July 9, 2007

Gauging Transcription’s Temperature
By Robbi Hess
For The Record
Vol. 19 No. 14 P. 14

To get a read on the industry’s current condition and its future prospects, For The Record sought out the thoughts and opinions of those in the know.

As the HIM profession continues to evolve at an unprecedented rate, the medical
transcription field is pulling out all the stops to keep pace. Never before has the industry faced such an intriguing—and slightly frightening—future.

To get an idea of what’s going on inside the business, For The Record (FTR) spoke with three experts who bring different perspectives to the table. Our trio consists of Kim Buchanan, CMT, FAAMT, director of credentialing and education for the Association for Healthcare Documentation Integrity (AHDI), formerly the American Association for Medical Transcription (AAMT); Kathryn Hill, CMT, quality assurance for regional transcription at Providence Health System; and Kulmeet Singh, vice president of healthcare strategic planning at Nuance.

FTR: What has been the impact of speech recognition?

Kulmeet Singh (KS): Our experience has been that with speech recognition, medical transcriptionists (MTs) can realize an increase in potential productivity gains anywhere from 50% to 150%. Speech recognition has arrived and is no longer a cutting-edge technology; it has become mainstream. I predict that within the next couple of years, most work will be speech recognized, then edited. There will be no more manual transcription.

Speech recognition has also impacted the accuracy and turnaround time for transcription. The transcriptionist is becoming an editor rather than a typist and has to start becoming truly knowledgeable about medical language. If I were an MT, I would embrace this as a tool that would allow me to do my job better.

There need to be three elements in place for it to be successful [in reference to his belief that when a hospital or clinic considers speech recognition, it will be a winning solution]. There must be the software and training in place for the physician and the MT, and there must be a reliable pool of editors. All three must be in place in order for speech recognition to make an impact on medical transcription costs.

Kim Buchanan (KB): For the past 15 years that I have been involved in [medical transcription], I have always heard that speech recognition was going to eliminate my job. I don’t believe that anymore today than I did 15 years ago. What we are seeing instead is an increasing need for back-end speech recognition editors.

Kathryn Hill (KH): When speech recognition was a new concept, it was basically front-end and pretty frustrating. But I think the very idea of it was threatening to the future of MTs. Now, I personally see it as evolution, especially with the development of back-end speech recognition. Instead of being threatened, I think MTs have been elevated to a higher functional level—it’s the brain that matters now, not the fingers, and that’s a positive.

FTR: What are your thoughts on offshore transcription?

KS: I don’t view it as controversial any longer, and it’s short-sighted to view it as a concern. Our supply of MTs at home is just not matching the demand. Moreover, some of these offshore companies beat out onshore companies because they have access to a highly skilled work force. They deliver excellent service and deliver it not only faster but, in some cases, with more accuracy. Those who have said there are problems with accuracy would be wrong.

KB: I am hearing that 5% to 10% of the outsourced work in this country is being sent overseas. I think that is slightly up from the 3% to 4% we quoted in 2002. However, every business owner I have talked with regarding their use of offshore transcription tells me that it is not about cost but instead about capacity. We simply don’t have enough MTs stateside to get the work done. Personally, I don’t fear offshore transcription, just like I don’t fear speech recognition. I think there is plenty of work to go around.

KH: I can support offshore MTs’ desire for this particular work but think they should be working in their own countries. I see offshore outsourcing as exploitative of the offshore transcriptionists because they work cheaper than American MTs, and it degrades the profession by taking jobs away from U.S. transcriptionists, leaving medical data vulnerable because other countries are not as bound by the same laws that protect medical data in the United States.

FTR: How do you feel about the AHDI offering credentials to overseas MTs?

KS: As long as they are qualified, they should be offering credentials to any qualified MT.

KB: This is a personal belief, but I don’t care who transcribes my record as long as they are qualified and do a good job. As director of credentialing and education, I can tell you that the offshore transcriptionists value their credentials and want to become certified.

