OVERWHELMED BY MEDICAL RECORDS MANAGEMENT??

Consider Outsourcing, But Ask These Questions First!

By:	Elizabeth B. Juliano
	Jean C. Bourgeois James R. Fell Carey J. Marousek

Whether due to workload volume, cost containment initiatives, knowledge demands, or other factors, corporate legal departments, insurers, and law firms may be confronted by the need to outsource Medical Information Management (MIM) functions to specialized service providers. These MIM activities typically include, but are not limited to: medical record acquisition; medical record review, summarization, and analysis; medical and scientific literature research; location, evaluation, and contracting of experts; and consultation on the medical aspects of discovery, settlement decisions, and trial preparation.

MIM service companies range in scope from part time, solo Legal Nurse Consultants (LNCs) to large MIM providers employing a variety of medical professionals, case managers, record acquisition experts, information systems specialists, and so forth. Some providers are able to offer exceptional MIM services to legal departments/insurers/law firms (collectively referred to as "the decision-maker" for the remainder of this article) predicated on many years of experience in the field and by their recruitment of highly qualified personnel. However, the capabilities of MIM providers are not equal across the board. For example, an examination of the 2000-2001 annual report of the American Association of Legal Nurse Consultants indicates that 55% of LNCs surveyed have five years or less experience in the field of legal nursing.¹

Is outsourcing MIM functions always indicated? How can the decision-maker ensure that the right work product will be received at the right time at the right cost? How might quality MIM providers be located and evaluated? Asking these and several other questions will enable the attorney, claims manager, and legal administrator to decide if outsourcing MIM functions is appropriate.

1. How does the client maintain control when outsourcing the important elements of medical case management?

This is an often heard and valid concern of a number of decision-makers. Although designated MIM functions may be outsourced by a decision-maker, executive oversight of the case must continue to reside with the corporate counsel, claims manager, or lead attorney(ies) defending the lawsuit. Accordingly, while an MIM provider may be responsible for the acquisition, review, and analysis of medical records for a particular lawsuit, the decision-maker can retain control over larger procedural matters.

It may be the decision-maker who establishes the form the final work product will assume when contracting the services of an MIM provider. This process involves early consultation with the provider to ensure that the final deliverables are compatible with the decision-maker's internal case management system and that they will be presented in a familiar format. The decision-maker may wish to collaborate with the MIM service to gain insights into various formats and data collection methodologies based upon the expertise and experience of the provider in the litigation, particularly if the provider has previous experience with other clients in similar types of cases.

Open communication with the MIM provider may be essential for the decision-maker. Attorneys and paralegals overseeing case preparation should expect easy access to the professionals reviewing medical documents. Any agreement for outsourcing MIM activities will define when and how the MIM provider's staff members can be contacted for consultation on case matters. The MIM provider should also keep the decision-maker informed with periodic written and verbal updates on the status of the contracted project.

The decision-maker may wish to prescribe the structure for billing and invoicing. This is an issue that may be reviewed and agreed upon early in the engagement with the provider to avoid any issues at the time of invoicing. The agreement should consider flat fee versus hourly rates, timing and format of invoices, activity codes, and descriptions to facilitate the reimbursement of the medical information services by the decision-maker's client. These statements should contain sufficient descriptive detail to expedite auditing of services rendered.

2. What is the best way to identify potential medical information management service providers for a given case?

When seeking an MIM provider, the initial action might be to survey possible candidates through journal advertisements or legal directory listings. It should be noted that publishers' screening and evaluation of MIM advertisers can be superficial; therefore, responsibility falls upon the decision-maker to make the ultimate determination of the capabilities of an MIM provider following personal discussions and review of promotional literature.

Consultation with other attorneys for their recommendations has always been the optimum resource to locate quality providers of medical information management services. These “word of mouth” contacts generally have a proven performance track record. Yet, for those cases in which networking yields few leads, decision-makers must resort to other strategies.

Many attorneys report they have successfully identified exemplar MIM providers at legal conferences. In some cases, these providers have been featured as speakers with the degree of their expertise becoming evident during the presentation. In other cases, MIM providers have demonstrated their capabilities via conference exhibitions at which the attorney might begin to establish a relationship, examine marketing materials, evaluate sample work products, etc.

Another way to seek out quality MIM providers is to peruse medical legal publications. Some MIM providers are well published in books and journals directed to an attorney readership specializing in drug and medical device, toxic exposure, professional malpractice, and other medical litigation.

