january 30 , 2013

electronic submission of Medical Documentation (esMD)

electronic Determination of Coverage (eDoC) Workgroup

Charter Review

January 30, 2013

Welcome and IntroductionsMELANIE COMBS-DYER, RN

Deputy Director,

CMS / OFM / Provider Compliance Group

DAN KALWA

Health Insurance Specialist,


ROBERT DIETERLE,

Initiative CoordinatorVIET NGUYEN, MD

Chief Medical Information Officer

Systems Made Simple, Inc.MARK D PILLEY, MD AAFP, AADEP, ABQAURP

Medical Director

StrategicHealthSolutions, LLC

MICHAEL HANDRIGAN, MD

Medical Officer


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Agenda

Clarification of Scope

Phase 1 Scope

Phase 2 Scope

Workgroup Charter

Timeline

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Underlying Challenge:• Enable provider capture of documentation and benefit determination based on

payer rules• Secure exchange of templates, decision support, and documentation between

payers, providers, service suppliers and beneficiary

Scope:• Focus on defining the use case, user stories and requirements supporting a standards-

based architecture• Reuse of existing S&I Initiative efforts where possible• Creation of structured data capture templates and supporting exchange standards• Power Mobility Device as initial Use Case

Outcome:• Successful pilot of templates, decision support, information exchange standards over

standard secure transactions for the purpose of determining coverage • Validation with initial use case for Power Mobility Device

Electronic Determination of Coverage (eDoC)

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eDoC General Workflow

Payer

Patient

LCMPSpecialist /Service Provider

Physician

Templates and Rules

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ScopeIn Scope – Phase 1• Structured and unstructured

data requirements• Exchange standards • Digital signature requirements

In Scope – Phase 2• Templates for Structured Data

Capture (SDC)• Decision Support (rules, data

capture, order sentences and behaviors) (HeD)

Out of Scope• Specific provider service

implementations• EHR implementations• Provision of Information exchange

services (e.g. HISPs for Direct)

eDoC PMD Workflow

Payer

Patient

LCMP

DME SupplierPhysician

1

5

4

3

2

6

78

Payer

Templates and Rules

10b10a9a

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9b

10c

Signed Document

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eDoC Workgroup Structure

Sub-Workgroups

Structured Data• Determine documentation

requirements• Evaluate appropriate

clinical elements• Clinical Vocabularies• Define CCDA template

Documentation Templates• Define template requirements• Define template workflow• Define EHR data capture

requirements• Specify storage requirements

Decision Support• Define rules to guide

documentation• Define rules to present

covered alternatives• Determine workflow

issues

eDoC Workgroup

Charter Use Case Harmonization Pilots

Consolidated CDA Structured Data Capture Health eDecision

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Structured Information for PMD

• Based on clinical template developed by CMS• Available at http://

www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/ESMD/Downloads/Suggested-PMD-Electronic-Clinical-Template-v98-posted-11-02-12.pdf

• Supports• Data collection by providers during face-to-face evaluation• Reporting of clinical information for coverage

determination• Clinical decision support and automated determination of

coverage

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http://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/ESMD/Downloads/Suggested-PMD-Electronic-Clinical-Template-v98-posted-11-02-12.pdf





Components of PMD Clinical Template

• Chief Complaint• History of Present Illness• Past Medical History• Review of Systems• Physical Exam• Patient Assessment and Plan• Physician Information and 7 Element Order

Components focused on data to support a PMD order and coverage

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Evaluation Process for PMD Clinical Template

• Examination of individual clinical elements for each section of the template

• Determine if a clinical element is codifiable (e.g. Diagnosis), requires a narrative (e.g. History of Present Illness), or is mixed (e.g. Review of Systems)

• Compare coded elements to existing standard coding systems (e.g. SNOMED-CT, ICD) and CDA components

• Develop Templated CDA based on consensus and best practices

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Sub-Workgroups









issues

eDoC Workgroup



12

Structured Data Capture (SDC)

SDC Standards


Sub-Workgroups









issues

eDoC Workgroup



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Clinical Decision Support

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Sub Workgroup PMD Structured Data

PMD Phase 1Implementation Guide

Use Case #1: PMD Phase 1PMD Phase 1Pilots (TBD)

Pre-DiscoveryWorkgroup

Charter/Scope

Kick-Off

Mar ‘13 May ‘ 13 July ‘13Feb ‘13 Apr ‘13 Jun ‘13 Aug ‘13

Standards/Data Model/Harmonization

Sub Workgroup PMD Data Capture Template

Sub Workgroup PMD Decision Support

PMD Phase 2Implementation

Guide Use Case #1: PMD Phase 2 Standards/Data

Model/HarmonizationPMD Phase 2 (TBD)

PMD Phase 1

eDoC Timeline

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SummaryeDoC workgroup identifies Best Practice for:

1) Payer interaction with providers for determination of coverage

2) Developing, delivering and using structured documentation templates to support coverage determination

3) Developing and instantiating decision support rules to facilitate provider decision making in light of payer standards

4) Addressing Author of Record requirements

5) Secure electronic communication between payers, provider, suppliers and beneficiaries

6) Creating implementation guides for payers and providers (usually via HIT vendors) for all required eDoC processes and transactions

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january 30 , 2013

Documents

pmd order

tbdpmd phase

rules5scopein scope

planphysician information

element order components

order sentences

implementation guideuse

best practices