Click to edit Master title style

• Click to edit Master text styles

– Second level
• Third level
– Fourth level
» Fifth level
Standards for National Health Claim Exchange (NHCX)
National Resource Centre for EHR Standards (NRCeS)
C-DAC Pune
Click to edit Master title style
Agenda
•• Background
Click to editon Interoperability
Master text stylesStandards implementation in ABDM
• About FHIRlevel
– Second Standard
• FHIR• Interoperability
Third level Paradigm
• Adoption of FHIR
– Fourth levelin ABDM
• Adoption of» FHIR for NHCX
Fifth level
• Key Use cases
- Profiling Requirements for NHCX
- NHCX Standardization Approach
- FHIR Resource Under Consideration for NHCX
- Design Approach for NHCX
- NHCX Profiles
- Understanding the Structure of the Claim Bundle
Click to edit Master
Background - Healthtitle
Information
style sharing over ABDM
• ABDM Implementation is based on the guidelines laid in the National Digital Health Blueprint
• Click
(NDHB)to edit Master text styles
– Second
• Content level
& interoperability standards – FHIR, DICOM, SNOMED CT, LOINC, ICD
• A set •ofThird
8 essential
level and minimum class of health record artefacts for data capture in NDHB were
recommended
– Fourth level
» Fifth level
ClickHealthcare
Fast to edit Master
Interoperability
title style Resource (FHIR)
•• Health Data
Click to exchange
edit Master standard developed and nurtured by
text styles
HL7 International
– Second level
• Internet-based approach to connecting different discrete
• Third level
elements
– Fourth
• Aims to build a setlevel
of bae resources that, either by
Fifth level
themselves or» when combined, satisfy the majority of
common use cases
• FHIR has around 150 resource types covering several
categories including Entities, Clinical, and Financial types
• Representable in XML, JSON, or RDF formats
• Provides Restful CRUD specifications for common operations
• Extensible by design - allows usecase specific customization
• Terminology binding to popular code sets
Scope
Click FHIR
Why to edit Master title style
• Click Easy
to edit Mastershallow
to develop: text styles
learning curve and minimal custom tooling
requirements
– Second level
•Easy to implement
Third level
– Fourth level
Semantically
» FifthRobust:
level can be mapped back to other standards

Implementer friendly: uses common tools and formats, and web-based

technologies for the specification (HTTP, XML, JSON, etc.)
The artifacts/records can be validated electronically

Open specification, multiple open-source implementations, vibrant community

Support human-readable serialization formats

Click to
FHIR Usage
edit Scenarios
Master title style
• Click to edit Master text styles
– Second level
A2
A1
• Third level
App
– Fourth level FHIR
» Fifth level
FHIR
Common API Comm
Interface

FHIR PHR
DB

FHIR object sharing FHIR exchange FHIR objects storage

6
Click to
FHIR Interoperability
edit Master title
Paradigms
style
• Click to edit Master
FHIR text styles
supports interoperability via 4 paradigms
– Second level
• Third level
– Fourth level
» Fifth level
Rest Documents

Messaging Services
Click to
FHIR Resource
edit Master title style
• Resources represent
Click to edit Mastera text
unit of exchange of data that can be justifiable in
styles
interoperability
– Second level
• A resource
• Thirdislevel
made up of elements, each of which is a particular data type
• A resource has alevel
– Fourth known identity (a URL) by which it can be addressed
• Resources combine
» Fifth level
both computer processable and human-understandable data
– Metadata to aid in searches and cataloging
– Structural specification
– Defined value sets for any enumerators
– A display element for direct print or display of simplified text
– Links to other resources
• Example of resources: Patient; Practitioner; Observation; Organization
ClickParts
Key to edit
of Master
a Resource
title style
• Click to edit Master text styles Resource Identity
& Metadata
– Second level
• Third level Human Readable Text
– Fourth level Extension with URL to Definition
» Fifth level

Standard & Structured Data:

• Identifier
• Name
• Telecom
• Gender
• DOB
Click to edit
Resource listMaster
in FHIRtitle style
• Click to edit Master text styles
– Second level
• Third level
– Fourth level
» Fifth level

