ASTM E1959-2005 Standard Guide for Requests for Proposals Regarding Medical Transcription Services for Healthcare Institutions《视为医疗保健机构医药处方服务建议要求的标准指南》.pdf

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1、Designation: E 1959 05An American National StandardStandard Guide forRequests for Proposals Regarding Medical TranscriptionServices for Healthcare Institutions1This standard is issued under the fixed designation E 1959; the number immediately following the designation indicates the year oforiginal a

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

3、 for the development 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 theresponsibi

4、lity of the user 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

5、 is anticipated that both a commercial contract forservices and a HIPAA Business Associate Agreement will bebased upon the responding proposals submitted to the RFP.2. Referenced Documents2.1 ASTM Standards:2E 1384 Guide for Content and Structure of the ElectronicHealth Record (EHR)E 1762 Guide for

6、Electronic Authentication of Health CareInformationE 1869 Guide for Confidentiality, Privacy,Access, and DataSecurity Principles for Health Information Including Elec-tronic Health RecordsE 1902 Specification for Management of the Confidentialityand Security of Dictation, Transcription, and Transcri

7、bedHealth RecordsE2117 Guide for Identification and Establishment of aQuality Assurance Program for Medical TranscriptionE 2184 Specification for Healthcare Document FormatsE 2344 Guide for Data Capture through the Dictation Pro-cess2.2 Other DocumentsAmerican Association for Medical Transcription (

8、AAMT),Metrics for Measuring Quality in Medical Transcription,20053AAMT Book of Style, Second Edition, 20023Medical Transcription Industry Association (MTIA), BillingMethod Principles4Public Law 1004-191 Health Insurance Portability and Ac-countability Act of 1996 (HIPAA)53. Terminology3.1 Definition

9、s: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, version control, access, etc.).3.1.2 authenticationprocess of (1) verifying authorship,for exam

10、ple, 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 Transcriptionistmedical tran-scriptionist who has met the qualifications for voluntarycertification s

11、et by the American Association for MedicalTranscription (AAMT), by demonstrating proficiency in thefield, meeting accepted standards, and maintaining the desig-nation through continuing education activities as required bythe certification process established by AAMT.3.1.4 compliance clauseitem in a

12、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 informationfrom a healthcare record, organized in an analytical manner.3.1.7 data extractionspecification of a su

13、bset of data froma master data source for a new data format.1This guide is under the jurisdiction of ASTM Committee E31 on HealthcareInformatics and is the direct responsibility of Subcommittee E31.15 on HealthInformation Capture and Documentation.Current edition approved Nov. 15, 2005. Published De

14、cember 2005. Originallyapproved in 1998. Last previous edition approved in 1998 as E 1959 98.2For 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

15、Summary page onthe ASTM website.3Available from American Association for Medical Transcription, www.aam-t.org.4Available from Medical Transcription Industry Association, .5Available from U.S. Government Printing Office, Superintendent of Docu-ments, 732 N. Capitol St., N.W., Mail Stop: SDE, Washingt

16、on, DC 20401. See alsohttp:/aspe.hhs.gov/admnsimp.1Copyright ASTM International, 100 Barr Harbor Drive, PO Box C700, West Conshohocken, PA 19428-2959, United States.3.1.8 data miningextraction of selected elements ofstored data to be used for a purpose other than the one forwhich the information was

17、 originally intended.3.1.9 dictationinformation that is stated or read aloud tobe transcribed 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 recor

18、ding system.3.1.12 documentreport in any form (print, electronic, orvoice file).3.1.13 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 distributiond

19、elivery of a document ordocuments (original or copies) to appropriate recipients, in anyform (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 late

20、r use or retrieval.3.1.17 electronic authenticationverification of authorshipof a document 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

21、information in any electronicmedium, protected by HIPAA Privacy and Security Regula-tions.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 insti

22、tutionany facility whose primarypurpose is delivery of health care, for example, hospital, 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 asses

23、sment, workup, therapeuticprocedures, clinical course, diagnosis, prognosis, etc., intoreadable 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 healthc

