Those of us who work in oncology are constantly amazed by the progress being made in the fight against cancer. The miracles of modern medicine are on display every day as patients with cancer receive novel treatments, such as promising new immunotherapies or the very latest radiation treatments. Consequently, it seems a bit ironic that practices administering these cutting-edge therapies often rely on a dinosaur technology― the fax machine―to obtain prior authorization for treatment. In a time of tremendous technological advancement, how is it that 90% of communications between providers and payers for prior authorizations are still done by phone or fax, and how do we move to more automated processes?

Faxing Negatively Affects Healthcare Processes

The ramifications of being tethered to the fax machine for prior authorizations are far reaching, affecting both quality of care and costs. In oncology, the biggest concern is the delay in time to treatment and the impact to the patient, causing unnecessary stress and anxiety. Certain types of cancer are extremely aggressive, and even a week’s delay can be detrimental. Faxing and other asynchronous communications as well as the overall process to seek approval for needed services can slow down prior authorization and reduce the ability to follow up in efficient, intelligent ways.

Faxing also drives up costs. According to the nonprofit Council for Affordable Quality Healthcare, both payers and providers would profit from fully electronic prior authorizations. Payers could save at least $3.64 per transaction, while providers could save more than $3.20 on each request. With the average provider submitting roughly 50 to 60 prior authorizations a day, the savings would be substantial.

Although most industries left the fax machine behind in the 1990s, it’s still a fixture in healthcare. It has become a standard, with systems and procedures built around it in virtually every medical facility across the country. Shifting away from an established communication standard that has existed for decades is challenging. A standard makes it easier for people to follow a common process, but it also makes it harder to transition to other options. For instance, in healthcare, there are many factors that inhibit the move away from fax, such as:

Some interpret the wording of Health Insurance Portability and Accountability Act (HIPAA) to mean that fax is an acceptably secure medium, whereas email or digital communications are not. In reality, the risk of exposing a patient’s protected health information to someone who should not see it can be greater with fax than email and other digital technologies. Faxing to a phone number sends documents to one location, but many unintended recipients could be at that site. Misdialing is also a problem, sending the fax where it should not go at all. It seems a little ironic that faxing is perceived by some to be more secure than an email address, which at least has the advantage of targeting 1 individual. Obviously, cybersecurity is a concern with email and other digital technologies, but there are many digitally secure methods for transmitting protected health information, such as patient portals and other secure communication platforms.

Oncology (and medicine in general) is in a state of transition right now where some payers require faxing for prior authorizations, some have portals, and others utilize third parties with their own requirements for receiving documentation. Practices are burdened with a wide range of complex methods and processes that vary from payer to payer. Managing every case differently and inputting information into different systems are much more complicated and riskier than just faxing documents. Because oncology therapies are quite costly, practices and payers do not want to leave anything to chance. If given a choice, many will fax, even if it takes much longer. Faxing is a standard they know and trust, providing a certain level of comfort and documentation that the prior authorization request was received and processed.

Interoperability remains an obstacle to data sharing throughout healthcare. Difficulties communicating important sensitive information from 1 computer system to another are still common, forcing reliance on the fax. Different languages exist across the various health systems that can alter the context of information and quickly create the inability to make sense of the shared data. Interoperability is still a long journey that will require collaboration across competing businesses, nonprofits, information exchanges, and federal regulators.2

There is nothing unique about oncology that makes it more challenging to move away from fax than other areas of medicine. In fact, there is a higher incentive to switch to real-time communications and real-time feedback regarding the status of the request (eg, approved, denied, pending). Further, clinical criteria regarding prior authorization clinical protocols should be more transparent to providers; processes to facilitate efficiency and faster response times are essential. All patients deserve access to needed care, and prior authorization should never be a barrier to the delivery of appropriate, evidence-based medicine.

The burden of phone calls and faxing is greater in oncology than other branches of medicine because providers must furnish an in-depth level of clinical information to support the appropriate use of costly therapies. The barriers to change can also be higher because both practices and payers have a substantial investment built around existing prior authorization systems. Both care greatly about making sure documentation for these high-cost therapies is handled appropriately, so there are many processes in place around the old standards.

The government can play a key role in moving medicine away from outdated modes of communication by helping to establish electronic communication standards that are HIPAA compliant, technically feasible, and acceptable to all stakeholders. The proposed Secure Electronic Prior Authorization (SEPA) rule is a huge step in the right direction. It begins the process of creating a common language so payers and providers can efficiently communicate without having to create their own language.

Other legislation has advanced basic standards addressing health information interoperability, but the SEPA rule is a more targeted proposal that would create something tactical that companies could begin to engineer around for product development. Although SEPA would be a good start if passed, some parties will invariably be unhappy with it. If this occurs, we need to ask ourselves if the rule is better than what we have today and if it is a step in the right direction. If the answer is yes, stakeholders should enthusiastically rally around it. Waiting for a single policy or standard that is going to work for everyone will get us nowhere.

