ANSI ASTM E1959-2005 Standard Guide for Requests for Proposals Regarding Medical Transcription Services for Healthcare Institutions.pdf

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1、Designation: E1959 05 (Reapproved 2011)Standard Guide forRequests for Proposals Regarding Medical TranscriptionServices for Healthcare Institutions1This standard is issued under the fixed designation E1959; the number immediately following the designation indicates the year oforiginal adoption or, i

2、n the case of revision, the year of last revision. A number in parentheses indicates the year of last reapproval. Asuperscript epsilon () indicates an editorial change since the last revision or reapproval.1. Scope1.1 This guide covers recommended guidelines to health-care institutions for the devel

3、opment and issuance of requestsfor proposals (RFPs), as well as guidelines for medicaltranscription service organizations (MTSOs) responding torequests for proposals. It does not purport to address all of thelegal aspects of the RFP, if any, associated with its use. It is theresponsibility of the us

4、er of this guide to establish appropriatelegal guidelines prior to use.1.2 It is appropriate for healthcare institutions to issue RFPsfrom time to time or at regular contractual intervals for thepurpose of facilitating the process of contracting for medicaltranscription services.1.3 It is anticipate

5、d that both a commercial contract forservices and a HIPAA Business Associate Agreement will bebased upon the responding proposals submitted to the RFP.1.4 This international standard was developed in accor-dance with internationally recognized principles on standard-ization established in the Decisi

6、on on Principles for theDevelopment of International Standards, Guides and Recom-mendations issued by the World Trade Organization TechnicalBarriers to Trade (TBT) Committee.2. Referenced Documents2.1 ASTM Standards:2E1384 Practice for Content and Structure of the ElectronicHealth Record (Withdrawn

7、2017)3E1762 Guide for Electronic Authentication of Health CareInformation (Withdrawn 2017)3E1869 Guide for Confidentiality, Privacy, Access, and DataSecurity Principles for Health Information Including Elec-tronic Health Records (Withdrawn 2017)3E1902 Specification for Management of the Confidential

8、ityand Security of Dictation, Transcription, and TranscribedHealth Records (Withdrawn 2011)3E2117 Guide for Identification and Establishment of a Qual-ity Assurance Program for Medical TranscriptionE2184 Specification for Healthcare Document Formats(Withdrawn 2011)3E2344 Guide for Data Capture throu

9、gh the Dictation Process2.2 Other DocumentsAmerican Association for Medical Transcription (AAMT),Metrics for Measuring Quality in Medical Transcription,20054AAMT Book of Style, Second Edition, 20024Medical Transcription Industry Association (MTIA), BillingMethod Principles5Public Law 1004-191 Health

10、 Insurance Portability and Ac-countability Act of 1996 (HIPAA)63. Terminology3.1 Definitions:3.1.1 audit traila record of users that is documentaryevidence of monitoring each operation performed. Audit trailsmay be comprehensive or specific to the individual and event(that is, document routing, vers

11、ion control, access, etc.).3.1.2 authenticationprocess of (1) verifying authorship,for example, by written signature, identifiable initials, orcomputer key, or ( 2) verifying that a document is what it ispurported to be, such as comparison with other records, orboth.3.1.3 Certified Medical Transcrip

12、tionistmedical transcrip-tionist who has met the qualifications for voluntary certificationset by the American Association for Medical Transcription(AAMT), by demonstrating proficiency in the field, meetingaccepted standards, and maintaining the designation through1This guide is under the jurisdicti

13、on of ASTM Committee E31 on HealthcareInformatics and is the direct responsibility of Subcommittee E31.15 on HealthcareInformation Capture and Documentation.Current edition approved July 1, 2011. Published August 2011. Originallyapproved in 1998. Last previous edition approved in 2005 as E1959 05. D

14、OI:10.1520/E1959-05R11.2For referenced ASTM standards, visit the ASTM website, www.astm.org, orcontact ASTM Customer Service at serviceastm.org. For Annual Book of ASTMStandards volume information, refer to the standards Document Summary page onthe ASTM website.3The last approved version of this his

15、torical standard is referenced onwww.astm.org.4Available from American Association for Medical Transcription, www.aam-t.org.5Available from Medical Transcription Industry Association, .6Available from U.S. Government Printing Office, Superintendent ofDocuments, 732 N. Capitol St., N.W., Mail Stop: S

16、DE, Washington, DC 20401. Seealso http:/aspe.hhs.gov/admnsimp.Copyright ASTM International, 100 Barr Harbor Drive, PO Box C700, West Conshohocken, PA 19428-2959. United StatesThis international standard was developed in accordance with internationally recognized principles on standardization establi

