Understanding clinical data exchange and cda (hl7 201)
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On top of simple needs for doctors to be connected and be able to efficiently exchange information, there is a lot of external factors driving standardization of information exchange from market to various government initiatives and as the industry moves toward a population health model, there is more need for wider applicability of standards. This Slide share covers an introduction to CDA and establishes the importance of clinical documentation for claims and prior authorization attachments
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Understanding clinical data exchange and cda (hl7 201)
- 1. Understanding Clinical Data Exchange and HL7 CDA for Claim and Prior Authorization Attachments
- 2. 1. Overview: Why HL7 was created 2. Benefits: How Health Plans can utilize HL7 today. Use Cases 3. CDA: Understanding the building blocks 4. CDA and IGs: Understanding different IGs 5. C-CDA and Attachments: How C-CDA are used with Attachments 6. Resources: A list of supporting websites for more info. Agenda Speakers Julia Sakhnov, Product Manager, Trading Solutions
- 3. Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Healthcare Industry Initiatives Paper to Electronic Records Meaningful Use standards Public Health National-Regional IT Networks Personalized Medicine Driving standardization of information exchange Population Health Payment Reform On top of simple needs for doctors to Be connected and be able to efficiently exchange information, there is a lot of external factors driving standardization of information exchange from market to various government initiatives: The cost of providing healthcare is constantly rising Move from paper to electronic records Meaningful use standards Public health reporting Consumer empowerment National-regional IT networks Personalized medicine And as the industry moves toward a population health model, there is more need for wider applicability of standards.
- 4. Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Healthcare Collaboration Move toward value-based models requires more collaboration and integration of all data-sets (Clinical, Admin and Financial) to drive down healthcare costs. PAYER ENTERPRISE PROVIDER ENTERPRISE Encounter Data x12 5010 (ICD10) Quality-Based Incentives HL7 v2.5 (CCD) Patient Data Pop Risk
- 5. Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Healthcare Payer HL7 Use Cases Enrollment Health plans design the process of on-boarding of new members. Utilization Management Health plans design care pathways using evidence-based medicine to focus on the right amount of patient care – not more or less than required. Reimbursement All providers submit claims to a health insurance organization to be reimbursed for care provided. Care Management A small number of individuals will incur the most serious health problems and a disproportionately large percentage of total healthcare expenses. Care management seeks to identify individuals with these conditions and dedicate resources to managing their care. Disease Management Disease management focuses on patient populations who already have or are at risk for a specific chronic illness or medical condition. Unlike care coordination, the members within the identified population do not receive customized care. Rather, one plan or campaign is implemented in the same way for all members of the identified population.
- 6. Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Healthcare Why Electronic Attachments Medicare FFS Improper Payment for FY 2014 Service Type Improper Payment Rate Improper Payment Amount Inpatient Hospitals 9.20% $10.4B Durable Medical Equipment 53.10% $5.1B Physician/Lab/Ambulance 12.10% $11.0B Non-Inpatient Hospital Facilities 13.10% $19.2B Overall 12.70% $45.8B ?
- 7. Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Healthcare Why Electronic Attachments 2014 CAQH Index: Electronic Administrative Transaction Adoption and Savings (2013) Claim Attachments: plans for 103 millions enrollees 1 claim attachment for every 24 claims health plan cost - about $0.63 per transaction provider cost – about $5 per transaction Prior Authorization Attachments: plans for 49 millions enrollees 1 attachment for every 11 prior authorizations provider cost – about $45 per transaction http://www.caqh.org/sites/default/files/explorations/index/report/2014Index.pdf
- 8. Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Healthcare Electronic Attachments for P&C P&C: Jopari Solutions - 5 Year Case Study
- 9. Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Healthcare Electronic Attachments 2005 Health Care Claims Attachments NPRM : ANSI X12N 275 version 4050 HL7 CDA R1 – Additional Information Specification (AIS) Booklet http://www.gpo.gov/fdsys/pkg/FR-2005-09-23/pdf/05-18927.pdf Expectations: ANSI X12N 275 version 6020 HL7 C-CDA R2 and CDP1
- 10. Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Healthcare Covered Further Deep Dive into Clinical Data Architecture Demo of patient use CDA Samples: Operative Notes Header nonXML Body Structure Body Constraint Levels and LOINC Codes Schematron Rules with Example CDA Implementation Guide And More…… Also learn about CDA In relation with C- CDA,CCD,CDP1 Demo of Payer and Provider Use cases Useful Resources And More……
- 11. Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Healthcare Question and Answers Edifecs http://www.edifecs.com/downloads/Clinical_Health_Level_7_Brief_2014.pdf HL7 http://www.hl7.org/ CDA and Implementation Guides http://www.hl7.org/implement/standards/product_brief.cfm?product_id=7 HL7 Payer User Group http://www.hl7.org/Special/committees/pug/ Resources
- 12. Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Healthcare Next Steps Coming SoonContactShare Look for invitations to our next HL7 Educational webinar Access recorded webinar Questions/more information contact: courtney@edifecs.com or call 425-452-0620
Editor's Notes
- HL7 CDA Presentation
- Thank you Diane. During today’s presentation we are going to discuss how and why HL7 was created, what benefits payers can get from using it, what HL7 and some of its standards actually are and how they look and used. Today I will be joined by Gregg who is going to help me by formulating some common questions and concerns about HL7 and hopefully this will help to answer some of your questions. Before we proceed with HL7 information we’d like you to take a poll to see how familiar you are with HL7.
