations that are using it to power the shift to value-based care.

The adoption of FHIR is picking up speed because of this growing recognition of its benefits in reducing clinician burden, improving the exchange of quality measure data and enabling real-time access to data by patients, providers and payers. The adoption of FHIR-based use cases also provides a way for organizations to meet federal rules governing interoperability and patient access to their medical information.

Program Showcases Individuals Making Significant Contributions to Advancing Implementation Guide Use

Initiatives such as the Da Vinci Project make strides toward interoperability as organizations adopt the vision and push it forward to reality

To achieve the progress the HL7 Da Vinci Project has made to date, it relies on the extraordinary efforts of individuals who consistently work to advance the organization’s goals. This might entail stepping forward to lead a work group of peers, spending extra hours editing and reviewing work in progress workflows, recruiting business partners to test early versions as early adopters, or scouring their organization to find the right subject matter expert for a particular business challenge or question, all to ensure that early HL7 Fast Healthcare Interoperability Resources (FHIR®) implementation guides work.

These team members exemplify the spirit and intent of our collaborative industry-first Da Vinci efforts, said Jocelyn Keegan, program manager for the Da Vinci Project. “The work of Da Vinci is, at its core, a human powered effort,” she noted. “It is imperative that we publicly acknowledge the contributions of the smart, dedicated thought leaders who are redefining how payers and providers collaborate.”

To recognize individuals who are taking a lead role in working to make the outputs of Da Vinci real, the project has named six leaders as the initial class of the Da Vinci Community Champion program for their contributions in 2020.

With the ascent of value-based care, interoperability is expected to evolve at an even faster pace to meet the business demands that new reimbursement incentives are producing.

Monthly Event is Scheduled for 4:00 to 5:30 p.m. ET on Wednesday, March 24, 2021

Advancing the use of HL7’s Fast Healthcare Interoperability Resources (FHIR®) takes both strong proponents advocating for the cause and pioneering organizations that lead the industry by putting concepts into practice.

Both aspects important to FHIR adoption will be on display at the March Community Roundtable of the Da Vinci Project, scheduled for Wednesday, March 24, from 4 to 5:30 p.m. ET. The roundtable has become a staple of the Da Vinci Project’s efforts to highlight successful deployments of its implementation guides, intended to help healthcare organizations manage value-based care initiatives.

MiHIN Shares Lessons Learned with Plan-Net

An example of a real-world implementation will be provided by the Michigan Health Information Network (MiHIN). A team from the organization will share lessons learned from its deployment of Plan-Net, the Payer Data Exchange (PDex)-Plan Network Directory Implementation Guide that focuses on Payer-Provider Directories. FHIR offers the potential to automate this typically manually intensive process for all parties, and MiHIN will describe its journey to putting the implementation guide into place to achieve this.

Project Achieves a Tipping Point as Adoption Begins in Earnest to Meet Upcoming and Proposed Federal Regulation and Solve Interoperability Challenges

The Da Vinci Project made significant progress in 2020 in advancing the maturity of implementation guides, and now looks to increasingly demonstrate the value of its implementation guides (IGs) across production implementations this year.

Members of the HL7 FHIR® Accelerator group helped push forward work on several implementation guides that were published in 2020, but further refinement lies ahead, said project managers who presented a progress report on the Da Vinci Project at its January Community Roundtable.

In addition to the update on progress with publishing new standards, the presentation offered members a tour of the Da Vinci Project’s enhanced Confluence website, as well as an invitation for more organizations to consider membership to help ensure implementation guides meet the needs of the entire healthcare community.

This year, there will be a growing need to use the HL7 Fast Healthcare Interoperability Resources (FHIR®) standard, as application programming interfaces (APIs) emerge to meet federal information exchange requirements and business needs of value-based care.

Primary author: John D'Amore, Co-Founder, Diameter Health; Co-authors: Brett Marquard, Principal, Wave One Associates and Wayne Kubick, CTO, HL7 International

While HL7 FHIR® (Fast Healthcare Interoperability Resources) is today’s hottest healthcare standard, clinical documents are already exchanged in the billions today. HL7 published the Consolidated Clinical Document Architecture (C-CDA) in 2011 to support care coordination and patient engagement. The ONC 2014 certification rule named C-CDA R1.1 and adoption exploded. The current version of C-CDA, R2.1, remains backwards compatible to that version today. While C-CDA is a flexible, robust standard to record patient care longitudinally or for an encounter, it is structurally complex. The C-CDA standard itself is over 1,000 pages long. Applying the standard to the latest US requirements for clinical data exchange, known as the US Core Data for Interoperability, also routinely requires information from the C-CDA Companion Guide.

