How Does Question Set Automation Obtain Clinical Evidence?
Question set automation retrieves clinical data from the EHR using FHIR APIs (Fast Healthcare Interoperability Resources). It communicates through back-end codes called expressions, which query precise, structured clinical criteria needed to answer ePA questions. These expressions return only the minimum necessary data if the criteria are met, ensuring privacy and compliance.
They rely on standardized terminologies such as:
- ICD-10 for diagnoses
- SNOMED CT for clinical concepts
- RxNorm for medications and medication allergies
- LOINC for laboratory tests
- NUCC Taxonomy for prescriber specialties
Expressions also incorporate parameters like timeframes, status, and coverage periods to ensure accuracy. In addition, Question Set Automation leverages data from the NCPDP message (PAInitiationRequest or NewRx) to identify medication details, quantity, and associated diagnoses.
If clinical evidence is found, Question Set Automation will only provide the specified number of matched items that the question asks for. For example, if the question requests one migraine drug, Question Set Automation will return only the first matched migraine medication even if the patient has multiple past migraine medications. Similarly, if the question asks for two migraine drugs, the answer will list two medications if found. This logic ensures compliance with minimum data sharing requirements.
The success of Question Set Automation depends on discrete EHR data being present and accurately coded to answer prior authorization questions.