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April 23, 2012

ROI in a Hybrid Environment
By Elizabeth S. Roop
For The Record
Vol. 24 No. 8 P. 14

Unless properly managed, the transition to an EHR can create havoc on the release-of-information process.

Pain is a natural part of the transition from paper to electronic. For the clinical side of the house, it typically lessens as familiarity with the new EHR system increases. For those involved in the release-of-information (ROI) process, however, the pain can continue for years until a tipping point is reached.

“It’s one of those situations where you have to take a step backward before you can take a step forward,” says George Abatjoglou, chief operating officer of IOD Incorporated, an information management services provider. “The ROI process gets a little more complicated for a period of time. Finding all the components of the medical record is a little more challenging until you get far enough out postconversion to where the majority [of information] is in an electronic state.”

Defining, Finding the Legal Record
Most facilities follow a date-forward process when transitioning to an electronic environment or converting to a new EHR system. Records that were created or updated prior to that date remain on paper or in whatever electronic format was in use previously. As a result, fulfilling ROI requests often means pulling information from multiple systems.

“Eventually, once you’re far enough out to have the full legal record [in the EHR], it becomes more efficient. … Until then, it’s a matter of communication and documentation,” says Abatjoglou.

Indeed, locating and accessing the paper medical record was a primary challenge for Broward Health Coral Springs Medical Center, an IOD client, during its transition. The hospital based in Fort Lauderdale, Florida, took three years to finalize its conversion—three years during which charts were split between paper files and the EHR.

“The record could be in various locations within the hospital, so accessing the chart when it was needed for ROI [was difficult],” says Jill Finkelstein, MBA, RHIA, the hospital’s regional manager of HIM. “We were fortunate because we didn’t have multiple disparate systems to access. It was either the paper chart or electronic. We were challenged with ensuring there was a minimal backlog on a daily basis in filing loose work, otherwise ROI may not have a complete chart.”

With the conversion complete, Broward Health is seeing the benefits to the ROI process. For example, the process is far more efficient now that all the information needed to fulfill a request can be accessed immediately from one location within the EHR. It also has helped speed the revenue cycle by enabling faster processing of ROI requests related to claims and payments.

Finkelstein credits solid policies and procedures, open communication, and ongoing education and training with enabling Broward Health’s HIM departments to successfully navigate the hybrid world.

“We developed a legal health record policy so everyone understands what information is considered part of the legal medical record,” she says. “Also important is making sure that the ROI staff knows where to look [for information] in the clinical system. We have one clinical system to access. However, facilities with multiple clinical systems may have to go to two, three, or even four systems [to fulfill a request], and the ROI staff must know that.”

Defining the Workflow
Knowing where to find information to fulfill ROI requests is repeatedly cited as one of the most challenging aspects of functioning in a hybrid environment. Facilities that address this challenge early are often the most successful at navigating what can be treacherous waters.

According to Kim Murphy-Abdouch, MPH, RHIA, FACHE, a clinical assistant professor and clinical coordinator in the HIM department at Texas State University, a comprehensive workflow analysis is critical to designing procedures to successfully manage ROI during and after conversion. For all types of requests, the analysis should follow the release process from start to finish.

“It begins with defining what the legal health record is. That’s policy. Once you have the legal EHR defined as policy, it drives the workflow and processes for ROI,” says Murphy-Abdouch, adding that it’s important to understand what EHR content needs to be provided to fulfill different types of requests.

“The legal record may not be as clear in the electronic world as it is in the paper world,” she says. “That’s something that should be defined in the paper world as well as the hybrid and electronic worlds but often hasn’t been because we haven’t had to look [for information] in so many places.”

This is the approach taken by South Jersey Healthcare, which includes two acute care hospitals and more than 40 outpatient and satellite facilities. It started with evaluating the policies and procedures governing ROI and making changes as necessary to accommodate the new environment.

“From day one when planning the roll out, we kept going back and defining the legal record and what is being released. That was always the big picture. It’s something you have to think about, and it’s something you have to define,” says HIM Director Michele D’Ambrosio, MBA, RHIA.

