Elliot Stone, ESQ
The yearly average number of lawsuits filed in the United States may have stabilized due to Tort Reform and other factors, but litigation related costs have not. Offshoring medical record services, however, is primed to reverse this trend. Large corporations have already been offshoring paralegal and legal work for quite some time to India and other similar economies, but insurance companies have been slow in adopting the practice.
The terms “offshoring” and “outsourcing” have taken on a variety of different, sometimes controversial meanings, and is perhaps one reason why some companies are hesitant to investigate further despite the cost savings offered. However, “business process outsourcing,” especially India based, has grown tremendously in the last decade and shows no sign of abating. With its large, educated, English-speaking workforce, Indian BPOs work with firms in dozens of countries, but nowhere is it more widely used than in the U.S.
Can Indian MDs Cure Medical Records Headaches and Costs?
Sorting and organizing large medical charts can require hundreds and hundreds of hours of billable legal time. Significant attorney and staff time is expended ordering, organizing and summarizing medical charts. Medical file services usually involve organizing a massive unstructured assortment of documents to sorted ones then delivered to the attorney, often in the form of paper binders. If these files are to be reviewed by expert consultants, copying and shipping costs are incurred and passed along. While attorneys are increasingly scanning records for electronic delivery, this can be problematic if the format does not meet the expert’s specifications.
Insurers and defense firms have been slow to adopt the practice for several reasons. Carriers tend to be very traditional and resistant to innovation—in general, they are accustomed to delegating most record related services to counsel. These services are a profit center for law firms which are loathe to refer the work elsewhere. Furthermore firms have no incentive to reduce pass along copying and shipping costs.
Additionally, outsourcing medical records services requires some, albeit minimal, technical sophistication. Technology is one area where many carriers and law firms are lacking in. Attorneys and staff sometimes come across web browser compatibility issues when uploading files. A few questions should be asked before getting started. Can staff figure out how to compress large numbers of files into 1 ZIP file? Or be able to extract files from CD onto the hard drive and compress it to 1 ZIP file? These seemingly simple tasks can present problems but mostly, lack of experience with computers and old versions of Internet Explorer cause frustration with new users.
Several U.S. companies are now offering records services, with offshore partners in India whose staff organize records, review charts, and do hyper-linking and bookmarking (allowing rapid chart navigation for the reviewer).
Offshoring As A Solution
What qualifies these reviewers to do this work? And why is it economically viable for them to take it on in the first place?
India’s Cities Swimming in Physician Labor
India has a large pool of physician labor, graduating an estimated 20,000 physicians per year. The majority of the physician workforce prefers to work in cities, saturating urban areas while causing shortages in rural ones. This concentration of physicians in urban areas is one explanation for the availability of MDs for review work. A brief review of India’s medical education and professional environment offers other explanations.
India’s medical training differs from ours in several respects: medical schools are 4.5 years followed by a one year general residency then application to specialized residency programs if desired. Acceptance is highly competitive–well less than half of the doctors are accepted. There is, typically a one to four year waiting period before admittance. In the interim they are involved in primary care in the community or first on-call doctor if they prefer to work in the hospitals. Many junior physicians work in government run clinics 6 hours per day, earning approximately US $1000 per month, leaving considerable time for private practice and medical – legal review work. Senior physicians looking for extra income will review legal cases or oversee the work of junior physicians who want to include chart review work to their resume.
Receive, Reduce, Review
For the many firms for which piles (and boxes) of records and binders stand like skyscrapers throughout the office, taking the rather large step toward digitizing all records requires a change in business practice and mindset. While many firms claim they want to become paperless, actually taking the steps required can be daunting. Knowing some details about the process ahead of time and some of the issues to troubleshoot can save a lot of frustration later.
Online document transmission can be accomplished easily. First, legal staff scans all records and uploads them via a secure, HIPAA compliant internet portal. The most common file formats are DOC, XLS, PDF, JPG, TIF, ZIP, and SIT. Thereafter, organized digital files are downloaded and returned in the identical fashion.
