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November 16, 2012

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November 16, 2012

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  1. Automate Blue Button InitiativePayer Content Workgroup MeetingCharter synopsis: the aim of the ABBI Payer Content workgroup is to identify a practical human-readable and machine-readable content standard for Blue Button data, capable of conveying both clinical and non-clinical health data offered by existing payers today, either by Blue Button or in EOB (Explanation of Benefits) documents today. The goal is to arrive at a data & interoperability platform, feasible for payers & PBMs and attractive to developers to innovative apps & to create personally-controlled solutions that target clinical quality, affordability, access and the experience of care itself. November 16, 2012

  2. Meeting Reminders First…THANK YOU workgroup participants for sharing your valuable time & expertise. We are grateful. • Phone on MUTE – not hold • Meeting being recorded • Use WebEx “Chat” to queue questions & comments

  3. Payer Content WG Current Status

  4. Agenda

  5. Emerging Options More Feasible Near-term option balances cCDA compatibility with new data fields and glide path to common payer-provider standard More Useful Consolidated CDA, no financial info Option 1 + Financial Appendix as EDI 835 (either EDI or XML), separate file from CDA Option 1 + Financial Appendix, but map EDI 835 to HL7 C62 standard (like a “Misc.” section of CDA). One file, but could take a long time to map, and more like free form text. Go to HL7 and ask to create another section (like CCD) in CDA specifically for EOBs based on 835 Go to HL7 and ask to create another section with EOB + more (e.g. health savings account balances etc.) Special thanks to Chuck Officer for organizing this list

  6. ABBI Payor WG: Data Fields of Interest 11/9 draft

  7. Clinical Section Templates 11/16 DiscussionRelevant cCDA Sections for potential adaptation?

  8. Consolidated CDA Payer Section Payers Section 48768-6 • …contains data on the patient’s payers, whether a ‘third party’ insurance, self-pay, other payer or guarantor, or some combination of payers, and is used to define which entity is the responsible fiduciary for the financial aspects of a patient’s care. • Each unique instance of a payer and all the pertinent data needed to contact, bill to, and collect from that payer should be included. Authorization information that can be used to define pertinent referral, authorization tracking number, procedure, therapy, intervention, device, or similar authorizations for the patient or provider, or both should be included. At a minimum, the patient’s pertinent current payment sources should be listed. • The sources of payment are represented as a Coverage Activity, which identifies all of the insurance policies or government or other programs that cover some or all of the patient's healthcare expenses. The policies or programs are sequenced by preference. The Coverage Activity has a sequence number that represents the preference order. Each policy or program identifies the covered party with respect to the payer, so that the identifiers can be recorded.

  9. Consolidated CDAPayers Section Example Figure 121: Payers section example <section> <templateId root="2.16.840.1.113883.10.20.22.2.18"/> <!-- ******** Payers section template ******** --> <code code="48768-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Payments"/> <title>Insurance Providers</title> <text> <table border="1" width="100%"> <thead> <tr> <th>Payer name</th> <th>Policy type / Coverage type</th> <th>Policy ID</th> <th>Covered party ID</th> <th>Policy Holder</th> </tr> </thead> <tbody> <tr> <td>Good Health Insurance</td> <td>Extended healthcare / Family</td> <td>Contract Number</td> <td>1138345</td> <td>Patient's Mother</td> </tr> </tbody> </table> </text>

  10. Consolidated CDACoverage Activity Example <act classCode="ACT" moodCode="DEF"> <templateId root="2.16.840.1.113883.10.20.22.4.60"/> <!-- **** Coverage activity template **** --> <id root="1fe2cdd0-7aad-11db-9fe1-0800200c9a66"/> <code code="48768-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Payment sources"/> <statusCode code="completed"/> <entryRelationship typeCode="COMP"> <act classCode="ACT" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.61"/> <!-- **** Policy Activity template **** --> ... </act> </entryRelationship> </act>

