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Release of Information Strategies to Maximize Customer Service, Productivity, and Revenue

Patricia Tooley, BSN, RN, CIPP System Executive Privacy Compliance, Records Management, Central Scanning, Release of Information and Contract Management Memorial Hermann Healthcare System

Introduction

As the cost and complexity of healthcare spiral upward and scrutiny by regulatory agencies increase, the need to control operations and resources becomes increasingly apparent. Your Release of Information (ROI) department can leave you vulnerable and open to fines and penalties if not controlled. In the past, ROI has been a prime candidate for outsourcing due to laborious and time-consuming functions, cost, and state and federal regulations that carry heavy fines for violations. But how can you be sure your outsourced vendor is following all the federal and state regulations and meeting your patient and customer expectations? These are just the reasons why ROI should be an in-house operation and controlled by the Health Information Management (HIM) professional. Relying on outsourcing could put you, your patients, and your organization at risk for inappropriate disclosures, litigation, and unwanted press.

Memorial Hermann Healthcare System (MH) made a strategic decision in 2001 to bring ROI back in-house. MH is a not-for-profit, community-owned, health care system with spiritual values, dedicated to providing high- quality health services in order to improve the health of the people in Southeast Texas. MH’s roots extend almost 100 years into Houston history, even though the system as it is today was formed in the late 1990 s when the Memorial and Hermann systems joined. MH has 10 acute care hospitals, three long-term acute care hospitals, three specialty care hospitals, 21 regional affiliates, a home health agency, and a retirement/nursing center. We have 323,258 annual emergency visits, 3,185 annual Life Flight air ambulance missions, 3,286 licensed beds, 4,178 medical staff members, 26 residency programs, 46 fellowship programs, 1,324 physicians in training and 19,000 employees. Bringing ROI in-house was no small task.

Challenges

Historically, the outsourced ROI functioned at a loss financially, produced a high employee turnover rate, and negatively affected customer satisfaction. Once the decision to move this function to in-house was made, we had six weeks to complete the transition, resulting in many challenges. The most challenging included:

· Taking inventory of open requests and requests paid but not mailed.

· Choosing the right software

· Necessary interfaces

· Robust enough to handle the complexity of our organization

· User friendly

· Security and privacy features

· Hiring staff

· Intense staff education on both federal and state regulations

· Developing job descriptions and career ladders

· Establishing productivity standards

· Creating a budget

· Developing policies and procedures

· Capital equipment cost in the middle of a budget year

· Software licensing and maintenance fees

· Establishing billing and collection procedures

· Establishing charges by request type can be a major challenge. Make sure you know your state mandated charges for medical record copies. This will be your standard, but there are always exceptions. The following are the most challenging.

· Managed care requests – charge by contracted rate;

· Administration “give a ways”

· Physician requests

Another significant challenge was the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Knowing that the effective date was April 2003, a decision was made to implement the disclosure portion of the HIPAA Privacy Rule. In order to accomplish this, we had to crosswalk Texas Release Laws with HIPAA, no small challenge. A gap analysis was completed and mediation recommendations outlined. For example, the subpoenas we received were not valid. They either lacked a letter of assurance, proper court order, or if accompanied by an authorization, the required elements. Second , we met with the district attorneys from three surrounding counties in order to familiarize them with the new requirements and to promote a smooth working relationship. We developed what we call the Scott Durphy Letter, named after the Harris County District Attorney. It allows law enforcement limited access to patient information under specific circumstances per the HIPAA privacy rule. Mr. Durphy was flattered. Today, our legal release process is well known in the community. We continue to communicate with both private and county attorneys to ensure we are meeting their and our patient’s needs, while at the same time not disclosing inappropriately.

Technology Infrastructure. Choosing the right ROI documentation software is the first step in order to streamline the ROI functions and other aspects of patient record release management. You should investigate the total package. The application should be a comprehensive, integrated solution. Keeping requests manually or on a spreadsheet can be disastrous. The solution should interface to your MPI for instant patient identification, track communications, minimize data entry, have quick look up functions, integrated cash flow and productivity reporting and HIPAA compliant. I would think there are several companies out there that offer all of these great things. Of course you need to have these things, but when selecting a company, you need to look toward one that not only has the experience and technology to address your needs, but also has a partnering strategy that leverages existing investments. Memorial Hermann uses Meta Technologies Power Release. It has proven to be an asset to our operations.

Stakeholders. Choosing the right staff is important, but there are other considerations when designing your ROI department. First, is ROI going to be part of HIM or will it be a separate department? As part of HIM, there may be cost savings that could be realized due to combined staff resources and oversight. Can the HIM director give the needed time and attention that is required to make the department a success and be compliant with all federal and state regulations?

