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Prior Authorization System (PAS) - Pharmacist (Rph)

Design evolution of PAS from legacy to new automated screen.

What is PAS for Pharmacist ?

PAS is a utilisation management process used by United Health Group (UHG) to determine if they will cover a prescribed procedure, service, or medication. The process is intended to act as a safety and cost saving measure. There are number of reasons that insurance providers require prior auth. including:
Age
Medical Necessity
The availability of generic alternative
Checking for drug interactions

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How it works?

After request comes from a qualified provider of PA checks is to provide cost savings to consumers be preventing unnecessary procedures as well as prescribing of expensive brand name drugs when an appropriate generic in available. In addition, a prior authorization for a new prescription may help prevent potentially-dangerous drug interactions.

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General workflow

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Problem areas - Pateint

Problem 1 - Reliance on Fax

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Variety of reasons including  incompatible data systems. It's estimated that faxed account for about 75% of all medical communication.

Problem 2 - PA model is sequential

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This means that data must flow back and forth between doctors, Rph and PBM's multiple times for the same subscription before being authorised for processing at pharmacy level.

Problem areas - Pharmacist

Problem 1 - PA model is sequential

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Rph are the end decision maker in the process all the missing pieces needs to be solved by them. This increases their work pressure and forced to do things that are not their job.

Problem 2 - Low trust on system

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Rph correcting all the incorrect data filled by tech and other people in the process has cause low trust on the information provided to them. This has lead to needing all unnecessary info all the time.

More questions

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Has anything changed?

Electronic Prior Authorization (ePA) is being introduced to the system. Simpler, faster and error free process is in place now and 2/3rd of PA’s are electronic now

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How are delays compensated?

By overburdening the pharmacist to provide the authorization in the least time possible. they have to process huge amount of information in really short period of time. Which is the leading cause of errors.

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Then why is the pressure same on pharmacist?

PAS system for the pharmacist is the legacy system, designed decades back. UI is quite heavy with multiple tabs & info. UX is not clear in displaying important & unimportant throughout. The legacy system has multiple tabs, nav bars, buttons available from all screen which makes it difficult for providers to concentrate on the given task, hence the delays & errors.

A day in a life of Pharmacist

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User Persona

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User Journey

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What’s the problem again?

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Verification of every information provided

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Low trust on the system

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Unnecessary information

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Legacy system

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Multiple stakeholders

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Fax and letters involved

Reframing the problem statement?

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Final problem statement?

How can RPH analyse the key problems of the case and make a completely unbiased decision max under 5 minutes.

Measurable Objectives

Key Progress Indicator (KPI)

Objectives

How can RPH analyse the key problems of the case and make a completely unbiased decision max under 5 minutes.
75% Pharmacist can navigate through the design without any prior training on the new design.

Key Results

Strictly show predicted problem and immediate necessary information
80% problems can be found in under 2 min
20% problems can be found in under 3 min
System recommendation is correct 99% of the time.

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NPS Score - More trust, Less copy paste, Low cognitive load

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Accuracy of decisions

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Success metric on task completion

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Lesser training time for new joinees

Information Architecture

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Legacy Screens

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Early 1st attempt screens

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Problems solved in the re-design

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1. Less time taken to solve case

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2. Lack of accurate information

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3. Lesser clicks

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4. Low trust on the system

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5. RPH not held accountable for tech mistakes

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6. More pend to cases

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7. Information overload

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8. Time wasted in re-checks

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1. Less time taken to solve case
2. Lack of accurate information
7. Information overload

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  1. Re-thought the workflow as the case needs to be solved so there is less going back & forth.

  2. Considering all scenarios and customising each flow so unnecessary information is reduced.

  3. Even fax information to be converted inside the system so it read and automation can be applied if necessary.

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3. Lesser clicks

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  1. Making multiple components and experiences combine together so they can focus better and not waste time opening multiple tabs.

  2. Including paper information into text format in the system.

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4. Low trust on the system
8. Time waste in rechecks

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  1. Automating repetitive steps so it saves them time to confirm their fears and doubts for the case.
    Show them alerts and notifications exactly where they could need it to make decision so users do not miss out.

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5. RPH not held accountable for tech mistakes
6. More pend to cases

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  1. Not having Member, provider and drug edit options as those information is provided by Tech and if it not right it should be sent back to them. Hence saving time.

  2. Automation helping RPH decide better accurate information thus reducing cases pent to a senior.

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Did re-design change anyone’s life?

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I trust the information provided and do not verify them anymore.

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I enjoy working as the screens as there are no disctractions

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With automation I am getting help to make decision faster

How did re-design impacted the business?

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Lesser cases being pend to another senior to solve it.

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Decreased learning time.

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Lesser time taken to solve a case.

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Lesser instance of leaving the platform to find more information.

Thankyou

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