Vol. 17 Issue 9
The EMR & ROI Making the Important Decisions
Each HIM department needs to carefully consider the pros and cons of bringing ROI in-house, out-tasking only certain functions or outsourcing the entire process.
Outsourcing is defined as the delegation of non-core operations or jobs from internal production to an external entity that specializes in that operation. Outsourcing, over the last 10 years, has received an undeserved negative connotation due to the many jobs that have left the country to go overseas. This area is a subset of outsourcing called "off shoring" and is not the subject of this article.
This article focuses on domestic outsourcing within health care, specifically for the release of information (ROI) function within HIM. And even more specifically, when there is an electronic medical record (EMR) in place, as is the case in approximately 24 percent of U. S. hospitals.1
The State of Outsourcing
Surveys reveal that the United States market for outsourcing is growing at nearly 9.5 percent annually and is expected to reach almost $175 billion by the end of 2007.2 Within health care, outsourcing has been used for decades. The area most often thought of in discussions of outsourcing is that of IT. But outsourcing has been utilized in many areas, including food service, payroll, benefits and compensation, transcription and coding, and accounts receivable.
The outsourcing of the ROI function within HIM can include anything from turning over the entire process to a vendor or simply out-tasking a subset of ROI such as requestor billing and account collections. According to the Association of Health Information Outsourcing Services (AHIOS), nearly 80 percent of hospitals nationwide outsource the entire ROI function.3
The outsourcing of a specific task within a process, such as those listed above for ROI, is more accurately termed "out-tasking." Out-tasking takes a fairly narrow segment of the health care enterprise and turns it over to another business. This usually involves continued direct or indirect management and decision-making by the health care entity.
HIM departments are responsible for the very sensitive information of every individual who interacts with that health care enterprise. Foremost in those responsibilities is the security and privacy of that information. Every day these HIM professionals receive requests to release this information to many different requestors, including:
Life insurance companies
With today's time pressured society, these requestors want and expect the information "immediately." After all, how hard could it be to make a copy of medical records?
Unfortunately, most individual medical records receive inputs from multiple locations, often in many different formats, and in several media (paper, electronic, fiche, film, etc.) Simply getting a handle on this information is a big piece of any HIM department's job. Super-imposed on this complicated task is a series of state and federal governmental regulations, as well as the organization's own internal policies and procedures.
The latest federal regulations include HIPAA, which are aimed at protection, privacy and confidentiality. These rules and regulations combined with a health care entity's specific procedures dictate the parameters around which the ROI process operates. ROI involves:
Receiving and logging requests;
Authenticating the requestor;
Verifying and tracking;
Retrieving information (various locations and formats);
Judging the minimum information required to fulfill;
Protecting sensitive (non-releasable information) data;
Packaging and delivering the information;
Invoicing and collecting fees from requestors; and
Indexing and temporary storage.
Each of these steps has its own degree of difficulty and complications that involve judgment, knowledge of legal/liability issues, intimate understanding of the health care enterprise, technical skills, as well as detective skills. All of this is coupled with the tight timeframes dictated by law or internal policy. This process is controlled by ROI professionals who have the education, training and experience to handle this mission. Two factors complicate the picture.
First and foremost, ROI experts are often hard to find and keep. They must be well-versed in ROI policy and guidelines as well as exude world-class customer service toward requestors of all types. According to the American Health Information Management Association (AHIMA), 6,000 new HIM workers are needed every year, but only 2,000 graduate annually from approved programs.4 Additionally, the U.S. Department of Labor and Statistics expects 30 percent more HIM workers will be needed by 2014.5
Secondly, there are two levels of skill necessary for the ROI function: an expert skill set (as mentioned above) and a clerical skill set. It seems a waste of precious resources to relegate the experts to the clerical tasks of the ROI process such as preparing bills, invoicing and accounts receivable follow-ups. How do you balance the expert aspects of the process with the administrative and clerical aspects? The answer is easy: out-task the administrative functions within ROI, at the very least, to outsourcing the entire process, at the most.
Many enterprises are on the journey of implementing EMRs and according to recent surveys, 84 percent of facilities are managing in a hybrid record environment–part paper and part electronic.6 The suggestion has been made (primarily by EMR vendors) that an EMR can produce a revenue generating, automated ROI model that will help cost justify the EMR by enhancing the financial gains to a health care enterprise. Granted, the number of transactions is large enough to create a reasonable revenue stream which, in these times of increasing costs and declining reimbursement, becomes attractive. This would happen by bringing the ROI process in-house.
In support of the in-house decision, vendors suggest that this integration process of ROI is a by-product of implementing an EMR and that the implementation will be painless. EMRs certainly should be able to help with audit functions and electronic redaction (white out) as examples of EMR benefits. Staff will save time by pulling records electronically vs. by hand. Finally, photocopiers can be replaced by printers or electronic output.
While EMRs certainly have significant benefits to HIM departments and streamline the information retrieval step within the ROI process, there are several areas where EMRs are not focused and may in fact be problematic for ROI. For one, EMRs gloss over the staffing issues and cost increases necessary to bring ROI in-house (e.g., printing and postage costs). Secondly, EMRs tend not to focus on ongoing compliance and regulatory mandates related to ROI in a timely manner. Thirdly, EMRs tend not to provide complete billing and collections modules for ROI.
So, while an EMR system brings much to the ROI process, it is not a substitute for the technology system, infrastructure, processes and, most importantly, qualified people of the ROI mission. In fact, experience shows that the combination of an EMR and out-tasking creates the optimal balance of productivity, employee satisfaction and financial gain to the enterprise.