- On top of simple needs for doctors to be connected and be able to efficiently exchange information, there is a lot of external factors driving standardization of information exchange from market to various government initiatives: The cost of providing healthcare is constantly rising Move from paper to electronic records Meaningful use standards Public health reporting Consumer empowerment National-regional IT networks Personalized medicine And as the industry moves toward a population health model, there is more need for wider applicability of standards.
- Payers already have established relationships with majority of providers. And they can take advantage of already developed and proven standards for their business needs.
- What are some areas where HL7 can help? Lets start from the beginning – enrollment. HL7 data may help to facilitate the exchange of eligibility and enrollment information by providing a standardized content. Utilization Management A health plan does not necessarily pay for everything doctors prescribe or order or patients want. Some services might require prior authorization. This means the health plan has to assess whether the treatment is “medically necessary,” before agreeing to cover the charges. To make the assessment, health plans use evidence-based medicine to design care pathways that focus on the right amount of care for the patient – again -- not more or less than is required. The health plan then gathers clinical data about the patient to compare the patient’s condition and treatment request against the specified care pathway. Reimbursement As for utilization management, attachments with clinical data provide required details about medical necessity so claims are paid properly. Care Management Usage of HL7 documents may help to increase care coordination to reduce the cost and increase the quality of care by addressing the care fragmentation that results when individuals obtains services from several providers. Admission, Discharge and Transfer (ADT) messaging is one example of how HL7 standards can facilitate data exchange and analysis. There are shared market problems between payers and providers, particularly in the admission and notification process. Administrative costs spiral upward when lack of communication and coordination affects treatment authorizations, which can result in claims denials and back-office rework. The use of standards-based information exchange can reduce some of those problems, and also holds promise for better coordination of care. For example, patients’ primary care providers are not always included on admission notifications, and improved hospital-payer connectivity could help solve that problem. Standardized ADT message also could provide the foundation for other transactions and document exchanges, care reminders, and even payer-based health record integration. Payers use hospital admission, discharge, and transfer (ADT) message systems to help improve care coordination among providers with the goals of reducing hospital admissions, lowering unnecessary readmissions, and decreasing duplicate therapies. For disease managements, more accurate predictive models can be created. Gregg: how can it be used for DM specifically.
- Why are we talking about electronic attachments? https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/CERT/index.html The Centers for Medicare & Medicaid Services (CMS) calculates the Medicare Fee-for-Service (FFS) improper payment rate through the Comprehensive Error Rate Testing (CERT) program. Each year, CERT evaluates a statistically valid random sample of claims to determine if they were paid properly under Medicare coverage, coding, and billing rules. The fiscal year (FY) 2014 Medicare FFS program improper payment rate is 12.7 percent, representing $45.8 billion in improper payments, compared to the FY 2013 improper payment rate of 10.1 percent or $36.0 billion in improper payments (1). The table below outlines the improper payment rate and projected improper payment amount by claim type for FY 2014. In 2011: “CMS receives approximately 4.8 million claims per day, and the CMS Office of Financial Management estimates that improper payments totaling more than $35.4 billion dollars in Medicare and more than $22.5 billion in Medicaid are made each year. CMS has stated that most improper payments can only be detected by a human comparing a claim to supporting medical documentation. Currently, there are over 1 million requests for supporting medical documentation per year for review and CMS expects that number to grow significantly in the coming years as CMS Review Contractors increase their efforts to find and prevent improper payments (emphasis added).”