17、shed in the Decision on Principles for theDevelopment of International Standards, Guides and Recommendations issued by the World Trade Organization Technical Barriers to Trade (TBT) Committee.1continuing education activities as required by the certificationprocess established by AAMT.3.1.4 complianc

18、e clauseitem in a contract that definesremedies for default of contract specifications.3.1.5 data destructioneradication of data to a useless andirretrievable state.3.1.6 data elementsunits of fundamental information froma healthcare record, organized in an analytical manner.3.1.7 data extractionspe

19、cification of a subset of data froma master data source for a new data format.3.1.8 data miningextraction of selected elements of storeddata to be used for a purpose other than the one for which theinformation was originally intended.3.1.9 dictationinformation that is stated or read aloud tobe trans

20、cribed by another.3.1.10 dictatorone who dictates information to be tran-scribed by another; also known as originator.3.1.11 digital dictationinformation that is stated or readaloud and recorded by a digital recording system.3.1.12 documentreport in any form (print, electronic, orvoice file).3.1.13

21、document accessability to enter, exit, and, in somecircumstances, edit or make use of a document.3.1.14 document destructioneradication of all elements ofa document to a useless state.3.1.15 document distributiondelivery of a document ordocuments (original or copies) to appropriate recipients, in an

22、yform (print, electronic, or voice file), authenticated or notauthenticated.3.1.16 document storagerepository for reports in anyform (print, electronic, or voice files), authenticated or notauthenticated, for later use or retrieval.3.1.17 electronic authenticationverification of authorshipof a docum

23、ent or verification that a document is what it ispurported to be, or both, accomplished by electronic means orin an electronic format.3.1.18 electronic protected health informationindividually identifiable health information in any electronicmedium, protected by HIPAA Privacy and Security Regula-tio

24、ns.3.1.19 full-time equivalentwork force equivalent of oneindividual working full-time for a specific period, which maybe made up of several part-time individuals or one full-timeindividual.3.1.20 healthcare institutionany facility whose primarypurpose is delivery of health care, for example, hospit

25、al, clinic,physician practice, multi-campus healthcare system.3.1.21 medical transcriptionprocess of interpreting andtranscribing dictation by physicians and other healthcare pro-fessionals regarding patient assessment, workup, therapeuticprocedures, clinical course, diagnosis, prognosis, etc., into

26、readable text, whether on paper or on computer, in order todocument patient care and facilitate delivery of healthcareservices.3.1.22 medical transcription service organization(MTSO)provider of transcribed healthcare documentation;also referred to as vendor or contractor.3.1.23 on-site usersindividu

27、als who use a facilitys com-puter system via a terminal and other hardware elements thatare physically connected to that system.3.1.24 protected health informationindividually identifi-able health information, protected by HIPAA Privacy andSecurity Regulations.3.1.25 remote usersindividuals who use

28、a facilitys com-puter system via modem or wide area network connection.3.1.26 taped dictationinformation that is stated or readaloud and recorded by an analog tape system, such as a cassetterecorder, as opposed to a digital system.3.1.27 turnaround time (TAT)elapsed time beginning withavailability o

29、f the voice file to the contractor (also known asMTSO or vendor) for transcription and ending when thetranscribed document is delivered to the healthcare institution.3.1.28 unit of measuredefined unit of production fortranscription, including but not limited to a character, word,line, minute; measur

30、e used to quantify transcription produced.3.1.28.1 DiscussionBecause production statistics mayvary based on counting methods used, electronic or otherwise,even though units of measure are the same, the contractorshould clearly define the unit of measure being used, and thehealthcare institution shou

31、ld require full disclosure of themethods used to quantify production.3.1.29 vendor siteany MTSO where patient health infor-mation is stored, processed, or produced.3.2 Acronyms:AAMT = American Association for Medical TranscriptionCMS = Centers for Medicare Medical TranscriptionMTIA = Medical Transcr

32、iption Industry AssociationMTSO = Medical Transcription Service OrganizationPHI = Protected Health InformationRFP = Request for ProposalTAT = Turnaround Time4. Significance and Use4.1 This guide is intended to assist healthcare institutions increating appropriate requests for proposals to be issued

33、formedical transcription services.4.2 This guide provides recommended guidelines for theessential elements to be included in requests for proposalsissued to medical transcription services. The purpose of theserequests is contracting for the production and delivery oftranscribed patient care document