Collaboration and Compromise Are Essential

Adopting similar standards and shared frameworks is something all healthcare stakeholders must do to accomplish the move to more digital communications. We must all participate in the creation of standards and follow them once they emerge. At McKesson, we have made great progress toward electronic prior authorizations in some of our oncology- specific technologies, such as Clear Value Plus. This regimen support tool greatly reduces the burden of prior authorization by implementing Fast Health Interoperability Resources (FHIR) standards, enabling payers and providers to electronically communicate detailed clinical information and patient demographic data. The FHIR standards are a good start on the road to exchanging healthcare information electronically, and hopefully other technology developers are embracing this next-generation standards framework.

Unfortunately, a number of payers have produced their own proprietary solutions, each following a slightly different path in which clinical systems adhere to somewhat different terminology. One standard approach is essential. Obviously, we are all going to have to compromise and adjust along the way to develop standards, but once we do, all stakeholders― especially patients―will benefit.

Even if the FHIR standards and SEPA rule are successful in establishing some basic standards for interoperability, that is only half the battle in overcoming prior authorization challenges. Payers must embrace new payment policies and transparency, along with technology interfaces, to enable seamless, automated prior authorizations that support quality care. Adopting the following policy recommendations would help drive a timely, efficient process:

Unfortunately, some payers take as long as 2 weeks to respond, delaying treatment and heightening the anxiety patients already have about their cancer diagnosis.

Meaningful peer-to-peer review with a medical oncologist or relevant specialist

Oncologists often end up discussing treatment recommendations with physicians who do not specialize in oncology, such as a primary care physician or sometimes even an obstetrician. Requirements for peer-to-peer discussion delay needed therapies unnecessarily, but if the situation demands this, then the reviewer should know the field well.

Publicly posting the percentage of authorization decisions and coverage requirements

Physicians need transparency around the clinical protocols and requirements for authorizations. Posting this information would provide clarity and create a more efficient process.

Many patients with cancer have a treatment protocol that may extend over a longer period of time (according to evidence-based oncology guidelines), so requiring prior authorizations every few months when the therapy will not be changing for a prolonged period of time is a waste of both provider and payer resources.

By using these suggestions to build a framework for prior approvals, payers and technology vendors can automate the prior authorization process so providers can receive an automatic response if established criteria are met. Transparency that enables an understanding of the rules and an automated process are both required to overcome the prior authorization challenges that are seriously inhibiting physicians’ ability to deliver timely, high-quality care.

In working with both payers and providers over the years, 1 truth has emerged: Finding a solution that is ideal for all stakeholders is very difficult, if not impossible. Consequently, in modernizing healthcare communications, we need to consider how we can make progress in stages, rather than looking for the perfect solution. Unfortunately, this is easier said than done. When moving away from long-established standards and overcoming barriers that are decades old, there is no quick fix. We have to adopt the mindset and embrace change; making improvements in incremental steps is a win for patients, providers, and payers.

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In a time of tremendous technological advancement, how is it that 90% of communications between providers and payers for prior authorizations are still done by phone or fax, and how do we move to more automated processes?1

Moving to Electronic Prior Authorization Requires Incremental Steps

Addressing the Challenges of Prior Authorization

Several provider challenges and opportunities were highlighted during the 2017 State Oncology Society Forum, hosted by the National Comprehensive Cancer Network (NCCN) at its annual conference, held in March in Orlando. Presenters and attendees discussed how the application of technology can drive significant near- and long-term benefits by easing prior authorizations (PAs), increasing information exchange, and balancing the roles between technology and human interaction in patient care.

PA requirements continue to increase as higher cost treatments, including oral and injectable therapies, are used in the treatment of cancer. Although payers initially developed the process to verify that a treatment is appropriate for a specific patient’s condition before the start of therapy, recent trends have led many providers to conclude that PAs are primarily a subterfuge intended to reduce costs and risk for payers; they have little regard for provider challenges or the burdens they place on patients.

Many oncology practices indicate that the PA workflow and process continue to be frustrating, time consuming, and expensive. Billing staff commonly initiate the process of gathering information and communicating with payers or their intermediaries to confirm that therapies or imaging tests are evidence based. However, the increasingly finegrained inquiries of payers often require the involvement of expert clinical staff and physicians. The labor time and disruptions in workflow can increase costs and delay patient care. Commentary from the podium and audience at recent oncology meetings has suggested these delays can stretch to 2 weeks or longer.

The slowdowns are visibly frustrating for patients and their families who already feel anxious about their diagnoses and impending treatments and are not commonly aware of the behind-the-scenes hurdles their care teams face. These feelings compound with each additional day, as patients wait for scheduling and more information and look to their providers for guidance and affirmation that they’re clear to begin or continue the battle against their disease.

