July 19, 2010

Transcription’s Place in a Digital World
By David Yeager
For The Record
Vol. 22 No. 13 P. 14

As meaningful use requirements take shape, the transcription industry reexamines its role to find where it best fits.

The medical dictation and transcription industry has changed gradually over the years, but recent developments suggest the pace is going to pick up. The growing demand for improved speech-recognition and data-mining technology, the ever-changing role of medical transcriptionists (MTs), and the megamerger of MedQuist and Spheris will have a significant effect on the business in the years ahead. And while each of these factors will hasten the transformation, EHR meaningful use requirements will add urgency to the process.

“I think the furor over the electronic medical record probably will accelerate change unlike we’ve seen in the industry in the past, as will the new [American Recovery and Reinvestment Act (ARRA)] legislation,” says Larry Gerdes, CEO of Transcend Services, a medical transcription provider. “So even though our industry has always been slow to move and slow to change, I think that the speed of that change will pick up with this new emphasis.”

Because of the funding attached to meaningful use achievement, medical facilities are no longer wondering whether they should implement EHRs; they’re trying to figure out how to do it. Then they must make the big leap from EHR adoption to meaningful use.

“I think the industry has a long way to go to make these electronic records something that are usable because, for the most part, right now they’re electronic filing cabinets,” says Gerdes. “Where it has to continue to be developed is in the ultimate patient record and replacing the electronic filing cabinet with something that’s more intelligent and data that can be used much more easily.”

The Rise of Technology
To that end, many in the industry see developments in speech-recognition technology as a way to get more information from existing data. As front-end speech recognition has made inroads into the traditional dictation market, healthcare providers are becoming more comfortable integrating it into their workflows. And because meaningful use rules will require core measure reporting, companies have begun to explore methods for mining the patient encounter narrative to compile that data. For this reason, the demand for not only more efficient but also more intelligent speech recognition-technology has never been greater.

“As the move shifts to EHRs, all the provider organizations, the clinical leadership, are looking for speech technologies to help them drive the acceleration of the EHR,” says Peter Durlach, senior vice president of marketing and product strategy for Nuance Communications. “The customers want to get some structured data, such as active prompts, medications, allergies, and smoking status, out of the free-form narrative, whether it’s dictated the more traditional way on the back end or the front end. You have to be able to pull out the structured data from that narrative in order to provide structured data back to the EHR for all the downstream applications and to meet the meaningful use requirements.”

But the technology that will allow the type of interactivity required for meaningful use is still evolving. Most EHRs use templates and drop-down menus to produce reports. Templates can help standardize the reporting of certain types of data, but they can’t encompass all the necessary information related to the patient encounter.

“When physicians switch from traditional dictation transcription or from handwriting to an EHR, they get very frustrated because these point-and-click templates of the EHRs do two things: They slow them down a lot, and docs hate to spend time documenting stuff and, secondly, they lose the quality in the narrative when they use these rote templates,” says Durlach. “So the physicians want to get the documentation done quickly and, for patient care, they want to encompass part of the notes with the clinical narrative because that’s where the doctor documents their medical decision making.”

Efforts to effectively mine that patient data narrative are picking up steam, but Gerdes cautions that there is a lot more work to be done. He believes industrywide standards will need to be established before effective information exchange can take place.

Besides faster, more comprehensive dictation, another issue for doctors is mobility. With the rise of smartphones, doctors have shown interest in using the devices, especially when they’re rounding. “The idea is to be able to dictate a note quickly on an iPhone or view it either there or later when they get back to the desk and not have to go log into a PC to go to the EHR or pick up a standard telephone,” says Durlach. As these capabilities become more widely available, demand is certain to grow.

Along with doctors and hospitals, patients are also beginning to take an interest in digital record keeping. Although the possibilities for PHRs have barely begun to be explored, Scott Faulkner, principal and CEO of InterFix, LLC, a provider of technology solutions for HIM and medical transcription, believes this trend will become more prevalent.

“Evidence of that are things like PatientsLikeMe.com, Google Health, and Microsoft’s HealthVault. All of those models have a lot to do with patients sharing openly their information,” he says. “So I think that’s one of the disruptive technologies that are coming.”

How that affects medical dictation and transcription remains to be seen, but Michael Clark, chief operating officer (COO) of medical transcription service provider MedQuist, believes the industry will be a major player in connecting PHRs with EHRs.

“The medical transcription industry will play a critical role in repurposing health information for multiple applications and serve as a bridge between electronic health records and personal health records,” he says.

Bridging that gap and meeting the increased needs of medical providers will require not only more information but also more useful information. “The once-and-done model where after this information is processed it’s populated into the electronic health record and then it’s immediately actionable—clinically, financially, operationally—requires a more quality, precise document,” says Jay Cannon, president and COO of medical transcription service provider Webmedx.

