electronic submission of Medical Documentation (esMD)
electronic Determination of Coverage (eDoC) Workgroup
Charter Review
January 30, 2013
Welcome and IntroductionsMELANIE COMBS-DYER, RNDeputy Director,CMS / OFM / Provider Compliance Group
DAN KALWAHealth Insurance Specialist,CMS / OFM / Provider Compliance Group
ROBERT DIETERLE, Initiative Coordinator
VIET NGUYEN, MDChief Medical Information Officer
Systems Made Simple, Inc.MARK D PILLEY, MD AAFP, AADEP, ABQAURPMedical Director
StrategicHealthSolutions, LLC
MICHAEL HANDRIGAN, MDMedical OfficerCMS / OFM / Provider Compliance Group
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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
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Payer
Templates and Rules
10b10a9a
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9b
10c
Signed Document
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eDoC Workgroup Structure
Sub-WorkgroupsStructured 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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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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eDoC Workgroup Structure
Sub-WorkgroupsStructured 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 Data Capture (SDC)
SDC Standards
eDoC Workgroup Structure
Sub-WorkgroupsStructured 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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Clinical Decision Support
Clinical Decision Support
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Sub Workgroup PMD Structured Data
PMD Phase 1Implementation Guide
Use Case #1: PMD Phase 1 PMD Phase 1Pilots (TBD)
Pre-DiscoveryWorkgroup
Charter/ScopeKick-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 coverage2) Developing, delivering and using structured documentation
templates to support coverage determination3) Developing and instantiating decision support rules to
facilitate provider decision making in light of payer standards4) Addressing Author of Record requirements5) Secure electronic communication between payers, provider,
suppliers and beneficiaries6) Creating implementation guides for payers and providers
(usually via HIT vendors) for all required eDoC processes and transactions
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