Regence, MultiCare launch FHIR-based approach for pre-authorization

This first in the nation effort will facilitate information exchange directly from the ACO’s electronic health records system.

A FHIR-based approach is expected to speed pre-authorization of treatment for patients through use of a FHIR-based API.

An initiative using a standard-based method developed by the Da Vinci Project aims to facilitate the pre-authorization process for gaining approval for medical care for patients.

The effort involves Regence, a parent company of health plans in four northwest states, and MultiCare Connected Care, an independent accountable care organization that is a subsidiary of MultiCare Health System. The organizations say it is the first try in the country at using FHIR-based pre-authorization.

Anna Taylor, associate vice president of population health and value-based care, MultiCare

“When providers can spend more time collaborating with their patients on treatment plans, they have a better chance of improving outcomes.”

The intent is to use the Fast Healthcare Interoperability Resource (FHIR) standard to enable quicker turnarounds of prior authorization determinations. The process of gaining payer approval for clinical interventions has remained a challenge for the healthcare industry, with concerns growing that the traditionally manual process is an administrative burden, delays the clinical workflow and results in interruptions in care, which could impact patient safety.

Developed by the HL7 Da Vinci Project, the application programming interface (API) provides an interoperable method for providers to submit pre-authorization requests directly from electronic health records (EHR) at the point of care. The organizations believe this will enable faster determinations, reduce administrative burden and costs, and support better outcomes for patients.

Seeking more efficiency

The process of requesting and receiving pre-authorizations historically has been slow and labor-intensive. Pre-authorization requests are often submitted by fax or through health plan-specific portals where re-keying clinical information is necessary and can result in data entry errors and delays in treatment.

FHIR offers a way to accelerate the process. It is widely supported by most electronic health records and will enable providers to submit authorization requests, including all necessary clinical information, and receive near real-time determinations within their existing workflow.

Pre-authorization is both a way to ensure patients are receiving proven effective care, while also making sure that the cost of care is restrained.

“Pre-authorization helps ensure our members are receiving the most effective and appropriate treatments, while managing the costs of care,” contends Kirk Anderson, Regence’s chief technology officer.

Efficiencies will be enhanced by enabling FHIR to access information with MultiCare’s EHR, making it part of the clinical information system’s capabilities, the organizations contend.

“Embedding pre-authorization in our native EHR system is a gamechanger,” says Anna Taylor, MultiCare Connected Care’s associate vice president of population health and value-based care. “Not only will we ease the administrative complexity of healthcare, but the ability to receive transparent and actionable data at the point of service accelerates care delivery and increases adherence.”

Patient care benefits

“Regence and MultiCare share a vision of applying technology and data to transform the healthcare experience,” Anderson emphasizes. “Bringing pre-authorization to the point of care reduces the burden on health systems managing patient data and promotes timely, evidence-based care and a more seamless experience for our members.”

The effort is also expected to provide payback in terms of improved quality of care and results, Taylor adds. “When providers can spend more time collaborating with their patients on treatment plans, they have a better chance of improving outcomes.”

“Da Vinci Project fosters cross-sector collaboration to solve for common data sharing challenges that hinder care delivery and innovation,” said Jocelyn Keegan, Da Vinci Project’s program manager. “Regence and MultiCare are spearheading health care interoperability with this first-in-the-nation implementation of FHIR driven pre-authorization. This pilot will transform the member and provider experience and create the foundation for greater data sharing applications across the industry.”

With members from health plans, health systems and health IT companies, HL7’s Da Vinci Project is a national, private-sector initiative to accelerate the use of HL7 FHIR to enable value-based care through interoperable data. With support from the Centers for Medicare & Medicaid Services, Da Vinci Project was granted a HIPAA exception to test an end-to-end FHIR solution.

To learn more about the Da Vinci Project, visit this website.

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