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.
Use Case Focus (Dan Kazzaz)
Based on input from the working groups, our initial use case to focus on will be prior authorization for ambulatory services.
Prior Authorization for ePrescribing Today (Luke Forster)
Surescripts demonstrated a sample flow for prior authorization to be sent from the EHR, auto-populating fields from the EHR and the National Patient Index. When writing a prescription, prescriber can see that it requires prior authorization. The prescriber then utilizes the available information to submit the request. In 68% of requests, a questionnaire is returned to the provider in real time to prompt the provider to submit only the necessary information. Some EHRs have fully implemented this process, while other pop it up in an iframe or redirect users.
Question about supporting documentation: In terms of additional documentation, the NCPDP standard does support the exchange of six attachment types (CCD, ping, pdf, jpeg, etc) and if the PDM wants to request a CCD for additional information they can. However, the PDMs did not want to support the prescriber sending the CCD with all the information and preferred that they have control over the questions and the answer structure.
Question about additional standard use: What about Q/A, FHIR calls, CCD parsing, etc? Is there is the capability to send and attach additional documentation as needed? (Answer) In the Surescripts case, the PDM is sending the request for the exact information needed from the EHR and the EHR provides that. PDMs are updating the NCPDP Formulary and Benefit Standard Data on a regular basis so the EHRs like Epic are able to download the updated standard data on a regular basis.
Additional information: At times, the prescribers may know that a prescription requires a prior authorization even if the system is not triggering the mechanism, in which case they can send an ePA request. Appeals go through the same mechanism as requests and providers can respond rejections with an appeal in real time.
Comment: NCPDP is also working on a new standard that will also be used in real time for a decision on the patient’s benefits; using XML and EDI
Proof of Concept Status Update (Kim Peters)
Humana is working to figure how to enhance the referral process to get the information from the medical event. When a request is submitted to Humana, there is a need to recognize what additional information is needed. They are looking to use SES Direct to initiate responses (using Direct to automate). With Athena, they are working to set up a specific hospital/group to define what the referral process should look like for the pilot. The idea is to retrieve information from the physician, view it, and automate a response (allowing for back and forth if needed.) Humana is already using SES Direct to send information to providers but Humana is looking at how to bring information in. They hope to have a proof of concept with Athena in the next two months
Question: Is what you’re using Direct limited to one type of event?
Answer (from Humana): No, we are using Direct to automate processes regardless of type of event and looking to reduce cost of using faxes and phone calls.
Question: How are you addressing signatures?
Answer: We are starting with a proof of concept for sending/receiving the information first before expanding to the other use cases.
Answer from SES: In all SES Direct implementations, individual certificates are assigned to accounts and to individual users. This signing mechanism is in place today for all SES Direct workflows.
Market Education Update (Kevin Yang)
Interviews are ongoing with the sub-workgroups, as well as consolidating the information to help build the use cases; the conversations have been very good in discussing real world pilots. Once we get more info from the pilots, we can use them as case studies. A lot of the framing and data for the white paper is complete, including the end-to-end workflow for the integrated solution. Kevin is interested to see where the pilots fit into that model and what issues they are tackling with which standards. The marketing team is also working on a journey map to show the progress on all fronts.
• Continue to develop and track live uses cases
• Sub-work groups focusing on meta-data development and market education
• Diagrams development for adoption
Taskforce members will talking to different larger EMR vendors (such as Epic) as well as payers to work on ideas for auto evaluating information and what steps are needed.
• Beth Spears (TIBCO)
• Cathy Graeff (Sonora Advisory Group)
• Luke Forster (Surescripts)
• Dave Kraft (Country Meadows)
• Durwin Day (Health Care Service Corp)
• Leslie Elsarboukh (Surescripts)
• Kim Peters (Humana)
• Lisa Savicki Basham (Humana)
• 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)
• Rachel Forrester (RFA-EDI)
• Tammy Banks (Optum)
• Vince Albanese (Medscient)
• Dan Kazzaz (SES)
• Isabella Beaton (SES)
• Kevin Yang (Optimity)
• Karina Badillo (MEDHOST)
• Therasa Bell (Inofile)
• Murali Athurluri (MAEHC)
• Alan Swenson (kno2)
• Mary Kay McDaniel (Cognosante)
• John Bartley (SES)
• Jeff Salmon (SES)