What is CQL and How can it help in Electronic Prior Authorization for the New CMS Mandates?
Many Health Payers today are in the research mode for understanding the new CMS Advanced interoperability mandates. When speaking to the decision makers, many are not equipped to grasp onto the complexity and the tools technology can plan that can eliminate clinical and administrative burden let alone improve patient care. This article is a step to help them understand these basics which can be utilized in an performant interoperability platform.
CQL stands for Clinical Quality Language, and it is a Health Level Seven International (HL7) standard for representing and communicating clinical knowledge in a computable form. It is designed to enable the exchange of clinical knowledge and logic in a standardized manner, allowing healthcare organizations to share and execute clinical decision support rules and guidelines across different systems and platforms.
In the context of Electronic Prior Authorization (ePA), CQL can be incredibly beneficial. ePA is the process of obtaining approval from insurance companies before a patient can receive certain medications, treatments, or procedures. This process is often complex and time-consuming, involving the submission of clinical information and justification for the requested intervention.
CQL can help in ePA in the following ways:
Standardization: By using a standardized language like CQL, healthcare organizations can develop and share clinical guidelines and decision support rules for prior authorization processes. This ensures consistency and reduces errors in the evaluation and approval process.
Example: A healthcare organization develops a set of clinical guidelines for prior authorization of certain medical treatments using CQL. These guidelines specify criteria such as patient demographics, diagnosis, and prior treatment history that must be met for approval.
Benefit: By using standardized CQL-based guidelines, all clinicians within the organization follow the same criteria for prior authorization, ensuring consistency and reducing variability in decision-making.
Automation: CQL can be integrated into electronic health record (EHR) systems and other healthcare IT platforms to automate the prior authorization process. Clinical rules encoded in CQL can be executed automatically, streamlining the review process and reducing the need for manual intervention.
Example: An EHR system is configured to automatically trigger a prior authorization request when a clinician prescribes a treatment that requires approval. The EHR system uses CQL-based rules to assess whether the patient's clinical data meets the criteria for approval.?
Benefit: Automation reduces the administrative burden on clinicians and staff by eliminating the need for manual initiation of prior authorization requests. It also accelerates the approval process by quickly evaluating patient data against predefined criteria.
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Decision Support: CQL allows healthcare organizations to encode complex clinical logic and decision support rules into their systems. This can help clinicians determine the most appropriate course of action based on evidence-based guidelines and patient-specific factors, facilitating the prior authorization process.
Example: A clinician prescribes a medication that requires prior authorization. The EHR system provides real-time decision support using CQL-based rules to assess whether the prescribed medication is appropriate based on the patient's clinical history, medication allergies, and potential drug interactions.
Benefit: Decision support helps clinicians make informed decisions by alerting them to potential issues or conflicts related to the prescribed medication. It ensures that patients receive the most appropriate treatment while minimizing the risk of adverse events.
?Interoperability: CQL is designed to be interoperable, meaning that clinical knowledge encoded in CQL can be shared and executed across different healthcare IT systems and platforms. This enables seamless communication and collaboration between healthcare providers, insurers, and other stakeholders involved in the prior authorization process.
?Example: A patient's prior authorization request is initiated at a primary care clinic and later reviewed by a specialist at a different healthcare facility. Both clinics use different EHR systems but share interoperable CQL-based prior authorization rules.
?Benefit: Interoperable CQL rules enable seamless sharing and execution of clinical guidelines across different healthcare IT systems. This allows for efficient collaboration between healthcare providers, insurers, and other stakeholders involved in the prior authorization process, regardless of the systems they use.
Overall, CQL can play a valuable role in streamlining and improving the electronic prior authorization process by standardizing clinical knowledge representation, enabling automation, providing decision support, and promoting interoperability across healthcare systems and organizations.? Ultimately, it strives to improve patient care.
To Learn more about ePA and its technology to help meet the CMS-0057 Mandate, please contact Balaji Narayanan , SVP of Engineering of Onyx , [email protected].
Onyx Technology, LLC is a healthcare managed interoperability compliance solutions provider. Onyx emerged from work with CMS in establishing the nation’s first nationwide FHIR-based API, Blue Button 2.0. Building on this experience and expertise, Onyx has partnered with Microsoft to build the industry’s leading platform for FHIR-based interoperable exchange. Focused on standards-based, interoperable technologies that ensure security, privacy and the delivery of the right information to the right place at the right time, Onyx is the expert in enabling our customers to garner the greatest value from their participation in the healthcare eco-system of tomorrow.??Please visit us at?www.onyxhealth.io .