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How ONC Can Improve Electronic Prior Authorization Data Standards

Information exchange barriers have impacted patients, caregivers, clinicians, and payers, notably in the case of prior electronic authorization, the lack of data standards has led to burden among these groups.

A Health Information Technology Advisory Committee (HITAC) task force released 13 recommendations to ONC, suggesting ways the ONC Health IT Certification Program could incorporate data standards to improve electronic prior authorization.

Earlier this year, ONC released a Request for Information (RFI) that sought input on electronic prior authorization data standards, implementation specifications, and certification criteria that could be adopted for the ONC Health IT Certification Program.

Payers establish prior authorization requirements to manage costs and ensure payment accuracy by verifying that an item or service is medically necessary, meets coverage criteria, and is consistent with standards of care.

However, a lack of adopted standards and coordination across stakeholders have led to administrative burdens for patients, health care providers, and payers. The challenges related to prior authorization processes have delayed patient care and added to clinician burnout.

ONC charged HITAC with providing input and recommendations in response to this RFI. The Electronic Prior Authorization (ePA) RFI Task Force of the HITAC then created recommendations to reduce burden, increase efficiency, and improve care.

Additionally, the task force aimed to introduce automation to decrease redundancy and unnecessary effort through the guidelines.

“These recommendations, in the following 13 areas, seek to not only support the selection of health IT certification criteria, but move the healthcare industry toward streamlined, digitized electronic prior authorization processes with data-driven interoperability,” the ePA RFI Task Force wrote in its final report to ONC.

The first recommendation from the task force urged ONC to create a suite of ePA health IT certification criteria for health IT systems that support both providers and payers, enabling a complete prior authorization workflow. 

The task force also recommended that ONC work with the key stakeholders to develop appropriate health IT certification criteria that incorporate key functional capabilities for prior authorization.

The full list of recommendation topics includes: 

  • A suite of Certified Health IT Capabilities to Support the Prior Authorization Workflow
  • Readiness of Implementation Guides to Support Functional Capabilities
  • Patient-Centered Inclusion in ePA
  • Prior Authorization Roadmap to FHIR
  • Adoption at Scale
  • Regulatory Coordination
  • Attachments
  • Prior Authorization Proving Ground For FHIR
  • Establishment of an Advisory Process
  • Accessibility of Health IT for ePA at Scale
  • Innovation around ePA Integration
  • Innovation around ePA Bundles
  • Multi-Stakeholder Engagement

“Through these recommendations, the HITAC addressed a range of issues critical to advancing this important but complex topic,” Alex Baker and Michael Wittie wrote in the HealthITBuzz blog post. “Recommendations emphasized the need for an iterative and incremental approach to establishing technical requirements for ePA that would allow for further development and testing of emerging standards addressing different aspects of the ePA workflow.”

“Finally, the recommendations urged ONC and other stakeholders to focus on how ePA solutions can put patients at the center of administrative processes that affect their care.”

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