Electronic Prior Authorization Integration Faces Implementation Barriers

Misfiring issues and provider education are keeping electronic prior authorization EHR integrations from achieving success, according to a study published in JAMIA.

Time-consuming prior authorization requirements can lead to delays in prescription filling, which can subsequently lead to medication nonadherence. The process also places a substantial administrative burden on clinical practices; on average, physicians spend 15 hours a week completing prior authorization requirements.

In theory, electronic prior authorization could streamline the process, allowing providers to digitally authorize prescriptions for quicker medication fills and increased medication adherence. However, the study found the opposite.

Researchers implemented ePA at a large US healthcare system in two phases in September and November 2018, and used the later-implementing sites as controls. Using EHR and pharmacy data, the study authors matched epA prescriptions with non-ePA prescriptions based on insurance plan, medication, and site, before and after ePA implementation.

In total, 64.2 percent of ePA prescriptions (24,930) were filled, compared to 68.8 percent of control prescriptions (26,731), a negligible difference.

The researchers suggested several possible reasons for this finding.  

First, ePA fired for less than two percent of prescriptions, which is less than average nationwide. This suggests some potential misfiring.

There were no substantial differences for commonly used medications for chronic illnesses. However, there were larger gaps in medication adherence for dermatological agents and lifestyle medication for ePA compared to control prescriptions.

The study authors suggested that ePA may have misfired for medications that did not require prior authorization, such as vaccinations, low-cost topical medications, and glucose supplies.

Additionally, since not all payers have ePA capability, providers may have been using ePA and traditional prior authorization processes simultaneously. In fact, the study authors noted that approximately 75 percent of providers using ePA leverage several prior authorization solutions.

Next, the authors noted that upon the ePA EHR integration, providers may have been faced with a learning curve that prevented them from using ePA to its fullest capacity.

For instance, prior authorization denial in-basket messages may not have been read immediately. However, the authors noted that over time, these barriers could diminish with use.

The authors also pointed out a number of medication adherence challenges unrelated to ePA, such as patient out-of-pocket costs, variations across payers, and uncoordinated care and communication between providers and pharmacies.

“Unfortunately, ePA technology is not designed to solve these barriers to care, so addressing efficiency may have been insufficient to observe an effect of ePA on adherence, particularly given the complexity of the US healthcare system,” the study authors wrote.

The researchers suggested that reducing fragmentation between payers and ePA could reduce the potential misfiring of medications, especially because payer information may not have been up-to-date.

“This may be increasingly possible as integrated delivery networks and risk-bearing contracts with insurers grow, due to focus on the use of technology to improve care coordination,” they explained.

Additionally, integration of data and processing with pharmacies into the EHR may enhance efficiency.

“These findings offer several broader lessons for health information technology interventions, particularly the importance of testing whether the interventions that are supposed to improve care actually do,” the study authors explained.

“Health information technology represents just one type of tool, and, in this case, computerizing the prior authorization process may not have actually addressed the barriers to efficiency, especially when not all payers participate in the technology,” they continued.

The researchers noted that future studies should investigate whether different ePA implementation processes could improve efficiency.

“This research emphasizes the need for rigorous study of these types of interventions not only to inform effectiveness within healthcare systems but evaluate any issues with implementation,” the authors explained.