Risk Based Contract Member Identification (Da Vinci project; PSS in Confluence)

Description

This PSS will enable Payers and Provider to exchange information that identifies members of a patient population associated with particular risk based contract. The solution needs to define a simple, reliable, exchange method for payers and providers to synchronize data from practice management and EHRs, and to enable providers and payer organization to validate enrollment in VBC programs at the point of care and for population level program management. The information that will be exchanged should be sufficient to identify a specific existing patient for inclusion in a risk based contract or create such a patient in the PM/EHR if the patient does already exist and the PM/EHR has the capability.

Workflow will be defined to initiate the exchange process automatically (e.g. CDS Hooks) or via an explicitly triggered request.

In addition, guidance will be provided for the use of these member lists to establish the scope of exchanges of provider and payer information defined in other Da Vinci implementation guides using the FHIR Bulk Data standards.

This PSS builds on the HRex implementation guide for the automated exchange of information between a payer and provider using standard profiles and constraints on existing exchange methods.

This project will reference, where possible the "standards" defined by the Health Record exchange (HRex) Library/Framework Implementation Guide which in turn will utilize prior work from Argonaut, US Core and QI Core effort for FHIR DSTU2, STU3, and R4 where appropriate.

The ultimate goal is to support the accurate and timely exchange of risk based contact member information between payers and providers to facilitate VBC programs. The secondary goal is to use these member list to enable FHIR bulk data exchange using the standards defined by other Da Vinci implementation guides (e.g. PDex, CDex, DEQM).

The project team plans to work with existing FHIR artifacts where possible. If changes are necessary, the project team will work with the responsible Work Group to review and implement (via tracker items or new PSS) any necessary enhancements to base FHIR resources, extensions, and/or profiles.

Misc Notes
2025 December: TSC approved an STU Extension Request for HL7 FHIR Implementation Guide: Member Attribution List, Edition 2 - US Realm for 1 year 2025 February: TSC approved Unballoted STU Update Publication Request for HL7 FHIR Implementation Guide: Member Attribution List, Edition 2.1 - US Realm 2023 December: TSC approved STU Publication Request for HL7 FHIR Implementation Guide: Member Attribution List, Edition 2 - US Realm for 2 years 2022 February: TSC approved Updated STU Extension Request for HL7 FHIR Implementation Guide: Risk Based Contract Member Identification, Release 1 - US Realm for one year 2019: PSS updated and approved. External Vocabularies: HCPCS, SNOMED, CPT, ICD, RxNorm, LOINC For FHIR IGs and FHIR Profiles, what product version(s) will the profiles apply to? R4, STU3, DSTU2 Other Stakeholders and Providers: Federal Healthcare Agencies (e.g. CMS), Providers (e.g. Physicians)