Conditional Question Logic

conditional question logic purpose the ncpdp epa standard is designed to minimize the number of questions a provider vendor must answer when requesting prior authorization for a medication to accomplish this, the standard has features that enable the provider vendor to present only those questions that pertain to the situation, based on the patient’s specific pharmacy benefit the particular prescribed medication the provider vendor’s answers to clarifying questions contained in the electronic pa message ideally, the electronic process should be an improvement over paper and pdf forms, which often contain questions relating to multiple medications and/or patient conditions properly designed question logic should allow the provider to skip irrelevant questions and only concern themselves with those that apply to their patient and prescribed medication using the ncpdp epa standard, the pbm/payer and provider vendor do the work of determining the specific subset of potential questions that need to be presented to the provider the result is that the pbm/payer limits the starting set of potential questions to those relating to the particular requested medication and the terms of the patient’s pharmacy benefit the provider vendor only presents relevant questions as the provider works through the electronic message for example, the provider’s answer about the patient’s diagnosis results in the provider vendor skipping questions related to other diagnoses question logic features the following epa message types may contain question sets painitiationresponse paresponse paappealresponse the elements are available in the question element inside the response structure and they function the same in all three message types conditional question logic overview conditional question logic determines the next question to be answered by the provider vendor in some cases, the next question is always the same, regardless of how the current question is answered in other cases, the next question is based on the answer given to the current question pbm/payers need to ensure strict quality control on the data fields so that the conditional question logic works as desired otherwise, additional questions will need to be sent to the provider vendor that should have been answered on the initial question set this creates more work for both the provider vendor and the pbm/payer pbm/payers should develop their question sets in the most efficient way and return only when necessary if the pbm/payer does not provide conditional question logic, it will take provider vendors longer to answer the question sets it will also increase work on the pbm/payer side because the pbm/payer would have to review all answers other question logic features expand on the “if yes, then this; if no, then that” conditionality, enabling the next question to be determined based on the answer to a multiple choice question, or the range in which a numeric answer falls pbm/payers should avoid asking for information that is populated in other segments of the epa message (e g patient age, gender, etc ) or repeating questions one option to consider is to pair a technical writer with a clinician so they can work together to determine the best way for the question sets to flow in order to get the necessary information from the provider vendor as efficiently as possible question logic examples below are typical situations where epa question logic would be used to convert conditional portions of paper pa forms into their electronic equivalents the examples call out a few ncpdp message elements that play key roles in defining and arranging questions, including sequencenumber indicates the order in which questions are presented questionid a unique identifier for each question in the message defaultnextquestionid used when the same next question is appropriate regardless of the current question’s answer nextquestionid answer specific field used when a question’s answer determines the next appropriate question nonechoiceid in a 'select multiple' question type, this enables a "none" option that, when selected, disables other options and clears any prior selections key considerations include selecting nonechoiceid makes other choices unselectable any previous selections are cleared if nonechoiceid is chosen additionally, a "next question condition" has been introduced to compare the submitter's choices to a single value or a range, using supported values ( lt less than, gt greater than, le less than or equal to, and ge greater than or equal to) this enables branching logic based on user selections the epa question types that support conditional, answer based logic the select question type used for yes/no and multiple choice questions the numeric question type and its singlecomparison and rangecomparison options enable the next question to be based on the answer’s relationship to a single value or a pair of lower and upper bound values notes regarding the examples use of yes/no or multiple choice questions does not demand that conditional logic be employed the next question following a multiple choice can be the same regardless of the choice selected by the provider vendor to accomplish this, the defaultnextquestionid is specified for the question, and the nextquestionid element for each answer choice is not sent the questionid gives a unique identity to each question in the pa it is included for system use only, and is not intended to be presented to the end user not required to match the sequence of the overall set of questions (i e , a question with questionid 999 may precede a question with questionid 1) instead, the sequencenumber determines the order in which questions are presented the number of questions presented to the provider vendor may vary depending on the question types and options defined in the epa question set the same electronic question set could result in two or ten questions for the provider vendor example 1 yes/no questions this example is of a conditional next question logic based on yes/no questions original paper pa form what is the patient’s diagnosis? has the patient had past use of any generic ssri for the treatment of depression? (y/n) if not, does the patient have a history of contraindication, allergy, or intolerance to generic ssris? is the patient currently taking the requested medication with a beneficial response? electronic version sequence number question id default next question id question type question text choice text next question id 1 0640 406 freetext what is the patient’s diagnosis? 