  11. Consolidated CDAPolicy Activity Example <act classCode="ACT" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.61"/> <!-- ******** Policy Activity template ******** --> <id root="3e676a50-7aac-11db-9fe1-0800200c9a66"/> <code code="SELF" codeSystemName="HL7RoleClass" codeSystem="2.16.840.1.113883.5.110"> </code> <statusCode code="completed"/> <!-- Insurance Company Information --> <performer typeCode="PRF"> <time/> <assignedEntity> <id root="2.16.840.1.113883.19"/> <code code="PAYOR" codeSystem="2.16.840.1.113883.5.111" codeSystemName="HL7RoleCode"/> <addr use="WP"> <!-- HP is "primary home" from codeSystem 2.16.840.1.113883.5.1119 --> <streetAddressLine>123 Insurance Road</streetAddressLine> <city>Blue Bell</city> <state>MA</state> <postalCode>02368</postalCode> <country>US</country> <!--US is "United States" from ISO 3166-1 Country Codes: 1.0.3166.1--> </addr> <telecom value="tel:(781)555-1515" use="WP"/> <representedOrganization> <name>Good Health Insurance</name> <telecom/> <addr/> </representedOrganization> </assignedEntity> </performer> <!-- Guarantor Information The person responsible for the final bill. --> <performer typeCode="PRF"> <time/> <assignedEntity> <id root="329fcdf0-7ab3-11db-9fe1-0800200c9a66"/> <code code="GUAR" codeSystem="2.16.840.1.113883.5.110" codeSystemName="HL7RoleClass"/> <addr use="HP"> <streetAddressLine>17 Daws Rd.</streetAddressLine> <city>Blue Bell</city> <state>MA</state> <postalCode>02368</postalCode> <country>US</country> </addr> <telecom value="tel:(781)555-1212" use="HP"/> <assignedPerson> <name> <prefix>Mr.</prefix> <given>Adam</given> <given>Frankie</given> <family>Everyman</family> </name> </assignedPerson> </assignedEntity> </performer> CONTINUED ON NEXT SLIDE…

  12. Consolidated CDAPolicy Activity Example CONTINUED FROM PREVIOUS SLIDE… <participant typeCode="COV"> <time> <low nullFlavor="UNK"/> <high nullFlavor="UNK"/> </time> <participantRole classCode="PAT"> <id root="14d4a520-7aae-11db-9fe1-0800200c9a66" extension="1138345"/> <!-- Health plan ID for patient. --> <code code="SELF" codeSystem="2.16.840.1.113883.5.111" displayName="Self"/> <addr use="HP"> <streetAddressLine>17 Daws Rd.</streetAddressLine> <city>Blue Bell</city> <state>MA</state> <postalCode>02368</postalCode> <country>US</country> </addr> <playingEntity> <name> <!-- Name is needed if different than health plan name. --> <prefix>Mr.</prefix> <given>Frank</given> <given>A.</given> <family>Everyman</family> </name> </playingEntity> </participantRole> </participant> <participant typeCode="HLD"> <participantRole> <id extension="1138345" root="2.16.840.1.113883.19"/> <addr use="HP"> <streetAddressLine>17 Daws Rd.</streetAddressLine> <city>Blue Bell</city> <state>MA</state> <postalCode>02368</postalCode> <country>US</country> </addr> </participantRole> </participant> <entryRelationship typeCode="REFR"> <act classCode="ACT" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.1.19"/> <!-- **** Authorization activity template **** --> ... </act> </entryRelationship> ... </entryRelationship> </act>

  13. cCDA Health Insurance Type Value Set (excerpt)

  14. Consolidated CDA Reference (12/11 Draft) http://www.hl7.org/search/viewSearchResult.cfm?search_id=212869&search_result_url=%2Fdocumentcenter%2Fpublic%2Fwg%2Fstructure%2F20111202%5FConsolidation%5FPublication%5FDraft%2Ezip (Now say that three times fast.)

