DA VINCI PROJECT UPDATE March 8, 2018

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Pre-Collaboration / Controlled Chaos: Project Challenge To ensure the success of the industry’s shift to Value Based Care Pre-Collaboration / Controlled Chaos: Develop rapid multi-stakeholder process to identify, exercise and implement initial use cases. Da Vinci simply is an group of industry payers, providers and HIT partners that understand how critical it is to develop common, ideally eventual standard ways for providers and payers to exchange the critical data required for value base case to work. Collaboration: Minimize the development and deployment of unique solutions. Promote industry wide standards and adoption. Success Measures: Use of FHIR®, implementation guides and pilot projects.

Empower End Users to Shift to Value As a private industry project under HL7 International, Da Vinci will unleash critical data between payers and providers required for VBC workflows leveraging HL7® FHIR® So this is a journey, not immediate change, increasingly providers and the extended care team must have access while caring for a patient, as triggers or integrated in their workflows. While the shift from Fee for Service to paying based on outcomes is a giant shift in US healthcare, this is not a US centric problem. We believe FHIR is best option at this time to get providers across this chasm. Source: © 2018 Health Catalyst

Focus

2019 MEMBERSHIP

3 EHRs 12 Use Cases 12 HIT Vendors 12 Payers Dozen Providers Founding Members 12 Payers 3 EHRs 12 Use Cases 12 HIT Vendors Our initial founding group of payers, providers and HIT vendors has grown to a membership group of 27 organizations, including 12 payers, 10 HIT vendors, 6 providers and 3 EHR vendors.  Cross-functional teams are currently involved in the project to develop and deploy FHIR-based solutions that positively impact clinical quality, cost and care management outcomes. We’ve paused on adding additional members , but all artifacts including IGs, reference implementations and pilot partners will be open source and available to public. Members have begin to implementing use cases. Dozen Providers

For current membership: http://www.hl7.org/about/davinci/members.cfm Da Vinci Members Premier Members Associates For current membership: http://www.hl7.org/about/davinci/members.cfm

Da Vinci Members Sponsors Members

ACTIVE USE CASES

Use Case Alignment Project Outputs 2018 Use Case Inventory and Project Deliverables Use Case Alignment Data Exchange for Quality Measures Coverage Requirements Discovery Documentation Templates and Coverage Rules Project Outputs Define requirements (technical, business and testing) Create Implementation Guide Create and test Reference Implementation (prove the guide works) Pilot the solution Deploy the solution Health Record Exchange: Clinical Data Exchange Health Record Exchange: Payer Data Exchange Prior-Authorization Support Gaps in Care & Information Risk Based Contract Member Identification Alerts: Notification (ADT), Transitions in Care, ER admit/discharge Use Case Status In HL7 ballot reconciliation as draft standard Under active development Planned 2019 Use Cases Future Use Case Performing Laboratory Reporting Chronic Illness Documentation for Risk Adjustment Patient Cost Transparency 11

x Da Vinci 2019 Use Cases –Year 2 Proposed 2019 Use Cases Prior Authorization Support Comment Prior Authorization Support Payer Data Exchange (Payer to Provider) Comment Payer Data Exchange (Payer to Provider) Clinical Data Exchange (Provider to Provider/Payer) Comment Clinical Data Exchange (Provider to Provider/Payer) Document Templates & Rules R1/STU Document Templates & Rules R1/STU x CRD Covergage Requirements Discovery Update STU Data Exchange Quality Measures – Add’l Measures STU Dec Dec Jan Feb March April May June July Aug Sep Oct Simple timeline and Nov HIMSS19 Vignette HL7 Connectathon HL7 Connectathon Connectathon HL7 Connectathon 12

2019 Expanded Use Case Status - Post NPRM Update Data Exchange for Quality Measures Coverage Requirements Discovery Documentation Templates and Coverage Rules Use Case Status In HL7 ballot reconciliation as draft standard Under active development 2019 use cases Use cases in discovery Health Record Exchange: Clinical Data Exchange Health Record Exchange: Payer Data Exchange Prior-Authorization Support 13 Gaps in Care & Information Risk Based Contract Member Identification Alerts: Notification (ADT), Transitions in Care, ER admit/discharge Performing Laboratory Reporting Chronic Illness Documentation for Risk Adjustment Patient Cost Transparency Health Record Exchange: Patient Data Exchange Payer – Payer Coverage Determination

TRUE INTEROPERABILITY Progress Toward End Goal Payer Provider + Implementation Guide Reference Implementations Tools = TRUE INTEROPERABILITY STEERING COMMITTEE Senior level executive, can make decisions and commit organization resources Driving interoperability strategy within home organization and responsible for coordination with industry Technology and business ownership to drive “business case” approval OPERATING COMMITTEE Budget planning and approval for “in kind” and project fees Leader and/or influencer across home organization Work closely/aligned with senior leadership at home organization, can queue up commitment and decisions and drive to conclusion Understands and will own HL7 standards relationship, commitments Roll up sleeve and problem solve use case development and inventory, priorities, details Identify and gain access/time for “in kind” resources for priority use case work Build Your Implementation Success Story

Activities By the Numbers Stats Total practice runs 3 Total public runs 23 Filming runs 1 Total variations 14 Total roles 96 Total role system issues 7 Role availability 92.7% AEGIS Touchstone available 100% Total MCs 6 Total EHRs 2 Total Payer/Partner 4 Total Payer only 5 Total Sponsors 16 Number of visitors (approx.) 500 Percent that left during vignette < 10 % HIMSS19 Demonstration Each step represents a provider – payer exchange using FHIR IG Disclaimer

