How FHIR streamlines Prior Authorizations for Faster Patient Care (eHealth Exchange use-case)

Electronic Prior Authorizations with eHealth Exchange

Key Concepts:

• Electronic Prior Authorization (ePA)
• Interoperability
• Fire (Fast Healthcare Interoperability Resources) APIs
• EMR (Electronic Medical Record)
• Payer (Insurance Company)
• HL7 Da Vinci Project
• Smart on Fire app

1. The Problem: Cumbersome Prior Authorization Process

• The current prior authorization process is described as "clunky" and "cumbersome," involving significant back-and-forth communication (often via fax) between providers and payers.
• Providers often deal with around 30 different insurance companies, each with potentially different web portals, fax numbers, and prior authorization requirements. This leads to "portalitis" and makes it difficult for providers to keep track of everything.
• Example: A provider wanting to perform a laminectomy (spine procedure) needs to get prior authorization from the patient's payer.

2. The Solution: eHealth Exchange's Fire-Based Approach

• eHealth Exchange offers a technology solution using Fire APIs to streamline the prior authorization process.
• The solution involves a "Smart on Fire" app that integrates within the provider's EMR.
• Providers establish a trusted connection with the eHealth Exchange app.
• The eHealth Exchange platform handles the connections with various payers, retrieving the necessary information and presenting it to the provider.
• The solution is built on the InterSystems technology platform.

3. How the Fire App Works

• The provider clicks on the eHealth Exchange app within their EMR.
• The app allows the provider to select the patient's insurance company (e.g., Blue Cross, Aetna, Cigna, Medicare).
• The app then determines if prior authorization is required for the specific service.
• The app presents a questionnaire to the provider, asking for relevant information.
• The app can "preload" or "suggest" answers to the questionnaire by pulling relevant data from the provider's EMR.
  • Example: If the questionnaire asks if an MRI was performed and showed spinal stenosis, the app can retrieve this information from the EMR and pre-populate the answer, allowing the provider to verify or modify it.

4. Benefits and Advantages

• Reduces the burden on providers by eliminating the need to interact with multiple payer portals.
• Streamlines the workflow by integrating the prior authorization process directly into the EMR.
• Improves efficiency by pre-populating questionnaire answers with data from the EMR.
• Potentially reduces the back-and-forth communication between providers and payers.
• Ultimately benefits patients by speeding up the approval process and reducing delays in care.

5. Standards and Technology

• The solution implements the HL7 Da Vinci Project standards.
• The solution utilizes Fire APIs for interoperability.
• The solution is built on the InterSystems technology platform.

6. Quote:

• Jay Nakashima: "...we ask each of these providers to trust the ealth exchange smart on fire app...and then within that EMR when they click on that ealth exchange app they're able to say hey this patient has Blue Cross or this patient has Etna or Sigma or CMS or you know Medicare and they're able to therefore get to that insurance company and uh see if there's a a prior authorization really required and then start to answer the um the prior authorization questions."

7. Conclusion:

eHealth Exchange's Fire-based solution for electronic prior authorization aims to address the inefficiencies and complexities of the current process. By integrating directly into the provider's EMR and leveraging Fire APIs, the solution streamlines the workflow, reduces administrative burden, and ultimately improves the patient experience. The use of HL7 Da Vinci standards further promotes interoperability and data exchange between providers and payers. While still in the early stages, this approach holds significant promise for transforming the prior authorization process in healthcare.