  15. Financial Templates 11/16 Discussioncontinued from 11/9 discussion

  16. Care Management Data Field:Use Interoperability to Drive Patient Engagement? • Often HMOs, insurers & self-insured employers, as well as ACOs, offer health coaching & other wellness benefits free of charge to the beneficiaries. There may even be financial incentives for some of these programs. • Flagging & signalling the existence of these programs to downstream users – patients, doctors, 3rd-party apps – may be critical to driving engagement. • Data fields could resemble payer-type data, simplified • Title of Benefit (plain text) • Eligibility Time Period Begin (date) • Eligibility Time Period End (date) • Description (plain text) • Contact/linkage information (e.g. phone number; URL)

  17. Agenda

  18. Document Integrity & Digital Signatures • It may be important to have a digital “wax seal” for downstream consumers of the data • We have heard from healthcare organizations that the lack of document authentication inhibits them from ingesting & incorporating data • Hashing mechanisms can provide for two key functions • Document Integrity (to ensure it hasn’t been tampered with) • Document Authorship (to verify who created the document)

  19. Document Integrity & Digital SignaturesHashes MD5 = Message Digest 5. 128-bit hash, used for integrity check. SHA1 = NIST developed, FIPS PUB 180-1. Modeled after MD5. 160-bit hash. Greater security. SHA2 = Family of two similar hash functions, with different block sizes: SHA-256 and SHA-512. Also truncated versions of each standardized, known as SHA-224 and SHA-384. Designed by NSA

  20. Document Integrity & Digital SignaturesHashes Proposed Data Fields (optional) • Hash method • Message Authentication Code / Message Digest Can permit flexibility for those seeking only document integrity (e.g. MD5) up to those with secure certificates with digital signatures (e.g. public/private key)

  21. ABBI Workgroup Meetings, Site & Contacts Fridays 1-2p ET: Payor Content Workgroup Meetings Next meeting afterThanksgiving (no meeting 11/23) Wednesdays: All-Hands Community Meetings Web Site with meeting details, materials, discussions and recordings: http://wiki.siframework.org/Automate+Blue+Button+Initiative Contacts: • Initiative Coordinator: Pierce Graham-Jones (pierce.graham-jones@hhs.gov) • Presidential Innovation Fellows: • Henry Wei MD (henry.wei@va.gov) for Payer Content WG • Ryan Panchadsaram (ryan.panchadsaram@hhs.gov) • Project Manager: Jennifer Brush (jennifer.brush@esacinc.com) • S&I Admin: ApurvaDharia (apurva.dharia@esacinc.com) 21

  22. Appendix

  23. Synopsis & Charter from 11/9 Synopsis • The aim of the ABBI Payer Content workgroup is to identify a practical human-readable and machine-readable content standard for Blue Button data, capable of conveying both clinical and non-clinical health data offered by existing payers today, either by Blue Button or in EOB (Explanation of Benefits) documents today. The goal is to arrive at a data & interoperability platform, feasible for payers & PBMs and attractive to developers to innovative apps & to create personally-controlled solutions that target clinical quality, affordability, access and the experience of care itself. In Scope • Leverage existing elements defined by public & private payers • Leverage existing standards if possible e.g. MyMedicare.gov ASCII, X12, HL7, cCDA extension, HealthVault EOB data model • Produce implementation guidance • Payor-generated Health Financial data and Clinical Claims Data • Examples of relevant data : Explanations of Benefit (EOBs) -- with noted concern about proprietary network discounting information 10 Yes 0 No Abstain = 1

  24. Voting Comments & Proposed Mods. (11/9) Eligibility Data • Insurance approval or service provided or both? Financial Data • [We have some concerns about] expansion of the scope to replace EOB's/include financial data. Member Usability • Also, I don't believe we should consider the X12 format. We need to focus on formats that will be usable by members and I don't feel X12 will be useful in member settings.

  25. Clarification: What’s the “Ask”? Proposed standard may be non-binding; probably will not actually require some fields be populated (especially if they are unavailable, e.g. Rx data for some payers). For organizations who do want to supply those fields, though, they will benefit from a common content format – especially to be interoperable with consumer-controlled applications. Example: For Sensitive Network Discount Information, some organizations may choose to share structured & interoperable data about PR (patient responsibility) amount only. Others may share the full set of data already available on the paper-based or PDF-based EOBs (explanations of benefit) sent to the beneficiaries. ASC X12 is being discussed in a non-traditional sense, as an existing standard that contains the typical fields found in payor-generated data. The Use Case is fundamentally different than what X12 is used for today, i.e. consumer-centric data, vs. payer-provider transactions.