Use Case Details Disclaimer

Sample Project Timeline Represents 4 weeks 2 - 4 sprints IG Development Specify profiles, … IG Framework Create Draft IG Revise and Finalize IG FHIR Gap Analysis Assemble Team Requirements RI Tech Approach Project start RI Development Build Initial RI Test RI Update Final RI Build Data Set Build Test Set Week 0 2 4 6 8 10 12 14 16 Work with appropriate HL7 workgroup for IG sponsorship and input Disclaimer

30 Day Medication Reconciliation 1. Discharge Notification Payer Acute Care Provider 2. Med Rec Need Need for provider to attest that Med Rec has been completed post-discharge Increasingly required for HEDIS and commercial at risk contracts Focus is to compare pre/post medication lists to avoid errors Today done through claims processing or manual review of lists Implementation Guide Shifted to Framework to Support Wider Set of Data for Quality

Subscribe for Measure Data Quality Data Exchange Implementation Guide Submit Measure Data Use case creates a common framework for quality data exchange Enables the exchange of raw quality measure data between quality measurement Teams and Care teams that provide patient care Timely exchange of key data is critical to evaluate and capture quality Future work will incorporate additional use cases 1. Submit OperationOutcome Payer Aggregator Collect Measure Data 2. Collect Return Measure Data Provider Payer Subscribe for Measure Data 3. Subscribe OperationOutcome Aggregator Provider

Pilot Implementation REST Architecture Model Provider EHR Implementation Scope Da Vinci’s Deliverable Scope Payer Implementation Scope EHR Backend Services Payer Backend Services EHR Payer Request Resource Translation Services Endpoint & APIs Endpoint & APIs Translation Services Response Resource EHR Database Payer Database Implementations conforming to the DaVinci FHIR Profiles following the Implementation Guides Industry standard DaVinci Use Case FHIR Profiles with respective Implementation Guides Implementations conforming to the DaVinci FHIR Profiles following the Implementation Guides Disclaimer

Order Procedure, Lab or Referral Coverage Requirements Discovery Provider Order Procedure, Lab or Referral Discover Any Requirements Payer Providers need to easily discover which payer covered services or devices have Specific documentation requirements, Rules for determining need for specific treatments/services Requirement for Prior Authorization (PA) or other approvals Specific guidance.   With a FHIR based API, providers can discover in real-time specific payer requirements that may affect the ability to have certain services or devices covered by the responsible payer.  Response may be The answer to the discovery request A list of services, templates, documents, rules URL to retrieve specific items (e.g. template)

Coverage Requirements Discovery Implementation Guide Based on a specific clinical workflow event: scheduling, start of encounter, planning treatment, ordering, discharge Provider’s send FHIR based request, with appropriate clinical context to the responsible payer Payer may request additional information from the provider EHR using existing FHIR APIs Payer responds to the EHR with any specific requirements that may impact the clinical decisions or coverage Payer Provider Provider requests coverage requirements from payer Optional: request additional information Payer responds to the request Provider utilizes this information to make treatment decisions while considering specific payer coverage requirements.

Pilot Implementation CDS Hooks/REST Architecture Model Provider EHR Implementation Scope Da Vinci’s Deliverable Scope Payer Implementation Scope EHR Backend Services Payer Backend Services CDS HOOKS Payer Request Resource Endpoint & APIs Endpoint & APIs Translation Services Translation Services Response Resource EHR Database Payer Database Industry standard CDS HOOKS implementing Use Case FHIR Profiles with respective Implementation Guides Implementation interfaced with the DaVinci SMART on FHIR application Implementations conforming to the DaVinci FHIR Profiles following the Implementation Guides Disclaimer

Available Use Cases Stage Q1 2019 Activities 2019 Min Investment Ballot Reconciliation & Connectathons Publish Identify Implementers Test Two new measures in inflight: colon cancer screen (COL) and deep vein thrombosis (DVT) v2: sync with FHIR STU4 Incorporate feedback Further define patterns and add measures CMS drive Pilot Test Add pricing by location functionality Data Exchange for Quality Measures Thousand of potential use cases available. HL7 and thought leaders representing payers and CMS in coordination and working with groups like HL7 Partners in Interoperability meetings identified initial need for common workflows for Value Based Care led to identification of initial priorities. Further fleshed out with input from early founders. Focus – Use cases looking for high volume, manual activities that would benefit from automation of portions of workflow that collect critical data to improve outcomes. Coverage Requirements Discovery 24

2019 In Flight Use Cases Stage Q12019 Activities 2019 Min Investment Definition Finalize scope Build Implementation Guide & Reference Implementation Identify Implementers Ballot initial IG Connectathons Implementations CMS Testing Discovery & Definition Finalize architectural Get IG work underway Ballot initial IG for payer to provider, provider to payer, prior authorization support & eHRx framework Documentation Templates and Coverage Rules eHealth Record Exchange 25

Follow Progress, Test, Implement FIND Background collateral Implementation Guide Balloted Sept ‘18, reconciliation underway Reference Implementation HL7 Connectathon participants Publicly available RESOURCES HL7 Da Vinci Wiki & Listserv signup - http://www.hl7.org/about/davinci/index.cfm HL7 Confluence Site - https://confluence.hl7.org/display/DVP/ Data Exchange For Quality Measures (DEQM) Implementation Guide STU1 Ballot 1 http://hl7.org/fhir/us/davinci- deqm/2018Sep/STU3/index.html Coverage Requirements Discovery (CRD) Implementation Guide STU1 Ballot 1  http://hl7.org/fhir/us/davinci- crd/2018Sep/index.html Reference Implementation Code Repository - https://github.com/HL7- DaVinci

Da Vinci Program Manager: Jocelyn Keegan, Point of Care Partners jocelyn.keegan@pocp.com Da Vinci Technical Lead: Dr. Viet Nguyen, Stratametrics LLC vietnguyen@stratametrics.com Disclaimer