Recently a multi-stakeholder consortium led by the American Medical Association (AMA) published a white paper entitled “Prior Authorization and Utilization Management Reform Principles.”
This paper identifies 21 principles on utilization management (UM) programs, to reduce the negative impact that these programs have on patients, providers and the health care system (21 principles). Many focus on transparency of UM requirements, the evaluation and approval process and the appeals process.
While the 21 principles were primarily directed to utilization review entities, there are several which could be solved by EHRs and, as a result, have an impact on electronic health records (EHR) and ePrescribing software vendors. Many (or all) of the 21 Principles could end up being legislated as regulations. A proactive approach by vendors ensures that workflow designs can be elegant and functional, rather than rushed out to meet a regulatory requirement.
Principle #9 proposes that utilization review entities provide, and vendors display, accurate, patient- specific, and up-to-date formularies that include prior authorization and step therapy requirements in electronic health record (EHR) systems for purposes that include ePrescribing.
It is widely believed that the formulary information available to prescribers in the EHR is incomplete, and coverage restrictions aren’t always available or displayed. This principle seeks to address the issue from two perspectives. First, to ensure that the payers include complete coverage restriction data in the formulary files provided to the EHRs. Second, to ensure that the EHR and ePrescribing software vendors have developed their products to accurately display the coverage restrictions.
Principle #12 proposes that a utilization review entity requiring health care providers to adhere to prior authorization protocols should accept and respond to prior authorization and step-therapy override requests exclusively through secure electronic transmissions using the standard electronic transactions for pharmacy and medical services benefits.
The integration of electronic prior authorization (ePA) functionality in EHRs has been slow. EHR and ePrescribing vendors are moving conservatively to embrace ePA because of uncertainty of utilization by providers, despite the fact that there are state mandates requiring ePA. When all UM entities support ePA, provider demand will be sufficient to implore their software vendors to build ePA functionality.
Principle #18 encourages utilization review entities to standardize criteria across the industry to promote uniformity and reduce administrative burdens.
This principle is of vital importance to EHR and ePrescribing software vendors because it will enable vendors to query stored clinical data and respond to UM questions, rather than necessitating practice staff completing and faxing paper forms. Standardization of the query data means that questions are phrased the same way when asking for the same data, for example requiring a patient’s date of birth vs. patient's age or how old is the patient.
Some of the other principles can be enhanced by a new standard that is being developed at NCPDP and companies are piloting that provides patient-specific, real-time formulary and benefit information at the point-of-care (see more information here). As UM entities elect to leverage this emerging technology, EHRs should actively consider incorporating it into their solutions.
We applaud the multi-stakeholder consortium for coming together to draft these 21 principles. EHRs can remain proactively at the forefront of the evolution toward patient-centered care by embracing these principles and enhancing software to enable providers to ensure that patients have timely access to treatment.