oncology clinical pathways: prior authorization
TRANSCRIPT
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Oncology Clinical Pathways: Prior Authorization
June 24, 2020
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Oncology Clinical Pathways and Prior Authorization
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Draft Clinical Pathway
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Community:A new HL7 FHIR Accelerator
A community and platform accelerating interoperable datamodeling and implementation
around FHIR and mCODE, leading to step-change improvements in
cancer care and research
http://hl7.org/CodeX
CodeX Use-Case-Based Projects
EHR Endpoints for Cancer Clinical Trials (ICAREdata)1
Integrated Trial Matching for Cancer Patients and Providers
2
Cancer Registry Reporting3
Oncology Clinical Pathways
4Radiation Therapy Treatment Data for Cancer
5
Oncology Clinical Pathways: Prior Authorization Support6
Alternative Payment Model Data Reporting for Cancer7
Drug Value Based Agreements for Cancer
8
mCODE++ Extraction0
In Discovery
Active Community Development
Active CommunityPlanning
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CANCER
Providers Research
Payers
Government
/ RegulatoryVendors
Patients
Standard:minimal Common Oncology Data Elements
▪Small, stable set of critical data elements
▪Driven by oncology experts
▪Standardized for collection
and sharing, using FHIR
▪Better cancer care and research
http://hl7.org/fhir/us/mcode/https://mcodeinitiative.org/
mCODE Release 1 :
TM
TM
HL7 Implementation Guide
8
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Oncology Clinical Pathways: Prior Authorization Support
Run Pathway App Receive and Accept
Treatment RecommendationReceive Pathway Accept or
Decline Message plus cancer
data
X12N Interface
X12N Interface
ASC X12N 278/275
mCODE++ Extraction
(as needed)
mCODE++: leveraging mCODE with possible extensions
Retrieve
FHIR
Map
mCODE++
mCODE++
mCODE++
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Prior Authorization (PA) – Healthcare System Costs• Key driver of high US healthcare system administrative costs: lack of
adoption of electronic, automated approaches to transactions
• Save up to $10 billion annually by adopting fully electronic administrative transactions
• Least automated activities are PA and claims attachments
• Greatest per transaction savings opportunity is PA - $2.11 (partially to fully electronic) or
$12.11 (manual to fully electronic) per transaction
Adoption of Fully Electronic Administrative Transactions, 2019
CAQH. 2019 CAQH Index. Available at: https://www.caqh.org/sites/default/files/explorations/index/report/2019-caqh-index.pdf?token=SP6YxT4u (Accessed on April 2,
2020)
Leveraging the mCODE™ standard (minimal Common Oncology Data Elements), CodeX will expand around this core to encompass additional use cases, accelerating opportunities to create a learning health system
based on interoperable data and improved patient care.
Learn more www.hl7.org/codex/
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