Shortages of qualified professionals in several key. Shortages Create Unique Opportunities for Healthcare Outsourcing

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1 Healthcare Services Shortages Create Unique Opportunities for Healthcare Outsourcing Successful healthcare outsourcing requires the ability to partner with the facility, conduct a comprehensive evaluation of specific needs, and then match those needs with the right combination of personnel, technology, and ongoing support. Shortages of qualified professionals in several key areas of healthcare have created new opportunities for those outsourcing organizations that have the right combination of people, experience, credentials, and technology necessary to step in and fill the gaps. Three areas cancer registry, medical coding, and nursing have the greatest demand for skilled professionals and thus offer the greatest opportunity. But because of the unique yet critical role each plays within a healthcare facility s organizational structure, meeting that demand requires more than just the ability to place a warm body into a vacant position. Each area requires the ability to partner with the facility, conduct a comprehensive evaluation of the specific needs, and then match those needs with the right combination of personnel, technology, and ongoing support. Cancer Registry Over the past decade, the cancer registrar has emerged as a critical player on the National Cancer Surveillance Team, one credited with providing the aggregate data needed to support the development of new, more effective cancer therapies as well as new prevention and control measures. That, coupled with an increase in the amount of cancer data to be tracked, has propelled cancer registry into the top 20 fastest growing fields. Part of the burgeoning health information management (HIM) industry, the field of cancer registry involves the collection and analysis of detailed information on the diagnosis, treatment, and outcomes of cancer nationwide. Registries are classified into three general types: 1. Healthcare institution registries, which maintain data on all patients diagnosed and/or treated for cancer at their facility. This data is then reported to the central or state cancer registry. 2. Central registries, which are population-based registries that maintain data on all cancer patients within certain geographical areas. 3. Special-purpose registries, which maintain data on a particular type of cancer, such as brain tumors. Cancer registrars are the data management profession- 32 AFSM International

2 BY SAM NAGEL als who collect cancer data from various sources and manage statistical reporting to the various agencies. Their primary responsibility is to ensure timely, accurate, and complete collection and maintenance of data including patient demographics, stage at diagnosis, and treatment on all types of cancer that have been diagnosed or treated within an institution or other defined population. Over the years, as the field of cancer registry has developed, the registrar s role has matured along with it to become the backbone of the National Cancer Surveillance System. The modern field of cancer registry dates back to 1926, when Yale-New Haven Hospital in New Haven, Connecticut, established the first hospital registry. That was followed in 1935 and 1946 with the first central cancer registries, established in Connecticut and California, respectively. Then, in 1956, the American College of Surgeons (ACoS) formally adopted a policy that encouraged the development of hospital-based registry programs by making it a requirement of their Approvals Program. Those early registries consisted mostly of unused card files, with the most valuable data coming from large central registry systems such as the National Cancer Institute s Surveillance, Epidemiology, and End Results (SEER) program, which was launched in 1972, and ACoS National Cancer Data Base, which was established four years later. However, everything changed in the 1980s with the advent of the microcomputer, which finally made it possible to standardize and pool data from multiple registries, which in turn enabled the identification of patterns of care and outcomes. Yet even with the growing attention to the importance of cancer registries and the computerization of data, it wasn t until Congress enacted The Cancer Registries Amendment Act in 1992 which established the National Program of Cancer Registries (NPCR), set funding requirements, and provided funds to states and territories to enhance, plan, or implement registries that cancer registry began to blossom as a career of choice among HIM professionals. By 2000, the Centers for Disease Control and Preven- July/August 2003 Sbusiness 33

