FHIR Risk Adjustment (PSS in Confluence)

The risk adjustment use case acknowledges the importance of risk-adjusted premium calculations to government managed care and seeks to

- better inform clinicians of opportunities to address risk adjusted conditions,

- better enable payers to communicate risk adjustment information, and

- enhance government sponsors’ ability to allocate funding accurately.

To accomplish this:

- Payers need a standard protocol to share and receive clinical data related to risk adjustment with responsible providers.

- Providers need a standard protocol to share and receive clinical data related to risk adjustment with responsible payers.

- Payers and providers need a standard methodology to communicate risk based coding, documentation and submission status of chronic illnesses.

The resulting bi-directional, real-time, FHIR-based communication will connect payer intelligence with EHR data at the point of care, facilitating providers documentation of relevant chronic illnesses. This model ensures accurate and complete patient assessment to support Value-Based Care programs.

This project may utilize specific triggers and exchange methods (CDS Hooks, Pull, etc.), use of other interoperability 'standards' (e.g. SMART on FHIR, CQL) and specific use of FHIR resources to effectively verify and facilitate documentation supporting chronic illness needed for risk adjustment, medical necessity and care coordination.

This project will define a standard methodology for payers to communicate risk based coding gaps to providers. This project will also define a approach to trigger the evaluation and/or collection of documentation for specific chronic conditions that are sufficient in scope to satisfy both clinical and administrative needs. The project team will select an initial set of chronic conditions (e.g. CHF, COPD, Diabetes) to use as demonstrations/examples of the underlying framework.

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 R4 where appropriate. If this FHIR implementation guide is unable to use a US Core profile, we will follow the Cross Group Projects WG's variance request process, and provide the US Realm Steering Committee an approved rationale for deviation in the implementation guide where applicable.

The ultimate goal is to support the accurate documentation of chronic illnesses to support communication of risk based coding gaps and to facilitate risk adjustment and care management.

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.