Why Your Solution for Electronic Prior Authorization Should Support Adaptable Questionnaires

Originally published in Becker’s Payer Issues
by Steven Berkow, Head of Value-based Care Market Strategy, InterSystems

HL7® FHIR®, the modern data exchange framework powering US healthcare’s move to electronic prior authorization (ePA), offers two digital approaches for specifying documentation needed for prior authorization: standard and adaptive questionnaires. Other technical considerations that must be addressed by this coming January to meet regulatory deadlines have, understandably, dominated recent meetings about ePA and development efforts. But ePA solutions must account for adaptable questionnaires to fully deliver on the core aim of reducing the burden prior authorization currently places on providers.

The clinical documentation needed by health plans to determine prior authorization requests varies widely by product, clinical scenario, member context, and a host of other factors. Standard or static questionnaires for complex treatments commonly top 40 questions. Asking all these questions for a single prior authorization request risks placing an outsized burden on the submitting provider as well as the provider’s EHR. The official Implementation Guide published by Da Vinci for Documentation Templates and Rules warns that any question with response options exceeding 40 codes can cause the provider’s screen to crash if embedded directly into the questionnaire package (Da Vinci Documentation Templates and Rules STU 2.2, Section 10.6).

Adaptive questionnaires have already shortened assessment tools in other areas of healthcare significantly. For example, a study of nearly 3,000 cardiac rehabilitation patients found that computerized adaptive testing reduced the number of questions in a needs assessment by 36% without loss of data quality (Peute, 2020). Likewise, patients benefited from adaptive testing for patient-reported outcomes, with one instrument reducing test length by 50% (Morris, 2017). And a study of orthopedic trauma patients found an adaptive questionnaire for assessing musculoskeletal function could be completed in less than one-tenth the time needed for the standard instrument while achieving equally high reliability (Hung, 2014).

Adaptive questionnaires achieve such remarkable time savings through their dynamic structure. Instead of presenting every question in a standard question set, they marshal the next best question based on information already provided and suppress questions that aren’t relevant to the specific individual and context. Together, adaptive questionnaires and auto-population of response fields from provider EHRs constitute a remarkably powerful one-two punch for reducing the burden prior authorization currently places on providers, with adaptive questionnaires minimizing the scope of needed documentation and auto-population minimizing the number of remaining questions providers must manually address.

Incorporating adaptive questionnaires into ePA requires two symbiotic advances. First, utilization management systems housing medical guidelines must include the logic needed to determine the next best question for evaluating medical necessity, clinical appropriateness, and alternative treatments. Second, the conduit between plans and providers for specifying and providing needed clinical documentation, payer FHIR APIs, must support this next-best-question FHIR functionality, as detailed in the Da Vinci IG for Documentation Templates and Rules. It is important to note that this functionality must be additive to standard questionnaires, as standard question sets are often sufficient for less complex treatments. Also, most medical guidelines currently use static question sets to specify documentation requirements for prior authorizations. Restructuring these question sets as dynamic assessment tools is itself a resource-intensive process that will require time to execute.

The resulting reduction in provider burden, however, will actually be twofold as well. In addition to minimizing the total number of questions asked, adaptive questionnaires reduce provider guesswork. With adaptive questionnaires, it is plan-side utilization management servers, not provider EHRs, that determine the next best question based on documentation already ingested.

To help speed health plan adoption of adaptive questionnaires, InterSystems, a creative technology provider powering more than one billion health records globally, is working with InterQual®, a market-leader in evidence-based, clinical support tools.
Learn more about this integrated solution.