April 16, 2007

Character Study
By Elizabeth S. Roop
For The Record
Vol. 19 No. 8 P. 16

A Joint Task Force recommendation moves the transcription industry closer to a standard unit of measure based on the visual black character.

In what is being touted as a “tremendous first step” with the potential to eliminate confusion, improve customer relations, and transition purchasing decisions from price- to value-based, the AHIMA and the Medical Transcription Industry Association (MTIA) Joint Task Force on Standards Development has issued its recommendation that the medical transcription industry adopt visual black character (VBC) as the standard unit of measure for the medical transcription of patient medical records.

The task force announced its recommendation in February during the HIMSS meeting and released a detailed white paper on its decision titled A Standard Unit of Measure for Transcribed Reports.

As defined in the task force report, a VBC is a character that can been seen with the naked eye and is “the only counting method that can be easily understood, verified, and replicated by all parties in the medical transcription business process.”

The call to adopt VBC as the standard unit of measure came only after a thorough review and comparative evaluation of the six different standards identified by the task force as the most commonly used in the industry: the ASCII line; 65-character line; gross line; gross page; per minute pricing; and VBC.

The task force also weighed the issues involved in establishing a standard unit of measure from both the vendor and healthcare entity perspectives to ensure that the final recommendation was applicable to all types of medical reports and various technologies and was suitable for use by both in-house transcription staff and external transcription service providers.

“Simply, the VBC can either be counted by very basic character-counting applications or even determined with the human eye in viewing a document. This methodology eliminates all formatting and past variances utilized to determine a line of transcription,” explains MTIA President Jay Cannon, adding that “the intent of the standard is not to promote a specific price. Instead, the intent is to promote uniformity in billing, which will do nothing in my experience but improve customer relationships as real value and differentiation become the focus.”

A Long Time Coming
There is little disagreement that the need for a standard unit of measure within the transcription industry is long overdue. Indeed, the standardization movement has been steadily gaining traction for several years.

The MTIA first addressed the issue three years ago with the formation of its Billing Methods Principles Committee and publication of a statement of practice designed to provide a way to evaluate any medical transcription billing or internal transcription cost accounting method.

Previously, the AHIMA and the American Association for Medical Transcription (now the Association for Healthcare Documentation Integrity [AHDI]) had collaborated on the 65-character line standard, which defined characters as including all letters, numbers, symbols, and formatting codes to maintain and reproduce a document, including space bar, shift key, bold, underscore, and other keystrokes. The line was calculated by counting all defined characters and keystrokes and dividing the total number of characters by 65.

Unfortunately, although the 65-character line gained some acceptance, it wasn’t widespread. As a result, vendors and clients continued to negotiate individual pricing agreements based on variants of existing measures or their own proprietary formulas.

“Vendors were trying to distinguish themselves from the competition; they were trying to win customers. So they would come up with innovative ways to measure production. As a result, you have a good number of proprietary methodologies out there,” says Harry Rhodes, MBA, RHIA, CHPS, CPHIMS, the AHIMA’s director of practice leadership and a task force member.

The confusion generated by the lack of a standard unit of measure affects both vendors and providers, according to Wendy Mangin, MS, RHIA, task force cochair and director of medical records at Good Samaritan Hospital in Vincennes, Ind.

Providers have no real way to compare request-for-proposal responses because vendors use different methods for measuring one line. It is also difficult to monitor the transcription process and verify whether service level agreements are being met.

On the vendor side, because there are so many units of measure, providers tend to focus more on the counting methodology, which makes it difficult to focus sales and marketing efforts on their unique competencies and service levels rather than price.

Having one standard unit of measure “will place all suppliers on equal footing and allow them to simplify their proposals,” says Mangin. “It will bring further credibility to the industry by demonstrating a willingness by suppliers to have their production volume measured on the same basis as other suppliers.”

Indeed, the need to clean up the industry’s image is a key reason the task force heard generally positive feedback from both sides of the business when they sought comments from groups, including transcription service organizations, software vendors, and organizations such as the Healthcare Financial Management Association and the AHDI, during their research and evaluation process.

A standard unit of measure—and VBC in particular—levels the playing field and allows clients to make an apples-to-apples comparison of vendor proposals and offerings, according to Dave Woodrow, president and chief operating officer of healthcare for SPi America LLC.

“A loose definition of the measurement metric just gives an opening for subsequent problems which, frankly, we have seen in this industry,” says Woodrow, who cochaired the task force with Mangin. “We want to clean that up, and we want to give folks a mechanism to begin the conversation from a benchmark that everyone can reasonably understand. There is a lot of value-add that goes into providing [transcription] service levels, but a lot of times, you never get to that part of the conversation because everyone is trying to identify what is a line.”