HL7 publishes the C-CDA standard and its Companion Guide as PDF documents. That will remain the official version of the standard, but a small team from the CDA Management and Structured Documents Working Groups saw an opportunity to make the C-CDA content easier to use by developing a new web tool. Since the C-CDA has reusable parts, known as “templates,” it seemed logical to make each template searchable and distinct via unique web pages so the standard would be much easier to absorb.

The new HL7 C-CDA Online Search Tool is a searchable, web-based navigation resource for the Consolidated Clinical Document Architecture (C-CDA 2.1) and its Companion Guide. The solution includes over 240 unique web pages that make each template accessible on the web with linkage back to the original PDF content. This navigation is managed through a single searchable index page, like a smart table of contents.

Using the template webpages, health IT vendors can ensure that their C-CDAs are conformant and high-quality for document exchange.  The search tool enables users to search the C-CDA by description, template object identifier (OID) or conformance number. Conformance number searches are particularly valuable for C-CDA implementers, since validators will return these numbers when there’s a violation or warning associated with C-CDA testing. 

Join the Webinar Highlighting MCG Health’s Prior Authorization Journey and Da Vinci’s Two New Use Cases for 2021 on Wednesday, February 24 from 4:00 - 5:30 pm ET.

Healthcare organizations increasing their exposure to value-based care find many tasks complicating the transition, and reducing the burden of those changes is key to thriving under new reimbursement schemes.

New payment approaches incentivize both payers and providers to become more efficient, and that means reducing the number of manual interventions in exchanging data. In addition, value-based care is uncovering new reasons to make information more easily available, to bring new efficiencies to the system.

Examples of these capabilities will be featured in the HL7 Da Vinci Project’s Community Roundtable on February 24. The title for the event is "What it Takes: Learn about MCG Health’s Journey to Help Reduce Prior Auth Burdens and Discover New Da Vinci Use Cases."

The upcoming roundtable will offer an inside understanding of the 18-month effort at MCG Health to advance the use of the HL7 Fast Healthcare Interoperability Resource (FHIR®) standard in solutions that support burden reduction in facilitating the prior authorization process.

The Centers for Medicare & Medicaid Services (CMS) released the much-awaited Interoperability & Patient Access Rule in March 2020. The objective is to reinforce this rule by further improving health information exchange and obtaining member health records at a single location to reduce burden on payers, providers and members.

The enforcement date for this rule is January 1, 2023, and will be applicable to Medicaid programs, the Children’s Health Insurance Programs (CHIP) and Qualified Health Plan (QHP) issuers on the individual market Federally Facilitated Exchanges (FFEs). However, it will not be applicable to Medicare Advantage (MA) plans.

The CMS proposed rule will include policies to enhance the current Application Programming Interfaces (APIs) from its interoperability rule such as patient access API and payer to payer API. There are a few new APIs and requirements proposed to improve the overall prior authorization process.

Monthly Event is Scheduled for 4:00 to 5:30 p.m. ET on Wednesday, January 27, 2021

In the first community roundtable of 2021, project managers of the HL7 Da Vinci Project will provide updates for how the project’s implementation guides can be used to solve interoperability challenges and meet federal rules.

The roundtable is intended to highlight how Da Vinci Project implementation guides can help organizations reduce burden, advance data exchange and enable better patient access to data.

Participants from the HL7 Da Vinci Project include Jocelyn Keegan, program manager; Viet Nguyen, MD, technical director; and Vanessa Candelora, project manager. The Da Vinci team will show the progress of Implementation Guides (IGs), which give guidance for using the HL7’s Fast Healthcare Interoperability Resources (FHIR®) coding. The team will also provide linkages to specific federal rules and policies, giving you the recipe to solve challenges in alignment with federal rules and leverage the power of standards to improve connectivity across all of your patient populations.

A Closer Look at the 26th Virtual HL7 FHIR Connectathon Held January 13-15, 2021

Despite adjusting almost everything in life to a pandemic-driven “new normal” these past ten months, most of us have discovered a few unexpected benefits from the upheaval. Such is the case for the HL7 FHIR Connectathons, which migrated from in-person to virtual beginning with the May 2020 Connectathon. The January Connectathon #26, occurring last week, carries the distinction of being the largest Connectathon yet – with over 800 participants!

The in-person, face-to-face Connectathons of the past provided a rare (and delightful) opportunity to join developers, implementers, clinicians and interested stakeholders in testing and development of FHIR standards. Moving to the virtual format, however, has allowed more people to participate without having to travel to the event.

What Happens at a FHIR Connectathon?

If you are still fuzzy on the detailed activities of Connectathons—and whether you should attend one, there are many avenues where you can learn more. FHIR Connectathons serve as events that are centered upon developing the FHIR specification; including resources, profiles, and implementation guides (IG). The first Connectathon occurred in September 2012 and readily set the stage for future Connectathons that typically occur in the days ahead of an HL7 Working Group Meeting, thereby encouraging members to participate in both.