34、ation for a healthcare insti-tution.E1959 05 (2011)24.3 This guide recognizes the necessity of a HIPAA Busi-ness Associate Agreement.4.4 This guide recognizes the necessity of researching local,state, and federal requirements that may apply.5. The Current RFP Process5.1 Healthcare institutions often

35、 outsource the production ofpatient care documentation to an external vendor known as amedical transcription service organization (MTSO). Thereforerequests for proposals (RFPs) for those services are moreimportant than ever for management consideration. Establish-ing sensible standards for the RFP p

36、rocess is a necessarybeginning for successful partnerships between healthcare insti-tutions and MTSOs. RFP standards will help to ensure that thehealthcare institutions goals and expectations become anintegral part of the working relationship with the MTSO.5.2 In reviewing RFPs presently in use, it

37、is clear that noparticular standards are being followed in their composition.5.2.1 The information necessary to select an appropriateMTSO should be realistic in order to achieve the desiredresults. Otherwise, inadequate service may result or otherdifficulties may arise after the contract is awarded.

38、 If an RFPdoes not ask for sufficient information about the MTSO for thehealthcare institution to be able to judge the company fairly orto make an informed decision, or does not give enoughinformation to enable the MTSO to provide an informedresponse or set up the account adequately, the outcome may

39、 beunsatisfactory to all parties. This may leave the healthcareinstitution with poor service, no service, or rebidding.Furthermore, the cost to the healthcare institution of repeatedlyre-establishing relationships with MTSOs can be excessive,and the quality of service during the transition may be le

40、ss thanoptimal, adversely impacting patient care and patient safety.5.2.2 The healthcare documentation process and quality ofthe data are enhanced by well-defined requirements as set forthin the RFP. High-quality data supports quality patient care,improves efficiency, and results in cost-effective s

41、ervices.6. Systematic Approach to Writing RFPs6.1 A systematic approach to the RFP includes items thatmake the situation of the healthcare institution clear to theMTSO, including the healthcare institutions existing state oftranscription, goals for the future, and the requirements forsuccess: respon

42、se criteria, confidentiality fundamentals,security, disaster recovery, document or data destructionguidelines, or both, as well as MTSO disclosure and referencerequests.6.1.1 The RFP structure should include:6.1.1.1 Current status of the healthcare institution,6.1.1.2 Expectations of the healthcare

43、institution to includescope of work,6.1.1.3 Response requirements,6.1.1.4 Terms and conditions of contract,6.1.1.5 Confidentiality issues,6.1.1.6 Information security issues,6.1.1.7 Disaster recovery issues,6.1.1.8 Document and data destruction,6.1.1.9 MTSO disclosure,6.1.1.10 Reference requests,6.1

44、.1.11 Scope of services (to include quality improvementprogram, staffing capabilities, and transition plan),6.1.1.12 Product pricing to include change orders,schedules, etc.,6.1.1.13 Compliance clauses to include HIPAA, and6.1.1.14 Selection process to include the weighting criteriaand timeline sche

45、duled for selection.6.2 The RFPshould be set up in such a way that it will allowthe MTSO an adequate opportunity to present the full scope ofservices to the healthcare institution as a partner in achievingthe healthcare institutions goals. It should not be so rigid thatthe MTSO cannot demonstrate cr

46、eative solutions and ap-proaches to service and pricing. This sort of openness, whilemaking clear the requirements of the institution, promotes aresponse of cooperation toward a common goal.6.3 In each of the sections of the RFP, the document shouldset out the requirements in such a way that the com

47、pliance ornoncompliance of the MTSO can be verified. This should befollowed by a field for comment by the MTSO. In areas wherethe healthcare institution has a preference, but not necessarilya demand, the same format can be followed. Some sectionsmay be an invitation for information from the MTSO and

48、should be so arranged. Such an invitation acknowledgesrespect for the MTSOs expertise in its field, while wiselyprotecting the interests of the healthcare institutions.7. Structure of the RFP Document7.1 Current Status of the Healthcare Institution:7.1.1 A complete description of the healthcare inst

49、itutionsexisting technology and transcription practices and currentstatus enables the MTSO to formulate comprehensive answersto the requirements listed in the RFP.7.1.2 Organizational PictureA general description of thehealthcare institutions corporate structure (that is, number andtype of locations for healthcare facilities) should be specified.The healthcare institutions relevant policies and procedures(that is, Notice of Privacy Practices, etc.) should be provided tothe MTSO.7.1.3 Healthcare DocumentsA description of healthcar