In general, firms who do this work, including ours, receive the medical records, reduce, sort and organize them into a text – based medical file. Any PDF documents are converted into text based files as well. They capture the record dates, procedure(s), treatment/occurrence(s) and other customized data fields. The finished product is a thorough text-based medical record summary that is presented chronologically, enabling the reviewer to better and more quickly understand a sequence of events. Important points in the summary can be highlighted in yellow. The file can be delivered in either WORD or PDF formats. The PDF format option may include two digital navigation tools – Hyperlinks and Bookmarks. Hyperlinks allow for instant navigation from summaries and timelines to corresponding source pages by clicking on the desired corresponding source page. Bookmarks form a digital table of contents allowing for organization of documents by user-defined categories such as provider and date. The printable version contains tab sheets for the hard copy binders that are so familiar to PI attorneys.
In addition to preparing medical chronologies and timelines, Indian physicians, in the appropriate specialties, can provide medical liability and causation opinions. While they certainly cannot testify at trial (more on this later), physician opinions are generally preferable to those by nurses or lay staff members.
Pharmaceutical and Mass(ive) Tort Records
If any type of legal work requires efficiencies that necessitate an outside solution, it would be mass tort litigation. Even with significant capacity within existing staff—sorting and organizing the records of several hundred plaintiffs requires serious stamina in terms of labor and hours. Physicians, however, have been trained to analyze complex medical content, filter out the irrelevant and quickly find the desired information. Attorneys and other staff simply cannot match their speed and accuracy; which medical review work demands.
Overseas BPOs with access to a large pool of medical staff are able to organize quickly to handle large volumes of work. Organizing medical records for mass tort litigation is similar to the general process, except that once medical staff receives the files they review and highlight key class parameters to determine claimant inclusion in the class in a chronology format. Parameters may include medical care date ranges, usage, dosage, quantity and duration, proximity of injury to dates of ingestion, confirmation of side-effects. Potential defenses including alternative causation due to predisposing risk factors including pre-existing conditions, elements of comparative or contributory negligence are evaluated and identified.
For large classes, spreadsheets can be prepared addressing individual parameters with hyperlinks embedded that link to actual chart for ease of confirmation. .
Offshoring: Advantages and Disadvantages
Offshore outsourcing medical records services to Indian BPOs offers both advantages and disadvantages. Files that are chronologically sorted into easy-to-read and navigate electronic files, reduce both attorney and expert reviewing time and billing. Billable record preparation and case review can be redirected to physicians and other medical professionals, for $US25-$50 per hr, significantly less than legal staff, U.S. nurse and physician rates. Law firm staffing size can be better managed with personnel free to focus on more productive legal work. By deciphering and interpreting illegible and complex medical terminology, physician reviewers enhance the attorney’s comprehension of the chart. Indian physicians can review charts with opinions for anywhere between $US50-$75 US dollars per hour compared to $300-$500 for their US counterparts. Electronic transmission of charts eliminates the accompanying copying and shipping costs for co-counsel and expert reviews.
The time difference between the US and India and phone expense limits communication between attorney and Indian consultants mostly to email transmissions. While physicians are fluent in English, Hindi pronunciation and diction can make oral communication challenging for American English speakers. Physician’s written English is usually strong and rarely poses a problem.
Further, any physicians offering medical opinions cannot testify – adding an additional layer of expense.
Carriers should carefully weigh the costs, savings and benefits of sending records work to Indian based companies (or other popular offshore outsourcing destinations.) Regardless, this service brings us another step closer to fully leveraging the business potential of the internet. Openness and receptivity to the pace of technology driven business is critical, unless insurers want to be left behind by those who have adopted the global economic mindset. For better or worse, it is the new reality and carriers need to decide whether they will continue relying on defense counsel doing business as usual – or evolve and improve the bottom line..
Elliot Stone, Esq is a former defense medical malpractice attorney and is CEO of Record Reform℠, which provides medical record outsourcing services to attorneys and insurers.