understanding clinical data exchange and cda (hl7 201)

Understanding Clinical Data Exchange and HL7 CDAfor Claim and Prior Authorization Attachments

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

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

PopulationHealth

PaymentReform

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 ofstandards.


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

PROVIDERENTERPRISE

Encounter Data

x12 5010 (ICD10)

Quality-Based Incentives

HL7 v2.5 (CCD)

Patient Data Pop Risk


Payer HL7 Use Cases

EnrollmentHealth plans design the process of on-boarding of new members.

Utilization ManagementHealth plans design care pathways using evidence-based medicine to focus on the right amount of patient care – not more or less than required.

ReimbursementAll providers submit claims to a health insurance organization to be reimbursed for care provided.

Care ManagementA 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 ManagementDisease 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.


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

?


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


Electronic Attachmentsfor P&C

P&C: Jopari Solutions - 5 Year Case Study


Electronic Attachments

2005 Health Care Claims Attachments NPRM :ANSI X12N 275 version 4050

HL7 CDA R1 – Additional Information Specification (AIS) Booklethttp://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

http://www.gpo.gov/fdsys/pkg/FR-2005-09-23/pdf/05-18927.pdf

http://www.gpo.gov/fdsys/pkg/FR-2005-09-23/pdf/05-18927.pdf


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 aboutCDA In relation with C-CDA,CCD,CDP1

Demo of Payer and Provider Use cases

Useful Resources

And More……


Question andAnswers

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

http://www.edifecs.com/downloads/Clinical_Health_Level_7_Brief_2014.pdf



http://www.hl7.org/

http://www.hl7.org/

http://www.hl7.org/




http://www.hl7.org/Special/committees/pug/




Next Steps

Coming SoonContactShare

Look for invitations to our next HL7 Educational webinar

Access recorded webinar Questions/more information contact: [email protected] or call 425-452-0620

http://www.edifecs.com/insights/webinars/?utm_source=Organic&utm_medium=slide-share&utm_term=Enrollment-Management&utm_content=Webinar-Recording&utm_campaign=Understanding-Clinical-Data-Exchange-HL7-CDA



http://www.edifecs.com/insights/resources/understanding-clinical-data-exchange-and-cda?utm_source=Organic&utm_medium=slide-share&utm_term=Enrollment-Management&utm_content=Webinar-Recording&utm_campaign=Understanding-Clinical-Data-Exchange-HL7-CDA

http://www.edifecs.com/insights/resources/understanding-clinical-data-exchange-and-cda?utm_source=Organic&utm_medium=slide-share&utm_term=Enrollment-Management&utm_content=Webinar-Recording&utm_campaign=Understanding-Clinical-Data-Exchange-HL7-CDA

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