HITSP Communicate Referral Authorization Capability Public Review

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HITSP Communicate Referral Authorization
Capability Public Review
Administration and Finance Domain Technical
Committee October 1, 2009
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HITSP Communicate Referral Authorization
Capability Requirements and Design Public Comment

• Introduction
• Schedule
• Review of Capabilities
• Technical Approach
• Public Comment

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HITSP Communicate Referral Authorization
Capability Requirements and Design Public Comment

• Introduction
• Schedule
• Review of Capabilities
• Technical Approach
• Public Comment

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Introduction

• The purpose of this Webinar is to provide a
  high-level overview of a HITSP proposed solution
  for exchanging prior-authorization information
  between a Pay Benefits Manager and a Provider or
  Pharmacy
• Today we will be discussing the requirements
  section of the document. The capability and all
  associated HITSP constructs will be released for
  the traditional 4 week public comment period in
  early November

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Introduction Co-Chairs and Staff
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Healthcare Information Technology Standards
Program (HITSP)

• Providing specifications that integrate diverse
  standards to meet clinical and business needs for
  sharing information
• Develop specifications that address broad
  stakeholder perspectives
• Support testing and validation of specifications
• Catalyze efforts of standards organizations to
  realize changes to address gaps and overlaps
• Enabling Interoperability between healthcare
  stakeholders

Specifying Standards needed to enhance care
quality and contain costs
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HITSP Interoperability Specifications
Type 1 Base or Composite Standards

• A complete IS set provides a
• framework that defines
• A hierarchy of constructs
• The role of each construct
• The relationship of one construct to another in
  the context of specific business and/or clinical
  requirements

Interoperability Specification (construct)
Interoperability Specification (Complete Set)
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• Capabilities and Service Collaborations

Keys to Simpler Definition and Implementation of
HITSP Specifications
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Service Collaboration (SC)

• Defines a standards-based secure infrastructure
  needed for interoperable information exchanges
• Includes a secure transport mechanism with
  topology and other options
• Uses HITSP Constructs to specify the secure
  infrastructure
• Does not specify the content of the information
  exchange but may include information to support
  the exchange (e.g., authorization information)

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• Patient consent Management

• Delivery notification

• Email address/
• distribution list

• Patient Identification

• Topology
• System-to-System
• Portable Media
• System-to-HIE
• HIE-to-HIE

Service Collaboration
Standards-based Secure Infrastructure Needed for
Interoperable Information Exchanges
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Service Collaborations

• SC108 - Access Control
• SC109 - Security Audit
• SC110 - Patient Identification Management
• SC111 - Knowledge and Vocabulary
• SC112 - Healthcare Document Management
• SC113 - Query for Existing Data
• SC114 - Administrative Transport to Health Plan
• SC115 - HL7 Messaging
• SC116 - Emergency Message Distribution Element

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HITSP Capability

• Enables systems to address a business need for
  interoperable information exchange
• Bridges between business, policy and
  implementation views
• Defines a set of information exchanges at a level
  relevant to policy and business decisions
• Supports stakeholder requirements and business
  processes
• Defines information content and secure
  infrastructure
• Specifies use of HITSP constructs sufficiently
  for implementation
• Includes constraints and identifies specific
  network topologies

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What is an example of a capability?
I want to exchange a prescription with an
Ambulatory or Long-Term Care (LTC) Organization

• System Roles
• Medication Order Prescriber
• Medication Order Filler
• Health Plan
• Health Information Exchange (HIE)

• Requirement An organization wants to exchange a
  prescription with an ambulatory organization
• The diagram on the right shows how Capability 117
  was assembled to support this requirement

CAP117 Communicate Ambulatory and Long Term
Care Prescription
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Existing HITSP Capabilities Clinical Operations
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Existing HITSP Capabilities Public Health and
Emergency Response Administration and Finance
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Existing HITSP Capabilities - Security, Privacy,
and Infrastructure
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Capability

• Delivery notification

• Email address/
• distribution list

• Patient consent Management

• Patient Identification

• Topology
• System-to-System
• Portable Media
• System-to-HIE
• HIE-to-HIE

Service Collaboration
Marrying Content Definition with Secure
Infrastructure for a set of Interoperable
information exchanges
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HITSP Communicate Referral Authorization
Capability Requirements and Design Public Comment

• Introduction
• Schedule
• Review of Capabilities
• Technical Approach
• Public Comment

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Schedule

• Requirements for Prior-Authorization introduced
  to the Public via Webinar October 1st
• Comment feedback on the Requirements for this
  work item closes October 8th
• The process for submitting comments is included
  on slide 46 of this presentation
• The Capability with all supporting constructs
  will be released for a 4 week Public Comment
  period in early November

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HITSP Communicate Referral Authorization
Capability Requirements and Design Public Comment

