Why incremental steps are the key to ePA success

Automatic processes to achieve prior authorization intersect with every facet of the healthcare industry, so it’s critical to get it right the first time.

It's critical to streamline the ePA process, providing standards and time for testing to ensure success.

This is the last column in a four-part series examining the need for ePA, the barriers presented by the current environment, necessary capabilities and functionality for progress, and the EHR Association’s policy recommendations. View part 1

Health information technology holds great promise for contributing to efforts to streamline and improve the efficiency of the highly complex prior authorization process, and the EHR Association is confident that electronic health record (EHR) systems have a vital role to play in doing so.

However, the adoption of electronic prior authorization (ePA) is not without its challenges – all of which will require time, significant cross-stakeholder coordination, and standardization of access to and exchange of related data.

As noted in the previous three blogs in this series, the EHR Association supports streamlining the ePA process, provided the effort is appropriately supported by accepted standards and ensuring that care is taken to avoid past mistakes of rolling out policy requirements faster than standards have been developed to support the work. 

Standard maturity

As discussed in the second blog, standards are crucial to the successful adoption of ePA. We are seeing progress in the form of the Da Vinci Project’s Coverage Requirements Determination (CRD), Documentation Templates and Rules (DTR) and the Prior Authorization Support (PAS) implementation guides.

However, in their current state, these standards are not mature enough to enable a robust, testable certification program because they do not yet cover all relevant interactions among critical health IT components within both the provider and payer infrastructures.

Also problematic is the USCDI standard, which lacks agility in allocating the relevant subset of USCDI data for specific use cases. This is particularly germane considering that health IT solutions would need to be certified to support all USCDI, even though ePA requires only some of the data.

In light of this, the EHR Association urges ONC not to assign responsibility for all provider-side interactions to any single health IT solution, such as EHRs. Instead, ONC should work first with the Centers for Medicare & Medicaid Services to focus on the adoption and certification of the implementation guides on the payer side and establish a clear implementation standard for any interactions with the payers supporting prior authorization.

We also discourage establishing certification criteria for provider-focused health IT until there is clarity on how the specific functional needs addressed within the implementation guides map to the various systems supporting prior authorization that are in use at healthcare organizations.

Pacing policies

On the policy front, the EHR Association suggests that ePA regulations roll out at a pace and with a legal and regulatory cadence that aligns with the ability of stakeholders to deploy and use solutions that follow consistent standards – something that can’t happen if policy requirements outpace standards development. 

Further, policymakers need to approach the rollout of requirements with clear expectations. Any unintentional release of ambiguous definitions, the inclusion of unclear enforcement procedures or failure to sufficiently address intersections between other federal, state and local regulatory frameworks will weaken the ability of actors to have confidence that they are compliant.

The EHR Association recommends a two-stage approach to ePA. Stage 1 would focus on working with CMS on the adoption and certification of the CRD and PAS Implementation Guides (developed by the Da Vinci Project) on the payer side – saving Documentation Templates and Rules (DTR) for a later date – while establishing a clear implementation standard for any interactions with payers supporting prior authorization.

It is important to note that while the CMS notice of proposed rulemaking appears to support this approach, we will not have a full understanding of what the proposed first stage for rolling out ePA support across CMS and ONC should be until the latter issues its own rule-making notice.

Stage 2 would involve the establishment of EHR certification criteria based on the matured and evolved interaction distributions across health IT, with the typical interaction sets documented clearly within each Implementation Guide. Further, this should include extending the provider functional requirement for prior authorization engagement with the use of certified health IT to support the prior authorization workflow.

Next steps

The path to ePA is one that intersects not only with patient care but also with every facet of the healthcare industry. The stakes are high. It is critical that we get it right the first time.

Proposed rulemaking has already been issued by CMS, and we expect related regulations from ONC shortly. It is time to move past individual stakeholder issues and wish lists and dig into how the proposed implementation of ePA will span the entire healthcare industry, impacting patients, payers, providers, and even health IT developers. 

To that end, the EHR Association is interested in discussing its suggestions with all industry stakeholder groups. We look forward to exploring and advancing a practical and deliberate ePA roadmap to establish a more efficient and effective process for providers and payers, and ultimately the ability to improve the provision of timely patient care.

David Bucciferro (Foothold Technology) is the chair of the EHR Association.

This is the last column in a four-part series examining the need for ePA, the barriers presented by the current environment, necessary capabilities and functionality for progress, and the EHR Association’s policy recommendations. View part 1

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