HIM Departments Speak Out
As previously noted, more than 20 percent of HIM departments have implemented EMRs either through a document management system or computer-based patient record.6 While this number has grown, the percentage of hospitals that outsource the ROI function has remained consistent. If performing the ROI function in-house with the support of an EMR is easier than outsourcing or out-tasking, why hasn't this percentage decreased as more and more facilities go electronic? Several fully electronic HIM departments were interviewed to find the answer.
The consistent theme in these interviews was the partnership established between vendor and HIM departments. When "we are in this together" is the prevalent theme, all obstacles can be overcome. This partnership is achieved through strategic outsourcing or out-tasking and subsequent revenue-sharing opportunities. With shared revenue, both sides have the same incentives and win.
Premier Medical Group in Mississippi implemented the EMR with the out-tasking combination. The organization's existing staff performs up-front request validation and information retrieval using an electronic upload from the EMR and occasional digital image capture for older, paper documents. Invoices from Premier's EMR are also automatically uploaded to the ROI vendor's system. The vendor's staff does the rest. Revenue and responsibilities are shared.
Cindy Kramer, RHIA, director of HIM for Premier, spearheaded the effort. Kramer stated, "I am in total control. SDS's staff comes directly to me with any records-re-lated questions, just like they are our own internal staff. We finally have the visibility and tracking data to make sure all our "I's" are dotted and "T's" are crossed. And we really appreciate that SDS handles all invoicing and collection issues. Billing was just another headache that we really didn't need."
Spartanburg (SC) Regional Healthcare System is another success story in out-tasking. Lynn Henderson, RHIA, corporate director of health information for Spartanburg said, "When I looked at how many full time equivalents (FTEs) we needed to handle printing, envelope stuffing and mailing, plus the cost of toner, stamps and other materials, I realized that the cost/benefit rationale just isn't there." Added Henderson, "on top of that, I added the hassle of invoicing and collections. I didn't want a stack of problems and uncompleted requests on my desk, and I did not see how processing ROI requests in-house made financial sense."
Like Premier Medical Group, Henderson's existing staff processes ROI requests using their EMR. Through electronic interfaces with SDS, images are captured and transported for processing by SDS. This leaves all the clerical functions of printing, mailing, fulfillment, invoicing and collections to the vendor. One part-time outsourced employee works on-site at Spartanburg to process requests to ensure timely turnaround during heavy workloads.
Gwinnett Hospital System in Lawrenceville, GA, decided to continue outsourcing the entire ROI process after going live with a complete EMR. Donna Samford, RHIA, director of medical records at Gwinnett, provides several reasons to continue outsourcing the ROI function even though her entire department is now "paperless." Primarily, she was pleased with the service she was already receiving and had no reason to change. Additionally, she cites the following reasons why hospitals with an EMR should still outsource the ROI function:
The ROI module within most EMR systems is not as efficient as software developed specifically to support the ROI process.
Too many additional staff would be required to bring the process back in-house.
ROI vendors have economies of scale for fulfillment and delivery of requests.
Facility can focus on core competencies.
While there are many others, these examples show that the combination of outsourcing (out-tasking) and internal control and management optimizes the outcome to the enterprise in an electronic environment.
Benefits of Out-Tasking
For health care organizations in general, the major expense is always people. With out-tasking only certain aspects of the ROI process, the enterprise does not need to hire, train or provide benefits to the FTEs required to do the administrative function. It is very easy for an agency to accommodate spikes in census through additional staff or provide alternative resources during vacations, etc.
The benefits are clear. Out-tasking to a specialist organization in the ROI area solves many problems. Access to their quality employees and well-established policies and procedures far outweigh the lost revenue potential involved in partnering with an outsourcer of ROI. There are a lot of options with EMRs and each HIM department needs to carefully consider the pros and cons of each: bringing ROI in-house; out-tasking only certain functions; or outsourcing the entire process (see Table).
The Winning Approach
The term "partnership" has been greatly overused and abused in all client/vendor relationships. But, when done properly, it is by far the best form of relationship. The key is two-way communication. A simple approach is to use all the interrogative verbs:
Who will be responsible?
What will be done by each party?
How will it be done?
Where will it be done?
When will tasks be accomplished?
Why are things done?
Which party gets what part of the revenue?
In essence, make as much as possible, as clear as possible, up front. This is much more than just a contract. It is a business relationship. Also important is to assign an executive to spear-head the process. This is an important project. Give it the proper attention at all levels of the organization. Lastly, be sure to leverage the upsides. That is, share them. That provides an incentive for both parties to accomplish the same goals and share in the revenue. If you follow these simple steps and focus on the objectives, you will succeed, regardless of your decision.
1.17th Annual HIMSS Leadership Survey sponsored by ACS Healthcare Solutions. Available online at: www.himss.org/2006survey/healthcareCIO_final.asp.
2. Disher, Chris, vice president, Booz Allen Hamilton. Available through the International Association of Outsourcing Professionals.
3. Bellenghi, G. Michael, "Release of Information Services: More Than Just Copying". Available online at: www.ahios.org.
4. American Health Information Management Association (AHIMA) Statement on the HIM Workforce, July 18, 2002.
5. Bureau of Labor Statistics, U.S. Department of Labor, Career Guide to Industries, 2006-07 Edition, Health Care. Available online at: www.bls.gov/oco/cg/cgs035.html.
6. Friedman, Beth, RHIT. "Coding Technology Today", Journal of AHIMA/April 2006, 77/4.
Jonathan Arkin is vice president business operations, Smart Document Solutions (SDS), Betty K. Bean is a consultant, health care consulting services, SDS, and Kelly Page Ward is a senior consultant, health care consulting services, SDS.