Resource FHIR R 4.0.1 List : http://hl7.org/fhir/R4/resourcelist.html

Click to
Data Types
edit Master title style
• Click to edit Master text styles
– Second level
• Third level
– Fourth level
» Fifth level
Click to edit Master title style
Bundles
• Click
A lab to
report in FHIR text
edit Master can be represented as a set of related resources:
styles
patient,
– Secondrequesting
level physician, observations, report in PDF format, order.
• Third level
– Fourth level
» Fifth level

Individual resources can be transmitted Multiple resources bundled for a logical

as multiple transactions purpose as a transaction
Click to edit Master title style
• Click to edit Master text styles
– Second level
• Third level
– Fourth level
» Fifth level

FHIR WITH OTHER STANDARDS

 Digital
Click toImaging and Communications
edit Master title style in Medicine (DICOM)

• •Standard
Click to by
editNational
MasterElectrical
text stylesManufacturers
Association (NEMA)
– Second level
• Global• specification
Third level for exchanging medical images in
radiology,–pathology,
Fourth level
cardiology and related disciplines
• Majorly used» to standardize
Fifth level output of medical imaging
hardware (X-Ray, CT, MRI machines) and software
(PACS, Radiological Reporting)
• DICOM is hierarchical information structure, has a
Client-Server service architecture, and also provides
File/DIR specifications
• Using DICOM with FHIR
– The DiagnosticReport FHIR Resource can carry a DICOM
ImagingStudy while exchanging information
 Click to edit
SNOMED CTMaster title style

• • Maintained
Click to editand
Master text styles
distributed by SNOMED International (also known as
– Seconda level
IHTSDO), SDO with about 47 countries as members/owners.
• Third level
• Structured vocabulary used in clinical practice to accurately describe the
– Fourth level
care and treatment
» Fifth levelof patients

• Purpose
– Semantic Interoperability
– To support clinical care:
• Recording statements about the health and health care of an individual patient
• Express meaning at various levels of abstraction for clinicians, patients,
researchers or organisations
 Click to edit
SNOMED CTMaster
Coverage
title style
Diagnosis

• •Comprehensive, multilingual
Click to edit Master textclinical
styles Symptoms/Chief Complaints
healthcare terminology Laboratory
– Second level
• Covers 18 major healthcare domains with Procedure/ Treatment
several• sub-domains
Third level Orders, Results
– Fourth level
• Contains 3,60,940 unique concepts Medications
» Fifth levelwith more than 1.4
relevant in healthcare, Body Structure
million descriptions and more than two Nursing
and a half million relationships between Substance
them Medical Devices
• Extendible for National Requirements Medical History
– AYUSH medicine Organisms
– Drug codes
Specimen
– Any other specific to India
Events
• Useful in research, data analytics, CDSS, etc. Environment / Geographical location

Record artifacts
Click to edit
SNOMED CTMaster
Data Model
title style
• Click to edit Master text styles
– Second level
• Third level
– Fourth level
» Fifth level
Click to edit
SNOMED CTMaster
in Health
title
Records
style
• Click to edit Master text styles
– Second level
• Third level
– Fourth level
» Fifth level
Click to edit
SNOMED CTMaster
in FHIRtitle style
• Click to edit Master text styles
– Second level
• Third level
– Fourth level
» Fifth level
Logical
Click toObservation
edit MasterIdentifiers Names and Codes (LOINC)
title style
• Click to editstandard
Universal Master text
forstyles
identifying (coding) medical and
– Second levelobservations
laboratory
• Third level
• Created and is maintained by the Regenstrief Institute, a US
– Fourth level
nonprofit» medical
Fifth level research organization.

