Recommendations For A North Star to Guide Electronic Prior Authorization Standards
A team from UCSF Health and our Center for Digital Health Innovation was recently privileged to submit a letter to the Office of the National Coordinator for Health Information Technology’s (ONC) Request for Information on Electronic Prior Authorization Standards, Implementation Specifications, and Certification Criteria. I was joined in writing and submitting by UCSF colleagues: Drs. Uma Mahadevan, Maria Byron, Stefano Bini, Diane Sliwka, and Anobel Odisho. Read our full letter to ONC here.
In the letter, we provided three different real-world examples where patients and care teams are feeling burden and distress:
(1) durable medical equipment prescribing, e.g. diabetes supplies,
(2) medication authorization, e.g. biologic medications for inflammatory bowel disease, and
(3) surgical procedure authorization, e.g. orthopedic procedures.
There is no doubt the current situation with prior authorization is untenable. Patients are routinely frustrated, waste hours and days battling the system, and worse, have frequent delays in basic care needs. Providers and clinical staff waste precious time completing paperwork instead of spending time with patients. Clinics and hospitals spend significant resources on hiring additional staff to deal with the paperwork burden, inhibiting our ability to put those resources to better use. The systems, with layer upon layer of middlemen and ever-changing rules and processes, have become so complex that we are often left uncertain of what the process is, what the next step is, what the rules of the game are. To all who suffer the consequences, it often feels like intentional denial of care is the goal. At a time when healthcare costs are spiraling upwards, patients are frustrated by a poor care experience, and healthcare workers are leaving the workforce in record numbers due to burnout, one only need to look at prior authorization as a prime example of a system in need of reform.
We based our 10 recommendations in our experience where technology initiatives are more likely to succeed when centered around a future state workflow or outcome, a “north star,” that they are trying to achieve. We suggested that Electronic Prior Authorization standards be anchored by a core set of patient-centered journeys and targeted clinical care outcomes, such as the real-world examples we give from diabetes care, inflammatory bowel disease care, and orthopedic surgery care. That is, what specific outcome should a patient be able to accomplish tomorrow that they are not able to do today, and what system changes and technology standards are needed to support that specific outcome? Which actors need to be involved and which underlying systems need to be developed to support an end-to-end workflow? ONC has already proposed an excellent set of functional capabilities to be considered. We suggest the ONC both (1) broaden the required set of capabilities, and (2) ensure that the work is completed by each tranche of work attempting to solve for a single end-to-end patient use case, as opposed to solving for individual fragmented capabilities that could fail to result in meaningful patient outcomes.
We applaud the efforts of many to move forward these desperately needed standards and electronic capabilities. We believe they will only be as successful as their ability to help support patients receive the care they need and deserve in a transparent and efficient manner, and to support providers in helping care for their patients without undue administrative burden and loss of time. Technology and standards without a north star to guide the journey may lead us to get lost at sea.
Aaron Neinstein, MD