HL7 Attachments Working Group Meeting Minutes
Location: San Diego, CA / Date: September 11, 2017
Time: 1:45 – 5:00
Facilitator / Durwin Day / Note taker(s) / Penny Probst
Quorum Requirements Met: Yes
First Name / Last Name / Affiliation
Liora / Alschuler / Lantana
Tony / Benson / BCBSAL
Laurie / Burckhardt / WPS
Mary Lynn / Bushman / National Government Services
Terry / Cunningham / AMA
Laurie / Darst / Mayo Clinic
Durwin / Day / HCSC ***co-chair***
Robert / Dieterle / EnableCare
Rachel / Foerster / CAQH CORE
Craig / Gabron / PGBA ***co-chair***
Christol / Green / Anthem
Liz / Hartley-Sommers / BCBSLA
Phil / Heinrich / DHCS
Robin / Isgett / BCBS of SC
Lenel / James / BCBSA
Chris / Johnson / BCBS of AL
Jocelyn / Keegan / Point of Care Partners
Farrah / Khan / BCBSA
Anna / Meisheid / CMS
Debbi / Meisner / Change Healthcare
Lisa / Nelson / Life Over Time Solutions/"Janie Appleseed"
Nancy / Orvis / DoD MHS
Russ / Ott / Deloitte/DoD
Cathy / Plattner / Kaiser Permanente
Penny / Probst / Highmark, Inc
Sam / Rubenstein / Montefiore
Walter / Suarez / Kaiser Permanente

Agenda Topics

  1. Industry Updates
  2. Open Discussion

Supporting Documents: posted on AWG site as appropriate

Minutes/Conclusions Reached:

  1. Industry Updates
  2. The AWG published two guides
  3. WEDI Prior Authorization Forum
  • The Prior Auth Council created this forum and WEDI was the convener
  • Charles Jaffe is the HL7 representative on the council
  • The first day of the forum was information gathering from various stakeholders on their use of prior auths. Overall, there is low utilization.
  • A lot of prior auths require attachments. We need to be aware of the issues for use cases.
  • There was discussion about the progress NCPDP has made with prior auths and how Rx is significantly different than medical.
  • Concern was raised about recommended workflows within each organization after the attachment is received. CAQH CORE is researching this.
  • Cooperative Exchange Meeting with CMS
  • There were letters to CMS from several organizations, including BCBSA, AHIP and the Cooperative Exchange suggesting the attachments regulation be published sooner rather than later.
  • ONC Interoperability
  • Hans did a presentation about making sure the right standard is used for the right purpose.
  • Wayne Kubick gave an HL7 presentation as well.
  • The presentations can be found by googling ONC Beyond Boundaries
  • Open APIs lead to interoperability
  • NCVHS Update/ Predictability Roadmap
  • Predictability Roadmap: transaction standards and operating rules provide the health care industry with a degree of certainty in the timing and sequence of the development and adoption of new or revised standards and operating rules as required under HIPAA and other legislation
  • It was noted that HL7 suggested that additions can be made to existing standards, and used as agreed between trading partners. When next version is published, it will be determined whether to include the additions in the next standard version or not. This is something to think about as an option.
  • All SDOs need to come to the table to agree on a common vocabulary before moving forward with the roadmap.
  • IFR vs NPRM (Walter)
  • The industry wants to see the publication, which would tend toward publication of an NPRM
  • The ACA specifically allows for an IFR
  • It was noted that the current administration is pushing for regulatory relief, which may lean toward the NPRM to get the industry input.
  • Walter noted that there can be a relatively quick publication of an NPRM with a quick turnaround of the comments. This could be as quick as 3 months. There is no official 'expedited NPRM'
  • It was noted that technical comments related to the standards would have to be addressed by the SDOs (HL7/X12)
  • The regulatory agenda will be posted at the end of October.
  • It was suggested that an NPRM be published to do the right thing
  • Comments against publication of an NPRM: 1) opens up the regulation to versions other than those recommended, 2) there will be uninformed comments by those who have not been involved to date, 3) providers have not been involved and usually are not until a regulation is published
  • Joint HL7/NCQA Conference (Anne Smith)
  • The Digital Quality Summit is scheduled for November 1-2 in Washington, DC (
  • The agenda will be focused on HEDIS (NCQA)
  • This will be a working session with multiple tracks
  • Cross- Paradigm Storyboard Artifact Payer Perspective Value Based Care (Lenel)
  • April VBC summit - A concern about a FHIR instance not carrying a version number was raised during the April Value Based Care Summit
  • This PSS will be done in Normative
  • Lisa Nelson Health Story webinar
  • Lisa explained the objectives
  • The rendered C-CDA, Max MD forms were shared
  • There was concern about provider-based ACOs not being covered by this, since it appears to be tied to claims payment. This is only the first phase and the ACOs are out of scope for this project.
  1. Open Discussion
  • Liora shared that FHIR should be moved through the ballot process. There is a gap in CDA. There is a new implementation guide (sponsored by SDWG, co-sponsor AWG) to introduce CDA with US realm header, body xml with no specific requirements (non-xml) instead of pdf, a coded document can't be processed. This is a step forward for text processing. Mayo used this.

