When we introduced our workflow-integrated decision support platform, CarePaths, in 2019, we had the aim of changing the way physicians interact with their EHR. We built CarePaths after optimizing our Insight engine on millions of clinical records for decision support since 2011. Targeted, patient-specific advice and ease in workflows was associated with identifying relevant treatments for patients and reducing the barriers to accessing 3 types of important medicines:
3. Prior Authorization therapies:
A common obstacle to timely patient care and efficient physician workflow is the requirement for Prior Authorization for patient services and medications. Usually it is the patient’s insurance carrier that is authorizing services but occasionally the FDA or a pharmaceutical company can be the authorizing agent (as in Expanded Access Programs). Regardless of who’s authorizing, the questions are always of the same flavor:
- Name of the requested investigational medicinal product along with physician’s intended treatment plan, including therapeutic indication and expected duration of treatment
- Medical rationale for request including an explanation for why alternative therapy cannot be used, why the patient does not qualify for a clinical trial, and why use of the investigational drug is in the patient’s best interest
The role of timely information:
The process requires multiple steps but basically is information-driven. The electronic medical record plays an important role in providing this information. Currently this process is not automated within the EHR. The physicians, pharmacists and administrative staff have to gather the information manually from the EHR and submit it to the authorizing agent. Since the required information is not standardized, the provider must be familiar with the unique requirements for that submission. This often results in denial for incomplete information and the beginning of a time-intensive cycle of resubmissions and denials. For the provider, this means additional overhead costs and frustration. For the patient, there is denial or delay of care and resulting frustration.
Streamlining this process is possible with current IT technology integrated with EHR systems like Epic, and goes a long way to controlling physician costs and to improving patient care and satisfaction through better access and safer monitoring.
CarePaths works as follows:
1. The physician is alerted to the need for authorization at the point of care after interviewing the patient to assess their condition, and documenting their visit note. This alert is determined by identifying diagnoses and therapies which are designated by the physician and comparing the patient’s insurance benefits with a database of benefits for that local region.
2. The physician considers the advice in the EHR alert and the relevant clinical data points would be gathered and populate the required form, including the requested drug, its regimen and justification for why that drug must be used (including other therapies which may have failed).
3. If more information is required, the physician is advised in real-time through established notification channels in their workflow through the Electronic Health Record system. Once completed the authorization form is automatically routed electronically through an API to the patient’s insurer. This entire process takes place during the patient appointment, eliminating any additional time and effort by the physician and her staff.
Physicians each spend an average of 50 hours per year fulfilling PA requests, not to mention the administrative and nursing burden. Payers are also taking longer to respond for newer biologic medications. The AMA estimates that doctors get 37 PA requests per week. The estimated annual cost of PAs per physician is in the thousands of dollars with negative impact on patients. The majority of PAs are rejected at the pharmacy and the rest delaying drug access. The major reason why the PA process consumes so many resources is that providers and their staff complete PAs outside of their normal workflows. Payers require practices to use proprietary portals or manually download forms. Medical practices manually re-enter data or even fax requests with excessive administrative waste.
The benefits of an automated prior authorization process is obvious to the physician and the patient: lower overhead, more timely care, better outcomes and greater satisfaction. The hospital and community pharmacists also benefit because the appropriate form is shared along with the drug order, simplifying the dispensing of the drug. But the insurer also is a beneficiary of improved data collection, resulting in fewer callbacks and less client frustration. The time for automated authorization has come with CarePaths.