Healthcare AI Agent Resources

1. Create "Guideline Review" AI Skill

Objective:

Create an AI Skill that reviews payer guidelines and criteria for pharmacy medications to provide recommendations on what to highlight from medical records.

Steps:

1. Create a new AI Skill named "Guideline Review"
2. Set the Model connection to "HC - GLP1 PA Agent KB"

3. Set the System prompt to:

You are a specialist in medical necessity criteria and guidelines for pharmacy medications and you're tasked with providing accurate and concise information.

4. Set the User prompt to:

For each of the below questions, review the document(s) in your knowledgebase specifically for the payer $sPayer$ regarding medication $sMedication$ and indicate what one should attempt to find in the medical record for each question to best demonstrate we have met said criteria. Respond only with your indications.
[questions]
$sQuestions$
[/questions]

5. Add test data for variables:

a. sPayer: Aetna
b. sMedication: wegovy

c. sQuestions:

{
  "question1": "Will the requested drug be used with a reduced-calorie diet AND increased physical activity to reduce excess body weight or maintain weight reduction long term in an adult?",
  "question2": "Has the patient lost at least 5 percent of baseline body weight OR has the patient continued to maintain their initial 5 percent weight loss?",
  "question3": "Has the patient participated in a comprehensive weight management program that encourages behavioral modification, reduced-calorie diet, AND increased physical activity with continuing follow-up for at least 6 months prior to using drug therapy?",
  "question4": "Does the patient have a baseline BMI of greater than 35 km/m2? If not, what is the baseline BMI?",
  "question5": "Does the patient have at least one weight-related comorbid condition (e.g., hypertension, type-2 diabetes, mellitus, dyslipidemia)",
  "question6": "Does the patient have a history of taking medications for weight-related comorbid conditions (e.g., hypertension, type-2 diabetes, mellitus, dyslipidemia)? If so, indicate."}

2. Configure "Guideline Review" API Task

Objective:

Configure the API Task to use the Guideline Review AI Skill and properly map input and output variables.

Steps:

1. Open the "Guideline Review" API Task
2. Go to Three Dots -> Properties and add the description: "Reviews the relevant payer guidelines and criteria"
3. Add the "Guideline Review" AI Skill to the API Task by using the AI Skill action.
4. Quick map variables to connect the AI Skill inputs.

5. Add the following description to the output variable sGuidelineReviewOutput:

Recommendations on what to highlight from the medical record (if present) when answering the questionnaire to best demonstrate the necessary criteria have been met.

3. Add Guideline Review Tool to GLP1 PA Agent

Objective:

Add the Guideline Review API Task as a tool to the GLP1 PA Agent so it can be used during the prior authorization process.

Steps:

1. Open the GLP1 PA Agent
2. Add the "Guideline Review" API Task as a Tool
3. Ensure the tool is properly configured and available for the agent to use by verifying the variables and the tool have proper descriptions.

4. Run GLP1 PA Process

Objective:

Execute the GLP1 PA Process and interact with the agent to complete a prior authorization submission.

Steps:

1. Open and run the GLP1 PA Process
2. Leave both variables at their defaults
3. Go to Requests -> All Requests and select the In Progress AI Agent
4. The agent will eventually prompt the user for patient not meeting requirements
5. Instruct the agent to continue with the prior auth submission
6. Once the agent completes, go to Requests -> All Requests and return to the In Progress Process
7. The user will be prompted to review the draft responses. Edit as one sees fit
8. The user will be prompted with a form indicating the form has been completed and is ready for submission. Click the hyperlink to view the completed form
9. Done!