Prior Authorization. The Role of HL7 FHIR. Charles Jaffe, MD, PhD CEO, Health Level 7. WEDI Summer Forum Chicago August 1, 2018

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1 Prior Authorization The Role of HL7 FHIR Charles Jaffe, MD, PhD CEO, Health Level 7 WEDI Summer Forum Chicago August 1, 2018

2 Guiding Principle How much easier it is to be critical than to be correct. - Benjamin Disraeli

3 Coronary Care Unit: EKG Rhythm Strip

4 I don t know is a satisfactory answer

5 Some thoughts on Prior Authorization Why am I here? HL7 FHIR Update: Is it really 8 years old? Prior prior authorization The Da Vinci Project: the reality & the promise Collaboration: my notion of what success might look like

6 One reason I m here 2 decades ago the Institute of Medicine published To Err is Human and we haven t gotten much better since then.

7 This is Jack s story

8 This is Jack Honor student Football hero College-bound

9 Jack complained to his Family Doctor about knee pain.

10 This is what Jack s knee looked like, but his doctor never saw the report.

11 This is Jack s chest x-ray after I first saw him.

12 The Pathology Report said metastatic osteosarcoma

13 Medical Errors are third leading cause of death in the United States

14 There should be no more stories like Jack s

15 The other reason I m here Patients & Clinicians deserve a much better solution for approving care.

16 21 st Century Cures Act: Reduce Clinician Burden Source: Humikowski, CA, JAMA, 320 (4):343-4, 2018

17 Fast Healthcare Interoperability Resources

18 A little compromise: FHIR for non-engineers in 3 minutes

19 The principles underlying FHIR development are meant to address the challenges learned in 30 years of standards development.

20 Fresh Look asked, What would interoperability look like if only we could start over? And not throw out the good stuff we learned along the way.

21 My coach said that I kick like a girl. I told him that if he tried harder, he could too. Mia Hamm

22 FHIR enables an evolutionary development path with other HL7 standards* * Many are embedded in Federal regulation

23 FHIR focuses on implementation* * and implementers

24 FHIR development is global* FHIR development workshops in UK, Canada, Australia, Netherlands, Argentina, and Japan as of Monday.

25 FHIR is licensed through Creative Commons without fees or royalties FHIR is Free

26 You can accomplish anything in life, if you don t mind who gets the credit. Harry Truman

27 What makes FHIR fast? Faster to learn Faster to develop Faster to implement

28 u The FHIR Development Process has created a Maturity Model that describes global implementation and validates reliability

29 Resource Maturity FMM1 Validated FMM2 Tested at approved Connectathon FMM3 Successfully balloted FMM4 Prototype implementation published FMM5 5 distinct production implementations, in 2 or more countries

30 Perfection is achieved, not when there is nothing more to add, but when there is nothing left to take away. Antoine de Saint-Exupery

31 Business Case for HL7 FHIR Faster to learn, to develop, to implement Based upon modern internet technology Supports REST & Service Oriented Architecture Human readable Supported by large implementation libraries Developed and implemented around the world Readily integrates with existing standards FHIR is FREE!

32 FHIR in a nutshell FHIR is both the technology and the agreement on the meaning of the data.

33 REST: The Essence of FHIR REpresentational STate Google, Twitter, Facebook Your favorite travel site

34 APIs Explained Your favorite travel site AnyAirplaneFlight.com Courtesy: Russ Leftwich, MD

35 FHIR Supports 4 Interoperability Paradigms RESTful Documents Messages Services

36 FHIR Profiles Profiles describe adaptations based on use & content Resources used API features required Terminologies employed Mappings to local requirements

37 FHIR Extensions Satisfy exceptions to 80/20 Rule Follow ISO definitions Do not break interoperability Support local requirements Reusable! hi

38 FHIR Implementation Guide* Scope of usage Implementation requirements Relevant FHIR artifacts (profiles) Usage Conformance validation *Computable!

39 FHIR Profiles & Implementation Guides

40 HL7 FHIR Foundation Registry

41 HL7 FHIR is more than technology. HL7 FHIR is about Community.

42 The HL7 FHIR Community of Implementers

43 Thanks Bulk Data on FHIR The technology & policy for exchanging records from an unlimited number of patients or study subjects Developed cooperatively with Boston Children s Hospital / Harvard Supports data analytics for population health, value-based care, clinical trial design and pharmaco-vigilance.

44 HL7 FHIRcast Application Context Synchronization Extends the SMART on FHIR Launch protocol Web-based approach to legacy HL7 CCOW* * Clinical Context Object Workgroup

45 What s Next for HL7 FHIR? CDS Hooks Implementation Guide FHIR Certification Inter-version Support Bulk data Support New content (New Resources) FHIR Foundation services R4 Normative Release

46 FHIR took more than a good idea.

47 Argonaut Project A private-sector initiative established in 2014 to accelerate FHIR implementation. Now serves as the bridge for Carequality & commonwell Argonaut implementation guides are utilized around the world for localization & international data exchange

48 Apple ios 11.3 & beyond supports EHR data based upon the Argonaut Project Implementation Guide

49 Solving the Prior Authorization Conundrum takes a community

50 50 Prior Authorization: History is Preamble Prior Authorization: one of the original HIPAA transactions X12N 278 (Health Care Services Review, Request & Response) standard adopted under HIPAA for electronic prior authorization. 2003: Version 4010 (e) adopted via CMS HIPAA regulations 2012: Version 5010 adopted

51 51 Prior Authorization: The list of challenges is a long one Variations in medical and pharmacy benefits result in different prior-authorization rules by different payers, which are cumbersome, require inconsistent workflow processes, and require submission of inconsistent, additional information through manual processes.

