Existing Wording: Use Case Description

Payers need to create complete, accurate risk profiles for members to support value-based care contracts and population health adjustments, or to confirm the accuracy of a claim. They gather information for this purpose on an annual contracting basis, on a monthly basis, and update it as new claims are paid. Risk adjustments are submitted to CMS annually, but receiving this information after each visit would make it more useful. The information can come from any provider (a visit at a time), but typically from outpatient providers and usually from network providers. Data needs to come from the Provider of Record, not from an aggregation created by an HIE. Medical records, a progress note or visit summary would be useful. C-CDAs of various types would be ideal when they include patient demographic data as well as Problems, Medications, lab results, Assessment for Diagnoses, vital signs (BP), and Narrative (clinical notes).

Use Case Description?

Payers need to create complete, accurate risk profiles for members to support value-based care contracts and population health adjustments, or to confirm the accuracy of a claim. They gather information for this purpose on an annual contracting basis, on a monthly basis, and update it as new claims are paid. Risk adjustments are submitted to CMS annually, but receiving this information after each visit would make it more useful. The information can come from any provider (a visit at a time), but typically from outpatient providers and usually from network providers. Data needs to come from the Provider of Record, not from an aggregation created by an HIE. Medical records, a progress note or visit summary would be useful. C-CDAs of various types would be ideal when they include patient demographic data as well as Problems, Medications, lab results, Assessment for Diagnoses, vital signs (BP), and Narrative (clinical notes).

Comment:

Same comment#2 as above: While increasing the authorized flow of information among providers and payers is critical for improving care coordination and efficacy, retaining the trust of patients that these flows will adhere to applicable laws is equally important.

Recipients of information under HIPAA Operations must not be mislead into thinking that this information is intended for treatment purposes.

Even with thorough Provenance Records for this information, providers should be cautioned about relying on this information for clinical purposes.

For this reason, please include information about how HL7 security labels for purposes of use can be used by implementers to ensure that senders and receivers are able to comply with applicable policies.

Summary:

While increasing the authorized flow of information among providers and payers is critical for improving care coordination and efficacy, retaining the trust of patients that these flows will adhere to applicable laws is equally important.