• Essentially a laboratory coding system

• Details the method, components, system, etc. used for doing a
particular test / observation
– 9156-0 Glucose [Moles/volume] in Urine by Automated test strip
– Glucose:SCnc:Pt:Urine:Qn:Test strip
Click towith
LOINC editFHIR
Master title style
• Click to edit Master text styles
– Second level
• Third level
– Fourth level
» Fifth level
Individual LOINC Test Code

LOINC Panel (Logical group of LOINC test observations)

Click to edit Master
International Classification
title style
of Diseases (ICD)
• Click
Created
to and
edit Maintained
Master textbystyles
the World Health Organization (WHO)
• Designed
– Second as a health care classification system, providing a system of diagnostic
level
codes for classifying
• Third level diseases
• Supported
– Fourth
clinical
levelcare use cases:
» Fifth level
– Monitoring of the incidence and prevalence of a disease
– Observing reimbursements and resource allocation trends
– Keeping track of safety and quality guidelines
• Enable aggregation of data to support their decisions and policies
• Allows government bodies to conduct epidemiological research of health trends
• Allows health data comparisons in the same location across different time
periods
Click–to
ICD 10edit
Examples
Master title style
• Click to edit Master text styles
– Second level
• Third level
– Fourth level
» Fifth level
Click towith
ICD-10 edit Other
MasterStandards
title style
• ICD-10
Click towith
edit SNOMED CTstyles
Master text
– Second
The granular
level data entry happens in SNOMED CT
– Standard
• Third level
SNOMED CT to ICD-10 mapping is available
– ICD-10– Fourth level classification is reported for epidemiology, insurance, etc.
code based
» Fifth level

• ICD-10 with FHIR

– The Claims Resource links to ICD-10 code
Click to edit Master title style
• Click to edit Master text styles
– Second level
• Third level
– Fourth level
» Fifth level

ADOPTION OF FHIR IN ABDM

 Click to edit
Approach used
Master
for Data
title sharing
style in NDHM
Fast Healthcare
• Click Interoperability
to edit Master text stylesResource (FHIR) standard based data sharing
for all– HI Typeslevel
Second supporting data in 03 formats -
• Scanned Documents
• Third level
– Helps uploading historic data
– Allows–quick
Fourth level
on-boarding
• Structured data
» Fifth level standard terminology
without
– Structured data sharing with flexibility to include free text
– Better understanding of context
– Tools like Natural Language Processing can be used for
analytics in future
• Fully structured data with Coding / Terminology
(SNOMED CT / LOINC/ ICD)
– Better understanding of data (interoperable and
processable data)
– Data accuracy is guaranteed to the maximum
– Data ready for analytics which can help in real time
decision support
• DICOM for medical images 26
Click to
FHIR Implementation
edit Master title
Guide
styleBuild 3.0.0
•• FHIR
ClickImplementation
to edit Master Guide text
(IG) for ABDM:
styles
https://nrces.in/ndhm
– Second level
• Describes requirements for ABDM FHIR implementation
– HL7• Third level ICD-10, SNOMED CT, LOINC
FHIR, DICOM,
– Fourth level
• 50 FHIR profiles include 07 Clinical Artifacts (HI
» Fifth level
Types); and 39 core profiles
1. OP Consultation Note 5. Wellness Record
2. Discharge Summary 6. Immunization Record
7. Health Record Document
3. Prescription
4. Diagnostic Report

• 04 Code Systems and 26 Value sets from

standard clinical terminologies to support their
use in profiles
www.nrces.in/ndhm
Click to edit Master title style
Profiling
• FHIR specification
Click to edit Mastersatisfy the majority of common use cases
text styles
– Second
Provideslevel
flexibility to extend and adapt it according to local needs
– Almost
• Thirdevery
levelelement in the base FHIR specification is optional
– Fourth level on content of the data and operations is needed
• The conformance
» Fifth level
• FHIR profiling is a way to build consensus on content, operations & search
parameters supported
– Defining required and optional resource elements
– Defining additional resource elements are needed
– Binding terminology and value sets to be used
– Deciding which API features are used, and how
Click to
FHIR - Profiling
edit Master
Resources
title style
• Click to edit Master text styles Required
– Second level
Must Support
• Third level
– Fourth level Optional
» Fifth level

- Define what is required, optional, etc.

