The Prior Auth Reckoning, Part 2: The Limitations of the EHR

By Dr. Steve Kim, Valer Co-Founder and CEO

This is Part 2 of our 10-part series examining the deep, interconnected complexities that keep prior authorization broken. While many hospital and health systems hope new regulation (CMS-0057-F) and AI will improve processes, the real barriers to progress lie in systemic challenges that span technology, workforce, regulation, and operations. These barriers won’t be eliminated by regulation, payer pledges, or today’s AI solutions—but providers have more control than they might think. Throughout the series, we’ll break down the entire prior auth landscape and include practical recommendations that can make a difference.

Picture this: Your patient access team opens the EHR to initiate a prior authorization. What should be a straightforward digital workflow immediately becomes a maze of screenshots, sticky notes, Word documents, and—yes, even in 2025—fax machines. Despite billions invested in electronic health records, most prior auth work happens outside the EHR through manual workarounds that teams have developed in a piecemeal fashion. If Part 1 of the prior auth story starts with workforce gaps, Part 2 picks right up where many workflows begin: the EHR. 

Challenge #1: The Clinical vs. Administrative Disconnect

EHRs were built with a clear mission: document patient care, support clinical decision-making, and ensure continuity across providers. Prior auth, however, is fundamentally an administrative and financial process that happens to require clinical data. This critical mismatch creates friction at every step.

While x278 EDI transactions were established to address prior auths, most EHRs and payers still to this day don’t broadly utilize 278 transactions, with the primary use case more limited to notices of admission rather than comprehensive coverage of  prior auth workflows.  A few EHRs (notably Epic) have standardized their workflows to the x278 transaction set, but the lack of broader adoption has limited its utility until now. 

Because 278 transactions aren’t universal, provider organizations have to adopt various other point solutions to cover the full patient journey and prior auth workflow. The result is a patchwork of semi-integrated solutions that create more complexity than they solve. Patient access teams find themselves jumping between EHR modules, payer portals, and homegrown tracking systems to complete what should be a single, unified workflow.

Challenge #2: DaVinci FHIR Assumptions vs. On-the-Ground Reality

The healthcare industry has pinned significant hopes on the DaVinci FHIR initiative, particularly Coverage Requirements Discovery (CRD) and Documentation Templates and Rules (DTR). These standards promise to embed prior auth intelligence directly into clinical workflows, theoretically streamlining the entire process.

But here’s the disconnect: DaVinci implementation guides assume that providers will respond to prior auth clinical questions within EHR workflows. In reality, most of this work is handled by patient access and office staff who work outside the clinical documentation flow. The assumption that already burdened physicians will pause their clinical work to address administrative requirements—like discovering that a patient is no longer eligible or that different payer rules now apply—simply doesn’t match how healthcare actually operates.

Embedding CRD and DTR into clinical workflows isn’t a simple plug-and-play. Each integration will require development work, ongoing maintenance, and constant updates as payers modify their requirements.

Challenge #3: Fragmentation (A Common Refrain)

Always a top theme when it comes to prior auth challenges, fragmentation is also a barrier when it comes to EHRs. Even when health systems invest heavily in EHR optimization, no two organizations run Epic, Cerner, or any other major EHR exactly the same way. Each health system customizes workflows, data fields, and integration points based on their specific needs, payer mix, and operational preferences.

This customization undermines standardized prior auth solutions. What works seamlessly in one Epic instance may require significant modification at another. Beyond customization differences, many organizations are running older EHR versions that lack the latest prior auth capabilities.

The separation between clinical and administrative functions creates real barriers to accessing the data needed for prior auth. Consider this common scenario: A community physician orders an MRI for their patient at your hospital. Your patient access team needs to gather clinical documentation from the ordering provider’s EHR (which they can’t access), combine it with facility-specific information from your EHR, and submit everything to the appropriate payer portal. It’s one workflow hurdle after another.

Challenge #4: The Missing Structured Data Problem

Healthcare is dynamic. A radiologist reviews an initial order and recommends adding contrast. A surgeon discovers additional pathology requiring immediate intervention. When orders change, some payers allow modifications to existing authorizations while others require completely new submissions. Worse, resubmitting can sometimes cancel the original authorization, leaving providers with no coverage for either procedure.

Despite digital capabilities, patient access teams resort to analog solutions because they work more reliably than the official digital channels. Screenshots capture payer portal information that can’t be directly imported into the EHR. Sticky notes track authorization numbers that don’t have proper fields in the system. Word documents compile clinical information from multiple sources because there’s no single repository that contains everything needed.

Automated prior auth depends on clean, structured data, but EHRs often fall short of providing what’s actually needed. Critical gaps include:

• Incomplete CPT/HCPCS coding: Providers may document procedures in clinical terms that don’t translate directly to billing codes required for prior auth.
• Order modifications: Say a CT scan order is modified to include IV contrast—the updated requirements may not flow properly to prior auth workflows.
• Order vs. appointment-based workflows: Some EHRs track scheduled appointments rather than specific orders, complicating data extraction for prior auth submissions.

The Solution

Relying on the EHR to solve and contain prior auth workflows is almost a guarantee that your team will need workarounds to accommodate every payer, specialty, and service line. The right prior auth solution can overcome the limitations of the EHR by providing one unified workflow for your whole patient access team.

Implement prior auth workflows that can handle the dynamic nature of healthcare orders and provide structured data management independent of EHR limitations. Look for platforms that can manage order modifications and track authorization statuses without relying solely on EHR data fields. We’ve put together a comprehensive checklist to evaluate vendors.

Rather than forcing your EHR to be something it’s not or waiting for DaVinci FHIR to provide just a partial solution, prioritize a solution that integrates with your specific EHR implementation and delivers simpler, faster prior auth processes.

Next up in Part 3: Once the submission process gets going, patient access teams have to figure out if prior auth is even required for any given service. As we’ll explore, that’s an unnecessary headache in and of itself.