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February 2, 2009

Find the Perfect ROI Fit
By Lindsey Getz
For The Record
Vol. 21 No. 3 P. 14

In-house, outsource, or a combination of both—there are a number of options available that can be tailored to meet the ROI needs of healthcare organizations.
Twenty years ago, physician offices and hospitals were inundated with so many requests for medical records that they became backlogged. As a result, getting through the old requests was as critical as completing the new ones. While today’s healthcare facilities have learned to better manage the process, there is always room for improvement.

Leaning on Technology
The release-of-information (ROI) process once meant manually tracking down records and making lots of photocopies. It was a tedious process. But, as with other areas of daily life and business, technology has made vast improvements in storing and sharing documents.

While paper records still exist in many cases, the shift toward electronic medical records (EMRs) has been significant. “In the paper world, there would only be one paper record,” says Lou Ann Wiedemann, MS, RHIA, CPEHR, director of professional practice resources for the AHIMA. “You’d have to find the individual paper record requested for each patient, even if you had 100 requests that day. And there were always problems that ensued. It could have been filed in the wrong spot or checked out by someone else. However, with technology, you can now track where a record is, and as long as it’s in one system, multiple people can have access to the record at the same time.”

Another bonus of using an electronic method is its effect on the environment. “Less paper, less printing, and less mail means less waste,” says Margaret P. Ezell, PhD, of Universata, Inc, who hosted two workshops on ROI at last year’s AHIMA conference. “It’s a greener practice, and it will also save you money. When the Medical University of South Carolina [MUSC] made the switch to our electronic Health Information Exchange and ROI eDelivery from their previous paper vendor, it saved them $20,000 in postage and $5,000 in paper.”

Through its Community and Enterprise Health Information Exchange, MUSC is able to receive electronic requests from trusted requesters, gather EMR content, and e-deliver the record. Nontrusted requesters must have HIPAA-compliant authorization and can receive the record via e-delivery, fax, or mail.

Transitioning to a paperless system can also save staffing costs, adds Ezell. “George Washington University Hospital … started off with just paper releases, using six or seven staff members to handle the ROI process. But when they transitioned to an electronic environment, they were able to cut back on the amount of staff needed. It now takes 21/2 employees working on the ROI e-delivery process with a one tenth of a day turnaround time.” While this kind of staffing change is not seen universally, it can be one of the outcomes of having an electronic health record.

Keep in mind that the staff who are handling the process do need to be properly trained, as a different set of skills are required for handling the ROI process on the computer, says Wiedemann. “You need to determine if it’s something your staff can handle and, if so, how much training they’ll need,” she explains. “And be mindful of your processes; going electronic isn’t an automatic fix. If you have had problems with ROI in the past, unless you make changes, you will have the same problems again, even after you go electronic. For instance, if your problem was that doctors were not completing records on time, having an electronic release system will not help solve that. You still need to address the problem of manual signatures. Take the opportunity of switching to new technology to seek out your problem areas and make appropriate workflow changes. That way, when the technology is implemented, you will have a smoother process.”

Going the electronic route has also changed how records are distributed. “We’ve recently started giving out patient information on CDs,” says Diana McLaughlin, acting director of HIM at Mount Sinai Hospital in New York. “We’re finding more and more demand for this. Of course, it depends who is making the request. We can accommodate them either way—paper or CD.”

Many say the advances will just keep coming. For example, Ezell says that Universata’s technology could allow healthcare facilities to have a kiosk where patients electronically request their own medical records and later receive them by e-delivery.

“In this information age, healthcare will get more and more technologically savvy,” says McLaughlin. “And as we get more sophisticated down the line, there will be more ways to get the records out in a timely and efficient manner.”

Who Handles the Process?
The amount of time and labor involved in handling ROI requests has led some to outsource the process to third-party vendors. “As the need for information surpassed the amount of labor a hospital or physician office could devote to it, the need for outsourcing was created in the industry,” says Bonnie Coffey, president of the Association of Health Information Outsourcing Services (AHIOS). “Today, ROI companies have not only helped hospitals keep up with these requests, but they have also brought the turnaround times to the lowest they could be.”

New technology, however, has some healthcare facilities thinking about bringing the process completely in house. “I think in the paper world, the ROI process was incredibly labor intensive and time consuming, since everything was manual,” says Wiedemann. “But implementing technology has caused many to look at the pros and cons of bringing it in house and perhaps to even reconsider the way they handle the process. In today’s economy, everyone is looking at ways to decrease their expenses, and it would be prudent for any HIM professional to review their outsourcing contract and make an educated decision. It could be that bringing it in house would not be worth the cost, but it’s still worth taking a second look.”

If the process is done in house, HIM directors should consider that they will be wearing two hats, notes Ezell. “One is doing their patients’ service as a caregiver. The second is doing customer service for those patients requesting records,” she says. “HIM directors may have a conflict as to which service they put the most time into, but it’s important that they need to serve both functions if they are handling the ROI process.”

What has worked for many healthcare facilities is finding a balance of sharing the process with an outside vendor. “Partnering with a vendor has allowed us to cut back on our workload,” says Richard Brown, MPA, RHIA, director of medical records for Inova Mount Vernon Hospital in Alexandria, Va. “We handle only the initial process and validation of authorizations and then scan and upload patient documentation to our third-party vendor, who in turn mails copies, collects payment, and provides receivables to our facility for the joint venture.”