- Allow building light weight objects
- Enable Minimal Data sharing
- Provision for maximum data sharing (as
needed in different contexts)
- Reuse standard defined data structures
- Productive time investment
Patient Resource
Click to edit
Reading FHIRMaster
Profiles
title
forstyle
ABDM
• Click
Text toSummary:
edit Master provides human-readable summary of changes that we
text styles
have made.
– Second It refers to the Differential View of a profile.
level
• Differential
• Third level
View: mentions the elements that are changed while profiling
– Fourth level
• Mandatory Element: Element with cardinality 1..1, 1..*
» Fifth level
• : element that must be supported.
• MUST Support: implementations that produce or consume resources
SHALL provide "support" for the element in some meaningful way
• MUST Support for ABDM: The Receiver (HIU) MUST have the capacity to
read the element though it is optional. The Sender (HIP) may opt not to fill
the element while sending (when data is not available)
Understanding the Structure
Click to edit Master of ABDM HI Types in FHIR
title style
subject: Patient (Ref)
• Click OP
to Consult
edit Master
Note text styles Syntactic
Interoperability
encounter: Encounter (Ref)
author: Patient | Practitioner |
– Second level
resourceType: Bundle "type" : {
PractitionerRole | Organization (Ref)

• Third level
Id: OPConsultNote-example-05 "coding" : [
{
type: document
– Fourth level "system" : "http://snomed.info/sct",
"code" : "371530004",
» Fifth level "display" : "Clinical consultation report"
Entry [0]: Composition }
],
title: “Consultation Report”
section: Chief complaints [Condition (Ref)]
Entry [1]: Patient
PhysicalExamination [Observation(Ref)]
FamilyHistory [FamilyMemberHistory(Ref)]
"code":
Procedure [Procedure(Ref)]
{
Entry [2]: Condition "coding": [
.
.
{
.
"system": "http://snomed.info/sct",
.
Entry [3]: Procedure "code": "297142003",
. "display": "Foot swelling" Semantic
. } Interoperability
. ],
"text": "Foot swelling"
}
Click to edit Master title style
• Click to edit Master text styles
– Second level
• Third level
– Fourth level
» Fifth level

ADOPTION OF FHIR IN NHCX

ClickUse
Key to edit
cases
Master title style
• Click to edit Master text styles
Get provider/payer details.
– Second level
• Third level
Eligibility check for a beneficiary – Check can be for Coverage eligibility / Package or procedure eligibility.
– Fourth level
» Fifth
Pre auth leveland approval flow – Claim Type as Pre-determination, Pre-authorization
request

Claims request and Approval flow – Claim Type as Claim

Payment notification

Reprocessing claims – In case of partial approval or rejection of the claim

Search/fetch claims data for status checks, regulatory compliance, etc..

33
Click to edit
Profiling Requirements
Master titlefor
style
NHCX
-•Ensure
Click tothe
editcycle
Masterspecific
text resources
styles are being shared
- – Second
Ease level
of use, validation and processing
-FHIR• resource
Third levelstructures to be adopted over NHCX APIs
– Fourth level
-The profiling should
» Fifth level be generic enough to support any insurance workflow
(including PMJAY)
- Value sets from Indian context are to be defined
- Ensure the practical scenarios of insurance processing are covered from
Indian context (Proof of Presence, Proof of Identity, etc.)
- Leverage the ABDM profiles & Resources and extend the same IG for NHCX
Click toStandard
NHCX edit Master
Development
title style Approach
• Collaborative approach
• Click to edit Master text styles
– End-user driven
– Second level
– Include Public & Private communities/users Relevant Standards: SNOMED CT,
• Third level LOINC, ICD, FHIR
– Consultation and feedback from national
– Fourth level
agencies (NHA, IRDIA, etc.)
» Fifth level
• Focus on implementing best suitable design Profile Designing
– Use-case driven
• Re-use existing efforts (ABDM profiles) Implementation Guide
• Leverage the existing/community work
• NRCeS to be the SPC and Maintainer for ABDM
Profiles, NHCX Profiles like CDCI, AYUSH Value Sets
standards and other initiatives of MoHFW
FHIR
Click Resource Under
to edit Master titleConsideration
style for NHCX
• InsurancePlan: InsurancePlan represents the product
• thatClick
can beto offered
edit Master text styles
to the customer. It describes a
health insurance level
– Second offering comprised of a list of covered CLAIM
benefits, costs associated with those, and additional
• Third
information about level
the offering. INSURANCE
PLAN
CLAIM
RESPONSE
• Claim: Claims–are used to
Fourth exchange financial and clinical
level
information between healthcare providers, payors
/insurers. » Fifth level
• Claim Response: Claim Response resource provides COVERAGE
TASK ELIGIBILITY
application-level adjudication results or errors after
REQUEST
processing a submitted Claim. FHIR RESOURCE FOR NHCX
• Coverage Eligibility Request: The Coverage Eligibility
Request asks the insurer for a CoverageEligibility
Response with information about valid coverage, COVERAGE
PAYMENT
available coverages, provided benefits, and pre-auth RECONCILATI ELIGIBILITY
ON RESPONSE
requirements.
• Coverage Eligibility Response: Coverage Eligibility
PAYMENT
Response provides eligibility and plan details from a NOTICE COVERAGE
Coverage Eligibility Request.
Click toProfiles
NHCX edit Master title style
• FHIR profiles
Click to NHCX text styles
edit Master
– Second level
• Third level
– Fourth level
» Fifth level