3 Shortages Create Unique Opportunities for Healthcare Outsourcing tion (CDC) was providing funding for participation in NPCR to 45 states, the District of Columbia, and three territories. The problem was, with only a handful of educational institutions offering in-depth cancer registry training, there weren t enough trained registrars to meet the immediate demand. And with approximately 3,000 certified registrars a number that grows by only about 300 per year not only is the current demand not being met, but the new demand created by the establishment of new programs and the expansion of existing ones is creating a further drain on the talent pool. Adding to the problem is the rapid growth in the number of ACoS-approved programs and the number of states requiring cancer reporting. Also at play is the increase in cancer data to be tracked, a result of cancer s standing as the second leading cause of death among Americans. Cancer registrars are needed in hospital and central registries. There is also a need for traveling registrars who rotate between facilities and registries in areas with low incidence of cancer. Remote registry is another growing area, particularly as online access to medical records increases. Opportunities also exist with registry software companies, pharmaceutical firms and clinical trials, medical research organizations, insurance companies, and even veterinary cancer registries. In response to the growing shortage of experienced registrars, facilities increasingly are turning to outsourcing firms to meet their needs in a variety of ways. For example, outsourcing firms often are called on to supply not only abstractors, but also registry management personnel to assist in ACoS survey preparations and do case findings and audits. For the client facility, the outsourcing option is attractive for reasons beyond the ability to fill vacancy. First, outsourcing agencies typically provide the training, supervision, and quality assurance, removing that burden from both the facility s staff and operating budget. Outsourcing firms also have the technology required to establish, staff, and even manage remote registries, and to fill in to help clear backlogs and help registries prepare for ACoS accreditation audits. A top outsourcing firm should, at minimum, be able to provide the following information or services to clients: A quality assurance program to audit on-site abstracting. A comprehensive compliance plan tailored to the client s specific needs. References of past or current cancer registry clients able to discuss the firm s performance. Further, to ensure it is providing only the best-quality cancer registrars, outsourcing firms should require that its consultants pass a rigorous cancer registry test and interview process. Finally, to ensure that their skills remain current, outsourcing agencies should offer registrars continuing education services to keep them abreast of the constant changes in data reporting and tracking, credentials, and so forth. Web-Based Medical Coding Medical coding is another area in healthcare that is suffering from a supply and demand problem. In fact, the impact of the growing shortage of qualified coders is deepening as hospitals struggle to clear logjams in administrative processes caused in part by the industrywide coder vacancy rate that has climbed to 18 percent in recent years. But this shortage isn t just a staffing problem; it s also a revenue problem. A medical coder s job is to ensure that invoices are correctly noted with the appropriate billing codes for each procedure so that Medicare, Medicaid, and private insurance companies will approve payment. Every uncoded chart represents unbilled revenue a serious concern for hospitals that, according to the American Hospital Association (AHA), failed again to break even in In fact, AHA surveys show that hospital patient, operating, and total margins have been dropping since To combat the problem, many hospitals are turning to outsourcing agencies to provide the skilled staff they need to clear backlogs, as well as to establish and manage remote coding programs to keep the revenue cycle humming. Handled properly, the outsourcing relationship can result in ROI through: 1. Increased productivity of remote coders, who tend to work better and faster from home, thanks in part to the lack of distractions and a need to continually meet minimum standards set for performance and quality. 2. Reduction or elimination of overhead costs by eliminating the need to install and maintain in-house the computer systems and high-speed data lines that are the heart of the remote coding concept. In fact, turning all or part of a remote coding program over to an outside partner eliminates the need for the hospital to deal with quality assurance issues and invest the time and resources into locating appropriately qualified supervisors and coders. Outsourcing also means that when workloads fluctuate such as with seasonal increases in patient census or when staff absences create unexpected backlogs, extra coders are just a phone 34 AFSM International

