Home  |   Subscribe  |   Resources  |   Reprints  |   Writers' Guidelines

November-December 2020

ROI Processes Adapt to a New World
By Elizabeth S. Goar
For The Record
Vol. 32 No. 6 P. 18

The pandemic has forced health care organizations to reevaluate how to best distribute protected health information.

Since the devastating arrival of the coronavirus in the United States, few aspects of the health care system have escaped its wrath unscathed. That includes release of information (ROI) operations, which were upended by the need to deploy a remote workforce with little notice and find safer ways to accommodate requests.

While emergency maneuvers were aided in part by a sudden drop in requests as elective procedures were paused and the industry turned to telehealth, volumes are quickly returning to normal. Now, with shelter-in-place orders easing in many parts of the country and surgical volumes climbing, health care organizations’ new pandemic policies and procedures are being put to the test.

“Initially, sending staff home was a huge change. But we weathered it well and … from a best practice standpoint, it could be an option for some job functions going forward,” says Jaime James, MHA, RHIA, a senior HIM consultant for legislative policy and compliance with MMRA. “Now, as we’ve moved through that and facilities are opening up, the challenge will be how to reopen to the public while keeping employees safe.”

An Overnight Pivot
Balancing employee safety while maintaining patients’ access to their medical records was one of the most significant challenges confronting health care organizations as they began to close their doors to the public and send ROI teams home.

The question was how to “close your medical records department to prevent infections while still responding to patients who need a copy of their medical records,” says Carlos Rodriguez, MBA, president of the Association of Health Information Outsourcing Services. “The more proactive health care systems have moved to a touchless exchange of PHI [protected health information] through patient portals or to ROI companies that have implemented e-patient request systems.”

The importance of e-patient request capabilities was driven home when organizations found themselves making the quick transition to a fully remote ROI workforce—not always voluntarily. Rodriguez points to facilities that found themselves faced with a positive COVID-19 test within its medical records department, necessitating sending the full team home to quarantine.

“This is why we stress to our clients the necessity of remote VPN [virtual private network] access as well as e-patient request portals,” Rodriguez says. “One of the lessons learned from COVID-19 is to ensure that your ROI outsourcing company has been given remote access through a secure VPN into the health care facility’s EMR. Without this, you are compromising the health care system’s ability to respond to medical record requests on time.”

James notes that the rapid transition to a fully remote workforce was aided in part by a significant drop in ROI volume across the board—in some cases up to 50%—when hospitals shut down elective procedures. However, it wasn’t enough to just send the medical records team home—processes needed to be in place to avoid disrupting ongoing services.

“We had to get creative on how to receive requests,” James says. “One of the things we did was set up a hospital ROI e-mail address where they could be received directly. We did also see more [hospitals] open to e-mailing and receiving faxes. They still receive the requests, but the way we receive them had some additional flexibility.”

In some cases, enabling a hybrid workforce was the primary challenge, one Ciox dealt with both internally and on behalf of its client organizations. Internally, the outsourcing company rapidly increased its remote workforce from 30% to about 60%. The challenge then became one of management, including establishing effective policies and procedures for remote medical records staff, performing audits, and ensuring remote teams remain productive and engaged.

“All these components were rapidly scaled to support the mass exodus,” says Elizabeth Delahoussaye, RHIA, CHPS, Ciox’s chief privacy officer.

On the facility side, Ciox sought to move rapidly to primarily remote teams while also protecting those who needed to remain onsite, says Stephen Mallinak, general manager and senior vice president of operations. Among the on-site considerations, in addition to masks, social distancing, and proper cleaning, were limiting public access to the department and installing Plexiglass.

Ensuring that newly remote staff were able to process requests compliantly was another hurdle that had to be crossed to keep the ROI machine humming. According to Art Gonzalez, vice president of client accounts for Midwest ROI, client facilities continue to receive requests through typical channels, but “it is now more than ever critical to make sure that staff equipment—laptops, phones, etc—are all configured to be HIPAA compliant.”

He continues: “It only takes one stolen laptop or phone with [protected health information] on it and not ‘configured to be HIPAA compliant’ to [cost] a hospital or clinic thousands of dollars in fines.”

The Portal’s Time to Shine?
There is no question that patient-facing technology plays a central role in any organization’s response to maintaining ROI operations throughout the pandemic. In fact, an easy assumption would be that the beleaguered patient portal would finally have its turn in the spotlight.

Or not.

If anything, reviews of the portal’s impact were mixed. Delahoussaye notes a “huge uptick in people accessing the patient portal. We’re seeing huge adoption because the pandemic made one preferred option—walking into a provider’s office and getting their information—more difficult. Now, you have to go through different avenues, [including the portal].”

Adds Mallinak, “The change in mindset around tools has changed drastically in a few months. People expect [the portal] now. If they can’t get to [their information] online, they want to know why not.”

