- Created by Blake Bergstrom, last modified by Kim Boyd yesterday at 2:59 PM
The below depicts the anticipated prior authorization workflow to improve access to care for cancer patients with a focus to leverage the implementation guides developed by the HL7 Da Vinci Accelerator as well as CodeX mCODE. CodeX Use Case members continue to endeavor to partner in operationalize this effort via the current Proof-of-Concept.
Public Use Case Calls are held the last Tuesday of every other month at 3:00 pm EST (subject to change).
Please reach out to Use Case Coordinator, Kim Boyd (kim.boyd@pocp.com) to be added to the public call invitations and to receive updates regarding any changes.
Project Overview
Problem:
- Payers vary widely on how prior authorization for cancer therapy is accomplished. Some use a web portal for oncologists to enter data into an electronic form. Others use oncology clinical pathways to develop a proposed treatment option. Despite the method, many prior authorization processes among payers rely on manual inspection, with no automation or standard interface to health systems.
- Prior authorization imposes a burden on patients, providers and payers
- Current manual processes require duplicate data entry, are costly and may delay treatment
Description:
- There is national interest, both in industry and the federal government, for standardization of the prior authorization process. The goal is reduction of costs by automation and standardization of health system-to-payer prior authorization interaction. This has the potential to greatly reduce oncologist burden, which is a known factor in physician burnout.
Target Outcome:
- Provide a standard method to supplement the Da Vinci Coverage Requirements Discovery (CRD), Document Template Rules (DTR) and Prior Authorization Support (PAS) FHIR-based information exchange framework with cancer specific data as defined by mCODE, to enable prior authorization auto-approvals.
- Base the solution on approaches referenced in CMS Proposed rules
- December 2022 Proposed rule CMS Advancing Interoperability and PA Rule
- December 2020 Proposed rule CMS interoperability rules.
- Reduce clinician, health system, patient and payer burden
Value:
- Patients receive timely care without delay because prior authorization turnaround time is reduced
- Provider burden reduced with automated approvals, and real-time access to payer approval requirements and documentation rules
- Payer burden is reduced by automating manual processes using a standardized information exchange
Equity:
The CodeX Prior Authorization in Oncology are committed to supporting an equitable health care system and have committed to the Federal Moonshot initiative.
We believe that improving and automating the prior authorization process for patients, providers and payers can result in timely delivery of appropriate and high-quality care. With timely delivery of care, we can assist in curing and/or prolonging the life of a patient and optimizing the patient’s quality of life.
Commitment #1: Define, model and scaling an automated prior authorization process for cancer patients via the use of FHIR-based healthcare data standards to extract and exchange the necessary information to expedite the prior authorization process for cancer patients and reduce burden for providers and payers. These data standards include the clinical specialty data standards (mCODE representing oncology data, and RTTD representing radiation therapy data) as well the Da Vinci FHIR standards addressing value-based care transactions including those needed for prior authorization. Clinical specialty data standards such as mCODE are essential to ensuring accurate clinical representation for the decision support needed to ensure correlation of the right treatments to the right cancer patients.
Commitment #2: In alignment with industry technical and data standards, modify or create as necessary, open-source technical specification(s) documenting the workflow and criteria necessary to expedite the prior authorization in oncology process.
Commitment #3: Implement the Prior Authorization in Oncology FHIR driven real-time process with point-of-care decision support for stakeholders to assist in expediting care for cancer patients.
Commitment #4: Capture metrics through this use case in hopes of providing additional insights and learnings that can potentially be applied to informing new best practice in prior authorization in oncology as well as reduction of burden for patients, providers, and payers.
