Existing Wording: Payers want to create a complete clinical record for each of their members to improve care coordination and provide optimum medical care (e.g. reduce redundant care, shift to more proactive/timely care, make better informed, more accurate medical treatment recommendations). They are looking to find new conditions, change in the status of existing conditions (based on HCC model), or predisposition for or risk of developing a condition, i.e. prediabetes.

Comment:

The AMA House of Delegates, a democratic forum representing a diverse group of physicians from more than 170 societies, has adopted official policy (https://policysearch.ama-assn.org/policyfinder/detail/H-315.975?uri=%2FAMADoc%2FHOD.xml-0-2591.xml) recommending that health plan's access to patient data. It is unclear how this use case aligns with the medical profession's policy on data access and use. This proposed use case seems to expand beyond the HIPAA defined use of patient data for treatment, payment, and healthcare operations.

The AMA strongly recommends CDex use cases be scoped to accommodate payment, billing, and "health care operations" defined to include only those activities and functions that are routine and critical for general business operations.

Summary:

This use case expands beyond the health insurer's role as performing payment functions. The AMA recommends that this and other use cases be scoped to accomplish payment, billing and related routine functions rather than medical care decision-making.