by Jennifer Shearer, RHIA
Editor's note: This project received third prize in AHIMA's Best Practice Awards Program. The Best Practice Awards are generously underwritten by a grant from founding sponsor Healthcare Management Advisors, Inc. (HMA) to the Foundation of Research and Education (FORE). Since 1990, HMA has provided compliance and clinical data quality services to more than 1,600 hospitals and 20,000 physicians and now also provides online solutions via the Internet. The Best Practice Awards are also supported by a grant from SoftMed Systems, Inc.
For staff at Inova Fairfax Hospital, coding at home had long been an unattainable goal. A new approach to the project, coupled with the support of an ASP, helped them make it a realityand a success. Here's how they did it.
Look at any HIM periodical and you'll see numerous advertisements for clinical coders, some offering sign-on bonuses as high as $10,000. Why such a high price tag? Many healthcare organizations today are experiencing a shortage of qualified coders.
Inova Health System had experienced this very problem for several years. Inova Fairfax Hospital, a 656-bed acute care facility in northern Virginia, had experienced a 20 to 25 percent vacancy rate for coders in the past three years. It seemed that once a vacant position was filled, another coder would resign.
Like many other organizations, Inova Fairfax Hospital had tried many solutions with little overall success. With more than $2.7 million being billed on a daily basis, the organization could not afford to have coding vacancies and the resulting increase in accounts receivables due to coding backlogs.
Despite spending significant amounts of money on outsourcing backlogged work, paying out more than $50,000 in retention bonuses and more than $6,000 in recruitment bonuses, and requiring mandatory overtime, the hospital was not making significant enough progress in relation to the overall shortage of qualified coders. With APCs on the horizon, it was very clear that something new and innovative had to be done.
Here's how the hospital successfully implemented a remote coding program, boosted retention, increased morale, and improved the overall performance of the department.
Coders Go Home to Work
In October 1999, Inova Fairfax was approached by an application service provider (ASP) company about in participating in testing and development of an Internet-based coding application that would enable coders to code from any remote site that has Internet access, including home.
Until then, coding from home had never been an alternative the hospital had been efficiently able to offer coders. Inova Fairfax transcriptionists had worked from home for several years, and coders had always expressed an interest in doing the same. Using an ASP and transferring charts securely over the Internet would enable coders to work at home and increase coding options with regard to contract coders and outsourcing capabilities.
After several meetings with the ASP's management and carefully reviewing its security capabilities versus the hospital's internal security requirements to ensure compliance and readiness for potential HIPAA requirements, the facility enthusiastically embarked on this new project.
During the early stages of the beta test, only two coders tested the system from home and provided feedback. Their excitement about the new system, however, soon had most of the coders anxiously waiting their turns.
Shortly thereafter, 10 coders were able to work remotely. We were restricted in volume only by our inability to connect remotely to our abstracting and clinical systems, as well as the encoder. We resolved the abstracting at home capabilities using terminal emulation software, and the coders willingly gave up reliance on the encoder to be able to work from home.
Coders took home reference materials that were supplied by the hospital. When they had questions they could not answer using the reference books, they e-mailed the on-site data quality manager. Similarly, questions for physicians were forwarded to the data quality manager, who passed them along to the clinicians. Sometimes coders were able to call physicians directly with questions as well.
Within two months of allowing coders to work remotely, we had no vacant coding positions and actually had a waiting list of qualified coders who wanted to work from home. Sixteen of our 18.5 coders now can work remotely. What's more, the department was able to:
- increase productivity by approximately 20 percent
- eliminate many of our outsourcing costs
- significantly reduce accounts due to coding receivables (a more than $11 million reduction in three weeks)
- tremendously improve coder morale
Overall, a cost benefit analysis indicated a net savings/gain of more than $380,000 annually.
Although the implementation of remote coding was straightforward and easy for Inova Fairfax, we needed to address a number of issues before sending coders home. These included:
- developing telecommuting policies/procedures
- human resource considerations
- departmental process changes
- Internet training
- hardware/software evaluation
- remote access to other systems
By the Rules: Telecommuting Policies/Procedures
Before implementing a remote coding program, ask all of the workers who will be working at home to sign a written telecommuting agreement. This establishes expectations for everyone involved, including managers and coders who will have very little direct supervision. It also establishes what the coders can expect from support and management staff.
The agreement should address issues such as:
- defining telecommuting as a management option rather than an employee benefit
- expectations relative to confidentiality issues
- productivity issues
- ownership issues
- time frame for working at home
- on-site availability
- potential for cancellation of the entire program
- reference materials and HIPAA regulations
If all of these issues are outlined at the start, there will be much less confusion, which will contribute to the program's overall success.
To recognize and reinforce the importance of the confidentiality of the online record, a separate confidentiality agreement should be developed and incorporated. This document should address the office location within the home, the need for a separate secure location that will not be accessible when the coder is not working, the security of the information on the PC, and the need to sign off the application when the coder is not physically in front of his or her PC. Once the employee has reviewed and signed this agreement, there should be no questions regarding expectations about confidentiality and security.
Safety First: Human Resource Issues
Several human resource-related issues need to be resolved. For instance, decide whether coders will remain employees or be classified as contract workers. Make sure you state that this is a management option and not a benefit to the employee for tax purposes.
