Automating Prior Authorization via Electronic Health Record Integration
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Solution Overview
Problem
Current processes for prescribing and fulfilling specialty medications are highly manual and inefficient, particularly due to the need for prior authorization, which requires multiple communications and manual data gathering, clinical reviews, and entry steps involving medical doctors, patients, and payors.
Innovation Solution
A computer-implemented system and method that connects to a patient's electronic health record to automate the process of obtaining prior authorization by identifying relevant medical information using a statistical model, populating a prior authorization question set, and submitting it to the payor, while also packaging and delivering the medication with minimal human intervention.
Engineering Contradictions & Design Principles
Engineering Contradiction Analysis
1Productivity
If manual processes are used for prior authorization and prescription fulfillment, then flexibility and human judgment can be applied, but the process becomes highly inefficient and time-consuming
Solution Approach 1:
The system enables self-service by automatically connecting to electronic health records, extracting relevant medical information, populating prior authorization forms, and submitting claims without requiring manual data gathering or clinical review by staff members
Solution Approach 2:
The patent replaces manual mechanical processes (data entry, form filling, communication between parties) with an automated computer-implemented system that electronically extracts data, populates forms, and submits prior authorization requests through digital interfaces
2Reliability
If multiple communication steps and manual data gathering are required for prior authorization, then accurate clinical review can be performed, but the administrative burden on medical doctors and staff increases significantly
Solution Approach 1:
The system extracts only the specific medical information needed for prior authorization directly from the electronic health record using automated data extraction techniques, eliminating the need for manual data gathering and reducing process complexity while maintaining clinical accuracy
Solution Approach 2:
The automated system performs multiple functions including data extraction, form population, claim submission, and status tracking through a single integrated platform, reducing the need for multiple separate communication steps and manual processes
3Loss of information
If manual data entry and communication steps are used, then detailed clinical information can be captured, but patient delivery timeframes are extended and satisfaction is reduced
Solution Approach 1:
The system performs preliminary actions by automatically connecting to and extracting relevant clinical information from electronic health records before the prior authorization process begins, ensuring information completeness is achieved upfront rather than through multiple subsequent communication steps
Solution Approach 2:
The automated system maintains continuous operation throughout the prior authorization process, electronically transferring data and submitting forms without interruption, thereby eliminating delays associated with manual data entry and multi-step communication while preserving complete clinical information
Data Source
AI summary
A system and method for obtaining prior authorization and fulfilling a prescription is described. The method includes receiving, by a computing device, prescription information for a patient from a prescriber; identifying, by the computing device, an electronic health record associated with the patient; collecting, by the computing device, medical information for the patient related to the prescription from the electronic health record; submitting, by the computing device, a claim for the prescription with a payor associated with the patient; and completing, by the computing device, a prior authorization request for the prescription.