With the legal record defined, South Jersey Healthcare undertook a comprehensive workflow analysis to identify the best approach for accessing all the data required to efficiently and accurately fulfill ROI requests. It also met extensively with its ROI vendor, MRO Corp, to ensure its processes were compatible with the new procedures that would be implemented during and after the conversion.

“We knew we were going to roll this out so we did a lot of work ahead of time. We looked at vendors to make sure they could do what we needed them to do. We wanted to make sure they weren’t just printing out records and scanning them into their systems,” D’Ambrosio says.

Ultimately, the workflow analysis should dictate processes to be followed by both the facility and any vendors involved in fulfilling requests. It should define policies and procedures governing when, how, and by whom information is accessed. This will become even more critical as new disclosure regulations under HIPAA take effect.

“Hospitals will need to determine the purposes for which information was accessed and how it was used. Additionally, all the disclosure points in the hospital will need to be defined,” says Don Hardwick, MRO’s director of compliance and field operations. “HIM is one source of disclosure, but it by far is not the only source. Information is being released throughout the organization. And when it’s electronic, more people have access to it than in the past. This increases the importance of hospitals getting a handle on who can access [personal health information] and keeping record of who is viewing it and the purposes and circumstances behind their access.”

In fact, Hardwick recommends procedures be established to create a single point of disclosure that could even extend to hospital-owned practices and clinics. This would help prevent improper disclosure, something that can happen far more easily in an electronic environment than in the paper world.

HIM, as the traditional guardian of the medical record, is the most logical location for such a plan. “Their expertise is the best place for it to continue to reside,” says Hardwick.

Adjusting Skill Sets
Because they outsource some or all of their ROI function, neither Broward Health nor South Jersey found it necessary to increase staffing to accommodate the extra work involved in managing the process in a hybrid environment. However, most agree that even when additional staff isn’t needed to manage the process, new skill sets are.

For example, pulling and copying records in a paper world is fairly straightforward because the information is generally available in the patient record either in the facility’s HIM department or at off-site storage.

According to Abatjoglou, that is not the case in the electronic world. Staff must demonstrate a high level of competency in an EHR environment and understand the laws governing record releases.

Thus, while comprehensive procedures can go a long way toward ensuring an accurate ROI process in the hybrid and electronic environments, additional staff training and education are imperative. That training should focus on enhancing the technical skills necessary to manage both the conversion of a chart from electronic to paper and accessing the data to process requests.

According to Murphy-Abdouch, whose background includes hospital operations, HIM, and finance experience, when any portion of records resides in an electronic environment, the clerical skills take on a far less significant role.

“The individual workers who are managing ROI need to have more technical abilities,” she says. “But it’s not only changing the skill sets. It also is changing the mindset.”

Murphy-Abdouch cites an encounter she had as a consultant working with a hospital on the transition to electronic records. Using the new system, ROI staffers could select a document and autofax it directly from the EHR to the requesting office. The staff was fully trained on the feature, yet she observed one staffer print out and manually fax information.

“It’s not only getting people trained but also getting them to continue using the enabling technologies and not go back to old habits,” she says. “It’s all about workflow documentation, making sure the technology works, training staff to use it, and then monitoring to ensure they continue to use it.”

Nilda Tamburello, RHIA, vice president of ROI for Medical Record Associates, concurs, adding that training can be a lengthy undertaking due to the complexity of managing a process that requires collecting information from multiple sources and in multiple formats.

Indeed, records can be found on multiple media types even within one department. For example, there may be paper records as well as electronic records, microfiche, and even scanned documents stored on CDs. Further, once a facility has completely transitioned to electronic, chances are high that information required to process various ROI requests will still reside on multiple systems.

“It’s a lot of work for ROI abstractors to make sure they have a complete medical record to do a release,” Tamburello says. “You still have to navigate through [multiple] databases … and you have to look at the record very differently than you did the hard copy record. It is a slow and complicated process but it’s always a learning process.”

In fact, ROI in hybrid and electronic environments requires such different skill sets and has so many moving parts in terms of disclosure that many have found it necessary to completely revamp job descriptions to “fit certain people who can access more or less [information] on the computer. We had to really look at different job descriptions and what they do,” says Tamburello. “There is a lot to learn, and the initial training is prolonged because of the learning curve. What used to take a shorter amount of time is now more intense, and you have to be careful of the integrity of the record.”