Once a pool of potential MIM providers has been defined, the decision-maker should next obtain marketing materials, work product samples, and fee structures from selected candidates. The MIM provider should make this information readily available, both via the Internet and in traditional hardcopy. The professionalism of these materials is one additional predictor of the potential quality of the provider's work products for litigation support.

3. Is the experience and expertise of the MIM provider compatible with the requirements of the presenting case?

The competency of an MIM provider first should be determined through an examination of educational credentials of the professional staff members within the company. For example, an MIM professional designated by the provider to review a case involving a toxic tort should not only possess some form of medical or nursing degree, but also coursework in toxicology, biology, environmental science, and organic, inorganic, and biochemistry. The MIM professional’s completion of some form of relevant graduate study is highly desirable, especially if this coursework includes classes in biostatistics and research methodology.

Certification can also offer an assessment of expertise. Medical, nursing, and other professional associations issue a wide range of clinical and other certifications, which attempt to validate competency and expertise for a selected practice field. When appraising an MIM professional’s certifications, the attorney may investigate the source of the credential. Web sites of most professional organizations now contain pages describing criteria needed to acquire their certification(s). As one illustration, the web site of the American Nurses Credentialing Center, located at www.nursingworld.org, describes requirements to attain certifications in a variety of nursing specialties.

Sample case reviews, chronologies, and other attorney work products are other excellent measures of an MIM provider's experience and expertise. The decision-maker may evaluate these materials to determine the provider's ability to clearly communicate a review of the sample case and to assess skill in the analysis of critical medical parameters. At least one of these sample work products should involve a lawsuit similar to the type currently represented by the decision-maker.

4. Does the MIM provider have the capacity to consistently meet deadlines imposed by pending depositions, trial, settlement negotiations, etc.?

Every attorney has been confronted by the challenge of preparing for a short lead-time deposition or court hearing. In these situations it is vital that all documents and reviews be on hand for effective case management. It is important to determine early in the selection process whether or not the MIM provider has the capacity to address the pressures posed by changing court dockets.

For some decision-makers, it may be necessary that an MIM provider be responsive to "surge capacity" issues associated with the multi-claim environment of mass tort and class action litigation. In these situations, the decision-maker may wish to once again consider retaining the services of a large MIM company that employs a variety of talented medical professionals and enjoys the flexibility needed to adapt to changing deadline pressures

5. Can the service provider prepare a case review in a format compatible with the decision-maker's case management system?

Work product format specifications are items that the decision-maker should articulate to potential MIM providers in the early stage of proposal solicitation. The decision-maker should consider its needs, as well as those of its client, in relation to electronic storage of information. For example, end-users may require a format compatible with a particular type of case management software (i.e. Summation®, Concordance®). Accordingly, the capability of the MIM provider to interface with such programs should be evaluated.

The MIM provider's ability to conduct searches within its case management database should be determined during the proposal solicitation phase of the relationship. The decision-maker may identify case-specific keywords that will need to be queried to extract certain relevant information contained in a medical record summary or analysis. The MIM provider also should possess the expertise to format these queries into chronologically organized keyword charts, which will then serve as useful adjuncts to the medical record summary and analysis.

6. Does the service provider have sufficient office technology to address the medical information management demands of this case?

The decision-maker should consider the technology requirements in current medical information management and the degree of complexity that will be demanded of the MIM provider. Beyond basic office equipment and services, a full service MIM provider should offer the decision-maker options for electronic delivery of work products, virtual private networks, advanced and high speed imaging, etc.

The decision-maker should consider its needs as they relate to electronic billing. Electronic invoices not only enable decision-makers to more quickly process payments for services rendered, but also to communicate more efficiently with their clients about the services being outsourced to the MIM experts.

7. Within an MIM company, who will be the responsible parties executing the contracted services?

Some MIM companies outsource the completion of medical information management services to solo, independent medical reviewers. Accordingly, while a decision-maker may believe that a particular MIM provider will be reviewing its case(s), this assignment could possibly be delegated to a subcontractor.

The decision-maker may consider inquiring whether or not the MIM provider utilizes subcontractors in the completion of its work. The decision-maker may then decide if this arrangement is appropriate for the firm and acceptable to its client. Issues of subcontractor clinical expertise, educational credentials, and experience conducting similar medical legal reviews should be contemplated as well as the security and confidentiality of the information being reviewed.

