May/June 2021

Medical Records—Everybody Wants ’Em
By Susan Chapman, MA, MFA, PGYT
For The Record
Vol. 33 No. 3 P. 10

High demand equals high stress levels in the HIM department. What steps can help alleviate the strain?

Hospitals deal with enormous numbers of medical record requests—from patients, insurance carriers, attorneys, auditors, and others. As that volume continues to grow, hospitals must devise effective strategies to keep pace with the rising demand.

“Prior to COVID-19, we already had a very high volume of requests, about 8,000 each month—roughly 4,000 requests every two weeks—and we see that demand coming from many different places,” says Thea Campbell, MBA, RHIA, executive director of health information at Cedars-Sinai Medical Center in Los Angeles.

To address the pandemic’s anticipated impact, Campbell and her team, including Michele Gomez, manager of health information, began encouraging patients to use the hospital’s patient portal, allowing staff the authority to give patients access to the portal who did not already have it.

“Because of the portal, which eliminates such things as handwriting discrepancies, the turnaround time for record requests has become much quicker and easier to manage,” Gomez says.

Paul Troutt, vice president of product development at Ciox, says allowing electronic access can streamline the process and support greater access. “Removing various manual processes that are currently being used for requests is one effective way to be more efficient. Facilities need to have a digital strategy in place so that they can receive the request electronically, which also helps remove interpretation of what is being requested,” he explains. “In many facilities that don’t have this technical capability, requesters submit their information via fax and mail, which leaves the requester wondering whether it was ever received. They start calling the provider to track the request, and frequently even send it multiple times to ensure that it got there. This model requires more effort to manage and is a recipe for frustration for both the requester and the provider.”

Troutt notes that high-volume requesters such as life insurance companies and attorneys have determined that, on average, they send in a request 21/2 times before it is fulfilled. To help address the problems that begin at the start of the process, Troutt believes that if the request comes into the system electronically, it prevents possible duplication of effort and removes uncertainty for the requester.

“When requesters can send their requests electronically, just by automating the intake side, we’ve determined it reduces their waiting time by an average of seven days,” Troutt says. “Once it’s in the system, things work, but we have seen, on average, a seven-day delay to get it into the system when the request is made manually. During that seven-day lag time, requesters call frequently to check status and may even send in duplicate requests.”

With the advent of the pandemic, Cedars-Sinai has capitalized on their patients becoming more open to electronic communication. “Our hospital uses the portal not only for the release of information but also for other communications. For instance, as vaccines have become available, patients receive notices in their portal,” Campbell says.

The system is not without its obstacles. “Our population is varied. We are a community hospital and an academic medical center. We’re equally distributed in our demographic,” Campbell explains. “So, for many patients, there is a learning curve. Organizationally, there is an entire population that does not have access to Wi-Fi and computers. Fortunately, our app is mobile friendly, and many more patients have phones available to them.”

Ryan Hallman, vice president of the Association of Health Information Outsourcing Services and founder of the startup hXe, believes that a more efficient system is needed. He notes that a recently discussed HIPAA proposal to remove a facility’s ability to charge for records would greatly increase the demand for medical records and stress systems that are currently struggling with the volume of requests. While the proposed change would not apply to paper records and legacy requests, attorneys would have to file two requests—one just to satisfy HIPAA, which would then double the number of requests.

In light of increased demand and the looming changes to HIPAA, Hallman says the EHR’s role is more vital than ever. “Organizations have to know about their EHR’s capabilities. Currently, release of information modules in EHRs are more of an afterthought than designed to handle all aspects of releasing medical records efficiently, including answering telephone calls and invoicing/collections if applicable. When you compare and contrast the operational needs of the department against the EHR’s capabilities, they often don’t align,” he says. “When facilities limit themselves to only what the EHR can do, it impacts how they can address the demand. They have to know that they may need to buy another tool to satisfy what is lacking.”

Identifying Obstacles and Bottlenecks
Hallman and his colleagues have noticed that organizations spend about half of their time reviewing requests and preparing the information and the other half outputting the records in various formats. “We see a lot of time spent printing the record or putting the record onto digital media,” Hallman says. “For instance, a facility had a person who dedicated one day to reviewing the requests and outputting the information to the printers and another day to reviewing, sorting, and mailing them off. Just dealing with the export to paper took a lot of time.

“Many facilities put records on CD, which is the most time-consuming digital process we’ve recorded. Basically, it can triple the processing time,” Hallman adds.

Organizations can be reluctant to embrace technology and digital transfers. “A lot of facilities are afraid of sending information over the internet—even securely—and they avoid it at all costs, which is why they spend time on more time-consuming processes,” Hallman says.

Troutt views the request itself as a place where bottlenecks occur, noting that each provider has its own rules about how a request can be submitted. “One place may take a wet signature; another does not. If the requester doesn’t remember what the rules are, the request could get rejected,” he says. “It becomes more difficult for the requester to get what they need.”

If facilities simplified the rules and eliminated legacy rules that have not evolved with technology, Troutt says they could make the process more efficient and improve the requester experience. He also encourages health care providers to support digital transformation and step away from the more conservative approach that is sometimes associated with HIM.

“Some providers are still doing things the slow way, and it’s costing a lot to do those jobs when we can do them more efficiently electronically. We have technology available on the intake and fulfillment sides, and we need providers to buy into them. HIM is a business driver and can be a primary advocate for a transition to a more efficient electronic process,” Troutt says.

When an electronic system is not in place, other issues become major obstacles. For example, when a request is made using a paper form, illegible handwriting, incomplete information, or requesting the incorrect records can create challenges and slowdowns. “Patients will sign the form and not indicate what they want or indicate they want it all. We have to send the release back to them or, if we have to, call them,” Campbell says.

