Electronic Prior Authorization: The e-prescribing capabilities doctors have been waiting for has arrived

"Prior authorization has become a dirty word in the clinical world. It conjures up an unpleasant hodgepodge of forms, faxes, portals, and phone calls," said Anita Murcko, MD, president and CEO of Cambiare, and a practicing physician for nearly 25 years. The process, in fact, has become increasingly messy, considering the fact that "every health plan has its own format, criteria and forms for various drugs and drug classes" and the average primary care office may work with 50 or more plans, according to Murcko. 

Fortunately, the status quo is poised for change, thanks to the SCRIPT Standard for electronic prior authorization. Murcko and Melissa Brown, director of benefits messaging at Surescripts, explained how this new type of electronic prior authorization (ePA) could radically improve efficiency, a welcome change from cumbersome manual processes, during "The New Standard for Electronic Prior Authorization," a pharmacy informatics webinar that was presented in April.

In July of 2013, the National Council for Prescription Drug Programs (NCPDP) approved ePA transactions within the SCRIPT Standard for e-prescribing.  These new ePA transactions enable real-time information exchange between the prescriber and the patient's health plan within the e-prescribing workflow.  When EHRs leverage this new capability, doctors and their office staff spend less time with paper forms, cumbersome faxing, and difficult-to-navigate web portals.  "The EHR integrated electronic prior authorization process allows pre-approved e-prescriptions to be sent to pharmacies.  This means fewer phone calls between doctors and pharmacies and a more satisfied patient," Brown said.  "Workflow efficiencies will be greatly improved for all of the stakeholders across the continuum of care – the prescriber, PBM, payer, pharmacy, and most importantly the patient," according to Brown.

Several companies now offer implementations of the new ePA standard for EHRs and portals, however their capabilities vary. Some prescriber portals and PBM/payer portals offer a "retrospective workflow capability" – meaning that drugs that need a prior approval by a health plan are identified after they have been prescribed. Additionally, such form-based portal solutions are not integrated into the e-prescribing workflow, so prescribers may need to visit different portals based on their patient's health plan. Another approach is "hybrid" solutions, with varying degrees of EHR integration and PBM connectivity. These solutions rely on dated electronic fax technology for the bulk of their PA processing.

These portal and hybrid solutions aren't viable long term options.  Prescribers desire full EHR integration and PBMs are unlikely to invest in the development of multiple connections that don't leverage the full features of the SCRIPT Standard.       

To truly tap into the full power of the new ePA standard, organizations need to use an ePA solution that integrates into their EHR system, leveraging the existing eligibility data and extensive PBM connectivity. As such, organizations can add other valuable capabilities such as integration into physician and e-prescribing workflow and the capacity to pull patient history from the EHR into prior authorization question sets.  Perhaps most important, these solutions can prospectively identify the need for prior authorization, making it possible for prescribers to know that the payer or PBM needs to approve a drug before they actually prescribe it to a patient.

Surescripts has developed a solution that supports the full functionality delineated in the latest SCRIPT Standard, CompletEPA.  With this solution, EHR vendors can select the range of features that best meet the evolving needs of their customers.  When EHRs choose to implement the full set of CompletEPA functions and features, they will embody the new "gold standard" that prescribers want, enabling them to:

  • Prospectively identify which drugs require a prior authorization before the prescription is sent to the pharmacy 
  • Eliminate forms by allowing specific prior authorization questions to be sent to the EHR, based on patient, plan and medication
  • Add efficiency and accuracy to administrative tasks through pre-population of required patient information
  • Support real-time communications with pharmacy benefit managers
  • Automatically route pre-approved e-prescriptions to the pharmacy, without subjecting them to a prior authorization block and patient delays

As the leading form free solution for sending verified, standardized messages from EHRs to PBMs, Surescripts' CompletEPA leverages eligibility and formulary data to notify providers of medication prior authorization (PA) requirements before e-prescribing; sends specific PA questions directly to the EHR, based on patient, plan, and medication; and supports real-time communications with PBM to complete prior authorization review before sending e-prescription.  With the new ePA as part of the SCRIPT Standard and the technologies currently available to support it, the challenge for healthcare organizations now is to fully tap these capabilities.  "It's great to have a standard," but, as Dr. Murcko reminds us, "its potential won't be reached until we learn how to best apply this new standard to improve care delivery opportunities for our patients." 

For more information visit www.surescripts.com/completEPA or view the HIMSS/NCPDP 2014 Pharmacy Informatics Town Hall Session entitled, The New Standard for Electronic Prior Authorization.