Memorial Hermann decided to separate the HIM and ROI departments. Each MH acute care facility ROI department has an RHIT supervisor. There are also 3 RHIA managers that oversee all the facility ROIs. We established a two-tier career ladder, one for the HIM degreed professional and one for the clerical level. Clerical level staff has three tiers and professional level (degreed) staff has four tiers. For example, a new HIM graduate would be hired at the first professional tier without requiring any ROI experience. From there, with experience and proven performance, the new graduate would advance up the career ladder. We receive many calls each year from new graduates wanting to work for MH ROI. This program has been a great success.

Operations. In order to keep your turn-around times within your state mandated time frame (Texas is 15 calendar days), productivity standards are a must. MH ROI employees have a minimum 350-point average (seven -hour work day equals 450 points) per quarter to achieve the minimum requirement. This standard is also one of their annual appraisal goals. Employees who achieve an average 450 to 500 points in a quarter receive a productivity bonus. Aligning the productivity standards with the annual appraisal, while giving a bonus to the high achievers has been both a morale booster and work incentive. (See productivity standard).

Another area that should be addressed as you set out your organization’s strategic goals for an in-house ROI is how you are going to handle customer complaints and physician demands for free record copies. These areas are by far the most challenging. When customers complain, no matter what or who the complaint is against, it seems they always demand a free copy of their medical record. The decision on how this will be handled should be decided up-front. At MH it was established that administrators, directors and other leaders could “give away” record copies for customer service recovery. The administrator was then charged the state- regulated rate for the customer’s copy. The “givea ways” dropped dramatically and today rarely occur.

The same strategy was used where physicians were concerned. Most do not realize that a physician’s malpractice coverage pays for medical record copies when the physician is involved in litigation.  Also, except for patient care, MH ROI does not copy records for physician billing or for the ordering physician. Records are pulled for the physician and his/her office staff may come to HIM to copy what they need for their billing or they have access to print from our electronic record. Physicians ordering tests/procedures must obtain the results from the department that performed the test. ROI is not responsible for this function. Two keys to success in this area are administration support and physician education.

You will also need to work closely with your managed care department to ensure they are contracting copy rates you can live with. Managed care companies are requesting record copies more often today than at any other time. Copy rates are not at the forefront of your managed care department’s contracting strategies. Explaining your processes, emphasizing the number of requests you are receiving each month, and the reproduction cost associated with the release will enable them to better understand your bottom-line goals.

In order to maintain mandated turn-around times, we had to think creatively. We established a Central ROI and an ROI Imaging department. Central ROI’s responsibility is to process and release the records that are currently fully electronic. The facility enters the request, ensures it is a valid request and electronically forwards that request to Central. There are 5 full time employees releasing electronic records for10 facilities. The ROI Imaging department comprised of 2 full-time staff and located at our record storage building, are responsible to scan the stored paper record when requested for release. Once scanned, these records can be processed from any location. The seven staff members process more than 50% of all requests.

Maximizing Return on Investment

Memorial Hermann ROI 2007 fiscal year budget was $1,689,175. This budget does not reflect employee benefits, which is another 20 percent of $1,327,207 employee salaries. In order to have a “break-even” operation, it is imperative that you maintain tight controls and processes. We anticipate approximately 64,000 requests, with an average of 98,000 records released this year. Our first year in business, we barely covered the cost of supplies. The second year was better and the third year even better. Today, our staff is seasoned and our policies and procedures are well established. Annualized revenue for current fiscal year is $2,047,981 with a contribution margin of $548,225. My salary is not reflected in this cost center. These monies pay for our capital expenditures and depreciation costs, as well as allow us to bring in the needed technology for optimal performance.

Revenue Growth Chart

Conclusion

Bringing release of information in-house is not a small decision. For the first two to three years the transition was tough. Change is not always easy and it is especially challenging when you are changing the culture. Our first goal was to safeguard patient information. The second goal was to enhance customer service, then to have a break-even operation. We wanted to transition the department from a manual process to an electronic environment, develop skills and competencies, ensure compliance with state and federal laws, and design operations and work flows that would accomplish these goals and provide efficiencies.

First, begin with the technologies you currently have and build upon them. Choose an application that enables you to capture all appropriate correspondence and revenue, while complying with all regulatory requirements. One that only allows authorized staff to access and easily record disclosures, generates invoices and form letters, and includes easy reporting to help you manage both receivables and productivity.

Work closely with your legal department to develop policies and procedures. Hire and train professional staff that will take pride their department and in the work they do. Communicate with physicians and the rest of the organization on how ROI will function and how it will benefit them and their customers. Develop your charge tables to accurately reflect both state and managed care contracted copy rates. Once accomplished, you will have a well- functioning, respected operation.

Memorial Hermann Hospital System. Release of Information Activity Tracking form