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August 2015

How to Outsmart ROI Challenges
By Juliann Schaeffer
For The Record
Vol. 27 No. 8 P. 16

Facilities face four common hurdles in their quest to meet today's release of information requirements.

The specifics of release of information (ROI) workflow vary with every health care organization. Some hospitals outsource the entire process while others deal with it in-house in the HIM department. Some facilities utilize technology to help expedite and streamline the process while others receive and respond to ROI requests primarily through faxes or paper means. Still others adopt a hybrid approach that incorporates multiple aspects of the various options.

But no matter what the ROI process looks like, there are common hurdles that can habitually trip up facilities, including a lack of time and organization, and poor quality assurance. And in today's regulatory climate, there's little room for error.

"Providers cannot risk error when disclosing PHI [protected health information] in today's highly regulated climate," says Don Hardwick, vice president of client relations and compliance for MRO, a provider of ROI solutions. "Request volumes are up and turnaround times are regulated by state and federal guidelines. At the same time, HIPAA/HITECH regulations are becoming more stringent. HIM professionals are being challenged to share more information at a quicker pace, often through electronic connections—and they are being asked to process the information with additional scrutiny and accuracy to protect a patient's privacy."

Common solutions to such obstacles tend to focus on two objectives: Ensuring adequate resources—perhaps a well-designed technology, an outsourcing partner, or information for in-house employees—and properly educating and training staff.

Four Common Challenges

Less Time
With health care organizations striving to meet meaningful use standards to have a chance at receiving the program's federal funds, it forces them to work under stringent ROI time restraints.

"Draft meaningful use standards are shortening the time for required release of information within a very limited time frame from patient discharge," says Darice Grzybowski, MA, RHIA, FAHIMA, president of H.I.Mentors. "The organization must have ROI handled as efficiently as possible seven days per week in order to meet requests in the required timeframe."

According to Rita Bowen, MA, RHIA, CHPS, SSGB, senior vice president of HIM and privacy officer for HealthPort, the entire ROI process depends on it being timely—from beginning to end.

"From the time you receive the [record request], it should be opened, logged, dated, and entered into the process," she says. "You should know where your response process is at any one point in time. So if someone calls to inquire, you should be able to go into that system and say your request was received on X day. You should know exactly where it is in the process. [For example, whether it is being processed, already mailed, etc.] If you send it to another area to be processed and/or mailed, then you should say it was sent to that office on this date, [and] their turnaround is estimated at X."

The days when facilities could take a week or more to respond to certain record requests are over, Grzybowski says. "Instead, with appropriate systems and staffing, best practice standards should be that all requests are responded to within 24 to 48 hours," she says, noting that facilities should expect a multitude of issues if they're not meeting these timelines. "Without access to records, insurance company reimbursement may be held up, erroneous information may be shared with health care providers who may be basing their plan of care on this data, or other problems may ensue, including upset patients."

Facilities that find themselves failing to keep pace may want to consider enlisting outside help. "Most HIM directors realize ROI is a very important function of health information management and needs to be performed well," says Diane E. Ferry, MS, RHIA, president and CEO of Star-Med. "However, inasmuch as it is a discrete function, it can be effectively and efficiently outsourced with the advantage of thereby freeing up department staff for functions that are more closely integrated with the organization's day-to-day health care operations. The key is to partner with a competent, reputable ROI company that will perform the function with the same attention to patient service that the organization strives to achieve in its health care services."

Lack of Organization
Bowen says many health care organizations have begun moving to a centralized ROI process (eg, with an electronic document management system). However, those that haven't often deal with fragmented processes or silos of information that can make patient information difficult to track. "For example, you might have to go to different places to get different things rather than just one central place, such as having to go to radiology to get radiology reports or having to go to the lab to get lab results," she says.

The best practice, according to Bowen, is moving to an enterprise response for customer service and consolidating the ROI processes so rules and regulations are applied properly.

