The Innovation Message group mission is to drive down healthcare costs by reducing the effort needed to implement complex message flows not yet addressed by any standards organization (for example, complex prior authorizations, claim attachments, DME orders, etc.) This group will oversee the development and adaptation of standardized, structured formats, data transport, and digital signature that support high value health care, improved quality, and enhanced efficiency.
XML Metadata Discussion
- This group may leverage the work of the 277/275 formats. The X12 board has been brought into a discussion about putting this information into a semantic XML model. The X12 board requested validation of the business need, which can also serve as the foundation of use case development. An X12-approved schema will encourage payer adoption and assistance in developing use cases.
- Humana is working on information gathering. Semantic XML schema will lend itself to this process, especially since using XML is already in the current processes. In addition, there is already a lot of tracking for this type of information.
- Medinformatix (providing the EMR Perspective on schema vs EDI guide) added that EMRs work with XML very well and that having a standard would determine the internal process to help vendors consume the information programmatically.
Prior Authorization Perspective – Commercial
- Humana; One of the primary struggles when requesting information for a Prior Authorization is the need for “additional information.” The “additional information” tends to determine the next endpoint in the process flow. If the “wrapper” in the semantic XML already has this information, it will save time and helps make sure that information is directed in a clear and transparent way.
- A current proof of concept is focusing on Prior Authorization management and will be studied over a 1-3 month period to determine how the process can be improved.
- There was consensus from other members that a defined “business problem” to serve as a foundation would be universally beneficial.
Prior Authorization Perspective – Medicare/CMS
- CMS has regulates on how quickly a PA must be responded to and this must be taken into consideration throughout program development.
- EMR Participation is increasing. NextGen has expressed interest in the taskforce and other EMRs are joining as well.
- SES is soliciting customer feedback continuously which is feeding both awareness of the taskforce and the implementation work we are doing.
- Through the discussion, the following questions were posed for those the sub-committee workgroups:
- What is a standard definition of “semantic XML” that we will all follow?
- Where is the market?
- What is the cost of implementation?
- What is the most cost efficient way to do this?
- What is the proof of concept?
- To answer these questions, Dan will work with the technical experts in the group to define the semantic XML for everyone to review and three subgroups are being formed:
- Business Subgroup
- Technical Subgroup
- Socialization Subgroup
- Rebecca Elhassid and Lisa Savicki Basham (Humana) will lead the creation of the subgroups and designate group leaders and members.
- Beth Spears (TIBCO)
- Luke Forster (Surescripts)
- Dave Kraft (Country Meadows)
- Luke Ellis (Optimity)
- Luke Hermiston (Optimity)
- Mary Dooley (Alpha II)
- Nathan Apter (Medforce)
- Shawn Wiese (MEDHOST)
- Teresa Autery (TIBCO)
- Tony Laurie (Noridian)
- Troy Aswege (Noridian)
- Vince Albanese (Medscient)
- Kevin Yang (Optimity)
- Karina Badillo (MEDHOST)
- Therasa Bell (Inofile)
- Alan Swenson (kno2)
- Mary Kay McDaniel (Cognosante)
- Rebecca Elhassid (SES)
- Isabella Beaton (SES)
- Cathy Graeff (Sonora Advisory Group)
- Corryn Cawley, Optimity
- Eldermark Software
- Leslie Elsarboukh (Surescripts)
- John Bartley (SES)
- Kevin Yang (Optimity)
- Murali Athurluri (MAEHC)
- Kim Peters (Humana)
- Durwin Day (Health Care Service Corp)
- Lisa Savicki Basham (Humana)
- Rachel Forrester (RFA-EDI)
- Tammy Banks (Optum)
- Dan Kazzaz (SES)