8. Does the MIM provider market its services to both the plaintiff and defense legal communities?

Despite the fact that many MIM providers work for decision-makers from both sides of the bar community, this practice may not be advisable. The decision-maker may consider the importance it places on this aspect of the service and determine if this will be a key factor in its selection of a particular MIM provider.

As one example, a serious conflict of interest may arise if an MIM provider reviews cases for a pharmaceutical defendant in one lawsuit and later seeks to review cases for plaintiff attorneys bringing a different product liability action against the same pharmaceutical company. While consulting with attorneys on either side of a case, an MIM provider may become privy to classified information, trial strategies, etc. In subsequent lawsuits, confidentiality can become strained if opposing counsel retains the MIM company.

Avoidance of any conflict of interest problem is quite simple. The provider's marketing materials should clearly articulate if the company serves the plaintiff, defense, or both sides of the legal community. When an MIM provider submits a bid and proposal to the decision-maker, a general list of past and current clients also should be provided to aid in determination of any conflicts of interest.

9. Will outsourcing MIM functions complement the operations of the decision-maker? What if the decision-maker already has its own legal nurses on staff?

The aforementioned questions must be evaluated according to several variables, such as time investment, total expenditures, and work product requirements. For decision-makers who do not have trained medical professionals on staff, the support services of an MIM provider may offer the most expeditious solution. As one example, an MIM provider can offer support in the analysis of issues including obscure medical terminology; indications, actions, and side effects of voluminous numbers of medications; rationales for various diagnostic procedures; etc., thus saving significant amounts of attorney or paralegal case management time.

However, some decision-makers hire their own legal nurses to perform in-house reviews of medical case documents. Decision-makers who manage a sufficient volume of casework to support the services of nurses on staff generally find this to be an effective practice for medical information management, although on some occasions a surge of casework with pressing deadlines may overwhelm the efforts of internal staff. Under these conditions, the collaborative services of an outside MIM provider may be indicated for the actual summarization of the medical records, thus freeing the decision-maker's legal nurse to consider the higher analytic and more global issues of case preparation. Retaining an MIM provider in surge situations also frees the decision-maker from the responsibility of recruiting and screening temporary personnel, plus the associated overhead costs.

10. Will the MIM provider deliver the work products at the budgeted rate?

An experienced MIM provider should be seasoned in the process of forecasting time and costs required to successfully undertake a given medical case management project. In the case of a large MIM provider, the company will typically maintain an extensive database for a variety of cases. Retrospective analysis of these cases enables the provider to accurately project costs associated with various phases of the presenting project, as well as an overall budget for the project in toto. The experienced and well-staffed MIM provider with broader resources can also integrate the capabilities of personnel from its finance, medical, information systems, research, and case management departments to develop time and cost estimates based on work product deliverables, litigation type, and volume of documents requiring review.

11. How will the MIM provider guarantee the security of medical records and other case documents?

Security of online and hardcopy documents may be of significant importance to the decision-maker. During the engagement process, the decision-maker will wish to assess the provider's capability as it relates to access to sensitive information. This access to confidential documents can be controlled using a layered approach to security, such as restricted admission to company office space, locked file rooms, computer network firewalls and virus protection, etc. Additionally, the decision-maker may wish to seek an MIM provider who requires employees sign confidentiality agreements and then renews these agreements with employees on an annual basis.

It may be important to the decision-maker that document security be managed by assuring that medical records remain in the office of the MIM provider. However, because some MIM providers subcontract the review of medical documents, these hardcopy records may leave the security of the office environment. If this is the situation, the MIM provider should be asked to describe document security protocols to which its subcontractors must adhere.

In some cases, MIM providers will transmit scanned document images for its subcontractors to review. This poses a different set of security issues, which the MIM provider should be prepared to discuss with the decision-maker. For example, does the MIM provider maintain these images via some type of network, and how does the company protect this system against intruders and hackers?

Security also becomes an issue once it is time to transmit work products to the decision-maker. A decision-maker may wish to have documents delivered in some type of electronic format. Because of the computer hardware and technical expertise required for secure document transmission, only the larger and more experienced MIM provider will be able to offer this capability.

It should be determined whether or not the MIM provider has the flexibility to offer electronic transmission service by both e-mail and extranet routes. E-mail transmission works best if the decision-maker only requires access to a work product in final completed form. The decision-maker will want to ascertain if the MIM provider offers proper programming services to encrypt material before electronic transfer of this information.