Make sure you are aware of any Occupational Safety and Health Administration (OSHA) requirements. Work with your human resources department to ensure workers' compensation will cover your employees in the home environment. It is a good idea to develop workstation design guidelines and offer a home inspection of your remote coder's work area. Also, consider developing a self-certification safety checklist for home-based coders to help minimize any risk of injury.
Eligibility for participation in the program should be included in HR policies so no one will feel they are being unfairly excluded from the program.
Other topics to cover include tax status issues, compliance issues, emergency situations, and use of benefit time (vacation, sick leave, paid time off).
The Way We Work: Department Process Changes
You'll also need to consider the impact of a remote coding program on your department. Managing a remote work force can present its own unique challenges and may require some additional skills.
Many of the issues that will need to be addressed will be immediately apparentsome may take weeks to emerge. If everyone in your department is aware of the project, tries to identify potential issues proactively, and is not afraid to change the way they work, you will be prepared to address problems. Establish a mechanism for communication to your remote employees, such as a departmental newsletter via e-mail or a standardized e-mail template.
IS Issues: Hardware/Software Evaluation
Before implementing a remote coding program, you will need to decide who will provide or pay for the coder's workstation and Internet service. Will the organization provide and maintain the PC, or will the coder be responsible for purchasing and maintaining his or her own equipment?
Both options have positives and negatives. However, you may want to investigate whether the hospital providing a workstation is an extension of the workplace and whether any additional OSHA requirements would apply. Conversely, if the organization does not provide the PC, how comfortable will you be with the employee having other applications on the PC, as well as potentially other users (friends and family members) on the system?
Additionally, there may be conflicting needs from an operating system standpoint. For example, your facility may be running Windows 95 and your coders may want to purchase Windows 2000. Before you experience these conflicts, you need to be prepared to resolve them.
You will also need to settle questions about Internet connections. Are you or your coders willing to live with the downloading time of a 56K modem, or do they want higher-speed cable modems or DSL lines? If the answer is "faster is better," determine who will pay for the additional telephone line or the cable modem and corresponding monthly connection fee.
Your organizational security policies and procedures can help with your decision. If you don't have policies that address remote information systems issues, you may want to spearhead this initiative. It's important to create awareness of and support for this project at all organizational levels.
Getting Wired: Internet Training
It's easy to overlook the need providing some basic Internet/PC training to your coders, but this step shouldn't be missed. Your coders probably won't be able to call a help desk number for help with hardware, Internet service problems, or other general questions that may arise. Consider standardizing on a single ISP to minimize the number of issues that may arise. Simple error messages or disconnects from the ISP can severely affect daily productivity if employees do not have some basic understanding of how the process works.
Connected At Last: Remote Access to Other Systems
Finally, remote access to your abstracting system and clinical systems will be key to streamlining your processes and making the system a success. Although you can "go live" with remote coding without access to other systems, it will certainly be much more efficient if your coders have access to the systems they need (transcription, radiology, lab pathology, order entry/results) to accomplish their jobs.
Once you have implemented your system and are comfortably working with it, you'll be able to identify many other uses. For example, Inova Fairfax anticipates using the system to give access and queues to large-volume requestors, e.g., tumor registry, on-site managed care reviewers, quality improvement, and modified release of information. Consideration is also being given to make it our mini-electronic record for our obstetrics clinic to ensure the record is always available in labor and delivery and for transplant clinics for follow-up care and evaluation.
While our program is still fairly young, it has resulted in tremendous immediate gains from a financial perspective, as well as a tremendous boost for coder morale, recruitment, and retention, making this the most rewarding system implementation we have experienced. The opportunities for expanding the use of the system will only increase over time.
Before You Go Remote
Before implementing a remote coding system, you'll need to address a number of issues. Here's a sampler of questions to ask:
Human Resources Issues
- Will coders will be paid per chart or hourly?
- Will overtime be paid?
- Will any incentives be built into the program?
- How will coders report hours worked or number of charts completed?
- What types of charts will you scan?
- How will you accomplish scanning? Will this require an additional FTE or will you be able to incorporate the process into existing employees' daily workload?
- Do you need to scan all documentation, or can you eliminate some of the nursing documentation forms?
- Will the scanner's responsibilities be-administrative or strictly clerical?
- How much additional prep work is needed to be able to scan? Do you still need to assemble charts before they are scanned?
- Will you be scanning large-volume charts or will that process be too inefficient?
- How many volumes will you scan?
- How will you identify charts that have been scanned versus those that will be coded on site?
- Will all your coders work at home full time, or will you try to find the perfect blend of in-house work versus time worked at home?
- How will you make sure that loose material (e.g., path reports) that appears days after discharge gets added to the scanned chart if it is needed for coding purposes?
- Who will attach the coding summary form to the chart?
- How will coding questions for physicians be handled?
- If you do not have remote access to your abstracting system, how will the codes get into the system?
- How will your data quality individual review charts and answer coding questions
Jennifer Shearer is director of health information management at Inova Fairfax Hospital in Falls Church, Va. Her e-mail address is email@example.com.
Shearer, Jennifer. "Remote Coding at Home: Tips for Success." Journal of AHIMA 72, no.2 (2001): 62-65.