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HL7 Attachments Working Group Meeting Minutes
Location: San Diego, CA / Date: September 12, 2017
Time: 9:00– 5:00
Facilitator / Durwin Day / Note taker(s) / Penny Probst
Quorum Requirements Met: Yes
First Name / Last Name / Affiliation
Liora / Alschuler / Lantana
Alex / Beckner / Cerner
Tony / Benson / BCBSAL
Keith / Boone / GE Healthcare
Dennis / Brinley / Highmark, Inc
Laurie / Burckhardt / WPS
Mary Lynn / Bushman / National Government Services
Terry / Cunningham / AMA
Durwin / Day / HCSC ***co-chair***
Robert / Dieterle / EnableCare
Richard / Ettema / Aegis Inc
Rachel / Foerster / CAQH CORE
Craig / Gabron / PGBA ***co-chair***
Rick / Geimer / Lantana Group
Christol / Green / Anthem
Liz / Hartley-Sommers / BCBSLA
Phil / Heinrich / DHCS
Robin / Isgett / BCBS of SC
Lenel / James / BCBSA
Chris / Johnson / BCBS of AL
Dan / Kalwa / CMS
Jocelyn / Keegan / Point of Care Partners
Farrah / Khan / BCBSA
Paul / Knapp / HL7 FMWG - FHIR
Mary Kay / McDaniel / Cognosante
Anna / Meisheid / CMS
Debbi / Meisner / Change Healthcare
Russ / Ott / Deloitte/DoD
Melissa / Mendivil / Optum
Cathy / Plattner / Kaiser Permanente
Penny / Probst / Highmark, Inc
Sam / Rubenstein / Montefiore
Corey / Spears / Infor
Sue / Thompson / NCPDP
Margaret / Weiker / NCPDP

Agenda Topics

1.Preliminary PSSs

2.NPRM vs IFR (cont'd)

3.Apple Healthcare Kit

4.HL7 Payer Questionnaire

5.ONC Beyond Boundaries Meeting

6.FHIR Connectathon

7.Business Flow

8.FHIR Resources

Supporting Documents: posted on AWG site as appropriate

Minutes/Conclusions Reached:

1.Preliminary PSSs (Rick)