  26. Clarification: Dual Aim is related • Generalized Use Cases Human-Readable Machine-Interoperable Payer and PB Based Claims & Rx Databases Front-end Member & Patient Portals Original Claims & Other Data e.g. X12 Payer & PBM Supplied Individual Health Data Consumer-Centric Use Cases (Generalized) Aggregate & Reconcile Apps & Services View Share Human Readability needed Machine Interop. needed

  27. Interoperability allows Payers & PBMS to • Benefit from Shared External Innovation No Interoperability for Consumer-Facing Uses Interoperabilityfor Consumer-Facing Uses A B C D A B C D PCHR* PCHR = Personally-Controlled Health Record, e.g. Microsoft HealthVault App Dev 2 App Dev 1 App Dev 3 App Dev 2 App Dev 1 App Dev 3 Consumer apps face an “n-hard” problem today – number of technical negotiations is exponential (handshakes = n * m, where n = # of suppliers and m = # of developers), in addition to probable HIPAA business associate agreements. SLOW, COMPLICATED, THWARTS INNOVATION. • Patient is in control of their data • Fewer handshakes needed for data • Risk of innovation shifts from data suppliers to developers, in exchange for larger accessible market for any given developer • FASTER, SIMPLER, DRIVES INNOVATION

  28. Health Financial Data: Issues Raised So Far Health Financial Data • Is Financial data in-scope? • Unlike “traditional” clinical health data • Patient advocate organization represented in broader ABBI community meetings have expressed it as a priority, however • Could be a “home run” for the ABBI Community if it enables more affordable care. But if not us, who else will tackle this? • Solutions are out-of-scope; data standards & interoperability in-scope, and pre-requisite for 3rd-parties to create solutions. • How are patients getting it today? • Explanations of Benefit (EOBs)  concern about proprietary network discounting information, may need QH Policy-like stipulations! • Limited electronic access today (mostly PDF and/or “scraping” aggregators like Simplee & Cake Health)

  29. Implications for Healthcare Affordability Comments from Keith Boone • [Patients will not only] be able to track all of their clinical data, but they'll also be able to track costs of particular illnesses. • The apps this content will support will be able link EOB data back to clinical data, so that patients can understand the true cost of a given diagnosis. • Patients could also agree to share the content anonymously to third parties (in exchange for other services using that data).   • Thus, a patient could give access to anonymized data that links services, diagnoses and costs, to particular aggregators.   • The aggregators could agree (similar to the QH Policy Sandbox) to certain stipulations on use of the data, with the patient.  See http://wiki.siframework.org/Query+Health+Policy+Sandbox • The aggregator would then be able to analyze and generate cost information for illness, by provider, payer, policy and region.  Such data could be used to enable patients to obtain: • For a given diagnosis and plan, average costs for services and providers in their region. • For given diagnoses, the expected annual out-of-pocket costs for providers that the patient uses, based on historical data. • The upside for payers is that access to such data across payers will enable them to drive costs downward. Source: “What ABBI can do for Healthcare Cost Transparency”, 9/13/12, http://motorcycleguy.blogspot.com/2012/09/what-abbi-can-for-for-healthcare-cost.html

  30. Implications for Personal Healthcare Quality Claims data-driven analytics focused on Clinical Decision Support & Quality are currently available to large self-insured employers, but not directly to consumers Through analysis of “rough” ICD-9, CPT, and NDC-coded data, these existing organizations can run “n-of-1” quality measures for individual patients & consumers.

  31. Implications for Personal Health Affordability Claims data-driven cost prediction is currently available to insurers & large employers, but not yet directly to consumers Individuals may be able to help predict & budget for their health care spending needs, if they have a level-playing-field & access to the same data used by actuaries & underwriters.

