By Linda L. Kloss, MA, RHIA, FAHIMA
COVID-19 has changed the way many of us work. While much of the focus has been on telework, that’s only part of the release of information (ROI) story. This article recounts the ROI-related experiences of the panel of health information management (HIM) leaders who took part in a series of discussions in 2020 and early 2021. These leaders represent a cross-section of health system types and complexities. Their ROI configurations range from in-house to full or partial outsourcing. Their experiences chronicle leadership challenges related to the COVID-19 response, including real-time adaptation of complex workflows and staffing, and thoughtful planning for ROI in the years ahead.
Three Critical Observation Points
The panel of HIM leaders first convened at the beginning of April 2020, and each member was asked to describe their plan for rapid adaptation of ROI and other HIM operations as health systems prepared for COVID-19 surges. Representing health systems from the East Coast of the United States—including Boston, MA, New York City and the surrounding boroughs and exurbs, New Jersey, Delaware, and North Carolina—these systems experienced early and dramatic lockdowns.
Six weeks after the first discussion, the panel reconvened to describe short-term impacts, focusing on ROI processes and workforce changes as they settled in. Early lessons were emerging in this period, characterized by adaptation and adjustment to new operational realities.
The third conversation took place in early 2021 after 10 months of the COVID-19 pandemic had passed and examined the “new normal.” The discussion focused on leadership lessons and planning for further adaptations to access and disclosure management. That third conversation is recounted in the balance of this article.
A recurring theme through all three conversations was that of agility. Sweeping changes were made quickly. HIM leaders were empowered—and expected—to act quickly and adapt to fast-changing circumstances. There was no road map and little experience to draw from. This is not how health systems usually operate. There is risk in taking rapid action without all the tools and solutions in place. For some, this was liberating; for others, daunting. The health system HIM leaders described ROI impacts in these four buckets: process, technology, workforce, and planning.
The rapid shift to telework for ROI required redesign of fundamental ROI processes: how a request is made, received, processed, and fulfilled. Under the circumstances, this meant using methods other than in-person requests, snail mail, or fax, all of which require manual intervention. Closing the walk-up customer service window was the initial much-talked-about hurdle, but that was accomplished quickly. The tougher process challenge involved dealing with many locations throughout the health system where requests by mail or fax were received. For health systems with decentralized ROI, retrieving mailed or faxed requests from shuttered physician practices proved a more complex challenge.
Health systems in the best position were those that had already centralized and standardized request processes through processing centers and call centers. No health system was fully ready, but agility had a lot do to with the stage of centralization, automation, and outsource services capabilities. Even the most advanced health systems dealt with residual paper, but paper as the exception is far different than paper as the norm.
The same applied to fulfillment. The most agile health systems were those that had stepped up their electronic fulfillment capability. Again, all health systems continue to process requests for hard-copy records, but working to deliberately decrease the proportion of hard-copy fulfillment made some health systems adapt more quickly.
The health systems reported that process adaptation was enhanced by the capabilities of its ROI services vendor. Health systems that were in partnered relationships with their vendor were able to shift and surge work as processes were adapted and volumes fluctuated. Some organizations shifted all requests to their vendor except those for continuity of care. Others shifted all calls to outsourced call centers, quality control, or fulfillment and billing services. Some continued to process all requests in house but added critical technology to enable and guide work.
The health systems experienced volatility in request patterns and volumes, particularly in early months. Over the year, volumes stabilized, but the way work was accomplished had changed dramatically.
The pandemic confirmed that fragmented and decentralized ROI is no longer effective. It also confirmed that paper-bound clerical transactions with overreliance on fax, forms, and walk-up service windows is outmoded. The HIM leaders agreed that the pandemic year had underscored that their priority for the next several years would be to ensure that all aspects of ROI were fully supported by customer-oriented technologies.
They first zeroed in on using an app to enable customers to request and receive records electronically. Some health systems that had implemented a request app prior to 2020 were in the best position for rapid adaptation to telework and physical distancing. Over the course of 2020, use of a cloud-based request app solution rapidly became the norm and the most frequent route for requests. In addition, by the end of 2020, more requestors received their records electronically. This technology rapidly transformed request and release with the bonus of turnaround times reduced by up to 50 percent.
Heading into 2021, the health systems planned to more fully integrate the request app into their patient portals, a step that many deferred for implementation speed. Plans also included introducing additional release management applications software for workflow, billing and accounting, productivity, and quality control. The ROI technology platform and tools are key whether the health system partners, outsources, or handles ROI in house.
