How Community Health Network Is Automating Prior Authorizations—With No Provider Disruption

Health systems know automating prior authorizations can help accelerate care, but many don’t realize how easy it is to integrate a new prior authorization solution within their existing processes and workflows.

I was fortunate to speak with Amee Lancaster and Randy Miller, both Directors of IT Business Solutions at Community Health Network, about how their organization layered Surescripts Prior Authorization Automation onto their existing approach in Epic and what happened next.

• Q: What are your roles at Community Health Network?

  A:

  Randy Miller: I'm a Director of IT Business Solutions, and I've been at Community Health Network for 27 years. My role focuses on aligning technology solutions with our operational and clinical needs, optimizing workflows within Epic and supporting initiatives like Prior Authorization Automation to improve efficiency and patient access.

  Amee Lancaster: I'm also a Director of IT Business Solutions, and I've been with Community Health Network for 27 years as well. My focus is aligning technology solutions with our clinical needs and priorities.

  Q: How does the prior authorization process work at Community Health Network today?

  A:

  Amee Lancaster: Today, prior authorizations are primarily managed through centralized teams, including pharmacy support staff and clinical administration, with administrative teams and providers engaged for any clinical input.

  Randy Miller: Most prior authorization requests originate directly from the e-prescribing workflow within Epic. We also see a portion coming retrospectively from pharmacies and from patient inquiries.

  Q: What led you to start automating prior authorizations?

  A:

  Amee Lancaster: We were really looking to reduce the manual effort and turnaround time. Prior authorizations can take a lot of time, so adding automation through Surescripts allowed us to streamline decision-making and improve the overall patient experience.

  Q: A lot of health systems worry automating prior authorizations means replacing the solution they already have, which can be costly and time consuming. Was that the case for you?

  A:

  Randy Miller: Not at all, it works right alongside our existing vendor. Surescripts Prior Authorization Automation is embedded directly in the Epic prescribing workflow, so it automatically retrieves the required clinical information from the patient's electronic health record, matches it against the payer's determination criteria and sends it to the pharmacy benefit manager (PBM) in near real time. When the requirements are met, the request can be approved without anyone having to touch it. And when a request can't be fully automated, it simply routes back to our existing process. For our staff, that's just their normal workflow.

  Q: What did implementation actually look like?

  A:

  Amee Lancaster: The work from my team was pretty minimal. There was some testing, but it didn't take much resource time to get up and running, which was a nice surprise. Sometimes you hear "this only takes two hours," and it really takes forty two. This really did not.

  Randy Miller: It's been seamless, our staff don’t even know it's happening, so their workflows didn't change a bit. The most complex part for us was coding our charge router to redirect the right medications and PBMs to Surescripts. A typical FHIR-app setup needs your Epic security team to create a background user, and from there it was straightforward. We did our testing on about an hour-long phone call and watched the data flow. It was one of the easiest implementations I've had with any vendor. We sent a note to providers, but since nothing changed in their workflow, no training was needed.

  Q: You're a few months in. What are the early results telling you?

  A:

  Randy Miller: The data is telling the story, higher automation rates and reduced turnaround times. Most of our numbers are coming from GLP-1s, and approximately 60% of our GLP-1 prior authorization requests are going through automatically, without any issues. Those authorizations take time, so turning them around quickly is a big deal and ultimately patients see the biggest impact, because they get their medication sooner.

  Amee Lancaster: We were pretty excited by the numbers. We're saving time, patients are waiting less for approvals and the minimal work our analysts put in delivered a great return.

“We're saving time, patients are waiting less for approvals and the minimal work our analysts put in delivered a great return.”

• Q: What would you tell other health systems considering this?

  A:

  Randy Miller: This is really where all healthcare needs to get to. When we know the rules, we know what payers are asking for and we have the data so there's no reason for so many people to be involved in holding it up.

  Amee Lancaster: There's opportunity to expand to more drugs and payers, but we're seeing a great trajectory. We're excited about this work, and the time it's going to save for patients.