52 52 Prior Authorization: Limited adoption is a major challenge In today s practice, the use of the required electronic standard transaction for prior authorizations is very limited, reported to be less than 10-15% in most user surveys.

53 53 Prior Authorization: eprior Authorization hasn t helped Alternative methods for achieving eprior Authorization include health plans web portals (predominant venue), Interactive Voice Communication (IVR), Phone calls, & faxes.

54 54 Prior Authorization: NCVHS weighs in ( ) Confirmed its low use due to complexity of the standard, cost, ease of alternatives. Confirmed that Prior Authorizations continue to be required extensively for multiple purposes. Recommended CMS consider withdrawing the requirement to use the current standard until the issues with it have been addressed

55 55 Prior Authorization: The cost of waiting for the next standard Version 7030 is not expected at the earliest (after completion of X12N review process) NCVHS to recommend to CMS adopt 7030 CMS accepted the recommendations and issued proposed rules, public comment, final rule issuance, and expected 2-year compliance timeline.

56 56 Prior Authorization: Concurrent initiatives WEDI Prior Authorization Initiative. X12N: Finalizing 7030 public review of 278 X12N: Innovations Task Force CMS: Incorporating simplification of the electronic Prior Authorization into the Reducing Clinician Burden initiative CORE: Developing Phase IV Operating Rules, including Prior Authorization HL7: Developing a FHIR Implementation Guide for Coverage Requirements Discovery, which will support both Da Vinci project as well as CMS Burden Reduction effort

57 Addressing Prior Authorization Conundrum at HL7

58 Da Vinci Project Advancing Value-Based Care by leveraging FHIR for the capture of granular clinical data from patient records to improve quality, to reduce costs, and to enhance care management

59 Da Vinci Founding Members 10 Payers 3 9 Use 4 HIT Vendors EHRs Cases ½ Dozen Providers Working with Founders to Identify Initial Sites by Use Case

60 Dirty Dozen & CMS CMS announced its participation and funding to support the Coverage use cases and to expose authorization rules. CMS participation provides a unique opportunity to capture required documentation for requests within the clinical workflow.

61 2018 Use Case Inventory & Project Deliverables 30 Day Medication Reconciliation* ehealth Record Exchange: HEDIS/Stars & Clinician Exchange Coverage Requirements Discovery* Notification (ADT): Transitions in Care, ER Admit/Discharge Documentation Templates and Coverage Rules* Risk Based Contract Member Identification 2018 Project Deliverables Define requirements (technical, business & testing) Create Implementation Guides Create and test Reference Implementations Prior Authorization Quality Measure Reporting Laboratory Results Pilot the solutions Deploy the solutions 61 * Initial use cases

62 ONC P2 FHIR Task Force Project A group of payers, standards developers, and healthcare organizations collaborating on the development of a FHIR API to reduce variability in industry implementation +Task+Force+Home

63 Relationship Between Da Vinci & P2 FHIR Task Force Using FHIR to Solve Payer-Provider and Provider-Provider Interoperability Problems Solve VBC Exchange HL7 Da Vinci Define solutions for Value Based Care (VBC) use cases Convener Stakeholder Participants Scope Scale the Solution ONC P2 FHIR Task Force Establish FHIR ecosystems standards and best practice to allow solutions to scale nationally Start with a VBC use case Define the requirements (business, technical) Create implementation guide and reference implementations Pilot the solution Identity management Security & authentication API discovery Scaling solutions Content identification & Routing Testing and certification

64 Da Vinci and P2 FHIR Task Force Payer, Provider and HIT vendors Using FHIR to Solve Payer-Provider and Provider-Provider Interoperability Problems Payers/Providers HIT Solutions P2 FHIR Task Force Scale Solutions Nationally How can a payer scale this to 30,000 providers serving 3 million members Providers Da Vinci Solutions to VBC Use Cases How can a payer request and receive a response from a provider regarding 30-day medication reconciliation HIT Solutions

65 FHIR Supported Prior-Authorization Environment Providers Request Medical Records Hospital EHR API Electronic Transactions Payer API API API Out- Patient Care EHR API ASC X12N 278 (PA request) /275 (attachment with CDA) FHIR based exchange

66 Thanks Quo Vadis HL7 FHIR?

67 Health Agency Collaboration US Federal agencies, including FDA, CDC, NIH, DoD, VAH, and others actively collaborate on FHIR integration programs

68 Thanks VA Lighthouse API Gateway API gateway platform enabling developers to build mobile and web Apps for both providers and patients

69 CDC is developing initiatives to leverage FHIR for reporting & analytics

70 The openfda Initiative has developed a library of open APIs to allow fluid access of research data to a broad community of investigators

71 Thanks The fundamental character of HL7 FHIR Community of Implementers is Collaboration

72 Collaboration IHE-HL7 Collaboration Shows at FHIR DevDays Source: IHE News, July 31, 2018

73 A Final Thought Every great scientific truth goes through three stages. First, people say it conflicts with the Bible. Next they say it has been discovered before. Lastly they say they always believed it. Louis Agassiz 19 th Century American Zoologist

74 My sincerest thanks to Viet Nguyen, MD Jocelyn Keegan Walter Suarez, MD Russ Leftwich, MD

75 Thanks Thanks