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September 2, 2008

Conquering ROI Backlogs
By Selena Chavis
For The Record
Vol. 20 No. 18 P. 16

Timely access to patient record information can be critical to many needs. Here’s how one hospital and government agency addressed the issue through creative collaboration.

The need for information can seemingly come from an endless list of sources. From patients and other healthcare providers to attorneys and government agencies, HIM departments can feel bombarded by requests for information in patient records.

And the key to making everyone happy, according to Bonnie Coffey, president of the Association for Health Information Outsourcing Services, is keeping an organization’s release of information (ROI) under control.

“The demand for information is so acute, and there’s a need to have it quickly and accurately … and they [outside entities] keep ratcheting up the goal,” she says. “Today, if you get a request outside the hospital, you have to be able to respond quickly.”

Consider the Illinois Department of Human Services, which in recent years was part of a pilot program for electronic disability processing known as Electronic Records Express. An initiative by Social Security and the state Disability Determination Services to increase the use of electronic options for submitting health records related to disability claims, the service is now available in all 50 states, according to Roseann Haven, Electronic Records Express coordinator with the state human services department’s Division of Rehabilitation Services (DORS). However, for Illinois, the urgency for faster retrieval of health records came much earlier.

“We needed to find ways to get information into these electronic files in a timely fashion,” Haven says, pointing to the demand for quick and accurate record turnaround to evaluate disability claims for their clients.

Like healthcare, many industries and government agencies are looking to electronic record keeping as a way to increase efficiencies through time and cost savings. Because many organizations are finding themselves in hybrid situations where records are maintained by both electronic and paper methods, it becomes imperative that groups work together creatively to collaborate on information sharing, Haven says.

“I don’t think EHRs [electronic health records] have focused on ROI yet. … They’ve had other priorities,” she notes. “Many have a print utility but not a way to capture electronically.”

That became the challenge for collaboration between DORS and Memorial Medical Center, a 562-bed, level 1 trauma, acute care hospital in Springfield, Ill.

“We were putting information in the mail and sending it,” recalls HIM Manager Debbie Sexton, who points to the fact that the two organizations are located in the same city. “It was taking too long.”

Collaborative efforts paid off in the long run as the organizations were ultimately able to implement a system for the secure, electronic transmittal of patient information—but the process did not come without its headaches.

“We started talking to Memorial Medical in 2004 because they have a history of really working with us,” Haven says. “We worked on it for years [with limited success], but we were determined to find a way.”

Persistence paid off in the end, according to Haven. She says collaboration has only become more paramount since that time as new efforts continue to raise the bar on expectations for timely response. In January, yet another initiative was introduced to DORS called Quick Disability Decision, in which a computer module assesses a situation and flags certain claims to be expedited.

Haven says conditions such as terminal cancer or a patient on dialysis waiting for a kidney transplant took on added priority. “Our goal is to get them out the door in 20 days or less,” she says. “With [Memorial Medical Center], we didn’t even need to talk to them about expediting because they were already delivering in five days or less.”

The Dilemma
During fiscal year 2007, Memorial Medical discharged approximately 23,465 patients and completed 465,250 outpatient visits. The flagship hospital of Memorial Health System, Memorial Medical is complemented by two additional critical access hospitals, a physician network, and a home service arm.

According to HIM Director Jennifer Vorreyer, patient records are comprised of a complete EHR that is created postdischarge as patient medical record information is scanned into the facility’s Cerner Millennium system. Scanned images augment patient data that are captured by the system itself.

Vorreyer says issues arose concerning the ability to integrate the Cerner system with the electronic system used by DORS because patient information could not be formatted and transferred in a compatible manner.

Along with the challenges of submitting the data electronically, Memorial Medical’s HIM department saw requests for medical record information increase almost 20%, from 6,945 in 2004 to 8,307 in 2007. Specifically, the organization points to an increase of nearly 80% in DORS requests over the past four years.

“You get this multitude of requests, and they are all important in different ways. It’s important to get the information out quickly,” says Vorreyer. “Neither our patients, DORS, nor the HIM staff at Memorial were pleased with the time it took to respond to DORS requests.”

At the time the Electronic Records Express system was implemented at DORS, it took approximately 17 days for Memorial Medical to fulfill a request. Already facing a need to improve response time, Vorreyer recalls that the increase in requests only compounded the issue.

“As volume increases, you can increase staff, streamline processes, or you can change the metric you operate by,” she notes, adding that streamlining processes was really the only resolution. “Adding an FTE [full-time employee] as a solution to volume increase is not always an option in healthcare. To change our metric would mean that it would take us twice as long to respond … which was not really an option for us as our constituents needed faster turnaround.”

In the case of DORS requests, Sexton emphasizes the sense of urgency for timeliness. “In this situation, the patients themselves get their disability approved or denied by this information. … It affects the patient’s financial situation,” she says.

