BlueButton+Plus+-+Payer+WG+Project+Charter+2012+Archived

include component="page" wikiName="siframework" page="ABBI Header" =(Archive 2012, Previous Version of) Payer Workgroup - Charter (Synopsis & Scope)=  =Dashboard=
 * __**Phase**__ || __**Status**__ || __**Subworkgroup Task(s) & Deliverables**__ ||
 * **Pre-Discovery**
 * (October)** || Done || Create synopsis, post for comment & feedback ||
 * || Done || Create charter, challenge, stakeholder ID, timelines & milestones ||
 * || Done || Define goals & outcomes ||
 * **Discovery**
 * (November)** || Done || Use Cases & Stories, functional requirements ||
 * || Done || Identify interoperability gaps, barriers, obstacles, costs ||
 * || Done || Identify alternative approaches, feasibility tests & prototypes ||
 * || Done || Identify existing standards, models, artifacts for harmonization ||
 * **Implementation**
 * (December**
 * to January)** || Done || Developer/Identify Harmonized Specification ||
 * || Done || Relevant documentation, e.g. Implementation Guides, Design Documents ||
 * || Done || Revise Harmonized Specification & "SDK" Documentation ||

Synopsis
The aim of the ABBI Payer Content workgroup is to identify a practical human-readable and machine-readable content standard for Blue Button data, capable of conveying __both clinical and non-clinical health data__ offered by existing payers today, either by Blue Button or in EOB (Explanation of Benefits) documents today. **The goal is to arrive at a data & interoperability platform, feasible for payers & PBMs and attractive to developers to innovative apps & to create personally-controlled solutions that target clinical quality, affordability, access and the experience of care itself.**

In Scope

 * Leverage existing elements defined by public & private payers
 * Leverage existing standards if possible e.g. MyMedicare.gov ASCII, X12, HL7, cCDA extension, HealthVault EOB data model
 * Produce implementation guidance
 * Financial data
 * Will not include self-reported or unstructured data for the current standards exercise in this version
 * Will not include solutions themselves, but standards should be able to support critical categories of use cases

Requirements
1. File content standard must allow for common data elements in payor & PBM-generated Blue Button ASCII files today, e.g. those generated by MyMedicare.gov. Elements that the standard should support include:
 * Eligibility Dates
 * Provider Identifiers
 * Diagnosis Codes
 * Procedure Codes
 * Rx Codes
 * Financial Information related to transactions/encounters (e.g. billed, allowed, paid & patient-responsible amounts)

Example Use Cases (not a complete list)

 * 1) Patient education
 * 2) Care Coordination & PCMH activities & services
 * 3) Quality-related applications & services for Accountable Care Organizations
 * 4) Patient-centered clinical decision-making
 * 5) Evidence-based medicine & clinical decision support
 * 6) Preference-sensitive care decision support
 * 7) Finding and understanding more affordable care options (e.g. brand vs. generic medication)
 * 8) Forecasting and planning a personal healthcare budget
 * 9) Chronic disease management, including personal health tracking (e.g. diabetes)
 * 10) Medication reconciliation & adherence tools
 * 11) Integrity (errors, fraud & abuse) detection and assistance services
 * 12) Patient-provider communication and scheduling (e.g. automatic pre-population of initial visit forms, triage of health issues, and scheduling & transportation support)

Example User Story
As a health care consumer and health plan member, I want to be able to download or transmit my health data from my insurer to downstream health applications. I want to do so in order to better-understand my clinical and health financial information, as well as have a record of my past health events and transactions, including the providers associated with my care. I want to be able to use my health data with my choice of 3rd party applications, ideally in an automated manner with fewer repeated authentication steps, but at basic level a download available from a patient/member portal in a format that can be loaded into downstream applications. I also want to be able to do this to be able to reliable transfer my health data from my data holder (in this case the health plan) to another entity (e.g. myself, a personally-controlled health record, an application or service, or another plan or provider) without having to re-enter the information manually.

In the case of download, I log in to my health plan's member portal first. I then indicate that I would like to download my interoperable Blue Button file by clicking on a button either directly on the Blue Button icon (as shown at healthit.gov/BlueButton) and specifying the format in which I'd like to receive it (e.g. XML). I also want to be aware of the limitations of the data that is being provided, in comparison to other types of health data (e.g. with a model disclaimer about payment-related information vs. clinical chart data).

In the case of transmit via PUSH method, I log into my health plan's member portal, and indicate that I would like the interoperable Blue Button data sent to a given DIRECT address, in order for me to control the transmission of my health data from my health plan to a provider.

