EMR Workflow Integration Using Clinical Decision Supports Hooks

Patient Segmentation and Improved Care Management
Context:
A specialty pharmacy deals with high-cost medications that often require prior authorization from insurers. Without prior authorization, claims may be denied, leading to financial loss and delayed patient access to critical medications.

Scenario:
Pharmacy staff currently spend hours manually checking each medication’s requirements with insurance providers, causing delays in getting necessary medications to patients and increasing administrative overhead.

Solution:
Integrate a CRD service that automatically discovers and tracks coverage requirements for specialty medications. This service helps identify the exact requirements for prior authorization, step therapy, or alternative drugs covered by the patient’s insurance plan. It also flags medications with common approval barriers, so staff can proactively manage authorizations.

Outcome:
Quicker authorization processes, reduced manual work for pharmacy staff, and timely access to medications for patients. This results in better patient adherence to treatment and potentially improved health outcomes.