The Changing Role of MTs
In addition, the need for faster, more accurate information will undoubtedly have an effect on MTs. In recent years, the MT shortage that was once considered inevitable has been held at bay by technological advances. And offshoring has provided the flexibility for some companies to provide 24/7 service. But the effectiveness of offshoring has limitations because of the need for increasingly skilled workers and restrictions in the ARRA legislation. Because a highly skilled, domestic transcription base will continue to be a necessity, the MT’s role will continue to evolve.

“On balance, transcriptionists are becoming more productive with the utilization of technologies like speech recognition,” says Sean Carroll, CEO of Webmedx. “Still, I think demand, in terms of information demand, transcription demand, is way beyond the available resources at the quality level it needs to be done.”

While technology has helped maximize the talent pool, it also requires workers with a greater range of skills. There is still a demand for about 40 billion lines of transcription each year, but estimating how many new MTs may be needed vs. how much of that capacity can be covered by emerging technologies is an ongoing debate.

“That’s not to say that the service part won’t be important; it will,” says Durlach. “But as you imagine more and more of the documentation migrating to real time with the physician doing it, there’s less and less need to have hundreds of people typing in the background.”

“What’s likely to happen is that as repetitive documents or very predictable language models are able to be handled much more effectively by speech recognition, the more difficult, unpredictable types of records are going to be more and more required of very skilled workers,” says Faulkner. “So I actually think that the skill sets of a medical language specialist, or whatever you want to call those specialists, is going to increase over time.”

Faulkner believes medical transcription, coding, and billing will eventually converge. MTs and other quality assurance people will need to acquire additional skills to stay relevant. Gerdes adds that a highly trained workforce will be a key to processing data in a way that will allow the information to be mined effectively.

“We’re finding, as we get into clinical data and clinical document architecture and the need for data by hospitals, our editors are becoming knowledge workers,” he says.

Industry Challenges
It will be difficult for medical transcription and dictation companies to leverage their technologies and human resources to meet healthcare providers’ increasingly high expectations. Although EHR adoption has become an important goal for many institutions, healthcare organizations want actionable data for additional reasons such as improving patient care, managing patient load, reducing costs, and billing accurately. Those functions require a higher level of interactivity and connectivity than current medical transcription and dictation models.

“In the past, it’s been kind of a necessary evil to provide a document back to a hospital that will end up in the medical record,” says Gerdes. “I think [the medical transcription industry] will become much more of a data partner, where it will provide all the tools to make it easy for doctors to dictate a broader expanse of reports.”

As patient volumes increase, healthcare providers will increasingly look for dictation and transcription solutions that encompass the entire patient encounter while providing more information than ever before, and they will want to use that information as they deem necessary. These factors will increase the pressure on vendors to add value to their offerings. Ultimately, speed, accuracy, and flexibility will determine which solutions are most successful.

“I think what you see are efficiencies provided through technology today, whereas just cheap labor in years past was one of the only ways to reduce cost or be more efficient,” says Cannon. “Now, part of the value proposition is how do you empower and make clinical documentation more valuable, both externally and internally, to the electronic health record.”

These changes are likely to have other consequences as well. Although the industry recently saw the consolidation of two of the largest players, MedQuist and Spheris, tougher competition and the big EHR push will likely accelerate the consolidation trend.

“Clearly, with the HITECH Act and ARRA funding pressures, there will be continuous turmoil in the transcription industry, especially for the smaller service providers who will be forced to either change their platform, get acquired, or go out of business because of their inability to deliver on the legislative expectations,” says Dale Kivi, MBA, director of business development for transcription service and technology provider FutureNet Technologies. “This is especially true for service vendors who primarily serve clinics with 20 physicians or less, as that’s the end of the market that has traditionally been neglected by the high-powered EMR vendors. Unfortunately, these are the same physician practices that are being squeezed the most by the legislative expectations because they simply have not been able to afford EMR technology in the past.”

Kivi believes affordable technology solutions designed to help smaller practices meet HITECH and ARRA requirements will be the biggest area for technology growth in the coming years, since there is currently a market void in this area.

The fact that consolidated companies will be able to achieve economies of scale and put price pressure on their competitors adds to the challenges for smaller companies in the industry. Navigating the maze of meaningful use requirements and dealing with a changing workforce will continue to be challenges for everyone. Perhaps the biggest challenge, though, will be meeting the needs of customers who favor an increasingly integrated and comprehensive approach to patient data. To remain viable, medical transcription companies will need to deliver reports with structured data designed to achieve more for their healthcare provider clients than they have in the past.

“What that manifests itself as, I think, is just the necessity to be a much more mature and complex operating business. Companies that are less sophisticated in terms of their technology and their business practices will be challenged by the emerging model that’s required to support that kind of customer,” says Carroll. “Longevity in this space will be dependent upon sustained, high-performance service delivery.”

— David Yeager is a freelance writer and editor based in Royersford, Pa.