2 406 select has the patient had past use of any generic ssri for the treatment of depression? y 888 n 999 3 888 999 select does the patient have a history of contraindication, allergy, or intolerance to generic ssris? y n 4 999 end select is the patient currently taking the requested medication with a beneficial response? y n the two provider vendor question/answer possibilities examples below show how questions may vary based on how the prior question was answered provider vendor question/answer possibilities what is the patient’s diagnosis? depression has the patient had past use of any generic ssri for the treatment of depression? y does the patient have a history of contraindication, allergy, or intolerance to generic ssris? y is the patient currently taking the requested medication with a beneficial response? n what is the patient’s diagnosis? depression has the patient had past use of any generic ssri for the treatment of depression? n is the patient currently taking the requested medication with a beneficial response? n example 2 multiple choice between diagnoses this example is of a conditional next question logic based on a multiple choice questions between diagnoses original paper pa form patient’s diagnosis if the diagnosis is asthma, is the patient currently using an orally inhaled corticosteroid? if the diagnosis is asthma and the patient is not currently using an orally inhaled corticosteroid, does the patient have a history of intolerance or failure to that treatment? if the diagnosis is asthma, does the patient have contraindications (such as allergy) to inhaled corticosteroids? if the diagnosis is asthma, is the patient physically able to use an orally inhaled corticosteroid device? if the diagnosis is allergic rhinitis, is the patient currently using a nasally inhaled corticosteroid? if the diagnosis is allergic rhinitis and the patient is not currently using a nasally inhaled corticosteroid, does the patient have a history of intolerance or failure to that treatment? if the diagnosis is allergic rhinitis, does the patient have contraindications (such as allergy) to inhaled corticosteroids? if the diagnosis is allergic rhinitis, is the patient physically able to use a nasally inhaled corticosteroid device? if the diagnosis is exercise induced asthma, is the patient effectively able to use a metered dose inhaler (i e , albuterol)? if the diagnosis is exercise induced asthma and the patient is not effectively able to use a metered dose inhaler (i e , albuterol), please explain the reason electronic version sequence number question id default next question id question type question text choice text next question id 1 0123 select what is the patient’s diagnosis? asthma 2000 exercise induced asthma 3000 allergic rhinitis 4000 2 2000 select is the patient currently using an orally inhaled corticosteroid? y 2002 n 2001 3 2001 2002 select does the patient have a history of intolerance or failure using an orally inhaled corticosteroid? y n 4 2002 2003 select does the patient have contraindications (such as allergy) to inhaled corticosteroids? y n 5 2003 end select is the patient physically able to use an orally inhaled corticosteroid device? y n 6 3000 select is the patient currently using a nasally inhaled corticosteroid? y 3002 n 3001 7 3001 3002 select does the patient have a history of intolerance or failure using a nasally inhaled corticosteroid? y n 8 3002 3003 select does the patient have contraindications (such as allergy) to inhaled corticosteroids? y n 9 3003 end select is the patient physically able to use a nasally inhaled corticosteroid device? y n 10 4000 select is the patient effectively able to use a metered dose inhaler (i e , albuterol)? y end n 4001 11 4001 end freetext please explain the reason the patient is not effectively able to use a metered dose inhaler the four provider vendor question/answer possibilities examples below show how questions may vary based on how the prior question was answered provider vendor question/answer possibilities what is the patient’s diagnosis? asthma is the patient currently using an orally inhaled corticosteroid? y does the patient have contraindications (such as allergy) to inhaled corticosteroids? n is the patient physically able to use an orally inhaled corticosteroid device? n what is the patient’s diagnosis? asthma is the patient currently using an orally inhaled corticosteroid? n does the patient have a history of intolerance or failure using an orally inhaled corticosteroid? y does the patient have contraindications (such as allergy) to inhaled corticosteroids? n is the patient physically able to use an orally inhaled corticosteroid device? n what is the patient’s diagnosis? allergic rhinitis is the patient effectively able to use a metered dose inhaler (i e , albuterol)? y what is the patient’s diagnosis? allergic rhinitis is the patient effectively able to use a metered dose inhaler (i e , albuterol)? n please explain the reason the patient is not effectively able to use a metered dose inhaler the patient… \[clinical reason] example 3 numeric answer this example is of a conditional next question logic based on a numeric answer original paper pa form what is the patient’s age? if the patient is 36 or older, does the patient have a documented diagnosis of acne vulgaris? if the patient is 36 or older, does the patient have a documented diagnosis of actinic keratosis? if yes, does the patient have lesions on the face? electronic version sequence number question id default next question id question type question text choice text comparison operator comparison value next question id 1 100 end numeric (single comparison) what is the patient’s age? ge 36 200 2 200 300 select does the patient have a documented diagnosis of acne vulgaris? y n 3 300 select does the patient have a documented diagnosis of actinic keratosis? y 400 n end 4 400 end select does the patient have lesions on the face? y n the four provider vendor question/answer possibilities examples below show how questions may vary based on how the prior question was answered provider vendor question/answer possibilities what is the patient’s age? 18 what is the patient’s age? 41 does the patient have a documented diagnosis of acne vulgaris? n does the patient have a documented diagnosis of actinic keratosis? n what is the patient’s age? 41 does the patient have a documented diagnosis of acne vulgaris? n does the patient have a documented diagnosis of actinic keratosis? y does the patient have lesions on the face? y further details on question types and question logic can be found in the ncpdp script implementation guide’s section question set usage