Adopting a standard unit of measure will also enable the medical transcription industry to begin addressing some of the more significant issues it faces along with healthcare as a whole, including responding to the call for the structured use of data, IT standards, and increased competition.

“Embracing a standard unit of measurement is important to transcription, an industry and profession in transition. Transcription has gone global, and as a result, is facing increased competition. There are rising expectations with regard to standardization and technology, and the industry is facing demands to do more complex things and find new methodologies to get more information out of the data and make it more useful than the traditional transcribed report,” says Rhodes. “I believe they’re ready to come to a unit of measurement solution because they’ve got bigger fish to fry.”

Everyone Benefits
According to the task force report, adoption and universal application of VBC as a standard measure will benefit the entire transcription industry by providing the following:
• Support of HIM departments in establishing and maintaining service level agreements: Patient medical record transcription may be managed in-house by facility HIM staff or an outside service supplier.

• Better business relationships between healthcare organizations and medical transcription service organizations: Hospitals, physician practices, and clinics commonly outsource their transcription to service organizations, which typically charge for services on a per-unit basis.

• Improved tools for evaluating and selecting transcription service providers: Many transcription service suppliers have adopted unique line-counting or character-counting definitions to stand out in a crowded field.

“Right now, the issue is that a great deal of time and energy goes into dealing with the various measures and methodologies that are out there. To the customer, it seems like every vendor, every employer, and even every contract has different units of measure and methodologies,” says Rhodes. “Having one standard will save a great deal of administrative time and a great deal of the rework and validation that is going on right now. It would also ease understanding and save time and energy on the negotiation of a contract. If you knew an entity was using visual black characters, there would be one less issue that would have to be negotiated and agreed upon. There would be greater transparency. VBC is easy to understand; it’s easy to measure and validate. VBC is all the letters, numbers, symbols, and punctuation marks you can see with the naked eye, so you don’t need special technology. There isn’t a black box feel to it.”

The clarity that comes with a uniform pricing methodology such as VBC will also shift the transcription business from a commodity to one that is driven by value and levels of service.

By leveling the playing field and allowing vendors to differentiate their services based on quality rather than price, negotiations can be refocused onto how well a particular vendor can achieve the customer’s expected service levels vs. a competitor, says Woodrow.

“When you do away with the fuzzy, obscure, and esoteric definitions and you get the measurement metrics down to something everyone can truly understand and track easily, this is where the conversations shift between the service provider and [its] customer,” he says. “This will move it from the commodity conversation that some customers want to have and get it back to a service level and value-based conversation. I truly believe that.

“For the customer, it’s easier to see that while this vendor’s prices are a little bit higher, they will do [the job] in 12 hours vs. 24 hours. They’ll see that there are premiums that need to go along with service levels. Things don’t get lost in the ‘Do you charge for bold and italics?’ [conversation]. That is yesterday’s conversation. That is not where we need to be focused,” Woodrow adds.

Selling the Concept
Despite generally positive reviews from the transcription industry, the task force isn’t sitting back and waiting. It knows that plenty of work still needs to be done to gain full acceptance of VBC as the standard unit of measure.

“This joint effort between MTIA and AHIMA is a tremendous first step,” says Cannon, adding that a number of additional educational activities are already underway. MTIA and AHDI have issued frequently asked questions to their memberships, and the AHIMA and MTIA plan a joint presentation at this month’s MTIA conference, as well as a session at the AHIMA annual conference in October.

“Current additional steps being reviewed include an implementation guide that contains more detail than that included in the published white paper,” Cannon says.

There are several factors working in favor of VBC adoption. First, it should not carry any significant financial impact on suppliers because most word processing applications already support VBC, although “contractual modifications will be necessary along with a financial analysis and comparative modeling to establish the VBC pricing in comparison with the existing rate and unit of measure,” says Mangin.

Second, the survey conducted by the task force found that VBC was already widely accepted and the preferred unit of measure for customer invoicing.

“There was already a certain amount of de facto acceptance in the market. We want to formalize that,” says Woodrow. “This is a solid first step and something that has come to fruition between the service companies and the customer group.”

Finally, the transcription industry is ready to eliminate the time wasted on defending the various units of measure methodologies and put it to better use by finding ways to improve the delivery of health information by embracing new technologies and standards, says Rhodes.

“There are many challenges facing the transcription industry and profession, and they need to dedicate their energies and talents to facing those challenges,” he says. “If we can put this issue to bed, it will improve relationships and free up time and money that can be better spent on meeting the new challenges of a transitioning industry.”

— Elizabeth S. Roop is a Tampa, Fla.-based freelance writer specializing in healthcare and HIT.