October 2019

Medical Transcription: Still Room In-House
By Elizabeth S. Goar
For The Record
Vol. 31 No. 9 P. 18

Step inside several departments that have—in one form or another—survived the overwhelming trend toward outsourcing.

It’s not breaking news to say that a significant majority of hospitals have outsourced their medical transcription departments to third-party vendors. In fact, while there are no specific numbers available, the American Healthcare Documentation Professionals Group puts the figure at more than 70%, according to its president and CEO, Peter Reilly.

“Their numbers,” Reilly says of hospitals that have not outsourced, “have dwindled and most are now leveraging a remote workforce—whether using internal or outsourced MTs [medical transcriptionists].”

Outsourcing makes sense from a purely financial standpoint. The savings can be significant, particularly if vendors are saving as much as they claim. A quick scan of several medical transcription vendors’ websites promise savings of anywhere from 28% to 64% based on reductions in costs for labor, equipment, and other add-ons such as training, office supplies, and office space.

The real news is that the small number of rebel organizations that are stubbornly keeping transcription in-house are finding ways to make it at least as economical as outsourcing.

Keeping It In-House
A prime example is TMC Healthcare, which includes the 600-bed Tucson Medical Center and TMCOne primary and specialty care practices.

TMC Healthcare’s 15-person transcription department leverages the Dolbey Fusion platform to generate an average of 6 million lines each year. It all happens under the watchful eye of Patt King, CHDS, the hospital’s manager of HIM-medical transcription.

“Since I came in six years ago, my goal has been to keep [the transcription department] here,” she says. “One of the main reasons we [can] keep us here is that our quality is exceptionally good. I also run a pretty tight ship in terms of cost.”

For example, while TMC Healthcare does make use of an outsourcing vendor for overflow, “we keep our [internal] cost per line equivalent to theirs,” King says.

A key aspect of the transcription department’s success is its ability to respond quickly to change—the one constant in today’s health care environment. Few were related specifically to cost, but the changes did provide the department with more ways to demonstrate its value to the health system, which King notes prides itself on the quality of its medical records.

For example, when TMC Healthcare’s radiology group decided to bring in its own transcription application, Nuance’s Powerscribe, King recognized the need for hands-on quality reviews to ensure the output was up to par. With that in mind, several of its health care documentation specialists (HDSs) transitioned to auditing. Today, there is one full-time auditor and three acute care HDSs who are also trained to audit radiology reports, which allows them to have at least one staff member auditing radiology transcription seven days a week.

More recently, providers who are required to enter their own notes pushed for speech recognition, resulting in TMC piloting Dragon Medical One speech recognition. As a result, “we are also doing document integrity auditing on those notes to quantify and qualify the quality,” King says.

The expansive set of responsibilities for transcription staff is no accident. “It’s all about flexibility,” King says. “The more cross-training of talent there is in a department, the more flexibility you have.”

Taking on the role of auditor is just one adjustment TMC Healthcare’s transcriptionists have had to make within their workflow. Another came in 2010, when the decision was made to transition the health system to Epic. With that came the requirement for physicians to type or use existing templates to create some of their own notes directly into the EHR.

Later came partial dictation, a process in which physicians can dictate the narrative portion of patient encounters. Once completed, the file transfers from Epic to the department’s Dolbey system where it is transcribed and sent back to the physician’s in-basket for review and approval. Until the transcribed file is approved, the audio file of any dictation is accessible via a hyperlink embedded in the patient’s chart, which is ultimately replaced by the approved text.

“It’s not particularly pretty, but it gives a much better picture of the patient’s story within the note,” King says, adding that the process has created a sizable increase in transcription volume at a time when the number of transcriptionists has dropped due to attrition. “It’s our second-highest work volume at this point. [The physicians] are limited to five minutes in their narrative, but most average a minute and a half. My team enjoys doing them because they’re simple and straightforward, but it definitely gives them a better opportunity to make sure they’re getting good-quality transcription for that narrative.”

One transcriptionist has moved into the position of application specialist to provide hands-on support for her colleagues with the software. Another is creating study groups and working with the transcription staff to prepare them for their credentialing exams as part of the department’s goal of becoming 100% credentialed.

“We feel that is important as we are doing more auditing and asking physicians to make corrections on critical errors. It is important to have that credential behind your name to show you really are qualified,” says King, who expects the speech recognition pilot to transition to an implementation, meaning less transcription and more document integrity audits. “We are maintaining ourselves in a very flexible position to be able to move forward that way.”