  • The PSSs were presented to the AWG to solicit interest as a sponsor or cosponsor
  • FHIR for Attachments PSS
  • The Connectathons have included a track for this
  • This mirrors 277/275 transactions
  • This creates profiles and defines services for exchanging attachments in order to explore exchange methods other than X12. It documents profiles and services only, using RESTful web services rather than X12 protocols
  • The tentative timeline is to have a for-comment ballot Jan 2018 and based on connectathon documentation, STU May 2018 ballot
  • There was discussion that while this is heavily US Realm oriented, international should be kept in mind. In some instances it is better to start specific, then go more global. This may be a two-phase project.
  • FM and PA may have interest.
  • There was discussion about collaboration with X12 and the impact the MOU may have on this PSS. It may have to be a joint project. It was suggested that we let the TSC deal with X12 question. HL7 requires a PSS for any work to be done, so this has to be completed first.
  • Mary Kay will take this to US Realm on Thursday since we need to move this forward.
  • Rick made a motion that Attachments sponsor this PSS
  • Mary Kay second
  • Discussion: a note was added that this may be of interest to international community but this phase is US Realm.
  • Vote: Approve - 22, Disapprove - 0, Abstain - 2,
  • Rick will email the PSS to Durwin
  • XDoc (will probably be renamed) PSS
  • SDWG is the sponsor, requesting AWG co-sponsor
  • This creates templates for C-CDA document types that use the US Realm header and a structured body, but have no other section or entry requirements
  • This is important for administrative documents
  • This may be the smallest implementation guide published to date
  • Mary Kay made a motion to approve AWG co-sponsor this PSS
  • Rachel second
  • Discussion: Rick explained that SDWG is balloting smaller imp guides then considering them for inclusion through the update process, rather than balloting the entire guide each time.
  • Vote: Approve - 20, Disapprove - 0 , Abstain-3, ,
  • This will be discussed in SDWG, Wednesday Q2

2.NPRM vs IFR (cont'd) (Daniel)

  • Dan noted that the decision about NPRM vs IFR is made at the HHS level based on statutory authority. NCVHS is only a recommendation.
  • The industry can share preferences, but the decision is not up to the industry
  • Look for the updated unified agenda that will be published at the end of October. All regulatory actions are listed. This is the first release of publication information. To find the agenda, google Unified Agenda (GSA site)

3.Apple Healthcare Kit (Craig)

  • Moving from wearables to diagnostics
  • Epic and Apple are working together -to create the Apple Health Kit
  • Health HIT is using CCD document
  • Some vendors are using CDA and FHIR
  • What are the opportunities for payers and providers to use the info from the devices? Is there a role for AWG or other HL7 WG? There is a mobile health WG
  • Many entities involved: Duke, Aetna, Apple, Microsoft, Amazon, Google
  • There was discussion about how the data gets into patient EHRs and how it is used

4.HL7 Payer Questionnaire (Chris)

  1. What challenges related to interoperability are you and those in roles like yours experiencing?
  2. It was noted that many of the payer issues also resonate with the clearinghouses and EHR vendors.
  3. Different payers have different needs, as well as different areas within a payer have different needs.
  4. There is a need for a common information semantic model. It was noted that there are HL7 starting models that payers don't take enough advantage of. The bigger issue is education for payers as to what it here.
  5. Feedback to HL7: Suggest education/webinars for payers to share within their organization. Focus on payer use case. It was suggested to include an education track associated with the payer summit (day before/after) - 3 or 4 classes that would cover C-CDA, FHIR, Attachments IGs, Quality Measures/CDS.
  6. A level setting webinar on the above topics then more detailed instruction face to face was suggested
  7. How do you and your peers currently view HL7 and standards in general?
  • The responses were hopeful
  • It was noted that all EMR vendors heading to the cloud. They are also looking to aggregate data
  • On the administrative side, providers use intermediaries to deal with many payers It is unclear if this is available for clinical data. .
  • There is a challenge in the US because the regulations mandate transactions that for the most part exclude HL7 for claims payment
  • Feedback to HL7: Foster an understanding between payer and provider. Build a use case to link provider, payer, others
  1. How would you describe HL7 and the value it brings to a payer?
  • Standards and networking opportunities
  1. What value does HL7 provide your organization? How does participation in HL7 benefit you?
  • This varies dependent on the responder's role within a payer organization
  • HL7 may be an unknown for a lot of payers.
  1. What would the world be like if HL7 didn't exist?
  2. There is innovative thinking and movement in HL7 which provides value to the industry as a whole
  3. If there weren't HL7, the need would still be there. Some other solution would arise.

