Health Data, Technology, and Interoperability “HTI-4” is the latest in a series of Assistant Secretary for Technology Policy/Office of the National Health Coordinator (ASTP/ONC) rules aimed at modernizing electronic health records and data exchange. Finalized in August 2025 as part of a broader Medicare regulation, the HTI-4 rule focuses on three key areas: electronic prescribing, real-time prescription benefit checks, and electronic prior authorization.
In plain terms, it sets new requirements for how certified health IT systems handle prescriptions and insurance approvals. The goal is to automate workflows, reduce the manual back-and-forth, and help clinicians make informed decisions faster. The updates officially take effect on October 1, 2025, giving health IT developers a clear target date to support these new capabilities.
Who Does HTI-4 Affect? If you develop or use certified EHRs or other health IT products, HTI-4 is on your radar. This includes not only traditional EHR developers but also vendors of electronic prescribing software and other ancillary health IT systems that support ePrescribing. An EHR developer planning their next software update will be building in these features to stay compliant, and eRx vendors should be doing the same.
Healthcare providers and their patients stand to benefit across the board. Once developers implement HTI-4’s requirements, providers will have better tools at their fingertips for checking drug coverage and completing prior authorization without endless phone calls and faxes.
Here’s HTI-4’s most important updates and why they matter.
Modernizing Electronic Prescribing
One major component of HTI-4 is an overhaul of electronic prescribing standards. It updates the long-standing ASTP/ONC certification criterion for e-prescribing (45 CFR 170.315(b)(3)) to enable richer information exchange among prescribers, pharmacies, health intermediaries, patients, and payers.
In practice, this means health IT systems must adopt the latest national standard for e-prescriptions so that when a doctor sends a prescription, the data flows seamlessly through the pharmacy networks and to insurance systems.
For the first time in about five years, this baseline e-prescribing standard is being upgraded. By incorporating the newest NCPDP SCRIPT format and the latest RxNorm drug vocabularies, HTI-4 will ensure prescriptions transmit all the information needed for downstream systems to process them smoothly.
Notably, electronic prescription workflows will also now include support for “electronic prior authorization” of medications. In the past, health IT developers could choose whether to include electronic prior auth in their e-prescribing module. HTI-4 changes that by making it a must-have. As a result, if a certain medication requires insurance approval, the health IT module must be able to initiate that authorization request digitally as part of the prescribing process.
For Drummond’s customers, this means updating eRx modules to handle those transactions and testing them for certification. Ultimately, this update addresses a chronic pain point in care delivery by reducing pharmacy phone calls and preventing treatment delays caused by prior authorizations with arduous prior authorization requirements.
Real-Time Prescription Benefit Checks (Cost Transparency)
The second big piece of HTI-4 is a new “real-time prescription benefit” requirement. This is all about giving providers and patients instant insight into medication costs and coverage before the prescription is sent to the pharmacy. Under HTI-4, health IT systems will need to integrate a real-time prescription benefit check at the point of prescribing.
Think of it as a built-in tool that lets a physician see multiple cost options of a drug, for example, “This drug will cost Jane $75 out-of-pocket with her insurance, but there’s a similar alternative that would only cost $20.” Instead of finding that out at the pharmacy (or after a claim rejection), the information is available during the office visit so the provider and patient can make a cost-conscious choice together.
This capability is powered by industry standards (specifically, the NCPDP Real-Time Prescription Benefit standard) that pull data from insurance and pharmacy benefit systems in seconds. By mandating it as a certification criterion, HTI-4 makes cost transparency a core feature of certified EHRs.
For developers, it means implementing the interface to query a patient’s drug coverage and display up-to-the-minute pricing and coverage details. For patients, it aims to cause far fewer “sticker shock” moments and frantic calls to switch medications. For pharmacists, this feature represents significant time savings, allowing them to provide better healthcare instead of waiting on hold.
Streamlining Prior Authorization with APIs
Perhaps the most impactful aspect of HTI-4 is its push to finally streamline prior authorizations (PAs) for tests, procedures, and medications. Currently, providers and staff spend hours manually chasing approvals; faxing forms, waiting on hold, or jumping between different payer portals. HTI-4 tackles this head-on by introducing three new certification criteria that enable end-to-end electronic prior authorization within an EHR. These criteria are built on modern API technology (specifically the HL7® FHIR® standards developed by the industry’s Da Vinci Project) to let EHRs and insurance systems communicate in real time.
What does that mean in practice? For example, if a clinician is ordering an MRI or referring a patient to a specialist, the EHR can automatically check the patient’s insurer to see if an authorization is needed and what documentation is required.
Next, the software helps the provider assemble all the necessary clinical information or fill out any required forms for the request, following the payer’s specific rules. Finally, the EHR can submit the prior authorization request electronically and then monitor the status of that request (approved, denied, or in progress), with updates flowing back into the system for the provider to see.