Project Plan
Phase | Milestone | Timeline |
---|---|---|
Discovery | Use case identification - Breast and Prostate cancer | COMPLETE |
Proof of Concept | Breast Cancer treatment regimen proof of concept complete - demoed at DaVinci Burden Reduction examples call, and at the April 2021 DaVinci Education and FHIR Implementation Event.
| COMPLETE |
Planning | Plan out high level project plan for synthetic environment Proof-of-Concept, deliverables, success measures, high level timeline, key stakeholders, etc. The focus by use case members is on Prostate cancer PA. See Project Plan found here - PA in Oncology - Documents | COMPLETE |
Execution | Use Case Moved to Execution Phase in November 2022 | IN PROGRESS |
Phase 1 | Radiation Oncology Prior Auth Proof-of-Concept for Prostate Cancer (MVP) with Synthetic Data Phase 1 include multiple POC Phases to test end-to-end connectivity, use of SMART on FHIR app, POC is in a test environment with synthetic patient and clinical data with defined test scenarios. This will be replicated in multiple phases. Then will go to Live Pilot with live patient and clinical data.
| As of January 2023 - Target 1st Live Pilot in Q3/Q4 2023 - |
Phase 2 | Prior Authorization Pilot
|
Quick Links:
FHIR-Based Prior Authorization for Oncology Fact Sheet.pdf
Execution Phase Quick Links
Member Meetings - Key Takeaways and Decisions
Planning Phase Quick Links
PA In Oncology Workflow Diagram as of 8.2.22 CRD DTR PAS Denoted
Discovery Phase Quick Links
Prior Authorization in Oncology–high level project plan
Summary and Next Steps from June 3, 2021, Discovery Session on Oncology Provider-Payer Data Exchange
Increasing Burden of Prior Authorization in Oncology (ASCO)
CMS Proposed Rule - DRLS and PAS
Member Call Discussions and Key Takeaways
Execution Phase | ||
Date | Key Findings and Takeaways | Members Present |
---|---|---|
3.22.23 |
| Pfizer, ASTRO, McKesson, EnableCare, Ontada, Evernorth, USONC, Oncora Medical, POCP, Varian, MITRE and Telligen |
3.8.23 |
| Evernorth, Ontada, McKesson, Varian, ASTRO, USC, Oncora Medical |
2.22.23 |
| MCG, Telligen, Evernorth, McKesson, ASTRO, POCP, Edifecs |
2.15.23 |
| eviCore/Evernorth, McKesson, Mettle Solutions |
2.8.23 |
| McKesson, Varian, Evernorth/eviCore |
2.1.23 |
| McKesson, Varian, Evernorth/eviCore |
1.25.23 |
| McKesson, Telligen, evicore/Evernorth, Varian, USONC, and Pfizer |
1.18.23 |
| Telligen, McKesson, Varian and Evernorth/eviCore |
1.11.23 |
| Telligen, Pfizer, ASTRO, McKesson, USONC, eviCore, Edifecs, and Varian |
1.5.23 |
| Varian, eviCore, McKesson USONC, Telligen |
12.21.22 |
| Varian, eviCore |
12.7.2022 |
| MCG, MITRE, eviCore, McKesson, Telligen |
11.30.2022 |
| eviCore, Edifecs, MCG, McKesson and MITRE |
Conference Call Schedule & Dial-Ins
CodeX: Oncology Prior Auth Use Case Public Calls
The Last Tuesday, every other month - 3:00 - 4:00 EST
- January 31, 2023
- March 28, 2023
- May 30, 2023
- July 25, 2023
- September 26, 2023
Meeting Details:
Register in advance for this meeting:
https://hl7-org.zoom.us/meeting/register/tJwpf--hpz0rH9U8X8uOO4O8WosEnCX--RoS
After registering, you will receive a confirmation email containing information about joining the meeting.
Reach out to Kim Boyd (kim.boyd@pocp.com) to be added to the invitation and received updates and modifications to call schedules.
Use Case Team
Role | Name | Organization | |
---|---|---|---|
Use Case Coordinator | Kim Boyd | Point-of-Care Partners | kim.boyd@pocp.com |
Clinical Coordinator | Dr. Liz Canzone | The MITRE Corporation | |
Deputy Program Manager | Michele Galioto, RN | Point-of-Care Partners | |
Terminology Coordinator | TBD | ||
Technical Lead | Rob Dingwell | The MITRE Corporation |
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