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Medication Electronic Prior Authorization, the Next Big Thing for EHRs
By Tony Schueth
Electronic prescribing (ePrescribing) has surpassed the tipping point, where more prescriptions are being written electronically than on paper. Now the industry must start thinking about the next big thing that will take ePrescribing to the next level and address one of healthcare’s most inefficient processes: prior authorization (PA) of prescriptions.
With ePrescribing considered table stakes in an electronic health record (EHR), software developers should be thinking about innovations that will take ePrescribing from a humdrum utility to a must-have. Electronic prior authorization (ePA) for the pharmacy benefit offers that innovation opportunity.
EPA is the #1 ePrescribing capability desired by physicians, according to market research conducted by NCPDP’s ePA Task Group. In order to foster a standardized approach to satisfy this demand, NCPDP approved an electronic data interchange (EDI) standard for ePA last year.
By design, the ePA transaction can be integrated with the EHR ePrescribing work flow, enabling prescribers to complete the prior authorization process within two minutes as compared with the manual process, which involves many phone calls and faxes that can take days to weeks to complete (15 days, on average). Considering that specialty medications dominate the drug pipeline and require prior authorization up to 95 percent of the time, the need for ePA is urgent.
Seven states have mandated the use of ePA beginning in late 2014 and eight others are engaged in ePA regulatory activity. In May, the National Committee on Vital Health Statistics (NCVHS) recommended that the Department of Health and Human Services adopt the NCPDP transaction as the standard for medication PAs. NCVHS recommendations regarding ePrescribing and related transactions often become requirements for payer participation in Medicare Part D.
The coming regulatory mandates afford EHR vendors the opportunity to be ahead of the curve. Rather than scrambling to meet multiple state regulatory deadlines at the last minute, vendors can take advantage of the interval between Meaningful Use (MU) Stages 2 and 3 to begin development of ePA functionality while there is still breathing room to concentrate on work flow enhancements.
The availability of ePA may sway some physicians in their EHR choice. Recently, Surescripts found that 28 percent of physicians surveyed would switch their EHR for one that supports ePA. While this percentage may be exaggerated based upon a single feature, there is no question that a robust replacement market for EHRs exists. Many physicians are looking to transition from early purchases of basic EHRs to more sophisticated solutions.
EDI networks such as Surescripts have begun offering ePA connectivity, while such established ePA services vendors as CoverMyMeds have introduced APIs to ease EHR integration. Some service providers offer connectivity for all ePAs – even if a pharmacy benefit manager or other payer isn’t electronically enabled, electronically initiated ePAs are delivered via fax.
The time is right. EPA is a logical and useful enhancement that physicians desire. A transaction standard that ensures compatibility is in place. Regulators are beginning to mandate its use. The number of PAs is growing. EDI networks and service vendors are eager to ease integration.
With the rare opportunity posed by the MU Stage 2 delay, vendors can roll out a new feature that is a “win-win-win-win” benefit for physicians, patients, payers, and EHR vendors.
Tony Schueth is founder, CEO and managing partner at Point-of-Care Partners of Coral Springs, FL.