1) Background: 2.2 "Where attribution is not present or non-repudiable, then HIE content is not acceptable for most payer use-cases." Recommend expand this paragraph with further explanation/examples.
2) 8 Specification: While paragraph references HRex, the importance of Security and Privacy could warrant a direct link to the specific section of HRex.
3) 8.1 Specification re Authorization: Suggest: if simple data pull (eg Hba1c in relevant Period) has been so approved for this payer/consumer, then EHR system might provide auto-Auth but Clinican review/opinion could be signed similar to an order/note.
4) 8.2.4 Specification: Queries SHALL/MUST be locked down to patients covered by that payer (at some point in time, with timing considerations to restrict access to pertinent patients) - suggest such an important consideration be noted here as well, not just HRex.
5) Specification: Strongly recommend: Any/all payer searches/queries SHALL/MUST be documented in the EHR patient record, with audit trail available for clinician/patient (queryable/reportable). While EHR dependent, process/specification should be standardized.
6) Localizing non-structured data elements by SNOMED, ICD-10 or historical data will be very challenging due to multiple concepts within text blocks or dictated text under catch all identifiers and therefore flow to clinicians' workflow in-baskets.
7) Clinicians are concerned re increases in volume/frequency/complexity of requests from multiple/recurrent payers overflowing their workflow in-basket impacting patient care due to increased face to screen time especially if it cannot be accurately/automatically delegated to EHR/support staff.

(Comment 68 - imported by: Jean Duteau)