High-Tech Solutions for Prior Authorization Problems

Nate Gosse, PhD
Published: Wednesday, Jun 07, 2017
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.

Balancing Technology with Human Approach

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—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.


View Conference Coverage
Online CME Activities
TitleExpiration DateCME Credits
Community Practice Connections™: 14th Annual International Symposium on Melanoma and Other Cutaneous Malignancies®Apr 30, 20192.0
Oncology Consultations®: The Advancing Role of CAR T-Cell Therapies in Hematologic MalignanciesApr 30, 20191.5
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