Impact of implementing electronic prior authorization on medication filling in an electronic health record system in a large healthcare system

Abstract

Objective Medications frequently require prior authorization from payers before filling is authorized. Obtaining prior authorization can create delays in filling prescriptions and ultimately reduce patient adherence to medication. Electronic prior authorization (ePA), embedded in the electronic health record (EHR), could remove some barriers but has not been rigorously evaluated. We sought to evaluate the impact of implementing an ePA system on prescription filling. Materials and Methods ePA was implemented in 2 phases in September and November 2018 in a large US healthcare system. This staggered implementation enabled the later-implementing sites to be controls. Using EHR data from all prescriptions written and linked information on whether prescriptions were filled at pharmacies, we 1:1 matched ePA prescriptions with non-ePA prescriptions for the same insurance plan, medication, and site, before and after ePA implementation, to evaluate primary adherence, or the proportion of prescriptions filled within 30 days, using generalized estimating equations. We also conducted concurrent analyses across sites during the peri-implementation period (Sept–Oct 2018). Results Of 74 546 eligible ePA prescriptions, 38 851 were matched with preimplementation controls. In total, 24 930 (64.2%) ePA prescriptions were filled compared with 26 731 (68.8%) control prescriptions (Adjusted Relative Risk [aRR]: 0.92, 95%CI: 0.91–0.93). Concurrent analyses revealed similar findings (64.7% for ePA vs 62.3% control prescriptions, aRR: 1.03, 95%CI: 0.98–1.09). Discussion Challenges with implementation, such as misfiring and insurance fragmentation, could have undermined its effectiveness, providing implications for other health informatics interventions deployed in outpatient care. Conclusion Despite increasing interest in implementing ePA to improve prescription filling, adoption did not change medication adherence.

The Impact of Electronic Health Record Interventions on Patient Access to Post-Hospital Discharge Prescriptions

“…EPA with real-time status updates is a feature widely requested by providers, though a previous study showed it did not improve medication fill rate and adherence. 23,24 In our experience with EPA, the key to successful implementation is developing a clear and coordinated workflow. The 3 hospitals using EPA established a system in which each time a medication requiring PA was prescribed, a message was sent to a queue in the EHR for clinical pharmacists to process.…”

“…With the increasing use of EHRs, interventions embedded within the EHR have shown potential to improve the discharge process on a systemic level. 4,22,23 At an 8-hospital system, a transition-in-care (TIC) team composed of pharmacists and nurses followed up with patients after discharge to identify and help resolve any postdischarge barriers. The recurrent issues identified by the TIC team from patients' responses prompted the creation of system-wide EHR interventions to address the most common barriers.…”

“…With the increasing use of EHRs, interventions embedded within the EHR have shown potential to improve the discharge process on a systemic level. 4,22,23…”

Is Three Company or a Crowd? Comparing and Contrasting U.S. and European Clostridioidesdifficile Clinical Practice Guidelines

“…For inpatients transitioning at discharge, outpatient pharmacy “meds to bed” services can play a vital role in ensuring the patient receives the appropriate CDI therapy before being discharged from the hospital [ 42 ]. Additionally, antimicrobial stewardship programs in the inpatient and outpatient setting can assist with ensuring continuity of care and anticipating challenges due to cost and access, including prior authorization requirements, which certainly influence subsequent adherence [ 43 ].…”

Pharmacist review of chronic inhaler therapy appropriateness for hospitalized patients with COPD or asthma

“…17 Though some healthsystems have implemented software aimed at increasing visibility of medication costs, these predictions do not always provide accurate or real-time data. [18][19][20] The American Medical Association and physicians have encouraged implementing price transparency into the EHR, so long as it is meaningful and actionable. 17,21 Given the high cost of many maintenance inhalers limits patient access to therapy, ensuring that prescribed inhaler therapy is covered by insurance and affordable to patients prior to discharge could reduce primary and secondary nonadherence 22 and improve patient satisfaction.…”