• Introduction
• Schedule
• Review of Capabilities
• Technical Approach
• Public Comment

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Definition of Capabilities

• Capabilities provide the ability for two or more
  systems to address a business need for
  interoperable information exchange
• The objective is to provide the bridge between
  the business, policy and implementation
  disciplines by
• Defining a set of information exchanges at a
  level relevant to policy and business decisions
• Supporting stakeholder requirements and business
  processes by including information content,
  infrastructure, Security, Privacy
• Specifying the use of HITSP constructs
  sufficiently for implementation
• Including constraints and operating on specific
  network topologies (contexts)
• Capabilities have topology and other options
  (e.g., point-to-point, portable media,
  system-to-HIE, HIE-to-HIE)

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What is a capability?
Requirements

• Capabilities are specified using HITSP Constructs
• As part of the HITSP Tiger Team effort addressing
  ARRA, Capabilities are meant to clearly state
  what types of data HITSP can and cannot
  exchange
• During the ARRA Tiger Team effort, no new
  standards were selected, and no new constructs
  were specified to build capabilities

Orchestration of HITSP Constructs and
System Roles
HITSP Constructs
System Roles
Capability
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HITSP Communicate Referral Authorization
Capability Requirements and Design Public Comment

• Introduction
• Schedule
• Review of Capabilities
• Technical Approach
• Public Comment

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Technical Approach of Capability 141

• High level review of the purpose of this
  capability
• Review of the requirements that have been defined

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Purpose of Capability 141

• Addresses interoperability requirements that
  support electronic inquiry and response for
  authorizing a health plan member to be referred
  for service by another provider or to receive a
  type of service or medication under the patients
  health insurance benefits.
• The Capability supports
• Transmittal of a patient and insurance
  identification information
• Identification of the type of service or
  medication requested for benefit coverage
• Communication of authorization number from the
  Payer System
• It provides clinicians and pharmacists with
  information about each patients medical
  insurance coverage and benefits. It may include
  information on referral or authorization
  permission

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Why The Capability Was Developed

• Capability 141 was developed to enable
• Consumers and Providers to request
  prior-authorization for medical related
  encounters and medications
• Payors to respond to such requests
• Payors to provide
• Non-patient specific guidelines for
  prior-authorization
• Patient specific guidelines for
  prior-authorization

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Capability 141 Information Exchanges
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Service Collaborations Included in Capability 114

• Uses HITSP/Service Collaboration 114
• SC 114 contains the Security, Privacy, and
  Infrastructure functionality depicted in the
  table below
• Also includes HITSP/T85 Administrative
  Transport to Health Plan
• T85 uses CAQH Phase II CORE 270 Connectivity
  Rule v2.0.0, which addresses the message envelope
  metadata and envelope standards, submitter
  authentication standards , and communications-leve
  l errors, and acknowledgements

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Information Exchange Options
NOTE As the gaps are evaluated email will be
reconsidered
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Capability 141 Requirements

• Detailed definition of the requirements,
  recommended solutions and identified gaps in the
  solutions may be found in Section 6 of the
  document
• The following slides provide a high-level
  overview of the requirements

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Consumer Requirements
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Consumer Requirements
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Provider Requirements
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Provider Requirements
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Provider Requirements
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Provider Requirements
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Provider Requirements
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Payor Requirements
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Payor Requirements
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Payor Requirements
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Payor Requirements
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Payor Requirements
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Payor Requirements
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Payor Requirements
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HITSP Communicate Referral Authorization
Capability Requirements and Design Public Comment

• Introduction
• Schedule
• Review of Capabilities
• Technical Approach
• Public Comment

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Comment Tracking System

• HITSP.org link http//www.hitsp.org/public_review
  .aspx
• Using the HITSP Comment Tracking System The HITSP
  Comment Tracking System allows registered authors
  to provide comments on documents that are
  undergoing public review or implementation
  testing. A unique user ID and password is
  required for each comment submitter
• Please note that the Comment Tracking System
  closes at 5 PM Pacific Daylight Time on the final
  day of public review, October 8th
• Current HITSP membersSubmit comments by
  following the link above and entering your
  current user ID and password
• New Users Contact Hzander_at_ansi.org for a user
  name and password to access the CTS
• Add CommentRegister a NEW comment in the
  tracking system
• View (My) CommentsView the status or
  disposition of a comment previously submitted
• Please contact Hannah Zander (HZander_at_ansi.org)
  with any questions or problems with entering
  comments

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Questions and Comments

• Comments regarding the Requirements outlined to
  meet the needs of Communicate Referral
  Authorization are welcome during this portion of
  the Webinar
• Comments regarding the complete Capabilities
  documents can be addressed via Comment Tracking
  System (see previous slide for instructions)