- http://www.caqh.org/sites/default/files/explorations/index/report/2014Index.pdf 2013 Enrollment and Transactions of Responding Health Plans (all types of transactions – electronic and manual – combined) claim attachment data are from plans representing 103 million enrollees – 58 millions transactions; prior authorization attachments are based on plans representing 49 million enrollees – 2.1 millions transactions. Claim Attachments and Prior Authorization Attachments There are two transactions measured for the first time in the 2014 Index: claim attachments and prior authorization attachments. As new measures, some responding health plans have not yet set up internal tracking mechanisms to count attachments, and others made extrapolations from part-year data. Therefore, our preliminary counting of these transactions is more uncertain than with the more established measures. Claim Attachments. For the 2014 Index, responding plans representing 103 million enrollees returned data on claim attachments. From those responses, there was approximately one claim attachment for every 24 claims in 2013. The vast majority of claims attachments were submitted manually, via paper delivery or fax. Among the plans reporting, we counted approximately 46 million claim attachments processed, which can be extrapolated to roughly 110 million claim attachments industry-wide. Our preliminary estimate is that manual claim attachment processing costs health plans about $0.63 per transaction, and about $5 for healthcare providers. Neither health plans nor providers estimated their costs for electronic claim attachments for 2013. We believe the relatively low cost of processing for health plans represents the cost of scanning the records and associating them with a claim. No other work is done in inbound processing at that stage of the claim (analysis of the medical records or other information contained in the claim attachment would be done at a later time as part of the claim resolution, but that is not considered a transaction cost associated with receiving and filing the attachment). On the other hand, the relatively high transaction cost for providers probably relates to the time and effort to send the documents, whether by mail, fax, or sending a scanned document by email. Even if attachments are sent by email, there may be considerable staff time involved in scanning, converting, and attaching files to emails. On balance, we believe that the savings potential from converting claims attachments from manual to electronic processing could be substantial. For example, if only half of the estimated 110 million manually processed claim attachments were converted to electronic processes that saved $4 per transaction for providers, costs for providers alone would be reduced by $200 million. Prior Authorization Attachments. Health plans that provided data on prior authorization attachments represent an enrolled population of approximately 49 million people. From those plans, we counted two million prior authorization attachments, or approximately one attachment for every 11 prior authorization requests. Although our projections to nationwide total are more uncertain due to the smaller response, our preliminary estimate of the number of prior authorization transactions nationwide is approximately 10 million, most of which are currently processed manually. As with claim attachments, we estimate that costs per transaction are much higher for healthcare providers than health plans. Our preliminary estimates indicate that costs for healthcare providers are nearly $45 per transaction to send attachments for prior authorization requests. Of course, the sample of providers able to return data on costs for preparing attachments was small, so this preliminary estimate is subject to uncertainty. One participant noted that many prior authorization attachments are related to major procedures costing thousands of dollars, and that providers may have an incentive to use rapid or overnight delivery services, to send the attachments. While this may decrease the time needed to complete the prior authorization process, it would indeed add greatly to the costs for such attachments; costs that could be greatly reduced by the use of electronic processes. The potential savings from automating prior authorization attachments is likely much lower than for claim attachments, since there are fewer of them. However, if even half of prior authorization attachments were sent electronically instead of manually, with a cost savings of $20 per transaction, $100 million in total savings for providers alone would be possible. As with claim attachments, these preliminary estimates are subject to considerable uncertainty. Future Index reports, with data from larger numbers of health plans and providers, will target improvements in these preliminary estimates.
- https://x12.centraldesktop.com/attachmentscollaborationwg/file/37315571/
- The Health Insurance Portability and Accountability Act (HIPAA) of 1996 (Section 1173(a)(2)(B)) identified electronic Health Claims Attachments as a transaction for which a standard was to be adopted. A proposed rule was published in 2005, but a final rule was never published due to questions about the maturity of the standards being recommended for adoption and concerns regarding the ability of potential users to implement the standards. In 2010, Section 1104 of the Patient Protection and Affordable Care Act (the ACA) directed the Secretary of Health and Human Services (HHS) to publish final regulations adopting national standards, implementation specifications and operating rules for Health Care Claims Attachments no later than January 1, 2014, with a compliance date no later than January 1, 2016. The 2005 Health Care Claims Attachments NPRM proposed to adopt version 4050 of the ANSI X12N 275 as the transaction to provide additional information for claims. Recently, the Accredited Standards Committee (ASC X12), author of the X12 Implementation Guides, endorsed version 6020 of the X12N 275 for use as the HIPAA standards for claims attachments. The 2005 NPRM had proposed that Health Level 7 (HL7) develop specifications for the content and format of communicating the additional information that would be transmitted within the X12 envelope. HL7 is expected to recommend the Clinical Document Architecture (CDA), i.e. C-CDA R2 and CDP1, as the additional information specification standard for attachments. The ACA requires that the Department of Health and Human Services (HHS) adopt an electronic standard and associated operating rules for the claims attachments. Because the information in attachments is mostly clinical in nature, HHS has signaled that the standard, or standards, that will be adopted will align with standards used in the electronic health records (EHR) environment. However, as of the end of 2014, HHS had not formally mandated standards and endorsed operating rules to enable consistent use of those standards, and the industry may be reluctant to make significant changes to current processing methods until those issues are clarified.
- And now I’d like to turn it back to Diane for Q&A session. Diane, do we have any questions? …. If you are interested about how Edifecs provides support for HL7, you can read the solution brief listed on Resource page. HL7 itself has a lot of information available free of charge. HL7 even started a special Payer User Group and those interested of you can join it. Also WEDI provides HL7 reports for its members.