5.ONC Beyond Boundaries Meeting (Durwin)

  • The21st Century Cures Act - Title IV - Delivery: this is the legislation that requires ONC to create the rules/regulations
  • This impacts attachments and may impact issues of privacy/security
  • ONC has three use cases. One is a payer case
  • The framework will be published in the next 5 months
  • Timeline for Trusted Exchange Framework: the comment period has passed, a webinar for review of comments is mid-Sept, release draft late 2017/early 2018, final 2018
  • There is an opportunity in early 2018 to provide feedback/have conversations about what trusted exchange and common agreement looks like
  • HL7 PAC did provide comments/feedback
  • This is incredibly important. There is a webinar at the end of September

6.FHIR Connectathon(Rick)

  • Rick ran the FHIR Documents and Attachments tracks
  • There were Payer, Provider and Clearinghouse roles
  • They included Solicited, Unsolicited and prior auths
  • Documents - exchange using document Bundle resources containing a Composition and other resources
  • Demonstrated the value proposition for Direct Trust and FHIR
  • Rick provided a summary of the tracks covered during the connectathon - Dynamic Health IT, CDA to FHIR Mapping
  • BCBSAL and Anthem worked on Attachments using Communication Request as a payer to provider requesting an attachment. There were several scenarios for prior auths. Anthem is currently using the patient resource to build a prior auth as well

7.Business Flow (Paul)

  • Paul shared the basic flow.
  • There are FHIR resources for eligibility request, eligibility response, PA request, supporting information (claim and PA), PA response , payment notification, payment confirmation
  • Paul demo'd the tool he uses for claims/PA/eligibility
  • There was discussion about including Attachments in the FM track, or keeping it separate. It was decided to keep both tracks for now and beef up integration.

8.FHIR Resources

  • On the FHIR site, click on Versions and choose Current to see what is currently being worked on
  • Current is constantly changing as work is done.
  • Finance has its own module
  • Eligibility and Enrollment tend to have different definitions in different countries
  • There hasn't been much work on Enrollment yet
  • The focus has been on content models
  • Next work will focus on more explanatory content
  • Paul reviewed the eligibility request and response resources
  • There was a discussion about the need for procedure code in eligibility request resource. Currently it doesn't go to that level. There are options for getting it in there.
  • We have to work with X12 on mapping. There may be issues with X12 IP in being able to share mapping
  • It is not the HL7/FM intent to conflict with X12.
  • There seems to be a benefit to having the mapping and profiles to progress in the industry.
  • Profiles are needed to create the level of rigor needed to make the resources applicable to US use cases
  • They are considering pulling out detail and creating another resource that is Insurance Plan, which includes utilization, etc. This is also in EOB
  • Laurie will talk to Cathy and Stacey at the X12 meeting to push for a better answer. It was noted that they have to understand the effort involved, especially for profiles. Resources are needed.
  • Laurie requested Paul and Mary Kay create talking points that she can present/interpret for X12 to understand
  • There is nothing associated with the mapping that is needed for the January ballot. If anything is identified as missing from the resources, it can be added for the May or September ballot
  • The claim resource was reviewed as well. It is complicated to cover all that is needed. A profile can be created to narrow it to the individual use case

Actions
  • Mary Kay: Take the FHIR for Attachments PSS to US Realm
  • Rick: Email the PSS to Durwin
  • Laurie: talk to Cathy and Stacey at the X12 Meeting about the mapping effort
  • Paul/Mary Kay: Create talking points for Laurie to present to X12