24、are documentation;also referred to as vendor or contractor.3.1.23 on-site usersindividuals 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, pro

25、tected by HIPAA Privacy andSecurity Regulations.3.1.25 remote usersindividuals who use 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

26、 a digital system.3.1.27 turnaround time (TAT)elapsed time beginning withavailability of 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 productio

27、n fortranscription, including but not limited to a character, word,line, minute; measure 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 contractors

28、hould clearly define the unit of measure being used, and thehealthcare institution should 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:Acronyms:AAMT = American Association

29、 for Medical TranscriptionCMS = Centers for Medicare Medical TranscriptionMTIA = Medical Transcription Industry AssociationMTSO = Medical Transcription Service OrganizationPHI = Protected Health InformationRFP = Request for ProposalTAT = Turnaround Time4. Significance and Use4.1 This guide is intend

30、ed to assist healthcare institutions increating appropriate requests for proposals to be issued 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

31、theserequests is contracting for the production and delivery oftranscribed patient care documentation for a healthcare insti-tution.4.3 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 require

32、ments that may apply.5. The Current RFP Process5.1 Healthcare institutions often 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 e

33、ver for management consideration. Establish-ing sensible standards for the RFP process is a necessarybeginning for successful partnerships between healthcare insti-tutions and MTSOs. RFP standards will help to ensure that theE1959052healthcare institutions goals and expectations become anintegral pa

34、rt of the working relationship with the MTSO.5.2 In reviewing RFPs presently in use, it 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, ina

35、dequate service may result or otherdifficulties may arise after the contract is awarded. 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 t

36、he MTSO to provide an informedresponse or set up the account adequately, the outcome may beunsatisfactory to all parties. This may leave the healthcareinstitution with poor service, no service, or rebidding. Further-more, the cost to the healthcare institution of repeatedlyre-establishing relationsh

37、ips with MTSOs can be excessive,and the quality of service during the transition may be less 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-quali

38、ty data supports quality patient care,improves efficiency, and results in cost-effective services.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 exi

39、sting state oftranscription, goals for the future, and the requirements forsuccess: response criteria, confidentiality fundamentals, secu-rity, disaster recovery, document or data destruction guidelines,or both, as well as MTSO disclosure and reference requests.6.1.1 The RFP structure should include

40、:6.1.1.1 Current status of the healthcare institution,6.1.1.2 Expectations of the healthcare 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,

41、6.1.1.8 Document and data destruction,6.1.1.9 MTSO disclosure,6.1.1.10 Reference requests,6.1.1.11 Scope of services (to include quality improvementprogram, staffing capabilities, and transition plan),6.1.1.12 Product pricing to include change orders, sched-ules, etc.,6.1.1.13 Compliance clauses to

42、include HIPAA, and6.1.1.14 Selection process to include the weighting criteriaand timeline scheduled 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 achieving

43、the healthcare institutions goals. It should not be so rigid thatthe MTSO cannot demonstrate creative 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

44、the sections of the RFP, the document shouldset out the requirements in such a way that the compliance 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 s

45、ame format can be followed. Some sectionsmay be an invitation for information from the MTSO andshould 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 C

46、urrent Status of the Healthcare Institution:7.1.1 A complete description of the healthcare institutionsexisting 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 desc

47、ription 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 Docum

48、entsA description of healthcaredocuments presently generated for each site should be specifiedand described:7.1.3.1 Healthcare document type (See SpecificationE 2184).7.1.3.2 The actual or anticipated, or both, volume to becontracted by document type and by unit of measurement asdefined in 7.12.1.7.

49、1.3.3 The percentage of each document type relative to thetotal volume.7.1.3.4 The percentage of total healthcare documentationcurrently being dictated and transcribed.7.1.3.5 The number of authors by specialty and percentageof English-second language dictators.7.1.4 Document Format and DistributionSpecificationsas to the actual documents presently produced should includethe following areas:7.1.4.1 Document Format,7.1.4.2 Document distribution forms (print, electronic, andvoice file),7.1.4.3 Document distribution copy requirements