Ultimately, most ROI inefficiencies lead back to the processes and the primary tools used to handle ROI requests, says Therasa Bell, president, chief technology officer, and cofounder of Inofile, a developer of direct messaging technology for ROI. If fax machines are involved, Bell says they must be operated by a dedicated resource or pool of resources to avoid costly errors. "The content coming in may be incomplete, which then requires human or phone follow-up or more faxing back to the recipient. This delays how quickly a physician receives critical content," she says, noting that faxing makes it difficult to track receipt of information or that all of the necessary information was received.

"Additionally, the fax content must be entered into the EHR or an alternative ROI tracking system for disclosure tracking purposes or the medical record content must be acquired and printed out from the EHR because medical records often don't fax well," Bell adds. "On the receiving side, the information must be indexed to the patient and physically transported or potentially scanned back into the EHR and attached to the patient record."

Every one of these steps can add inefficiencies and expand the potential for human error, she notes.

The request logging and tracking process is another area where slowdowns can occur, Hardwick says. "Typos and/or improper entry may result in records being distributed to the wrong place, especially in the case where institutions receive a large volume of requests," he says. "Also, HIM professionals are reporting inefficiencies as a result of needing to work in various legacy systems in order to complete the ROI process."

Want to simplify responding to ROI requests? Grzybowski says organizations with electronic records that charge a certified HIM professional or a paralegal with handling the task are ahead of the game. Under these circumstances, there's no need to physically retrieve, copy, and mail records. "Today's sophisticated release of information system modules and the ability for hospitals to collect any charged dollars due to them through the normal accounts receivable process lessens the burden on HIM staff to follow through," she says.

However, Hardwick notes that even when organizations operate in a hybrid or a fully electronic environment, it doesn't necessarily mean they have the proper methodologies in place to fulfill ROI requests electronically—which is why faxing remains a popular option.

Hardwick says direct secure messaging, a standard for the secure exchange of personal health information, is one alternative to faxing that can improve accuracy and reduce the potential of an improper disclosure.

Not Enough Quality Control
A lack of quality control is another issue that may plague ROI operations. However, Grzybowski says the problem could largely be solved via routine audits that would help keep processes in check. "Whether handled in-house or via an outsourced agency, routine audits should be conducted—just as they are in the coding area—to ensure that the appropriate information and the complete information has been released, as well as that the appropriate charges have been issued," she says. "With HIPAA requirements to track disclosures, the administrative component should also be audited. With this much revenue in store for hospitals that choose to handle their own release of information in-house—which is considered a best practice model—having tight controls in place ensures efficient and effective release of information."

Bell says direct secure messaging's ability to audit all points of exchange can be a game-changer in this regard. "The technology enables organizations to confirm when secure messages are received and opened with the flexibility for larger organizations to route ROI requests to a team of employees for quick response, all of which can be easily tracked," she says.

Bowen says stepped-up auditing efforts can help curb errors in the master patient index. "Many organizations have information that may have three numbers for one patient, or worse, they may have two patients but only one record," she says. "Having that already cleaned up or in the process of being analyzed so that information is clean and dependable is paramount for a streamlined ROI process."

In her position at HealthPort, Bowen has worked with health care organizations where policies and procedures regarding ROI functions have been absent. For facilities looking to establish an effective ROI process, creating or updating policies and procedures is an ideal starting point, she says.

"Having well-documented policies and procedures for ROI is definitely something that's important as part of the information governance plan to make sure it's handled correctly," Bowen says. No matter where it's located (online or on file), policies and procedures should be readily available to employees "as a constant living document that's being read, reviewed, evaluated, and improved upon," she says.

Executive leadership should be onboard with any strategies that promote more effective ROI processes, Ferry says. "Organization leaders may not be familiar with the details of ROI functions, but they do know the importance of patient satisfaction and regulatory compliance. They know that every contact with the organization is part of the patient experience—great care followed by poor interaction with the business office or the HIM department leaves the patient with a negative impression of the whole organization," she says. "Further, the leadership doesn't want to have the organization be the subject of the next news story about improper PHI privacy breaches. They understand that achieving that satisfaction and compliance doesn't happen without a well-trained and managed ROI staff."