HL7 Attachments Working Group Meeting Minutes
Location: San Diego, CA / Date: September 13, 2017
Time: 9:00– 5:00
Facilitator / Durwin Day / Note taker(s) / Penny Probst
Quorum Requirements Met: Yes
First Name / Last Name / Affiliation
Liora / Alschuler / Lantana
Korri / Andrews / XIFIN
Tony / Benson / BCBSAL
Dahlia / Bona / XIFIN
Dennis / Brinley / Highmark, Inc
Michael / Brody / EHR WG
Laurie / Burckhardt / WPS
Mary Lynn / Bushman / National Government Services
Patrick / Cannady / American Dental Association
Terry / Cunningham / AMA
Durwin / Day / HCSC ***co-chair***
Rachel / Foerster / CAQH CORE
Craig / Gabron / PGBA ***co-chair***
Christol / Green / Anthem
Liz / Hartley-Sommers / BCBSLA
Phil / Heinrich / DHCS
Robin / Isgett / BCBS of SC
Lenel / James / BCBSA
Chris / Johnson / BCBS of AL
Dan / Kalwa / CMS
Jocelyn / Keegan / Point of Care Partners
Farrah / Khan / BCBSA
Anna / Meisheid / CMS
Cathy / Plattner / Kaiser Permanente
Penny / Probst / Highmark, Inc
Sam / Rubenstein / Montefiore
Mark / Scrimshire / CMS
Corey / Spears / Infor
Pat / VanDyke / HL7 Board

Agenda Topics

1.Strategy for Addressing Industry Questions

2.ACP White Paper/Webinars

3.Work Group updates

4.Block Chain

5.Meeting Planning

6.Open Discussion

Supporting Documents: posted on AWG site as appropriate

Minutes/Conclusions Reached:

1.Strategy for Addressing Industry Questions

  • The industry will look to this group for information
  • There is no HL7 precedent for this
  • In the past listservs were used to monitor and respond to questions. Currently the FHIR WG uses something a bit more contemporary
  • Dan offered to be the conduit to CMS. In the past, CMS has had a communication plan for new regulations. They can schedule call and/or webinars for questions.
  • It was noted that questions asked during the town halls should be included in the FAQs.
  • The ACP Leadership work on identifying webinar topics was reviewed (see next topic for details)
  • Technical and business topics will be addressed
  • Expertise has to be identified
  • The HL7 Attachments page does have FAQs, which probably need to be updated. The FAQs should be easily accessible.
  • There had been a proposal for Attachments tutorials. This should be added to the education list. This should be offered in January and attached to the Payer Summit, which is scheduled for the Monday of the WGM.
  • HL7 does have a Help Desk. It is free to members and non-members can subscribe to it for a fee. This is a concern. We need to know how the help desk is staffed so that the correct resources are available. This may involve SDWG as well.
  • The community forum on the FHIR site was reviewed as a potential model for handling questions. Each question in the community has a separate url, so they can be referenced by the WEDI triage team. . The FHIR chat is used a lot during connectathons but may be a bit more than we need. An informational project has to be opened to create the FAQ Community
  • The Attachments Product page ( was reviewed
  • The two new guides are on this page
  • To get to our guides: Standards>Implementation Guides> scroll to Attachments (right after ANSI)
  • AIS 0009 Patient Information Unspecified Content Attachment is probably dated and should be removed. We have to vote on this. If it is no longer active, it can be sunsetted. There may be early adopters using this guide, but most likely not.
  • Attachments starter set: might be R1 of CDA 2004. Probably needs to be removed.
  • FAQs are 2003 - 2008. This definitely needs updated. Probably can be addressed from ACP White Paper and the supplemental guide
  • OID document: we need to check for current version
  • There was discussion about the need to segregate or identify older documents. We also need to identify and emphasize mandated standards.
  • The ANSI requirements for sunsetting may impact what can be removed from the product page.

2.ACP White Paper/Webinars(see potential attachment webinar sessions document above)