Again, the experiences of 2020 demonstrated that greatest flexibility was achieved when work could be shifted seamlessly using the same platform as circumstances required. Pacing and optimizing for fullest use of customer-oriented ROI technology will be the work of the next several years. The panel agreed that service and compliance requirements made automation a central priority. Revenue from ROI is being constrained by public policy and customer requirements; only automation will improve productivity, turnaround, and service while controlling operating costs.
It is remarkable to consider how quickly ROI was shifted to telework. For some health systems, this change took place over a weekend. Staff and managers dealt with a wide range of challenges relating to workflow, technology, communication, and those relating to all that was going on in people’s lives.
The experiences of 2020 confirmed that ROI telework does not compromise quality or productivity if the right training, support, and controls are in place. A great deal of learning occurred in 2020 by staff and managers alike. One lesson that stood out concerned the need for deliberate and frequent communication. In general, managers were in daily contact with team members, often one on one. There were frequent team-level communications. Health system executives were also communicating fully and frequently, sometimes with the entire organization. In a crisis, communication is key, and excellence in communications was reported as one of the ways that organizations overcame isolation and uncertainty.
Another major workforce lesson of 2020 was that not all team members had the skill to respond to the demands of telework and the shifting ROI processes. Some lacked skill to rapidly adapt from clerical to computer-based work. Others had to learn to process a broader range of types of requests. Some were called on to directly help patients and caregivers use a new request app.
The HIM leaders reported that managers successfully trained and supported team members to gain new skills and expand their capabilities as knowledge workers and do so in an extraordinarily disruptive environment. Lessons learned underscore that teams do not have to be physically together to function well together.
HIM leaders described an altered approach to planning. Historically, health system planning is tied to a three-year strategic plan and an annual budget cycle. The experiences of 2020 replaced this staid cycle with rapid adaptive change. The lessons conveyed in this summary demonstrate a changed planning process not tied to the next budget, but tied to very tangible operations and service goals and a sense of urgency. It was a time when action was rewarded and a too cautious response left staff and performance in jeopardy. These HIM leaders took advantage of flexibility to speed decision-making.
Change management often peters out because it’s difficult to gain the momentum needed to sustain change. In 2020, successful HIM leaders seized the momentum and instituted changes that met short-term needs. At the same time, the changes they instituted are consistent with new imperatives for ROI operations and compliance. The changes make sense for the future and can be extended and expanded in 2021 and beyond.
New Information Blocking Regulations went into effect on April 5, 2021. Comments on proposed revisions to the HIPAA Privacy Rule contained in the Notice of Proposed Rulemaking were due May 6. Access to health information is a cornerstone of these regulatory actions, placing ROI at the nexus of a changing environment. The lessons of 2020 can be summarized in four go-forward recommendations:
- Discard outdated methods and take care not to revert to them when the crisis is abated.
- Take advantage of momentum and greater flexibility to focus on measurable improvements in service, compliance, and productivity.
- Perfect the capability for adaptive change with more rapid introduction of improvements.
- Continually assess the environment to anticipate the next wave of change.
Leading with greater agility may turn out to be a lasting lesson of this pandemic. At some point, the pandemic will come under fuller control, but an abundance of uncertainties will remain for ROI leaders.
Special thanks to the HIM leaders who participated in some or all of these learning dialogues:
- Stefanie Brumberg, RHIA, Corporate Director, HIM Services, ChristianaCare, Newark, DE
- Tracy D’Errico, Director, HIM, Stony Brook Southampton Hospital, Southampton, NY
- Steve Eddington, MHI, RHIA, Director, HIM , Boston Children’s Hospital, Boston, MA
- Nicholai N. Ellis, Manager, Ambulatory HIM, Northwell Health Physician Partners, Manhasset, NY
- Shaunna Ellison, HIM Director, CentraState Medical Center, Freehold Township, NJ
- Pat Russell and Gretchen Haralson, Director and Associate Directors, HIM , Cone Health, Greensboro, NC
- Susan Tabickman, RHIA, HIM Manager of Operations, NewYork-Presbyterian Hospital, New York, NY
- Lauren Zuckerman, RHIA, Director, HIM, Garnet Health, Middletown, NY
Linda L. Kloss (email@example.com) is founder and president of Kloss Strategic Advisors Ltd.
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