  32. Strawman 1: MyMedicare.gov Blue Button MyMedicare.gov Blue Button Data File Current footprint = ~35 million eligible lives • FIELDS SUPPORTED • Demographics • Name • DOB • Address • Phone • Email • Eligibility • Effective Date(s) • Plan Contract ID(s) • Plan Period(s) • Plan Name(s) • Claims Summary • Claim ID • Provider ID • Service Dates • Financial data by claim • Charged • Approved • Paid • Patient may be billed • Diagnosis Code(s) • NDC Drug Code(s) • CPT Codes • UB04 Codes • NPI Codes • COMMENTS • Include clinical quality data • A Codes – unbilled codes used for quality reporting

  33. Example: Medicare Blue Button Mymedicare.gov 33

  34. Strawman 2: X12 835 : Health Care Claim Payment/Advice X12 835 Version 5010 : required for nearly every insurance transaction • FIELDS SUPPORTED (TRANSACTION SET) • Header Level • Amount • Payee • Payer • Trace number • Payment method • Detail Level • EOB information • Adjudicated claims and services • Summary level • Provider adjustment • COMMENTS

  35. Potential Standards • Standards for sharing claims information with beneficiaries • ASC X12 835 (Electronic Admittance Advice) - Health plan that contains multiple patient information to one provider • NCPDP D.0 telecommunication for pharmacy claims and remittance • ASC X12 837 (Health Care Claim Transaction Set) - File of 837 claims from a healthcare provider will contain multiple claims destined to either one payer or clearinghouse for multiple payers • Claim Submission • Post Adjudicated Claims • No EOB standard identified other than above • Typically a proprietary format exchanged • Minnesota print standard format • Other standards being considered for payer exchange of clinical information • Claims attachment to CCD • Payer data mapping to CCD • PHR to PHR standard being developed by HL7 / WEDI 35

  36. Strawman 3: Create a new CDA EOB template Potential XML template for CDA Implementation Guide • FIELDS SUPPORTED (TRANSACTION SET) • Insurer Information • Payer ID • Name • Policy Info • Patient Info • Identifier • Name • Address • Provider Info • NPI • Identifier • Name • Address • Diagnosis Table • Diagnosis • Service Performed • Date(s) of service • Price billed • Negotiated Price • Amount Paid • Patient Responsibility • Notes • COMMENTS • See http://motorcycleguy.blogspot.com/2012/09/what-abbi-can-for-for-healthcare-cost.html

  37. Generic components of an EOB • Payer’s Name & Address • Provider of services • Dates of service • Services or procedure code numbers • Diagnosis codes and/or Rx codes • Amounts billed by the provider • Reductions or denial codes • Claim control number • Subscriber’s and patient’s name and policy numbers • Analysis of the patient’s total payment responsibility • Amount not covered • Co-payment • Deductibles • Coinsurance • Other insurance payment • Patient’s total responsibility • Total amount paid by the payer

  38. Draft Use Cases as of 10/19 Emerging Blue Button App & Service Categories • Patient education • Care Coordination & PCMH activities & services • Quality-related applications & services for Accountable Care Organizations • Clinical decision-making, for both evidence-based decisions as well as preference-sensitive care • Finding and understanding more affordable care options (e.g. brand vs. generic medication) • Forecasting and planning a personal healthcare budget • Chronic disease management, including personal health tracking (e.g. diabetes) • Medication reconciliation & adherence tools • Integrity (errors, fraud & abuse) detection and assistance services • Patient-provider communication and scheduling (e.g. automatic pre-population of initial visit forms, triage of health issues, and scheduling & transportation support)

  39. Microsoft Healthvault EOB Specification Main Information http://developer.healthvault.com/types/type.aspx?id=356fbba9-e0c9-4f4f-b0d9-4594f2490d2f XML Schema http://developer.healthvault.com/types/schema.aspx?id=356fbba9-e0c9-4f4f-b0d9-4594f2490d2f

  40. HealthVault EOB Specification

  41. HealthVault EOB Specification

  42. 3rd-Party Developer Recommended Financial Data Fields Rationale: • Consistent with info already provided to members in EOBs • Key payment items enable individuals to see past health care spend & budget for future • Aims to lower healthcare costs, protects interest of payors Recommended Fields Paid amount Deductible amount Coinsurance amount Copay amount COB amount Employee member paid Explanatory codes Billed amount Allowed amount