However, others are less enthusiastic about the patient portal’s role in this new pandemic landscape. For example, Gonzalez notes that the technology doesn’t play a major role in managing ROI because most patients don’t access it for that purpose.

Rodriguez says that while patient portals have become the “telehealth solution to being able to function in a COVID-19 environment,” they do not provide the level of detail most requests require.

“Most health care facilities only display an abstract of the patient’s clinical records in their EMR portals,” he says. “There are many medical record requests where the entire record is needed, as well as any diagnostic imaging such as a CT or an MRI. These requests are typical for disability, life insurance, or legal subpoenas.”

The Way Forward
Patient portals may not be the primary framework upon which the postpandemic ROI process is constructed, but emerging technologies do play a significant role in what operations may look like. While a remote ROI workforce is expected to remain a permanent fixture, on-site teams will still be needed. Therefore, organizations must be able to protect both their staff and the members of the public who, despite everything, make their way to the medical records department.

“People will still find their way to the HIM department [so] how do we provide patients with top customer service when they walk in to request their records? Technology to assist [with that] is one thing that has come out of all this,” James notes. “MMRA is getting ready to roll out a patient kiosk that, if patients do come to the hospital and the ROI office is off the beaten path, can be used to request records.”

Available as countertop, wall-mounted, or freestanding units, the secure Patient Kiosk lets patients request records inside the organization without needing to travel throughout the facility or via face-to-face interactions. It allows for video calls to remote employees for assistance and provides multiple options for receiving the requested records, including MMRA’s TRACQuest portal, mail, in-person pick-up, and the patient’s portal.

“With COVID-19, people are not wanting to travel the distance within a hospital, and if the HIM department isn’t in an overly convenient location or we don’t want more people in an enclosed area, we might see more [technology] innovations, and the kiosk is one of them,” James says.

Ciox plans to consult with its customers to identify options, such as centralized call centers and electronic delivery, for extending its contactless front-desk solution. The end goal is to continue to meet patients’ customer service expectations—whether or not medical record departments open back up for in-person requests.

“The patient request portal was a primary tool pre-COVID, but we have to look at it more holistically now,” Mallinak says. “We’re investing in additional self-service options with everything we do regardless of whether you’re a patient or a third-party requestor.”

Along with patient-facing technologies, several best practices have emerged over the course of the pandemic that will aid facilities in safely moving forward to a more normal ROI environment without sacrificing staff or public safety. One is to consider outsourcing ROI services, which can reduce the number of staff required to be on site to process requests, Gonzalez says.

“If it’s not possible to outsource your ROI—for example, you have paper charts or records—the best practices would be limiting onsite office staff, following [Centers for Disease Control & Prevention] guidelines for workplaces, and perhaps adjusting work schedules to reduce the amount of staff on site at any one moment,” he says.

Rodriguez offers the following best practice checklist for maintaining a safe ROI working environment:

• Establish a work-from-home policy.

• Ensure the IT department can support remote workers.

• Have a plan in place if an employee tests positive for COVID-19.

• If you are still allowing walk-ins, determine how to protect your staff from COVID-19.

• Ensure your ROI outsourcing company has been vetted for remote access into your EMR system.

• Implement a touchless e-patient request and fulfillment system.

• Have a request system in place that allows patients to request and retrieve medical records anytime, anywhere through the device of their choice.

• Provide a live customer service representative to address any patient questions or concerns.

Ultimately, what it comes down to is a facility’s ability to provide a seamless, secure, and compliant ROI service without sacrificing the health or safety of employees and patients, Mallinak says.

“The key from the provider standpoint is that we need to make sure the experience is as good or better for patients,” he says. “We can’t just take something away without a replacement. If you take a person away from the front desk, patients still need to see a face. Satisfaction ratings from patients are still extremely important.”

— Elizabeth S. Goar is a freelance writer based in Wisconsin.


In the days following the nationwide pause on elective surgeries and the implementation of shelter-in-place orders, health care organizations realized not only a drop in the volume of release of information (ROI) requests but also a change in the types of information being sought.

According to Carlos Rodriguez, MBA, president of the Association of Health Information Outsourcing Services, stand-alone physician clinics saw a 30% to 40% decline in medical records requests as patients postponed nonurgent well care visits. Hospitals that shut down nonemergency surgical procedures saw a drop of 10% to 20%.

As request volumes began returning to normal, two types of requests have increased. One is for continuity of care records. The other, Rodriguez says, is quite interesting. “Patients are calling the medical records department and asking, ‘Did I test positive or negative for COVID-19?’ Most health care facility policies are to release the lab results, with appropriate HIPAA authorization and not interpret the results,” he says.

By late July, hospitals were seeing ROI request volumes return to normal as insurance companies and court systems both resumed full operations. However, Rodriguez says requests for COVID-19 lab results coming through the medical records department continue to increase, signaling perhaps another aspect of the postpandemic “new normal.”