HHS' proposed HTI-1 rule draws criticism for what's excluded—electronic prior authorization

The Office of the National Coordinator for Health Information Technology (ONC) has drawn mixed reviews from various organizations with its new proposed rule referred to as HTI-1.

The Health Data, Technology and Interoperability: Certification Program Updates, Algorithm Transparency, and Information Sharing Proposed Rule, or HTI-1, was published on April 18 with a public comment period ending June 20. The rule is drawing comments from several organizations, not for what is contained in the ruling but for what is not—electronic prior authorization (ePA).

“We are disappointed that the HTI-1 proposed rule would not require certified electronic health record technologies (CEHRT) to include electronic prior authorization,” America's Health Insurance Plans (AHIP) organization president and CEO Matt Eyles said in a press release. “Studies and pilots have shown that moving to ePA can dramatically speed care for patients, reduce the burden of a paper-based system for patients and providers alike and reduce costs.”

The HTI-1 rule includes the implementation of the electronic health record reporting program, modification in information blocking regulations and revising of the ONC Health IT Certification Program. Individual proposals within the rule focus on increasing interoperability, information sharing and algorithm transparency.

AHIP acknowledged that the implementation of ePA has already been proposed by the Centers for Medicare & Medicaid Services (CMS), but the organization argued that without a similar requirement in HTI-1 for CEHRT vendors, “health insurance providers are building ‘bridges to nowhere,’ adding administrative costs and waste into the health care system that will not benefit patients or providers.”

“CMS is committed to strengthening access to quality care and making it easier for clinicians to provide that care,” said CMS Administrator Chiquita Brooks-LaSure in a December 2022 press release announcing the CMS proposed ePA rule. “The prior authorization and interoperability proposals we are announcing today would streamline the prior authorization process and promote health care data sharing to improve the care experience across providers, patients, and caregivers—helping us to address avoidable delays in patient care and achieve better health outcomes for all.”

AHIP urged ONC to issue a second rule with ePA as a criterion for CEHRT that is in line with the CMS final requirements for health insurance providers to make ePA available.

Leigh Burchell, who works for Altera Digital Health and is an executive committee member of the Electronic Health Record Association (EHRA), told Fierce Healthcare that the incremental steps to ePA that the government is taking are supported by the EHRA. She mentioned that the ONC’s current plan to release a rule regarding ePA later this year allows for a better-designed rule.

ONC has been watching the feedback to CMS regarding their own ePA rule, according to Burchell. This way, the ONC’s future rule can be better written to address the needs of all affected healthcare entities.

“We as vendors have concerns about what seems to be the proposed timing on the ePA requirements,” Burchell said. “And I think it is probably going to be fairly compressed. By the time they get to rulemaking that affects us, it's going to be really tight and so we do want to know what they're thinking, we are eager to hear."

“But at the same time, we do appreciate what seems to be a pretty thoughtful approach of recognizing the scope and the big lift that's associated with this and therefore, making sure that the standards are fully developed, are fully consensus-driven," Burchell added.

Burchell said she understands AHIP’s desire to have as much information as soon as possible, but that she believes the iterative approach will ultimately lead to better outcomes. Without careful rule writing, she imagines the frustrating prior authorization process that currently exists to simply be digitized without taking the move to a digital space as an opportunity to iron out kinks.

EHRA Chair David Bucciferro, who works with Foothold Technology-Radicle Health, told Fierce Healthcare that while the timeline may not appear extremely tight from the outside, with the amount of rules that developers will have to implement in the next few years, he is concerned about ONC allowing enough time for the healthcare system to react in a “uniform, positive way.”

“This rule touches upon many sectors,” Bucciferro said. “Besides the providers, those who are going to get frustrated will be the actual patients, the recipients of care, because there's the potential for so many errors that could take place that could really harm healthcare. So this has to be well thought out, this can't be a trial and error piece.”

Late last week, the U.S. Department of Health and Human Services’ ONC held an information session to further explain the nuances of the rule. The session did not address the ONC's reasoning for excluding ePA in depth but did include the areas in which the office is most hoping to receive comments, one of which is the rule’s effect on ePA.