NCVHS panel hears potential and peril of standards adoption
Diverse opinions in moving to new standards for prior authorization show the challenge facing the healthcare industry.
Prior authorization remains a pain point for a variety of players in the healthcare industry. While efforts to automate information exchange are underway, there’s still concern about whether any changes can be rapidly assimilated by all players the industry.
Presentations at a listening session before the Standards Subcommittee of the National Committee on Vital and Health Statistics in late August highlighted both the need to find ways to solve vexing data exchange issues in the industry while concurrently gaining support from all participants.
At the listening session, HL7 and representatives from one of its accelerator programs made the case for further inclusion of HL7’s Fast Healthcare Interoperability Resource in national efforts to expand the use of healthcare standards to increase industry efficiency.
That accelerator program, the Da Vinci Project, is already working on a set of standards and related implementation guides that could support an automated approach to prior authorization.
There’s growing acceptance of FHIR use cases as ways to support information exchange in healthcare. FHIR and the implementation guides that support its use already have been referenced in seven final or proposed regulations from the Centers for Medicare & Medicaid Services.
Speaking at the listening session, HL7 CEO Charles Jaffe, MD, urged panel members to consider accelerating adoption of FHIR standards so that they are on equal footing with transaction standards included in the Health Insurance Portability and Accountability Act (HIPAA).
Also at the session, Jocelyn Keegan, program manager for the Da Vinci Project, outlined some of the progress of the HL7 accelerator had made in member-driven initiatives to develop standardized uses of FHIR and supporting implementation guides. She related how the Da Vinci Project is now working on “how to rethink prior authorization from the get-go,” with the goal of improving transparency or automating the information exchange that the process requires. “The goal is to create new ways to reduce efforts and waste for all members,” she added. “We encourage NCVHS to take a holistic approach (for prior authorization) instead of using a siloed approach for the existing HIPAA transactions.”
She described current efforts to interoperate with X12 standards for prior authorization, as well as the exception issued by CMS that enables testing of a FHIR implementation guide for prior authorization without the HIPAA-required use of X12 standards.
The ability to determine prior authorization requirements in clinician workflow is key, she noted. “Being able to get that simple answer is game-changing for folks sitting in the provider seat. And then documentation templates and roles in payer rules basically leverages SMART on FHIR emerging technology coming out of the HL7 FHIR community.”
FHIR-based interoperability also reaps benefits for payers, said Kirk Anderson, vice president and chief technology officer of Cambia Health Solutions. “What is most exciting for us and our provider partners is not the benefits and the improvements we realize on a one-off basis, but the opportunity for these improvements to be scalable across all of our partners. This is the build-it-once, leverage-it-repeatedly mindset – it is how we can maximize the return on innovation for healthcare.”
Anderson noted that prior authorization is also a burden for payers, which must work with hundreds of providers. “We receive prior authorization requests from them in every way imaginable … While we do not talk a lot about payer abrasion or payer burden, it is a real thing and it is expensive, and it exists any time we, as an industry, lack the ability to standardize and automate our work.”
But some industry groups expressed reservations about any rapid change in automation approaches, noting that existing HIPAA transactions to support prior authorization are underutilized.
A representative from the American Medical Association suggested a more measured approach in weighing potential changes. Heather McComas, the AMA’s director of administrative simplification initiatives said NCVHS should first recognize successful transaction code set standards and aim to preserve and enforce them. After that, unmet industry needs can be evaluated, and only then should new transaction standards “be rigorously evaluated and tested” prior to adoption. That testing needs to occur in all industry settings, including small physician practices.
As for automating prior authorization, “it is a pretty grim reality,” McComas said. “The adoption of the HIPAA-mandated X12 278 (the ANSI HIPAA code that supports prior authorization) transaction is meager. The industry largely agrees that the reason for this poor adoption is that we do not have a transaction standard – supporting clinical documentation for prior authorization. And that this lack of an attachment standard for the industry has paralyzed the industry.”
Standards organizations are working together to find the most productive approaches to advance data exchange for prior authorization and other uses, said Cathy Sheppard, executive director of X12.
“X12 and Da Vinci leaders have been actively working together to align the administrative and clinical data across our areas of focus so that we can consistently translate between X12 EDI transactions and FHIR transactions across the industry and we do not end up with hundreds of different crosswalks,” she said. “We know that many organizations have invested heavily in their stable and successful X12 EDI infrastructures and that those are necessary for financial stability.”
Still, advances are needed to assist future data exchange needs within healthcare, she noted. “We know that pairing and emerging in existing technologies in new ways presents opportunities for entities to better leverage the technology investments they have already made. And the best way to foster innovation is to standardize the data content while supporting various transmission syntaxes.”
“The industry must embrace modern technologies, increase automation, allocate our limited resources to their best use, improve patient experience and engagement, support privacy and security that underpin trust and transparency, and garner consensus on the best way to achieve intersection between clinical and administrative data,” concluded HL7’s Jaffe in his remarks.