A Road Map to Success
Knowing the rapport that existed between the two entities, Haven challenged Memorial Medical to find a better way to exchange necessary information in a more timely fashion. The two groups had tried numerous methods in the past, but Sexton acknowledges that “our efforts had not been fruitful due to various reasons, including system conversions and security concerns.”

One of the answers ultimately came in the form of off-the-shelf software called Nitro PDF. The software allows data and images to be converted into secure PDF files, which allowed the organization to send compatible files from its EHR to DORS’ secure Web site.

Once the issue of compatibility was solved, the next step was to establish a shared, secure Web site where requests for information could be posted and the necessary patient information could be submitted to DORS from Memorial Medical. Vorreyer notes that HIM worked closely with the Memorial Medical IT department to make sure the information would be protected.

Citing the close working relationship between HIM and IT, Vorreyer says, “We both refer to ourselves as brother/sister departments because we both report to the CIO [chief information officer].” She adds that the organization recognized early on that closely integrated IT and HIM departments would be beneficial. “We have been reporting to the CIO for three to four years now,” she says. “It made sense for our organization, especially as we move forward with EHRs.”

Once Memorial Medical was comfortable with the security issues, the team set up passwords and test patients to fully analyze the functionality of the process. According to HIM Supervisor Brandy Farley, it took about three months to solidify the workflow, pointing to the need to train team members on how to obtain DORS requests via the secure Web site and submit the corresponding patient information electronically. “There weren’t any struggles at all. It was very easy,” she recalls. “Our team was very open to it.”

The results speak for themselves. With the new system in place, response time for DORS requests has been reduced from 17 to approximately five days.

“They cut almost two weeks off their response time. Sometimes I see them respond in 48 hours,” Haven notes. “They don’t print anything, and we don’t print anything. It’s very efficient.”

A Timely Plan for ROI
Haven says Memorial Medical was a prime candidate for inclusion in the DORS electronic initiative because it is a high-volume, regional provider, and most other healthcare organizations in the region have been a little slower about coming on board.

“We’re running about 37% of requests. We would love to see that at 50%,” she says.

Stressing that each hospital situation is a little different, Haven suggests that “it takes a hospital finding a ready solution for their unique situation,” and “it depends on where they are with their hybrid record.”

For Memorial Medical, the answer came in the form of off-the-shelf software, but the answer may be different for other entities. According to Coffey, that will be the challenge for healthcare organizations in keeping their ROI backlogs under control, especially in an age where response times are critical.

“What I see is you have this HIM department that has its many areas of responsibility, but if you have a backlog of ROI, you have a ripple effect,” she says, pointing to payment delays, HIPAA compliance issues, and overall patient confidence. “You don’t want patients asking, ‘Why can’t I get my records?’”

Coffey suggests that healthcare organizations consider outsourcing the ROI piece to other groups. “There are so many different things that have to go on in an HIM department. They have a lot of things to juggle, especially now with EMRs [electronic medical records],” she says. “Your energy and time get diverted to the biggest issue at the moment. You really have to supervise the people doing this [ROI].”

At the very least, Coffey recommends that requests be logged in as they are received and HIM departments designate an experienced professional to prioritize the work.

— Selena Chavis is a Florida-based freelance journalist whose writing appears regularly in various trade and consumer publications covering everything from corporate and managerial topics to healthcare and travel.


Memorial Medical Center: Lessons Learned
By working in tandem with state agencies, Memorial Medical Center was able to cut its response time for release of information (ROI) by more than two thirds. HIM Director Jennifer Vorreyer, HIM Manager Debbie Sexton, and HIM Supervisor Brandy Farley share their experiences and offer these tips to any healthcare organization considering a similar project:

1. Keep the patient at the center of your focus and never give up. There were plenty of hurdles that had to be crossed, but there was a determination to make it work correctly. Everyone knew it could be done; we just had to have the patience to appropriately address all the issues.

2. Train your team members and trust them—they know what they’re doing. Prior structure in the HIM department had most ROI team members specializing in a particular function or filling a certain type of request. This led to increased turnaround times. By cross-training ROI team members on the DORS electronic process, we were not limited by any one person’s attendance or workload.

3. Look at the data. Once the process has been revised, continue to look at results to see what other variables impact the process and their affect on turnaround time. We recognized that some pretty simple items affected our process. For example, the sharing of printers, assigned phone times, or how the system is actually reporting the turnaround time impacted our results.

4. Let the technology work for you. Thanks in part to the implementation of new technology, Memorial Medical has maintained a similar staffing level in ROI from prior years, even though the volume of requests has increased nearly 20% during that time frame. Other technologies that HIM staff have deployed, such as PDF software and CD burners, have allowed Memorial Medical to provide patients a personal electronic copy of their records, as well as streamlined the workflow processes in requesting the chart.

— SC