From Hours to Minutes: AI Cleans Up Muddled Medical Records

Medical records play a vital role in our shared healthcare ecosystem. Just as physicians rely on a patient’s accurate medical history to determine appropriate treatments, healthcare payers use the same records to make coverage decisions and help patients manage their care more effectively and affordably.

But there’s a big problem with medical records today: they’re often extremely long, disorganized, and repetitive. For employees on the payer side, locating pertinent information in an exhaustive medical history can be a time-consuming slog. And that unfortunate reality saps the efficiency of healthcare insurance processes, increases costs and obstructs patients from getting the care they need.

As with many aspects of healthcare, however, modern technology has the power to alleviate these problems. Automation software, paired with emerging forms of artificial intelligence, can help payers streamline the records review process to work faster and smarter. Not only will these new solutions improve payers’ business performance, but they could also pave the way to more positive healthcare outcomes for millions of patients.

The problem with medical records

To understand the cure, one must first understand the disease. So, it is with overcoming the challenges created by dysfunctional medical records. Every patient’s medical history includes a hodgepodge of information such as physician’s notes, vital sign readings, tests, diagnoses, prescriptions, procedures and other data from every clinical encounter spanning many years. As if that weren’t enough, much of this information is duplicated many times over, the result of clinicians simply copying and pasting repetitive information into required forms. Amazingly, it is not unusual for a single physician’s encounter to add 1,000 pages or more to a patient’s medical record, which means their complete medical history could be many times that.

This is problematic because healthcare payers must review these records to make decisions about prior authorization and other functions such as case management, disease management and risk assessment. For example, a payer employee – typically a clinically trained specialist – may need to review the results of a specific test before they would authorize the patient for elective surgery. But finding this information in a thousand-page document can be like looking for a needle in a haystack, wasting the valuable time of a highly qualified (and highly paid) specialist. The problem is compounded as dozens of employees throughout the organization spend hours tediously poring over medical records every day.

Such systemic inefficiency creates a cascade of secondary issues. Labor costs increase because payers must hire enough skilled workers (if they can find qualified candidates) to manage the backlog of records review. Even with a large enough staff, payers may be unable to meet turnaround times set by CMS (Medicare/Medicaid), and thus face penalties for non-compliance. Healthcare providers may also find themselves inconvenienced by payers’ questions and requests for more information. Meanwhile, patients grow increasingly frustrated as they’re left waiting for authorization or further guidance from their insurer.

Beyond higher costs and slow service, these delays can also result in real health consequences for patients. Their condition could worsen as they wait for a response, or (as is often the case) they may abandon treatment altogether if they can’t get timely assistance from their insurer.

Simplifying the records review process

The cumbersome nature of reviewing medical records is a pervasive problem with harmful consequences. Until recently, most payers have had little choice but to accept it as an unfortunate reality of the healthcare industry. But that collective mindset is changing as technology continues to advance. In every industry, companies are using powerful automation software to alleviate the burden of repetitive, time-consuming tasks. And, with the addition of increasingly sophisticated AI, automation is taking on more challenging work every day. The same concepts can be applied to streamline and accelerate many healthcare processes, including medical records review.

Opportunities for improvement exist at every step in the process, starting with the intake of information. Payers typically receive new and updated medical records through various methods such as fax, email, or software interfaces, and the lack of data uniformity creates the first in a series of logjams. AI-powered automation can ingest all that disparate information, convert it to a common format and neatly organize it for review.

When employees need to locate a particular piece of information, AI can help them find what they need in a fraction of the time. Beyond just highlighting search terms in the text, today’s software – which incorporates auxiliary technologies like optical character recognition (OCR) and natural language processing (NLP) – can do things like identify redundant information and produce a summary of what’s new in the document. It can also consider the context and implications of medical data and bring key points to the reviewer’s attention. One might compare the experience to the convenience of Google versus searching for answers in a shelfful of textbooks.

Taking another step forward, automation software will not just get employees what they asked for; it will bring forward information they didn’t know they needed. AI can be programmed to identify trends that humans might miss and raise red flags to appropriate parties. For example, if a patient’s medical record shows they’ve been repeatedly visiting an emergency room for a non-emergent condition, software may direct the issue to case management for intervention.

Better for everyone

When technology solutions like these are deployed across millions of medical records, it’s easy to see how healthcare payers – and, in turn, the rest of the healthcare universe – will benefit. Quite simply, greater efficiency leads to lower costs, faster service and better results.

Dramatically reducing the amount of human labor required to review medical records will help payers overcome the nationwide shortage of qualified healthcare workers. And, as productivity increases, payers may find opportunities to reassign some existing employees to more value-adding job roles. Moreover, as AI helps improve intervention processes such as case and disease management, payers become more adept at steering patients toward lower-cost treatments.

Healthcare providers benefit, too. Software will help streamline their daily interactions with payers, cutting down on back-and-forth deliberation over treatment plans and authorizations. As a result, providers reduce their own administrative burdens and can stay focused on patient care.

Perhaps most importantly, the healthcare consumers receive a better healthcare experience when insurance companies work more efficiently. Patients can get the answers and guidance they need to manage their own care at the lowest possible costs, making them more likely to follow through on the tests and treatments they truly need.

Adoption accelerating

As in every aspect of society, technology continues to raise the bar for what’s possible in the healthcare sector. Breakthrough medical discoveries and innovative treatments may grab the headlines, but tech-driven improvements to everyday processes (like reviewing medical records) may ultimately make the biggest impact on human lives. Healthcare payers are recognizing the massive potential of automation and AI to drive productivity, lower costs and improve member service. Thus, it’s only a matter of time before the technology becomes table stakes to compete in the healthcare insurance industry.

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