Standards, Certification, and ePA: Proceed with Caution

By Hans Buitendijk (Oracle Cerner), EHRA Chair

This is part one in a four-part series examining the need for electronic prior authorization (ePA), the barriers presented by the current environment, necessary capabilities and functionality, and the EHR Association’s policy recommendations.

The prior authorization process required by health plans and payers frustrates patients and providers alike because of inconsistent requirements and associated delays, and it isn’t going away. 

It is clear that there is an opportunity to apply health information technology (IT) toward the goal of improving efficiency in this area, but doing so will be a challenge that requires significant cross-stakeholder coordination and standardization of related data. The need for a collaborative focus is further exacerbated by the widely varying approaches to the adoption and deployment of health IT systems among providers. Further, the process itself touches many different points and players in administrative, clinical, and financial workflows. 

Because prior authorization happens within a complex, fluid environment requiring many steps, rules, and wait times that vary from payer to payer, automation will not happen overnight and must be well orchestrated across all affected stakeholders to be successful. As the EHR Association mentioned in its response to a Request for Information (RFI) on electronic prior authorization (ePA) from the Office of the National Coordinator for Health IT (ONC), a staged approach that establishes a glidepath enabling needed flexibility and the availability of relevant, standards-based software will increase the chances of success. 

The EHR Association does not question the need for a streamlined ePA process if it is appropriately supported by the availability of accepted standards and sufficient time for development and certification. However, patients, caregivers, clinicians, and payers already struggle with associated barriers. To act with haste and/or require provider compliance with ePA rules when complete technical specifications to enable relevant health IT to consistently support the complex prior authorization workflow are not available will result in a roll-out that suffers from missed expectations and delays. 

The EHR Association does not question the need for a streamlined ePA process if it is appropriately supported by the availability of accepted standards and sufficient time for development and certification. However, patients, caregivers, clinicians, and payers already struggle with associated barriers.

The pace at which the ePA process rolls out and the regulatory cadence as standards are available are critical to the success of the initiative and its ability to deliver true value to all who are impacted. Other specific areas of concern – which potentially align with those of other stakeholder groups focused on provider advocacy – are transparency in decision-making, burden reduction, data privacy, and certification gaps.

It is clear to us that the industry will continue to explore and ultimately come to a consensus on the best path to the deployment of certified health IT that takes a standards-based approach to ePA, as well as associated requirements by regulators looking to affect change by both software developers and provider organizations. Standards development work is still to be done, changes must be made by the payers who are a critical part of the data loop, and further analysis of complex ePA workflows must be undertaken. 

To that end, over the next several months the EHR Association will publish a series of blogs – culminating in a comprehensive white paper – that lays out in detail the use case for ePA, barriers presented by the current health IT and regulatory environment, necessary health IT capabilities and functionality, and our policy recommendations. 

Along with Buitendijk, contributing authors to this blog series are EHRA Co-chair David Bucciferro (Foothold Technology), EHRA Public Policy Leadership Workgroup Chair Leigh Burchell (Altera Digital Health), and EHRA Public Policy Leadership Workgroup Vice Chair Janet Campbell (Epic).  

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1 Comment

  1. Standards will Make or Break Efforts Toward ePA | EHRA Blog

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