  43. Appendix: WEDI 10/22 Meeting Recap & Feeedback

  44. Draft Scope Presented at WEDI 10/22 Draft Charter for S&I Community Review on the Wiki Identify, define, and harmonize implementation standards, tools and services that facilitate the automated PUSH and automated PULL of patient information via the Blue Button Identify, define and harmonize content structures and specifications for the Blue Button so that information downloaded is machine readable and human readable Identify, define, and harmonize protocols around identification and credentialing, and protocols around access and authorization, that facilitate the automated PUSH and automated PULL of patient information via the Blue Button Presented at WEDI 2012 Fall Conference, Health IT Business & Policy Impact http://www.wedi.org/forms/meeting/MeetingFormPublic/view?id=1C37D00000210 44 #ABBI

  45. Schematic presented at WEDI 10/22Updated 10/26 Container Transport • Content • Capable • Recommended • Required “Automate” “Blue Button” For payors = Standardized EOB, or Standard Claims Info but.. ideally Consolidated CDA + financial data? Contacts:Pierce.Graham-Jones@hhs.gov& Henry.Wei@va.gov

  46. Feedback, Comments & Discussionfrom WEDI Fall Conference 2012 (1/2) Plan-to-Plan PHR Standard is worth looking at, was ASC, developed by BCBS and AHIP. HL7 component was based on CCD. Did not contain financial data though. (commenter) ASC X12 835 satisfies what this needs (commenter) Family History may be an interesting use case (commenter) Timestamping is important. Time, place – design it NOW. Lesson learned from data warehouses, can’t go back and timestamp things. Long-term members are interested in narratives that fit into the narratives of their lives. If you want to portray a narrative, these info points will need underlying structure. (Max ___, commenter) What about making this available/accessible to patients? Need clear messaging – lousy today. E-mail also not a good thing. (commenter) Have you considered Dental Data (Kathryn Jonzzon) Need some way to correct the data (commenter) Maybe could include a VOID list, to actually convey not only the data, but what we knew to be corrected (Henry Wei)

  47. Feedback, Comments & Discussionfrom WEDI Fall Conference 2012 (2/2) Claims data not perfect – but errors were in the data already. Blue Button doesn’t cause those errors – but DOES allows patients & consumers to finally at last see all their data. Still need to allow some 2-way communication & process to handle that error correction (Martin Jensen) When people download their ASCII files today, they start emailing their own PHR around. Potential abuse seems pretty hi; EMR seems more secure (Matt Warner) How many people really use this? Provider & payor % utilization is extremely low, PHR, EHRs, and payor portals do this already. Are we premature? We don’t have standards. We should let the industry work its way out. (commenter; ed. – may need clarification that this is a standard & brand for those PHRs, EHRs & portals) Personal story: my Medicare file had almost all the medical history incorrect, and also received an e-mail from Medicare in the clear with prevent service reminders. Very worried about security, privacy, and encryption. (commenter) Concern that EOB-type data has lower credibility, e.g. EOB has wrong date – couldn’t tell what was included – different name of other doctor who had billed for MD – not sure what it meant, e.g. negotiated rate (commenter) Feel “victimized” by Healthplan with “rule-out” diagnosis codes, as the health plan kept reaching out and contacting for a condition that I didn’t have; drugs were reclassified as COPD disease, and anurse wanted to help manage. Be careful with the data! (commenter)

  48. Appendix: Options Review

  49. Emerging Options as of 10/26As organized by C. Officer (thanks Chuck!) More Feasible More Useful Consolidated CDA, no financial info Option 1 + Financial Appendix as EDI 835 (either EDI or XML), separate file from CDA Option 1 + Financial Appendix, but map EDI 835 to HL7 C62 standard (like a “Misc.” section of CDA). One file, but could take a long time to map, and more like free form text. Go to HL7 and ask to create another section (like CCD) in CDA specifically for EOBs based on 835 Go to HL7 and ask to create another section with EOB + more (e.g. health savings account balances etc.)

  50. Minnesota Uniform EOB Standard Source & Standard: http://www.health.state.mn.us/auc/eobremitmanual2007.pdf Stems from Minnesota HealthCare Administrative Simplification Act (ASA) of 1994 Payers can raise consumer awareness and strengthen customer satisfaction Set of administrative standards and simplified procedures throughout the industry Consistent industry guidelines

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