Integrity Matters
If anything, maintaining the integrity of the information being released is more complicated in a hybrid environment. Because one mistake can spread like wildfire through multiple systems, the need for highly focused quality assurance is greater than ever.

This is especially true if the integrity of the master patient index (MPI) was compromised at the time the new EHR was implemented, leading to overlays and duplicate records. This can be particularly problematic for ROI vendors.

“Trying to pull that information apart is very labor intensive [and] from a vendor perspective, it may not be easily detected,” says Rita Bowen, MA, RHIA, CHPS, SSGB, senior vice president of HIM and a privacy officer at HealthPort. “[This could lead to] a breach of information or data being released in error. … When all is said and done and everything is correct, the process of ROI is fairly easy and no different than what it was in the paper world. But in the electronic world, [errors are] not as easily detected.”

She notes that electronic environments create more options for handling ROI. More options require stronger policies and procedures to govern access and disclosure. These policies and procedures must also be updated as technology advances throughout the enterprise, in particular to ensure that staff understands where to find information within the EMR and how it flows through the system.

“You have to understand the request that’s being made and how it’s threaded throughout the entire electronic record. It changes the complexity and the skill set,” Bowen says. “You have to make sure that all staff truly understand the enterprise MPI … and help them understand what’s within each folder of the EMR and how it flows within the record as well as the data mapping as to the flow of information in both electronic and paper formats. You have to help them understand that this is a transition, and the things that are in paper today may not be in paper tomorrow.”     

— Elizabeth S. Roop is a Tampa, Florida-based freelance writer specializing in healthcare and HIT.


ROI Service Providers Help Iron Out the Rough Spots
Hospitals can’t hit the pause button on release of information (ROI) just because they’re transitioning from one environment to another. Whether records are on paper, in an EHR, or somewhere in between, they still must be accessible to fulfill requests quickly and compliantly.

“The hospital might decide to change systems [but] nobody slows down sending out requests. The work still has to be received, properly processed, and returned in a timely manner. It can be very resource intensive for the hospital and specifically the HIM department to manage the changes while keeping up with day-to-day operations,” says Steve Hynes, president of MRO Corp.

It’s a common but erroneous assumption that transitioning to electronic records will reduce staffing needs around ROI. In fact, personnel requirements initially can often increase to avoid backlogs as staffs adjust to new procedures and systems.

There is also a need for specialized expertise to design the ROI process, train staff, and in some cases, assist with the actual implementation.

“This is where we can add value. We already have expertise in helping clients extract records. We know what it looks like and can implement the new design process,” Hynes says. “Over a long period, [resource needs] might fluctuate up and down, but there will be a temporary bubble to get everyone up to speed during the conversion.”

Kelly Quigg, product manager of interfaces at HealthPort, concurs, noting that moving to an EHR is a very labor- and education-intensive process for most facilities. Outsourcing ROI is one way to lessen the burden. It can also provide access to expertise that many hospitals don’t have and are unlikely to need for the long term.

“In addition to that, many vendors have the ability to work with other systems,” she says. “They can identify short cuts that help the facility make the processes more efficient. They don’t have to go through the learning curve all at once. Hospitals can take ROI back under their control in the future, but [outsourcing] gets them through the learning curve.”

Ultimately, vendors and hospitals have the same goal with ROI regardless of the environment in which the data reside. And both must go through the same learning process. For vendors, the learning curve is accelerated because they can focus their internal resources on just one thing: managing the ROI process.

“As an ROI company, our staff still needs to know how to research a record and what to look for. The training might be a little more involved because they are required to learn [individual] hospital systems as opposed to just learning the components of the medical record,” says Kathy Gordon, RHIA, vice president of ROI at Medical Record Associates. “But at this point, because it’s been slowly evolving for a few years now, it’s something we’ve grown accustomed to and have learned to work with. It doesn’t matter what the hospital’s system is, whether a hard copy or electronic record, our job is to ensure the confidentially and privacy of the patient.”