Prior authorization is a crucial process in healthcare that involves the approval of medical treatments before they are carried out. The Da Vinci Burden Reduction project has rearranged the prior authorization process into three implementation guides aimed at reducing complexity. The Coverage Requirements Discovery (CRD) guide focuses on determining authorization requirements using Clinical Decision Support (CDS) Hooks and AWS HealthLake. These tools provide information on coverage requirements and assist providers in making informed decisions.
Prior authorization is a process in healthcare where medical treatments or procedures need to be approved before they can be carried out. This is done to ensure that patients receive the appropriate care and that healthcare providers are following the correct procedures. However, the prior authorization process can be complex and time-consuming, involving a lot of paperwork and communication between healthcare providers, insurance companies, and patients.
The Da Vinci Burden Reduction project has reorganized the prior authorization process into three implementation guides that aim to reduce the burden on clinicians and payers:
1. Coverage Requirements Discovery (CRD): This guide provides decision support to providers when they are ordering diagnostics, specifying treatments, making referrals, scheduling appointments, etc.
2. Documentation Templates and Rules (DTR): This guide allows providers to download smart questionnaires and rules to gather information relevant to a service. It also provides a SMART on FHIR app or EHR app to run the questionnaires and rules.
3. Prior Authorization Support (PAS): This guide enables provider systems to send and receive prior authorization requests using FHIR, simplifying the processing for both exchange partners.
In this article, we focus on the CRD implementation guide, which uses AWS HealthLake and Clinical Decision Support (CDS) Hooks to determine if prior authorization is required. CDS Hooks is a specification that allows additional functionality to be embedded within a clinician’s workflow in an EHR. By utilizing CDS Hooks and HealthLake, providers can make more informed decisions and meet the requirements of their patients’ insurance coverage.
The CRD workflow involves the following steps:
1. A provider logs into the EHR system and opens the patient chart.
2. The EHR system retrieves patient condition information using the patient-view hook.
3. The patient-view hook invokes an AWS Lambda function that retrieves the patient condition information from HealthLake.
4. The provider reviews the patient condition and invokes the order-select hook to retrieve coverage requirements for a specific drug.
5. The order-select hook invokes another Lambda function that retrieves claims information for the patient, runs Clinical Quality Language (CQL) rules based on the medication and claims information, and determines if prior authorization is required.
To implement this solution, familiarity with services like API Gateway, HealthLake, Lambda, and AWS SAM is required. The solution can be deployed using the AWS SAM CLI.
To determine coverage requirements for prior authorization, two hooks (patient-view and order-select) are used, along with CQL rules. These hooks can be integrated with an EHR that supports CDS Hooks, or a publicly available sandbox can be used for testing purposes.
After integrating the hooks with the EHR, the patient-view hook is run when a user navigates to the clinical workflow. The API returns cards indicating the patient’s health condition and the need for a prescription. The order-select hook is then used to determine prior authorization eligibility.
Once prior authorization is determined, it can be submitted using the SMART app or other available mechanisms.
To clean up the resources created during testing, the CloudFormation stack can be deleted using the AWS SAM CLI.
In conclusion, HealthLake with CDS Hooks can help reduce the burden on providers and improve the member experience by determining coverage requirements for prior authorization. This solution can be implemented on AWS and can assist providers in making informed decisions during the prescription order clinical workflow.
Action Items:
1. Develop a protocol for prior authorization using CDS Hooks and HealthLake.
2. Create a documentation template and rules for providers to download and use in the prior authorization process.
3. Implement a system for provider systems to send and receive prior authorization requests using FHIR.
4. Review the Determine Coverage Requirements Discovery using CDS Hooks with AWS HealthLake GitHub repo for more information on the solution.
5. Familiarize yourself with the required services for this solution, including API Gateway, HealthLake, Lambda, and AWS SAM.
6. Deploy the application using the AWS SAM CLI by following the provided instructions.
7. Integrate CDS Hooks with your clinical workflow once the deployment is complete.
8. Test the patient-view and order-select hooks to determine if prior authorization is required for a particular prescription.
9. Submit a prior authorization using the SMART app or other available mechanisms.
10. Delete the AWS resources created by running this example if they are no longer needed.Assigned to:
1. Technical team – Action items 1-3
2. Executive assistant – Action items 4-5
3. IT department – Action items 6-7
4. Healthcare providers – Action items 8-9
5. AWS Representative – Action item 10