PA difficulties are only growing worse as payers view this process as an acceptable means of data collection and verification; however, this is where technology can improve the situation for patients and their providers. A best practice to help streamline the PA process involves use of decision-support technology that integrates with an electronic health record (EHR) system to give physicians direct visibility of evidence-based treatment options at the point of care. With further clarity on which treatments are recognized by clinical guidelines and pathways, a physician can make recommendations that are likely to meet thresholds for compliance for PA and payment. Access to this information at the point-of-care leads to a quicker turnaround time for PAs and means patient delays and anxiety are minimized.

These tools also can ensure all necessary clinical data have been considered and captured, streamlining the workflow of the business office and clinical staff by easing the burden of paperwork, number of clicks, and other time spent on PAs. Integrating a decision-support system with Web-based PA portals can help to initiate cases and eliminate manual re-entry of patient details, further reducing delays and staff burden.

When choosing technology, a practice should find a solution that offers point-of-care access to the library of NCCN Guidelines—the most widely recognized clinical treatment recommendations in oncology. From their technology, providers should also expect narrower clinical pathways, visibility into treatment cost, and the ability to highlight payer-specific preferences (or coverage) for patients. The ability to directly transmit required information for PA submissions and to provide real-time reporting and physician feedback will ensure that the challenges of PA can be minimized. This will enable physicians to focus on practicing medicine, not negotiating with payers.

In the consumer world, we quickly become irritated if we are repeatedly asked to provide the same information to complete a transaction. Yet in healthcare, we are only now moving to an era in which the same information or data can be repurposed to complete multiple tasks.

From the EHR to billing and practice management, inventory management, decision support tools, and patient portals, providers rely on multiple tools to collect and manage data related to patient care. When these systems are not working together or sharing data, it becomes necessary to manually enter that data into multiple systems. Not only is this tremendously inefficient, but the risk of error increases. For many providers, their health information technology (HIT) remains in an awkward adolescence. Oncology is further challenged by the rapidly increasing depth of clinical content, terminology, and values that are required to deliver appropriate patient care.

The current push by payers toward value-based payment makes interoperability more important than ever. Practices face new requirements to merge clinical and financial data, and successful performance requires fast and accurate understanding of costs, quality, use, and other outcomes.

Significant strides have been made in the realm of interoperability. Static standards have given way to extensible toolkits, like Fast Healthcare Interoperability Resources. Savvy HIT vendors now offer not just closed-off tools, but open platforms and suites of solutions that share information and work together to lower costs, increase access, and improve the quality of care. A practice looking to implement any type of HIT system should partner with a vendor that will consider the interoperability of all of applicable systems.

Looking to the future, it’s beginning to appear that one day, a computer will be able to simulate how the human brain works. In just the last 6 months, learning systems have outperformed humans in everything from driving cars to playing high-stakes poker. The promises of Big Data and cognitive computing in healthcare have yet to become a reality, but as these advancements make their way from pilot programs to everyday practices, providers are asking when it is best to still have human interactions and decision making.

Large amounts of information can be overwhelming at best and counterproductive or dangerous at worst—everyone in the industry is familiar with this challenge. But technology is excellent at applying logic and capturing, managing, and storing data. Our reliance on modern search engines and smartphones is an example of the value of being able to organize mountains of information to gain insight from it.

In a similar sense, Big Data, clinical algorithms, and cognitive computing—properly coupled with an understanding of workflow and operations&mdash;have the potential to enhance care. Early pilots of cognitive computing systems and the wide customer footprint and quantitative benefit of clinical pathways highlight the opportunities here.

Even so, physicians and their supporting care teams have access to far more information than is captured in systems, and there are many aspects of care that technology cannot replace. For example, every patient has different values and priorities when it comes to care. There are cultural differences and emotional reactions to consider when discussing diagnoses, and the best treatment option or end-of-life care decision is not always identifiable from structured data and algorithms. In these situations, nothing can replace the human aspect of care and the need for providers to stay closely connected with their patients.

Leading HIT systems are fine tuned to clinical workflows and offer the flexibility to incorporate future advancements in cognitive computing. However, all will face the challenge to balance the use of these sophisticated capabilities to complement human caregivers, not distract them or attempt to replace them.

HIT presents boundless opportunity to address many of the challenges practices face in the rapidly evolving marketplace. But significant risks persist, and having a well thought out strategy and capable partners are essential for optimizing practice operations and payment, as well as for allowing a focus on quality patient care. Comprehensive workflow and billing support, managed clinical content, and user- and IT staff— friendly cloud-based systems are no longer enough. Winning providers need to organically extend systems with decision support and tools that minimize the burden of PA, adopt interoperability to enable modular applications that support value-based care, and have the foresight to enable integration to benefit from advancements in data processing and cognitive computing.

Several provider challenges and opportunities were highlighted during the 2017 State Oncology Society Forum, hosted by the National Comprehensive Cancer Network at its annual conference, held in March in Orlando.

Nate Gosse, PhD

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Moving to Electronic Prior Authorization Requires Incremental Steps

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