Automated Data Retrieval Expedites Prior Authorization Process

Prescriptions requiring prior authorization typically result in weekly averages of 14 hours of administrative work for providers and their staff, per a 2022 American Medical Association physician survey.

The manual submission process further compounds this time-consuming workflow considering there are 66M pharmacy benefit authorizations across the U.S. each year.

“When prescribing a medication that requires a prior authorization, our caregivers are prompted to complete required documentation,” says Eric Boose, MD, Cleveland Clinic’s Associate Chief Medical Information Officer and a family medicine provider.

Dr. Boose continues, “Currently, caregivers manually review patient charts to pull the required information. They’ll enter the relevant details and then submit the information for review and approval. We’re constantly looking for better efficiencies.”

Beyond the logistical impact of the manual workflow for busy clinicians, it also poses a safety risk.

“While prior authorization is unavoidable, any delay in the process keeps patients from getting their life-saving medications when they need them,” says Cindy MacLaren, a lead systems analyst within Cleveland Clinic’s Information Technology Division.

MacLaren explains, “These interruptions can lead to patient and caregiver frustration, medication delays and workflow inefficiencies. So, any technical functionality to expedite and streamline the process is a win-win for patients, caregivers and insurance companies.”

To augment this cumbersome workflow, Cleveland Clinic worked with a pharmacy benefit manager vendor and a prescription processing vendor to develop an automated data retrieval system.

Proof of concept pivots to pilot launch

For the initial phase, the team targeted GLP-1 agonist medications, a class of drugs used to manage Type 2 diabetes that usually requires prior authorization.

By focusing on just one class of medications, the vendors were able to modify their coding algorithms to automatically pull the needed patient data – lab values, medication history, diagnosis and allergies – to complete the prior authorization documentation.

An onsite meeting allowed for a deeper dive into current practices and areas for improvement.

“Our heightened appreciation of the varying workflows led to an iterative process of adapting and adjusting aspects of the system based on our findings,” says Dr. Boose.

From those discussions, the clinical team made slight adjustments in the electronic health record (EHR) to require prescribers to link a diagnosis. This minor change expedites prior authorization while preventing downstream issues.

“The process of connecting our unique workflows was exciting,” says MacLaren. “Although our priorities and areas of focus differed, we were able to work together towards this shared goal of preventing patient care delays.”

Results broadens interest

Since the April 2024 launch of the automated data retrieval system, 1,567 prescriptions have been placed at Cleveland Clinic with 27% being auto-approved.

“Monthly data shows incremental but valuable time-savings for this small group of medications,” says MacLaren. “Prior authorizations now take a fraction of the time compared to the original 15 – 20 minutes. The fact that this is only a small sampling of prescriptions proves the tremendous value of automated efficiencies.”

Dr. Boose specifies, “The resulting timesaving may seem insignificant, but the automated process is all or nothing. For example, if five items are needed and only four are retrieved, the prior authorization defaults to the complicated, manual workflow.”

MacLaren adds, “Given this success, we’re working to expand the medications that can go through automation within our EHR to quicken the process and improve reliability even more.”

“An important caveat is that this functionality is automated information retrieval, which is different from artificial intelligence (AI),” Dr. Boose explains. “Whereas AI is a dynamic tool, automated retrieval only grabs the necessary data to complete the required documentation.” 

Less friction, better outcomes

The differing regulations and requirements among pharmacy benefits managers and insurers create obstacles that can potentially delay patient care.

“There are clear barriers that automation can eliminate,” MacLaren says. “With automation, we’ve been able to streamline the process and help patients get their medication quicker. What’s exciting is that we’re still in the early stages, so the process will only improve as others adopt this functionality.”

Dr. Boose concludes, “As a prescriber, this project proves there’s a much easier process. Adopting a frictionless workflow means less time is taken up for the provider and the patient, and that’s a better outcome for everyone.”