PCDE Overview and Track Activities FHIR Connectathon 25

PCDE Overview and Track Activities FHIR Connectathon 25 September 9 – 11, 2020 HRex/CDex/PCDE Track PCDE sub-track Co-Leads: Joseph Minieri, MITRE (jminieri@mitre. org) May Terry, MITRE (mayt@mitre. org) 1

PCDE Topics • Overview • FHIR Implementation Guide Walkthrough • PCDE Reference Implementations • Connectathon Activities • Next steps

PCDE Overview

Current Environment • Lack of care transition information between payers as patients move from one payer to another could result in • • • interruptions or delays to existing care for chronic and acute conditions potentially unnecessary change in therapies unnecessary consultation with additional providers schedule additional visits resubmission of additional documentation showing that the care is medically necessary and appropriate. • The overhead process due to the information gap creates a significant burden on providers, add unnecessary costs, and introduces risk to the patient. • Standardization for transition of care member data could help to address this issue.

Payer Coverage Decision Exchange (PCDE) • includes active treatments and services that are tracked or monitored from the member's previous health plan • contains information required to substantiate medical necessity for any treatment • Timeframe as far back as 5 years of covered services from the prior health plan • focus on transition of active care differentiates PCDE from PDex

PCDE FHIR IG Walkthrough

PCDE "Bundle" • The payload is a Coverage Transition Document which contains: • Active Treatments • Treatments • Prior Coverage • Supporting Information • Other Documentation • Supporting and Other Documentation scope • relevant to the active treatments. • up to 5 years prior to the payer transition. Old health plan member New health plan

PCDE Message Exchange Member Discovery (HRex) $member-match (Parameter) (patient, 2 coverage resources of old and new health plan) $member-match response (member. ID used to request data) Data Sharing options Task (Request PCDE Bundle) Old Health Plan Reference Implementation Server Task: w/ updated status (requested, in-progress, completed, failed) Task: (retrieve Bundle if not available) Task: w/ status completed + reference to PCDE Bundle Get PCDE Bundle New Health Plan Reference Implementation Client or Server

PCDE FHIR Profiles • Profiles: • PCDEBundle • PCDEComposition • PCDECare. Plan • PCDE "Care. Plan" is not exactly a clinical care plan by definition. • chosen because of convenience/resuability of certain key attributes: • activity. reference • activity. detail. reason. Code • activity. detail. reason. Reference • flexibility in the Care. Plan is a trade-off needing further guidance

PCDE Supplemental Guide • Further guidance on how to structure clinical and administrative data https: //confluence. hl 7. org/display/DVP/PCDE+Supplemental+Guide

Use Case Scenarios • 1 Complex Persona: Joe Smith • Scenarios considered: • change from brand to generic medication • recommendations in representation of different data sources: • native FHIR resources (e. g. : Medication. Request, Service. Request, Claim, etc. ) • EDI-X 12 • Unstructured document attachments Source: https: //confluence. hl 7. org/display/DVP/Payer+Coverage+Decision+Exchange+Use+Cases

PCDE Reference Implementations

PCDE Reference Implementation New Payer • https: //davinci-pcde-client. logicahealth. org/

PCDE Reference Implementation Old Payer • https: //davinci-pcde-ri. logicahealth. org/

PCDE Connectathon Activities

2020 -09 FHIR Connectathon PCDE Subtrack Scenarios 1. Member Discovery • Member matching $member-match 2. Old Health Plan organically generates a PCDE Bundle • Optional sub-scenario - Example PCDE bundle will be provided if needed. 3. Bundle Requested using Task resource 4. New Health Plan ingests all sections of a PCDE Bundle • Optional sub-scenario

HL 7 Virtual Connectathon (September 2020) Reference Implementations Old Health Plan Member Discovery $membermatch (Parameter) (patient, 2 coverage resources of old and new health plan) $membermatch response Reference Implementation Servers (member. ID used to request data) Data Sharing options Task (Request PCDE Bundle) Task: w/ updated status (requested, in-progress, completed, failed) others? Task: (retrieve Bundle if not available) Task: w/ status completed + reference to PCDE Bundle Get PCDE Bundle New Health Plan Reference Implementation Clients others?

Pressure testing the PCDE Payload • Test of the PCDE supplemental guide • are the guidelines on representing active treatments 1. 2. clinically sound? technical feasible to structurally or semantically represent • Areas of focus • formats for proof of active treatments • FHIR Medication. Request/Service. Requ est/Device. Request • Embedded Base 64 encoded claims and authorizations • Representing health sensitive data with FHIR security-labels (if needed) https: //confluence. hl 7. org/display/DVP/PCDE+Supplemental+Guide

Useful References

Next Steps • Follow-up Sync-up and Feedback sessions • Sept 9: Thursday 2 p ET • Sept 10: Friday at 1 p ET • Solicit feedback • Review PCDE FHIR IG • Try out the PCDE Server (via Postman) • Try out the PCDE client • inspect the content • Feedback and Questions on PCDE Zulip steam • https: //chat. fhir. org/#narrow/stream/179207 -connectathonmgmt/topic/PCDE. 20 Track/near/196671910

References Common References • HRex/CDex/PCDE Track Page: • https: //confluence. hl 7. org/pages/viewpage. acti on? page. Id=86975727 • Zoom/Conference Bridge: TBD • HRex FHIR Implementation Guide • https: //build. fhir. org/ig/HL 7/davinci-ehrx/ • HRex Member-Match Page • http: //build. fhir. org/ig/HL 7/davinciehrx/Operation. Definition-member-match. html • HRex Task Data Request • https: //build. fhir. org/ig/HL 7/davinciehrx/Structure. Definition-hrex-task-datarequest. html PCDE-Specific • PCDE FHIR Implementation Guide (CI Build) • https: //build. fhir. org/ig/HL 7/davinci-pcde/ • PCDE Supplemental Guide • https: //confluence. hl 7. org/display/DVP/PCDE+Supplemental+ Guide • Zulip PCDE Channel • https: //chat. fhir. org/#narrow/stream/179207 -connectathonmgmt/topic/PCDE. 20 Track

Reference Implementations PCDE-Specific • Reference Implementation Server • https: //davinci-pcde-ri. logicahealth. org/fhir/ • Reference Implementation Client • https: //davinci-pcde-client. logicahealth. org/