Equally important to the success of TMC Healthcare’s in-house transcription team is a focus on treating staff “as the valued employees that they are,” King says. “Treating your staff well, paying them a living wage, and recognizing the good work that they do results in a better quality job. It helps not only with keeping the charts clean but also maintaining high quality with great document integrity. It helps to pull everyone together and really function as a team to do the work your department needs to get done. That has been one of the biggest reasons I have been successful so far.”

A Slightly Hybrid Approach
While some organizations have found ways to keep all transcription in-house, others have discovered the best approach is a hybrid. For example, take Southern Illinois Healthcare (SIH), a three-hospital health system with about 290 total beds that outsources about 25% of its transcription needs.

“We had known for many years that the need for medical transcriptionists would decline. Management was upfront with the staff as far back as 2013,” says Cheryl Klopcic, BSN, RHIT, SIH’s Health Information-Transcription manager, who notes that several transcriptionists took advantage of the organization’s tuition reimbursement program to pursue nursing degrees, while others obtained their RHIT and still others retired. “When staff left for whatever reason, we did not replace them, [so] when we went live with Epic in 2017, the staff left was just about right to cover the day and evening shifts.”

Following the Epic implementation, SIH’s transcription volume decreased by about 60%, although the remaining volume was sufficient to keep the transcription department viable. The health system currently employs five transcriptionists, all of whom work remotely using Dolbey Fusion.

“The main work types dictated are operative notes, pathology PFTs [pulmonary function tests] and EEGs [electroencephalograms], and a small amount of what I call the big four: H&P [history and physical], consult, discharge, and progress notes,” Klopcic says.

Most of the transcriptionists are also trained in other work areas, such as importing eFaxes or paper documents into the patient’s EHR and helping with release of information requests.

“Since I oversee the transcriptionists and a large medical group’s health information, I have tried to intermix some of the job duties. It is a symbiotic relationship that really is a win-win for both areas,” Klopcic says. “As far as the clinical staff, I think those who don’t feel the need to dictate are fine with entering their own notes and those who have valid reasons to still dictate are grateful that option is still available to them.”

The fluid nature of transcription keeps the transcriptionists at SIH on their toes. “My medical transcription staff know there are always going to be changes and our senior leadership is very good about ‘paving the way’ so anticipated changes don’t end up as surprises,” Klopcic says.

Party of One
Kaiser Permanente Hawaii, on the other hand, has seen its transcription department dwindle from 13 medical transcriptionists to just one, who has become a jack-of-all-trades out of necessity.

The organization’s move to outsourcing is actually unique on the island. “Hardly any organizations in Hawaii are outsourcing transcription departments,” says Charlene A. Asato-Nitta, HIM manager for Kaiser Permanente Hawaii. “[But] our organization was looking for ways to cut costs and unfortunately the transcription section was affected. We had a transcription vendor able to provide transcription services at a low cost. So it was a huge cost savings to Kaiser.”

To justify keeping the bare-bones staff that remained, Asato-Nitta says the remaining transcriptionist performs quality assurance on the vendor’s output to ensure compliance with the contracted terms, as well as any stat dictation that is necessary. She also handles transcription testing for any EHR upgrades, spends one day a week in the lab entering patient information into its system, assists with transcription for diagnostic imaging (which has its own transcription team), and handles transcription for those physicians who require it to be managed in-house. Finally, she conducts focused reviews and monitors the operative notes completed by physicians to ensure they adhere to the required 24-hour turnaround time.

The transcription position “really morphed into other things,” Asato-Nitta says. “It happened over time. As dictation started decreasing, our HIM department didn’t have enough staffing to do focused reviews, so she was able to fill that void. She is also asked to help in other areas where there is a need.”

Rolling With the Punches
For those organizations committed to keeping transcription in-house, dealing with the continuous changes brought about by regulatory mandates and advances in speech recognition and other technologies is one of the greatest challenges they face.

Some, like Kaiser Hawaii and SIH, have found it necessary to revise transcriptionists’ job descriptions to keep at least some of their transcription department intact. They are not alone, either.

According to Reilly, “We have seen a significant uptick in the number of organizations who are repurposing their loyal teams of MTs and making them an integral part of the organization’s Team Documentation (scribe) initiative. For the right individual, this moves them from being a remote extension of the facility they serve to being on the frontline as an active member of the care team.”

Regardless of the path taken, a satisfied staff and quality output are integral aspects of staving off efforts to carve out some or all of an organization’s transcription volume and handing it over to an outsourcing vendor.

“Anything can happen in the future and change is constant, especially in the health care industry,” King says. “A lot of people are willing to accept less quality in their medical records, and that’s a shame. The employees are the most important part of the business. If you don’t treat them as if you value them, then you’re not going to have an excellent product when done.”

— Elizabeth S. Goar is a freelance writer based in Wisconsin.