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Automate Blue Button Initiative Payer Workgroup Meeting

Automate Blue Button Initiative Payer Workgroup Meeting. October 26, 2012. Meeting Etiquette. From S&I Framework to Participants: Hi everyone: remember to keep your phone on mute . All Panelists. Remember: If you are not speaking, please keep your phone on mute

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Automate Blue Button Initiative Payer Workgroup Meeting

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  1. Automate Blue Button InitiativePayer Workgroup Meeting October 26, 2012

  2. Meeting Etiquette From S&I Framework to Participants: Hi everyone: remember to keep your phone on mute  All Panelists • Remember: If you are not speaking, please keep your phone on mute • Do not put your phone on hold. If you need to take a call, hang up and dial in again when finished with your other call • Hold = Elevator Music = frustrated speakers and participants • This meeting is being recorded • Another reason to keep your phone on mute when not speaking • Use the “Chat” feature for questions, comments and items you would like the moderator or other participants to know. • Send comments to All Panelists so they can be addressed publically in the chat, or discussed in the meeting (as appropriate). 2

  3. Agenda

  4. Announcements and Reminders • Meeting Reminders • Payor Workgroup Meetings are Fridays from 1:00 – 2:00 pm Eastern. • The next Community Meeting will be held on Wednesday, October 31, 2012. • Meeting information is on the Automate Blue Button Wiki Page: http://wiki.siframework.org/Automate+Blue+Button+Initiative 4

  5. Next Steps & Reminders • Follow-up from Last Two Meetings: Homework • Standard that current blue button file is getting pulled from (UHG/OptumHealth example posted) • At least one comment on each straw-man standard so far (esp. re: utility & feasibility)

  6. Payer Content WG Current Status

  7. Agenda

  8. 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 8 #ABBI

  9. 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

  10. 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)

  11. 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)

  12. Agenda

  13. We Need You to VOTE (+/- comment) http://wiki.siframework.org/Payer+Charter+Vote+and+Use+Case+Prioritization Charter Use Case Prioritization

  14. Agenda

  15. Payer Content Standards Options for Blue Button to Review (as of 10/26)

  16. 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.)

  17. Agenda

  18. 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 Contacts:Pierce.Graham-Jones@hhs.gov& Henry.Wei@va.gov

  19. Design Challenge 2012http://healthdesignchallenge.com Visual Design for Consolidated CDA … Can we, the ABBI Payer Workgroup, pave the way to run the same play for payor data, e.g. X12 835-based data?

  20. Proposal:Embedded Machine-Readability Illustrations Self-Displaying CDA http://wiki.hl7.org/index.php?title=Self_Displaying_CDA Examples JSON Blue Button https://github.com/blue-button/smart/blob/master/smart-blue-button.html e.g. Styles and JSON data embedded in single HTML file IHE XDM .zip file http://wiki.ihe.net/index.php?title=Cross-enterprise_Document_Media_Interchange PDF with embedded data http://www.adobepress.com/articles/article.asp?p=1271244 e.g. machine-readable and human-readable – separate but part of whole Email: MIME http://tools.ietf.org/html/rfc1521 Contacts:Pierce.Graham-Jones@hhs.gov& Henry.Wei@va.gov

  21. Reminders / Contact • Meeting Reminders • The next Community Meeting will be held on Wednesday, October 31, 2012. • The next Payor Workgroup Meeting is Friday, November 2, 2012 @ 1:00 pm Eastern. • http://wiki.siframework.org/Automate+Blue+Button+Initiative • For questions, please contact your support leads • Initiative Coordinator: Pierce Graham-Jones (pierce.graham-jones@hhs.gov) • Presidential Innovation Fellows: • Henry Wei, MD (henry.wei@va.gov) for PayorWG • Ryan Panchadsaram (ryan.panchadsaram@hhs.gov); • Project Manager: Jennifer Brush (jennifer.brush@esacinc.com) • S&I Admin: ApurvaDharia (apurva.dharia@esacinc.com)

  22. Appendix

  23. 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)

  24. 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

  25. 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.

  26. 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.

  27. 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

  28. Example: Medicare Blue Button Mymedicare.gov 28

  29. 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

  30. 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 30

  31. 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

  32. 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

  33. 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)

  34. 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

  35. HealthVault EOB Specification

  36. HealthVault EOB Specification

  37. 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

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