Brown says that not having to tie up staff or hire new staff members to tackle the ROI process is outsourcing’s biggest plus. “To keep the full scope of the ROI process in house would easily become a staffing issue,” he says. “Even with outsourcing, we are still able to validate requests while using another entity to handle the collection process. And having staff validation ensures that we do not breach patient confidentiality.”

McLaughlin says that while many of Mount Sinai’s ROI requests are outsourced, it does handle some of the process on site as well. “It’s a large institution, so it makes sense to outsource the majority of our ROI needs,” she says. “It has benefited us because of the sheer volume of information requested on a daily basis. But we do some work in house, too. We track requests internally and always look for HIPAA concerns. And we scrutinize our requests to make sure everything is appropriate.”

HIPAA’s rules and regulations have significantly altered how the ROI process plays out. “It has created such a level of accountability,” says Coffey. “It’s accountability that the industry needs, and it [HIPAA] creates a level of security, and it does require having staff that is well versed in the requirements. HIM departments need to ask, ‘What steps are we taking to keep it private?’ or ‘If there is a breach, is it reported?’ If employees are making a mistake, even if only once in a while, they still require some retraining.”

The need to be well versed in HIPAA may prompt some organizations to choose the outsourcing route. “In many cases, a vendor’s staff is better trained on HIPAA than the hospital’s in-house staff,” says Ezell. “In an electronic release management system, users have an electronic workflow within their system that forces them into HIPAA compliance. The systems retain a digital copy of what was released, and for seven years, the authorization can be used to prove what was sent to requesters in case there is ever any question.”

It’s not only HIPAA but also the dawn of the recovery audit contractor (RAC) program that’s causing many healthcare facilities to reevaluate the management of their ROI process.

Zelda Greene, MS, RHIT, HIM administrator for the Lehigh Valley Health Network (LVHN) in Allentown, Pa., says the organization initially considered bringing the entire process on site but, after taking a serious look at how much extra staff would be required, decided to move from a fully outsourced ROI process to a shared services model. “It would have been too much wasted time and resources to take it completely in house,” she says. “But because of all the regulatory requests we get, as well as the RACs coming on board, we wanted to make sure we knew exactly what was being sent out, and we wanted to be able to control that process.”

LVHN’s transition to a shared process with MRO, a company that offers electronic ROI solutions, has allowed it to regain not only control but also visibility, says Greene. “When our ROI was completely outsourced, we didn’t have our hand in the process at all,” she says. “The outsourcing company basically represented the hospital for us. We’ve turned that around so that we now have most of the control.” The change in direction has also eliminated most service-related complaints and brought the average turnaround time for requests down to just five days. Like many hospitals, LVHN is happy to outsource the ROI billing and collection process, according to Greene.

“If you plan to keep the process in house, you have to ask yourself, ‘Once you bill the person for copies of the records, how diligent are you at actually collecting the money?’” says Coffey. “Quite honestly, hospitals and provider offices have their own issues for getting paid for their services. And they now have larger threats on the horizon with the RAC programs. To go after a couple thousand dollars in record costs when they have millions on the line for the RACs doesn’t make sense.”

“Hospitals are often not very aggressive with the billing and collection process,” adds Ezell. “They simply aren’t going to waste time fighting for small amounts of money when there’s so much other work on the table. A statistic from AHIOS shows that when the process is done in house, 50% to 70% is collected. But that figure is over 90% when the billing and collection are done by an outside ROI vendor. In a recent meeting I attended with an HIM director and CFO [chief financial officer] of a very large system, the CFO was surprised to learn that after three months of in-house staff trying to collect, the facility wrote off the rest of the bills—about $30,000 per month—collecting only about $16,000 per month.”

Generating Revenue
Whether the ROI process becomes a revenue generator depends not only on the ability to collect owed monies but also on state regulations. “In some states, you might have fees for records that are so low, it becomes difficult for you to even recover your labor costs,” says Coffey. “Because operating costs are so high, it can be difficult to make a profit.”

A lot of facilities decide to take the process in house for the purpose of bringing in revenue; however, it’s a decision that should only be made after careful consideration. “Look at what you pay for your current contract with an outsourcing company and then look at the expenses you will incur if you move it in house,” says Wiedemann. “Then decide if you’ll be making revenue. The HIM professional really has to do his or her homework on this one. Consider facts like whether you have the billing capabilities, the trained staff, the equipment or software you’ll need, plus all that extra time involved. Carefully weigh what you’d gain and lose by bringing ROI in house.”

“It comes down to what works best for the organization,” adds McLaughlin. “It could be revenue generating if it’s done in house, but it may not be worth it in the long run. It’s important for the HIM department to recognize all the costs associated with bringing the process in house. We’ve outsourced for a long time now, and it’s just always been more practical.”

Greene says creating a shared model of the ROI process has allowed LVHN to enhance its revenue generation. “It’s not our primary goal, but the revenue generation is definitely a nice by-product of the process,” she says. “And sharing in that jointly with our company has been a good thing for both of us.”

— Lindsey Getz is a freelance writer based in Royersford, Pa.