Lack of Trained Staff
Without strong and easily accessed policies and procedures in place, health care organizations can find themselves facing another serious challenge: inadequately trained staff. In fact, Bowen says this is the biggest detriment to a smooth ROI process.

For example, Bowen says a poorly trained staff can lead to the following:

• an inability to locate the policies and procedures (if they exist at all);

• a failure to stay current with federal and state ROI rules and regulations; and

• an inability to comprehend core HIM knowledge and/or anatomy and physiology that would prevent them from responding appropriately to record requests.

For example, a staff member who receives an order for a coronary artery bypass graft record must understand the request (or have access to the correct reference tools) and know where those reports are found. "However information is stored and formatted, you want to make sure staff know how to map that appropriately to get to that information," Bowen says. "That will have a major impact on your turnaround times and ensuring there aren't unnecessary delays in the ROI process."

Grzybowski says staff also must be trained on how to identify all parts of the electronic record, a skill she sees lacking in many ROI workflows. "If an organization is releasing information from a dynamic and discrete data-based EHR and the document is not stable—like within an electronic document management system—there's a risk that with a future request, the information may be changed and inconsistent data be sent out," she says, noting that this may affect patient care and create potential legal culpability.

Staff members also must be familiar with the facility's different source systems, Bowen says. "Staff may know this is the Cerner medical record, but they may not know the Cerner system is being fed by five other source systems, and they may not know what those systems are or how to effectively talk to those other departments regarding what they have and what they may need to respond to an ROI request appropriately," she says, noting that this is especially pertinent if a request is for a subpoena that's asking for a decision point.

"Patient care depends on quick and accurate release of information of the record," Bowen continues. "An HIM professional should be able to identify the specific parts of a record and know where to locate that information for the most expedient release. Organizations often make the mistake of delegating this function to noncertified clerical staff who don't have a background in HIM, nor have been trained in anatomy, physiology, and medical terminology and therefore don't understand the documents within a record and how they relate to each other. This can be especially true if [records are] supplied from an external agency.

"Since these are legal health records released—sometimes to attorneys—this lack of knowledge can increase risk to a hospital if incomplete, fragmented, or erroneous sections of the record are released," she adds.

A competent staff is one that appreciates the importance of the ROI function, Ferry says. "ROI staff should understand that they aren't just performing a clerical function, they are helping the patients and families that the health care organization serves, be it with continuity of care, a legal or insurance matter, or simply their right to know about their care," she says.

Victory Starts in the Training Room
A well-trained staff is the best weapon against common ROI issues, says Bowen, who offers several tips for facilities looking to beef up their HIM training. First, an organization must ensure staff members fielding record requests have the appropriate resources available, including legal handbooks for referencing state policies and procedures.

While such training begins at orientation, organizations should consider education to be a continuous process. "It definitely is not a one-time training," Bowen says. "You need a very detailed training that needs to be mapped out according to all the processes and evaluated during the orientation process. But you also need to have a continuing learning process as well."

For example, when a new system is introduced, facilities should offer in-service training. Or when a new cardiac procedure is set to debut, staff members must be aware because they'll likely receive a related ROI request at some point. "There has to be constant communication to ensure staff can respond appropriately for ROI," says Bowen, noting that it's an evolving process that grows from a solid foundation of basic anatomy and physiology, and medical terminology.

No matter how a facility chooses to manage its ROI process, be it in-house, outsourced, or a combination of the two, the key is to recognize challenges and manage them effectively. The benefits of such a strategy include decreased turnaround times, greater customer satisfaction, better staff morale, and improved patient safety and quality of care.

And it largely begins with staff. "The better educated the staff, the better the ROI process will be," Bowen says.

— Juliann Schaeffer is a freelance health writer and editor based in Alburtis, Pennsylvania.