Trailblazers: Using FHIR to automate prior authorizations

FHIR blazes the way

Anna Taylor, MS, CIPCT, associate vice president of population health and value-based care at MultiCare Connected Care, attributed prior authorization automation success to the use of Fast Healthcare Interoperability Resources (FHIR), a standard developed by Health Level Seven International (HL7) to define health data exchange between different IT systems regardless of how data is stored in those systems.

"We did a time study that compared different technologies, such as bots that screen-scrape portals. We tested our native EMR functionality to do auth work. We also compared human entry, and those on our auth team can be pretty speedy with data entry," Taylor explained. "So, we did a comparison of all four, and still what came out on top was this FHIR handshake that we're utilizing, and significantly so by several percentage points or minutes faster."

The FHIR-based prior authorization workflow is embedded in the EHR system to allow staff to initiate a prior authorization request without leaving the system. The workflow determines if an authorization is even required, and if so, prepopulates the request with relevant data and notifies staff if necessary information is missing.

Through application programming interfaces (APIs), the workflow enables MultiCare to bypass the payer portal -- a system many payers use to facilitate electronic prior authorizations, but that have actually contributed to slow electronic adoption, according to the Council for Affordable Quality Healthcare, Inc. (CAQH). The latest CAQH Index Report showed that providers spent 16 minutes using a portal, representing the highest time spent conducting an administrative transaction using a portal.

"The portal always requires a separate individual in the hospital or health system to authenticate [their credentials] and enter the portal to access information, review guidelines, et cetera, which would always lead to not only friction from the standpoint of finding someone to do that, but also with the time it would take to get the right information and populate into the systems," explained Laurent Rotival, executive vice president and chief information officer of Cambia Health Solutions, Regence's parent company.

The new workflow gets to the heart of the problem with health information exchange: the lack of information at clinicians' fingertips.

"As any doctor will tell you, the holy grail of providing information to a caring physician or clinical team is to make information available in the electronic medical record workflow that is standard to their practice, hospital or health system," Rotival stated. "We are able to do it now in real time while the patient is sitting in front of the doctor and the doctor is in, as in this case, Epic's electronic medical record."

But this workflow isn't just designed for Epic users. The FHIR APIs allow users to navigate what Rotival calls the jungle of technologies used by payers and providers, which don't always talk to each other the way both parties need to facilitate requests. The open standard FHIR APIs are EHR-agnostic, so they "don't really care what brand the EHR system is," he said.

The FHIR-based prior authorization workflow goes as far as submitting the prior authorization request to Regence. Within 20 seconds, the health system receives an answer -- approved, pending a human review or denied. That decision also includes a letter notifying staff if they need additional documentation, Taylor explained.

That being said, the workflow isn't perfect; she pointed out that authorization staff still need to input data "because…location matters, rendering provider matters, the code matters, and not all of that can be inferred from the EMR today through our APIs." However, the authorization team still refers to the workflow as the "magic button."

"They find it very efficient and easy to use. They want all the auths to go through the magic button," she said.

A spark

It would be ideal if all of MultiCare's prior authorizations went through the FHIR-based workflow; however, the health system isn't close to that, Taylor admitted.

"No other payer has come to the plate with a solution like this one, and we've also tried to engage vendors in this space to build an agnostic application that we could utilize as part of the workflow. But it's been really difficult to bring anybody to the table," Taylor said. "There's a lot of talk but not a lot of action."

Rotival also thought his organization would have had more provider partners up and running with the prior authorization workflow by now. In the five years since MultiCare went live with the prior authorization workflow with Regence, only about nine other health systems have adopted the approach, too.

"If you had asked me two years ago, I would have said we would have 25 to 30 health systems," he said. "I'm frustrated at the fact that we are nowhere close to that now. I thought [we would have faster adoption with] something that is so relatively inexpensive, that has so much value both on the provider and payer sides, and is so good for that patient."

The challenge with scaling the electronic prior authorization workflow likely lies with the nature of running a busy healthcare organization. Healthcare leaders already face many challenges on the clinical side, pushing operational efficiency goals down on the priority list, especially if they are more technical in nature.

"There's a perception that you need very deep technical and engineering skills to do this because, for a health system in particular, it's outside of their EMR platform," Rotival explained. "There's a perception that you need a third-party engineering partner, and that's expensive and it's complicated."

Taylor has received pushback from fellow health system leaders over a lack of widespread adoption among payers. To which, she implores leaders to think about incremental progress as this initiative grows.

"We have to stop thinking of perfection and start thinking incrementally," she stated. "The way innovation happens now in today's world, you deploy code and tomorrow you can have an entire data mart to run data through. It's different than it used to be."

Gone are the days of year-long implementations; this specific implementation could take a couple of hours, plus another few days to configure it, according to Taylor.

"Healthcare needs to adjust to start being more agile so that they can adopt these processes and these efficiencies. You can be agile and have all your safety and security controls in place," she said.

Feeding the fire

Recognizing the challenges of scaling an electronic prior authorization workflow, MultiCare and Regence have teamed up with other industry stakeholders to broaden the scope of their point-to-point solution to turn it into a networked service.

In partnership with eHealth Exchange, MultiCare and Regence recently founded the Trebuchet Collaborative with HL7 to pilot use cases using the FHIR standard to support collaboration between payers and providers.

As part of the Trebuchet Collaborative, eHealth Exchange created a hub-and-spoke technical architecture to enable a networked FHIR service. This means all participants can use the single connection to reach other network participants for purposes like exchanging prior authorization requests electronically. The idea is to support broader interoperability to create a longitudinal patient record across various systems and providers.

All payers and providers need is a connection to one of the seven recognized qualified health information networks (QHINs), like eHealth Exchange, to leverage electronic data exchange for initiatives like streamlining prior authorizations, Rotival explained.

"The only thing the two organizations need to worry about is being compliant to the full standard in the implementation guide for that particular secure API," he said. "QHINs will manage the traffic, so now you only have to manage one outbound-inbound connection. That will be a significant accelerator and enabler for the scaling of the technology."

New requirements from CMS from the Interoperability and Prior Authorization Final Rule (CMS-0057-F) will also fan the flames for this type of workflow. By 2027, the rule requires certain payers to use FHIR APIs to facilitate faster prior authorization requests and determinations, as well as health data exchange.

As the technical infrastructure gets into place and federal policy dictates its use, payers and providers can learn a lot from MultiCare and Regence.

"We've demonstrated that the standards work; the approach to open, secure APIs based on FHIR standards is not only practical and feasible but also cost-effective to exchange data between a health system and a payer," Rotival said. "And to do so not only in the context of making the experience of the patient easier, but to actually help the provider's ability to get the information and the data that they need to enable the care of that individual in quasi-real time, at the point of care, without having to access a portal or access some kind of third-party application."

Jacqueline LaPointe is a graduate of Brandeis University and King's College London. She has been writing about healthcare finance and revenue cycle management since 2016.