In comparison, extranet transmission basically consists of an Internet site hosted by the MIM provider. An extranet site offers a degree of dynamic interaction not found with e-mail transmission. The extranet can be erected by the MIM provider to allow the decision-maker access to work documents as the medical reviewers are actually developing them. Security of an extranet is maintained through use of SSP (secure sockets protocol) encryption, which requires an end-user password to access work product information.

12. Is the MIM provider able to provide a package of comprehensive medical information management services for the given case?

To maximize gains associated with outsourcing MIM activities, the decision-maker should identify an MIM provider who can offer a "one stop shopping" for medical record acquisition and review, medical and scientific case research, and location and screening of experts. Significant savings can be realized through the use of a total service MIM provider because the decision-maker will invest less administrative time and money in coordination of service providers and document transfer. Fragmentation of services can result in a scenario in which documents and work products pass through a complicated network of multiple companies.

13. Can the MIM provider manage medical documents in the mass tort/class action scenario, as well as the individual action?

The decision-maker who is appraising the possibility of outsourcing work for a larger mass tort or class action will want to screen the MIM provider based upon the company's ability to "ramp up" to address the collective demands of such large-scale litigation. While a small MIM provider may be very adept at reviewing medical records for a single case and composing its analysis of the medical documents using simple word processing software, dictates of multi-plaintiff litigation will require an expanded set of capabilities.

A basic requirement of most decision-makers litigating in the mass tort arena is to gain knowledge about the characteristics of the plaintiff group as a whole. Accordingly, decision-makers may require various types of "compilation reports" for the claimant population, in addition to individual case summaries and analyses.

When investigating potential MIM providers for these types of cases, decision-makers should ensure their technology is robust enough to properly manage complex litigation. Large MIM providers generally have better database capability to execute the aforementioned analytical case management functions and statistical calculations. Knowledge derived from these collective reports describing plaintiff population characteristics can then assist the decision-maker in planning strategy for optimal case resolution of the mass tort or class action.

14. How readily will the MIM provider be available for consultation on case issues?

The decision-maker and MIM provider may not be located in the same city or even same time zone. Consequently, when selecting an MIM service, the decision-maker should determine the requirements regarding the type, quality, and timeliness of communications with the medical case reviewer and the importance that will be placed upon these variables in subsequent case management.

Negotiations between a decision-maker and an MIM provider should establish up front which personnel in the provider's company will be available and during what days and times. Most decision-makers prefer that a single point of contact be identified to facilitate communications with the MIM provider. Typical office hours for this individual should be provided to the decision-maker to decrease time wasting "telephone tag."

Preferred format of communication (telephone, fax, email, regular mail) for the point of contact should also be solidified during this period. The MIM provider should offer the decision-maker the reassurance that any inquiry will receive a response from the company representative within a specified number of hours.

During contract discussions, the decision-maker may wish to specify what type of status reporting will be required for a particular case(s). These reports may be forwarded to the decision-maker as often as once a week, or perhaps on a less frequent, monthly basis. The decision-maker should stipulate the form, length, amount of detail, and other desired features of these status reports.

15. What performance metrics are currently in place within the MIM provider to ensure the quality and consistency of its medical information management services?

In the industrial sector, manufacturers and suppliers have learned that decision-makers expect high quality services and goods, with consistent performance metrics. No less should be required of the MIM provider in the provision of medical case management work products. The decision-maker will want to determine how the provider assures reliable medical information management through a review of the provider's quality assurance program. In turn, the MIM provider should be prepared to submit documentary evidence to the decision-maker as to how its medical case management work products will meet or exceed quality expectations of the end-user. For example, the provider should evidence a system of internal checks and balances that will guarantee an error-free final work product.

Conclusion

Ultimately, the decision to outsource Medical Information Management activities will be determined by the capacity and expertise available in the decision-maker's organization to handle complex medical issues of a given case and the interest of its client(s) in utilizing the medical aspects to prepare their case. Although application of the principles discussed in this article will serve to assist the decision-maker in selecting the most qualified MIM provider, nothing can replace the development of an effective, long term working relationship with an experienced MIM provider, coupled with open and ongoing communication throughout case preparation.

1 - American Association of Legal Nurse Consultants. 2000-2001 Annual Report. //www.aalnc.org/annualreport/2001 .

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