4 call away, as is any technical support that may be required for system maintenance. But as with cancer registry outsourcing, assuming all or part of a facility s remote coding program takes more than just the ability to provide trained coders. Outsourcing firms must be able to provide coders with at least three years of hands-on coding experience, plus specialized credentials recognized by the American Hospital Information Management Association (AHIMA). Further, any outsourcing company must have solid processes in place to establish audit trails and provide a qualified quality assurance team to review all records. The other critical element to providing outsource coding services is the Web-based software program used to run the entire operation. It s a relatively simple application that includes the following steps. (For purposes of illustration, we are using the system and software developed by ewebcoding.) Prep and scanning. Clerical staff prepare, scan, and upload key documents or complete patient charts. After records are placed in the scanner, images are captured and displayed on the workstation monitor and then automatically encrypted and sent to a secure server. For faster processing, an entire stack of records can be scanned off line and indexed at a later time. Batch scanning is the quickest way to scan and index ancillary visits, emergency records, and other outpatient charts. Chart management and chart view. This function assigns charts to a specific coder and includes the ability to monitor coder productivity; view, manage and create reports; add new users and facilities; and control access to records. The coder logs on and downloads the assigned records, processes the patient charts, and submits codes back to the facility. Codes are then entered into the organization s abstracting or encoding system through an electronic coding summary sheet for data entry at the hospital, for remote access to the hospital s abstract or encoder, or for automatic upload to the hospital s abstract or encoder via a system interface. Once the chart is marked complete, all images are erased automatically from the coder workstation. Code review. Once coded, records can be automatically included in a review queue for review by a supervisor. Records also can be randomly assigned to the queue based on the coder profile. Record storage. Long-term storage of medical records allows not only HIM professionals to access coded information, but also nurses and doctors, as appropriate. Obviously, the best software is useless without the right technology to base it on. That is why the technology offered by the top outsourcing firms must be able to demonstrate the following: Ease of use and implementation. Is the software user-friendly? Availability of technical support. Can they provide on-site training, onscreen assistance, assistance by telephone and Web site, in addition to user manuals? Security. Does the program meet or exceed HIPAA requirements governing administrative procedures, physical safeguards, and technical security? Internal security should include advanced encryption and multiple security layers that prevent the possibility of altering, copying, or printing patient information, as well as deleting charts from the coder s PC after completion. ROI and cost-benefit ratios. Can the outsourcing firm help you determine the value based on your specific needs? Nursing Services The third leg of the healthcare shortage stool is nursing. The continuing and, in fact, worsening shortage has underscored the need for a much closer partnership between healthcare facilities and the outsourcing agencies they turn to when they need assistance with staffing. Many client facilities are quite clear as to the performance they expect from staffing agencies, and often, staffing organizations accept and meet their clients high standards quite willingly. However, the root causes of the nursing shortage pay rates, high-stress working conditions, quality of work/life issues, decreasing nursing school enrollment have made it even more difficult to find and retain top-performing nurses, increasing the competition for the best of the best. To attract and retain the top nurses, many leading agencies are finding it necessary to reexamine their approach to recruitment and retention, shifting their focus from one of getting a nurse to one of building a team. And that requires three fundamental building blocks: Leadership, to set the right tone and create the right environment for nurses and other employees, including accessible management, and to empower teams by providing them with the tools they need to be effective. Accountability, to both clients and nurses, including what should be the cardinal rule of outsourcing: Never over-promise and under-deliver. Respect, for clients, nurses, col- July/August 2003 Sbusiness 35

5 Shortages Create Unique Opportunities for Healthcare Outsourcing leagues, and selves, which is often demonstrated through incentives, the work/life programs, and even expressions of gratitude. These building blocks may seem simplistic, but it s amazing how often their power is underestimated. By putting them to work, outsourcing firms will find that they are better able to attract and keep the high-quality nursing professionals they need to meet the expectations of their clients. In fact, leadership, respect, and accountability should be the foundation upon which any healthcare outsourcing services business is built. The top firms are the ones that understand the importance of creating an environment where their consultants can thrive one that places the greatest emphasis on keeping promises and building relationships over making a buck. Put those pieces together with the right technology and the proper credentials, and your agency will succeed in differentiating itself from the competition and take hold of a lucrative niche in healthcare services. Sam Nagel is group vice president, HIM/medical records and special services for Kforce Inc. Located on the Web at Kforce is a full-service professional staffing firm providing flexible and permanent staffing solutions in more than 40 North American markets as well as through online services. Sam may be reached at or snagel@ kforce.com. This article originally appeared in the July/August 2003 issue of Sbusiness, published by AFSM International, Fort Myers, Florida. 36 AFSM International