In the case of transmit via PULL method, I log into my health plan's member portal where I establish authentication credentials. Then in the health application which is requesting access to my health data, I am able to authenticate myself to that application and it is thenceforth able to access my data automatically from the data holder on my behalf. I do this with the goal making it more convenient and reliable for me to use another downstream application to help me store, understand, and/or connect my health data with other functions. =Straw Man Options=

1. MyMedicare.gov Blue Button file standard (2011-2012)
Sample Blue Button File from CMS Medicare @http://www.cms.gov/Research-Statistics-Data-and-Systems/Files-for-Order/NonIdentifiableDataFiles/BlueButtonInitiative.html

//**6. FHIR (Fast Healthcare Interoperability Resources)**//
//**HL7 Specification & Web Site for FHIR:**// www.fhir.org (http://www.hl7.org/implement/standards/fhir/)

//**FHIR Webinar: References & Additional Answers**// @http://www.healthintersections.com.au/?p=1281


 * PDF version (**How to use FHIR for Automated Blue Button Initiative)**:**

//**7. OMX - Open Medical Exchange (Intuit & Ingenix/UnitedHealth standard)**//
//**(pending feedback from Intuit & UnitedHealth)**// //Legacy description (PDF File): // =Other Documents and References= Examples of codes used in an actual Medicare Blue Button Record Example of API provider for X12 270/271 Eligibility Transactions (Eligible API, eligibleAPI.com) [external link] 2012 Wright et al. Preventive Care reminders / PHR study with outcomes showing improved preventive care behavior

Consumer Survey from United Health Group
Following are the summary findings of UnitedHealth Group's consumer-centric survey of what financial information people find valuable to them. Sample size of survey = >1,000 respondents. (thanks to Patrick Sauer for providing)

Consumers do have a desire to manage finances directly related to healthcare, such as:
 * Consumers do see a need to manage information about finances that are directly related to healthcare.**
 * HSAs;
 * Deductibles; co-pays, other/supplemental insurance and
 * Out-of-pocket health expenses

Combining health and financial information was a disconnect for participants in this research. In the minds of the people we spoke to, health information and financial information are separate issues.
 * Consumers do not make a direct connection between their needs for health information and their long-term finances.**
 * People have no desire to include longer-term financial vehicles, such as their 401(k), IRAs or stock portfolios, in a dashboard they use for health.

=Best Practice Disclaimer from Humana and Common Boilerplate Payer Disclaimer for Blue Button= The intent of this disclaimer is to help Blue Button file recipients understand that the health data provided through insurance claims information is a bit different from that they might find in doctor's charts. Namely, that it's used for payment purposes, and not necessarily complete, and may even contain errors.

Information provided through the CareProfile includes only information submitted to participating insurance companies for payment purposes. The information is not a medical report, nor is it intended to be a complete record of a patient's health information. Certain information may have been intentionally excluded (due to its sensitivity-psychiatric, substance abuse, HIV/AIDS, sexually transmitted diseases, and abortion related data) and the health record may also contain errors. Physicians must use their professional judgment to verify this information and should not exclusively rely on this information to treat their patients.
 * Original (2012):**

Information provided through the Blue Button by your health or pharmacy plan includes only information submitted to participating insurance companies for payment purposes. The information is not a medical report, nor is it intended to be a complete record of a patient's health information. Certain information may have been intentionally excluded (due to its sensitivity-psychiatric, substance abuse, HIV/AIDS, sexually transmitted diseases, and abortion related data) and the health record may also contain errors. Physicians must use their professional judgment to verify this information and should not exclusively rely on this information to treat their patients.
 * Adapted (2013):**

=Sample Lists of ICD-9 Codes to Filter for Allergies and Immunizations / Vaccinations= This embedded draft Excel workbook document contains several spreadsheets, including illustrative code lists for potential mapping to CDA. It is based on the Transitions of Care S&I work showing data portability document alignment. This workbook includes includes: 1. Chart showing alignment of payer Blue Button data elements to CCD template sections in consolidated CDA. 2. A sample list of selected ICD-9 codes for Allergies, for health plans that would like to fit specific ICD-9 coded data to the Allergies sections of consolidated CDA. 3. A sample list of selected ICD-9 and CPT codes for Immunizations / Vaccinations, for health plans that would like to fit specific ICD-9 & CPT coded data to the Immunization & Vaccinations sections of consolidated CDA. These are based on three main resources:
 * http://www.cdc.gov/vaccines/programs/iis/code-sets.html ||
 * http://www.aafp.org/online/en/home/practicemgt/codingresources/immunizations/ndcclaims.html ||
 * http://www.cms.gov/medicare-coverage-database/staticpages/icd-9-code-lookup.aspx ||



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