Gomez adds, “Our goal is staying in compliance with California regulation, providing access to the individual no later than 15 days from receiving the request. So, part of what becomes a challenge is the form. When we can’t decipher someone’s handwriting or if we’re not sure what they are requesting—in those cases we call the requester to inquire and sometimes the requester does not call us back.”

At Cedars-Sinai, patient records cannot be released while a patient is still in the hospital, a policy that can complicate the process. “We made the determination about not releasing records in-house for a number of reasons. We want patients to have conversations with their doctors,” Campbell says. “Additionally, without signatures, the records aren’t yet complete. Patients get uncomfortable if information in their records changes, even when it is supposed to. A doctor may have dictated something that needs to be edited.”

Because of the CARES Act, Campbell and her team have had conversations about how they can be more proactive using the patient portal. “Previously, we didn’t push the notes into the portal,” she says. “In order to comply with the act’s provisions related to information blocking, all notes will be made available in the portal without a patient request. Physicians are becoming more comfortable with the expanded access to these notes. With the expanded access to view notes in a more convenient fashion, we anticipate more requests to change or correct information contained within [them]. Through the portal, we also process patients’ requests to change something in their records. Our physicians will ultimately determine whether the requested change is clinically feasible in accordance with the HIPAA amendment provisions.”

For auditors and insurance companies, Cedar-Sinai has a separate mechanism for requests, dubbed CareLink, which allows the hospital to push medical records to the requesters. Requesters also can pull the records as long as a patient has that particular insurance. Campbell describes the process as being self-service but adds that there are safeguards in place to ensure the process’s integrity.

An Optimized Approach
It can be difficult to assess the full impact of problem areas without specialized tools and systems, Hallman notes. “We’re an ROI [release of information] vendor system, and we work by keeping track of the time between each step in the process. We can run a report and see where it’s taking longer. When we go into a site, look at the current process, and identify improvements, usually we find two to three pages of improvements,” he says. “I’ve shadowed staff for two or three days. The more time you do it, the more you can uncover. You want to record their productivity while you’re sitting with them, which sets a benchmark of what they’re capable of. We find inconsistencies of processes and knowledge of how to use EHR among staff members. We try to find out why they do things a certain way and help them see how they can do things more efficiently.”

Hallman believes the process itself needs refinement. By getting the request into the system as quickly as possible, staff can avoid many time-consuming activities such as fielding phone calls and checking for requests that have not yet been logged electronically. “You have to stay current and log the request as it comes in. Eliminate the manual process of looking through stacks of paper and you’ll be able to look things up immediately and respond immediately,” Hallman says.

“We also try to suggest to avoid taking record requests over the phone,” he continues. “You’ll only help that one person the entire time you’re on the phone. The time on the phone is a lot higher, and the number of phone calls is a lot higher. A change like faxing in a request instead can improve this. When we did this, there was a lot of pushback, but a few weeks later, the phone call volume and the ability to process work improved.”

Training and competency are two other areas where bottlenecks may occur. Staff may not know how to use the system properly, or a team member develops a workaround to an efficient process because they are unable to perform the task in the recommended fashion.

The EHR itself can also be a problem. Hallman says facilities must be realistic about the technology’s capabilities. “Some EHRs deliberately lock up the exporting of records. Some will output in the background, which allows you to use the time in other ways, rather than waiting. If it’s locked up, you can run a virtual system in the meantime. That is actually a common problem,” he says.

Encouraging Patients to Use Electronic Access
Cognizant of the fact that some portions of the population they serve do not have digital access, Cedars-Sinai has begun working on proxy access, which allows someone designated by patients to request records. “An older patient may be a good example of this, someone who designates an adult child to access their medical records,” Campbell says. “We’ve struggled with proxy access, and we’ve tried to promote and expand it. If someone wants to give access to someone else, we have a way to do that.”

Gomez notes that supervisors are meeting with their teams to learn how they can be more patient-centric overall. “We encourage our staff to promote the use of the patient portal and to send requested records via the portal. Processing the records timely, securely, and accurately is important to us,” she says.

Troutt points out two major areas that have allowed patients greater access to their medical records: applications and patient-engagement strategies on the part of providers. “In the direct-to-consumer world, you see apps that are popping up that allow patients to request their records. The challenge, though, is that they are limited to what they can pull and the sites at which they’re available. They don’t necessarily give patients all they need or improve efficiency and interoperability across the health care ecosystem,” he says.

Providers have always had a patient-engagement strategy, Toutt notes, one backed up by vendors with technology in place to support patient engagement. “For example, at a large regional health system, we have provided technology that provides an easy way for patients to request records with status updates and online delivery,” he says. “We’ve established this technology so that providers can offer it to their patients as part of their patient engagement initiatives. We have seen a high adoption rate among providers and a 95% approval rating from the patients who have used it.”

Hallman, an advocate for electronic methods to request and fulfill records, encourages patients to use them more often, which will help reduce bottlenecks and make the process more efficient.

“One of the things I see the most often is a disconnect between HIM’s understanding of what patients can and cannot do and what patients want,” he says. “We’re in an age where most patients have an iPhone and are conditioned to getting everything instantly. You’re doing a disservice to your patient population if you believe they can’t understand technology and don’t offer a better way to request medical records. The best analogy would be choosing not to offer smartphones to your team because a few people will struggle to use them despite the majority benefitting.”

From Hallman’s perspective, providers must be more willing to step out of their comfort zone. “There are more efficient ways to request records than what is currently available, including patient portals, and facilities have to be open to more options,” he says. “You can’t lose sight of the impact on the patients. You can’t be afraid to ask for more to improve the patient experience.”

— Susan Chapman, MA, MFA, PGYT, is a Los Angeles-based freelance writer and editor.