Payer Data Exchange PDex IG A What to

Payer Data Exchange (PDex) IG A “What to Review” Guide Mark Scrimshire (Mark. Scrimshire@onyxhealth. io) 10/20/2020 © 2019 Health Level Seven ® International. Licensed under Creative Commons Attribution 4. 0 International HL 7, Health Level Seven, FHIR and the FHIR flame logo are registered trademarks of Health Level Seven International. Reg. U. S. TM Office.

Tour of the IG • IG – v 0. 1. 25: – Home Page: http: //build. fhir. org/ig/HL 7/davinci-epdx – Latest Changes: http: //build. fhir. org/ig/HL 7/davinci-epdx/index. html#latest-changes • Source (including FHIR Shorthand source): https: //github. com/HL 7/davinci-epdx • Confluence Home Page: https: //confluence. hl 7. org/pages/viewpage. action? page. Id=40738760 © 2019 Health Level Seven ® International. Licensed under Creative Commons Attribution 4. 0 International HL 7, Health Level Seven, FHIR and the FHIR flame logo are registered trademarks of Health Level Seven International. Reg. U. S. TM Office. 2

BACKGROUND © 2019 Health Level Seven ® International. Licensed under Creative Commons Attribution 4. 0 International HL 7, Health Level Seven, FHIR and the FHIR flame logo are registered trademarks of Health Level Seven International. Reg. U. S. TM Office. 3

PDex Evolution • Work on PDex pre-dates the CMS Interoperability Rule • PDex was extended to accommodate: – Consumer-Directed Clinical Data Exchange – Payer-to-Payer Exchange • PDex Plan-Net (Provider Directory) and PDex Formulary were split out from PDex as Open Access APIs • PDex complements the Claims and Encounter Consumer-Directed Exchange provided by the CARIN BB IG • PDex is complementary to US Core (v 3. 1. 1) by adding Payer-specific profiles and workflows to US Core. © 2019 Health Level Seven ® International. Licensed under Creative Commons Attribution 4. 0 International HL 7, Health Level Seven, FHIR and the FHIR flame logo are registered trademarks of Health Level Seven International. Reg. U. S. TM Office. 4

PDex Relationship to Other IGs • Utilizes US Core v 3. 1. 1 for Clinical Content • Refers to Da Vinci Health Record Exchange (HRex) for: – Coverage – $member-Match Operation • References CARIN-BB for CPCDS to identify claims information that may fall into USCDI data categories: – US Core Care. Team, US Core Condition, US Core Encounter, US Core Procedure – HRex Coverage, PDex Medication. Dispense © 2019 Health Level Seven ® International. Licensed under Creative Commons Attribution 4. 0 International HL 7, Health Level Seven, FHIR and the FHIR flame logo are registered trademarks of Health Level Seven International. Reg. U. S. TM Office. 5

WORKFLOWS © 2019 Health Level Seven ® International. Licensed under Creative Commons Attribution 4. 0 International HL 7, Health Level Seven, FHIR and the FHIR flame logo are registered trademarks of Health Level Seven International. Reg. U. S. TM Office. 6

Actors, Methods and Payloads Workflow Initiator Methods Payload CMS Rule Member Info Request Provider CDS Hooks + Smart -on-FHIR US Core + PDex N Member-Directed Consumer App Consumer OAuth 2. 0 / SMART-on-FHIR US Core + PDex Y Member-Authorized Consumer Payer-to-Payer via Payer Exchange $member-match/ OAuth 2. 0 / SMART-on-FHIR US Core + PDex Y © 2019 Health Level Seven ® International. Licensed under Creative Commons Attribution 4. 0 International HL 7, Health Level Seven, FHIR and the FHIR flame logo are registered trademarks of Health Level Seven International. Reg. U. S. TM Office. 7

FHIR RESOURCES © 2019 Health Level Seven ® International. Licensed under Creative Commons Attribution 4. 0 International HL 7, Health Level Seven, FHIR and the FHIR flame logo are registered trademarks of Health Level Seven International. Reg. U. S. TM Office. 8

FHIR Resources and Profiles • An important design principle for PDex was to leverage existing profiles to avoid the same data being profiled multiple different ways – Easing the Implementation Burden • PDex utilizes US Core Profiles wherever practicable • PDex defines profiles when: – US Core Profiles are too restrictive – US Core does not provide the necessary Profile • PDex utilizes Profiles and Operations from Da Vinci HRex: – When a Profile is used across multiple Da Vinci IGs – When a common Operation is used by more than one IG © 2019 Health Level Seven ® International. Licensed under Creative Commons Attribution 4. 0 International HL 7, Health Level Seven, FHIR and the FHIR flame logo are registered trademarks of Health Level Seven International. Reg. U. S. TM Office. 9

PDex. Provenance • Profile agreed with Security Workgroup • Enables Payer to: – Declare their role as “Transmitter” – Identify Source by which data was received declared as Extension – Provide information about Non -FHIR data sources © 2019 Health Level Seven ® International. Licensed under Creative Commons Attribution 4. 0 International HL 7, Health Level Seven, FHIR and the FHIR flame logo are registered trademarks of Health Level Seven International. Reg. U. S. TM Office. 10

Device and Medication Dispense Device • US Core provides Implantable. Device • Payers handle claims for non-implantable devices Medication. Dispense • US Core does not provide a profile to define the dispensing of a medication • Payers typically don’t have visibility to the Medication. Request © 2019 Health Level Seven ® International. Licensed under Creative Commons Attribution 4. 0 International HL 7, Health Level Seven, FHIR and the FHIR flame logo are registered trademarks of Health Level Seven International. Reg. U. S. TM Office. 11

FHIR OPERATIONS © 2019 Health Level Seven ® International. Licensed under Creative Commons Attribution 4. 0 International HL 7, Health Level Seven, FHIR and the FHIR flame logo are registered trademarks of Health Level Seven International. Reg. U. S. TM Office. 12

Core FHIR Technologies (as applicable) • REST • SMART on FHIR • CDS Hooks • Payer-to-Payer Exchange will likely require FAST Endpoint Directory Services to enable Payer Endpoint discovery • Bulk FHIR is not required in STU 1 – It may be considered in future iterations of the IG as Payer requirements are better understood © 2019 Health Level Seven ® International. Licensed under Creative Commons Attribution 4. 0 International HL 7, Health Level Seven, FHIR and the FHIR flame logo are registered trademarks of Health Level Seven International. Reg. U. S. TM Office. 13

THANK YOU! © 2019 Health Level Seven ® International. Licensed under Creative Commons Attribution 4. 0 International HL 7, Health Level Seven, FHIR and the FHIR flame logo are registered trademarks of Health Level Seven International. Reg. U. S. TM Office. 14