HTI-4 introduces these new prior authorization criteria as optional certification criteria. In practice, this means developers are not yet required to implement them, but the framework paves the way for electronic prior authorization to become a standardized feature in the future. For health IT developers that choose to adopt them, it involves implementing the FHIR-based API calls and data workflows needed for each step and ensuring they function reliably in real-world scenarios.
For healthcare organizations and clinicians, the payoff could be significant (especially for rural and smaller practices): less time lost to paperwork and phone calls, and faster turnaround on getting patients the interventions they need.
New Integrations and Data Standards
HTI-4 doesn’t stop at prescriptions and prior authorization. It also ushers in broader API-based integrations that signal where health IT is headed. Two new certification criteria were introduced to enhance how EHRs exchange data with other systems.
First, a new Workflow Triggers for Decision Support Interventions (previously known as Clinical Decision Support Hooks) criterion establishes a standard way for EHRs to trigger and utilize external decision support apps through an API. In practice, an EHR can automatically call an outside tool (such as a drug-interaction checker or a risk calculator) at the appropriate point in a clinician’s workflow and then display the results right within the EHR interface. This opens the door to “plug-and-play” decision support, where third-party tools can integrate seamlessly into certified products without custom integrations.
Second, a “Subscriptions” criterion introduces standard event notifications. It lets a user or another system subscribe to certain events or data changes and receive real-time alerts when those events occur. For example, a care manager’s application could subscribe to be notified whenever one of their patients is admitted to or discharged from a hospital. By enabling such notifications, an EHR becomes more proactive in pushing timely updates to those who need them. ASTP/ONC anticipates this capability will be especially useful for public health reporting and care coordination, where up-to-the-minute information sharing is critical.
Finally, HTI-4 finalizes the adoption of several new data standards for patient, provider, and payer APIs. In non-technical terms, it makes sure everyone is “speaking the same language” when exchanging key healthcare data. This includes standardized formats for retrieving a health plan’s formulary (the list of covered medications) and provider directory information, as well as the specific FHIR API profiles that underpin the new prior authorization workflow.
By cementing these in regulation, ASTP/ONC is aligning the technology used by EHR vendors and health plans. In fact, the provisions in HTI-4 were closely coordinated with parallel CMS rules that push insurers toward electronic prior auth and data sharing as well.
What Should Developers and Providers Do Now?
With HTI-4’s compliance clock ticking, health IT developers should be planning and building these enhancements into their product roadmaps. The rule’s effective date of October 1st 2025 marks when the new requirements become official, but several features have staggered rollout timelines. (For example, the real-time benefit check will become a required part of the “Base EHR” definition by 2028 and providers will start being measured on electronic prior authorization use in 2027 under Medicare quality programs).
Timeline at a glance
- August 2025: HTI‑4 Final Rule officially released
- October 1, 2025: Final Rule become effective
- Through Dec 31, 2027: Transition period allowing use of older standards
- Throughout calendar year 2027: providers must attest ‘yes’ (or claim an exclusion) to using a Prior Authorization API; measure not point-scored in 2027
- January 1, 2028: Real-time benefit checks and updated e‑prescribing standards become mandatory for certification
Judicious developers will begin development and testing well in advance. As a result, Drummond’s testing and certification teams will be ready to help developers navigate the new criteria as they prepare for updates.
Engaging early with the relevant standards and APIs (from integrating those FHIR prior auth interfaces to upgrading e-prescribing modules) will make for a smoother path to certification. Many of these changes, such as real-time benefit checks, also require collaboration with external partners (like pharmacy benefit networks or payer API platforms).
Healthcare provider organizations, on the other hand, should stay in close contact with their EHR developers about upcoming HTI-4 features. While providers don’t need to do anything to get their systems certified (that’s on the developers), they will want to ensure new functions like cost transparency and one-click prior auth become available to them by their developers.
Additionally, front-line staff and clinicians may require training to make the most of these tools.
In short, those affected should plan ahead so they can hit the ground running as their technology partners roll out HTI-4 enhancements.
A Smoother Road Ahead
In summary, HTI-4 is a targeted but impactful set of updates to the ONC Health IT Certification Program. Rather than abstract policy changes, it delivers practical improvements that anyone in healthcare can appreciate: prescriptions that reach the pharmacy with fewer hiccups, instant visibility into medication costs, and a long-awaited fix for the prior authorization grind. HTI-4 represents health IT’s next leap forward in cutting administrative waste and improving care coordination.
It builds on years of groundwork by standards organizations and aligns closely with industry commitments to streamline approvals. By embracing these changes, we move another step closer to health IT that feels less like paperwork and more like truly seamless, patient-centered care.