• Relevant Value sets

Preview - https://nrces.in/preview/ndhm/fhir/r4/hcx-profile.html
Understanding the Structure
Click to edit Master of Claim Bundle
title style
Syntactic Claim
Interoperability
• Click to edit
Claim Master text styles
Bundle
"resourceType" : "Claim",
"status" : "active",
Claim Type as Pre-
determination, Pre-
"use" : "claim | pre-auth |pre-det, authorization, Claim
– Second
resourceType: level
Bundle "patient" : {"reference" : "Patient/1“},
“insurer”: {"reference" : organization/1}
• Third level
Id: Claim-01
type: collection
“diagnosis”:{“reference”: ”condition”}
“procedure”:{“reference”: “procedure”}
– Fourth level
Entry [0]: Claim
Patient Organization
» Fifth level "resourceType" : "Patient", "resourceType" : "Organization",
"name" : { "text" : "Ayush Sharma" }, "name" : "XYZ Insurance Pvt.Ltd.",
Entry [1]: Patient "gender" : "male", "telecom" : [ { "system" : phone",
"birthDate" : "1981-01-12" "value" : "+91 243 2634 1234",
"use" : "work" }
Entry [2]: Insurer
Practitioner
Entry [3]: Provider "resourceType" : "Practitioner",
"name" : [{ "text" : "Dr. Aysush" } ]
Procedure
Entry [4]: Procedure "resourceType" : "Procedure",
Condition "status" : "completed",
"code" : { "coding" : [ {
.
Entry [5]: Condition "resourceType" : “Condition", "system" : "http://snomed.info/sct",
"status" : "completed", "code" : "36969009",
. "code" : { "coding" : [ { "display“: "Placement of stent in coronary artery"
. "system" : "http://snomed.info/sct",
"code" : "53741008 ",
"display“: “Coronary arteriosclerosis “}}}
Click toFocused
NHCX edit Master
FHIR title
Resources
style
•• FHIR
ClickImplementation Guide text
to edit Master (IG) for ABDM: https://nrces.in/ndhm
styles
• Describes requirements for ABDM FHIR implementation
– Second level • Claim
– HL7 FHIR, DICOM, ICD-10, SNOMED CT, LOINC
• Third level • Claim Response
• 50 FHIR profiles include 07 Clinical Artifacts (HI Types);
– Fourth level • Eligibility Request
04 Health Claim
» FifthExchange
level (HCX) profiles and 39 core
profiles
• Eligibility Response
1. Claim Bundle • Insurance Plan
2. Claim Response Bundle • Coverage
3. Coverage Eligibility Request Bundle
• Payment Notice
4. Coverage Eligibility Response Bundle
• Payment Reconscillation
• Task

www.nrces.in/ndhm
 Click to edit Master title style
Examples
• Click to edit Master text styles
– Second level
• Third level
– Fourth level
» Fifth level

CoverageEligibilityRequest with purpose: ’auth-requirements’

Claim with use: ‘claim’
Click to edit Master title style
• Click to edit Master text styles
– Second level
• Third level
– Fourth level
» Fifth level
Thank You

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