KH: I think that in the future, having credentials will be one of the defining qualifications for being hired as an MT both onshore and offshore. The reason I went for my CMT—which I only did this year after 27 years of transcribing—was basically my desire to legitimize my relationship to the profession. If the AHDI is going to offer credentials offshore, they should be held to the same—if not higher—standards that U.S. transcriptionists are held to, including demonstration of competency with English idioms and regionalisms.

FTR: Do you feel there is a shortage of MTs and, if so, how should it be addressed?

KS: We will double productivity by using speech recognition, and if you double productivity for any given volume, you will need half the MTs. However, as documentation needs climb, the need for good editors will rise. The best way to address the resulting MT shortage is by going to a global workforce in combination with excellent back-end speech recognition. I feel the biggest shortage right now is among speech recognition editors.

KB: The MT shortage exists for a couple different reasons. For one, we have an aging workforce in medical transcription. In 2002, an AAMT membership survey showed the average age of an MT to be around 50. While we haven’t done a survey since, I would predict that the average age would be 55. We just aren’t bringing many young folk into this profession.

Another reason for the shortage could be supply and demand. The amount of dictation has increased and will continue to increase as we get our country moved over to electronic records.

KH: I’ve noticed that for MTs, the emphasis on production instead of quality and education is a turn off. The joy of learning to transcribe and researching has been diluted by the pressure of production. Verbatim accounts are an insult, and I myself refuse to work on verbatim accounts. An MT is, by nature, an intelligent and detail-oriented human being with a passion for the story behind each patient.

FTR: Has speech recognition affected the pricing structure for line counts?

KS: If you use back-end speech recognition and double productivity, the customers should be feeling the savings with lower rates on line counts. Companies committed to speech recognition should be going to hospitals and saying, “We are charging you ‘x’ per line this year, but with speech recognition, it could be ‘y’ next year,” where y is less than x. The company a facility chooses should be able to offer 5% to 10% or more savings annually, and they should be able to commit to that in a contract.
In addition, Nuance is a big believer in front-end speech recognition where the doctor is using it and performing self-editing. An immense savings can be realized in that scenario.

KB: Nothing is more frustrating for an MT than the myriad ways their compensation can be manipulated. [The AHDI] has always advocated for full disclosure regarding compensation. A transcriptionist should be able to verify that what they are being paid is in line with the work they are producing. While some transcriptionists love the current production-based compensation model, others find it difficult to make a living this way. Ideally, [the AHDI] would advocate for a pricing structure that does not commoditize transcription. We would like to see a model that truly reflects the value that transcriptionists bring to the table, not just the speed with which they can type.

The MTIA [Medical Transcription Industry Association] and the AHIMA recently produced a white paper recommending that MT services start billing using the visual black character. [The AHDI] released a letter of support that included a caveat that this pricing structure not be used to lower the salary of the transcriptionist. The fact is it is time we stop talking about transcription from the viewpoint of lines and widgets and start talking about the real value of dictation. Medical records are more than just words on a piece of paper or on a computer screen. A medical record is truly the patient’s healthcare story. It is the document that medical decisions are based on. It if isn’t correct, there can be serious consequences.

KH: When I had my own business 20 years ago, my line count pricing structure had to include hard copy printing, delivery of hard copy, etc. Things are different now, but I do think that pricing structure must include an accuracy percentage component or it means nothing and, again, it degrades the business.

FTR: How are HIT initiatives affecting medical transcription?

KS: That’s a very interesting question. What we have found—and we have concrete data to support this—EMR vendors go in, and their sales pitch is, “Buy our EMR, and you will reduce your transcription costs.” Invariably, their transcription volume does not go down because physician adoption of EMRs is very low.

But we have found selected customers’ transcription volume did go down. We found it was going down because physicians were using front-end speech recognition to drive adoption of the EMR solution. But that’s not the rule. When you don’t have the speech recognition, physician adoption of EMRs is low.

KB: HIT initiatives are providing a real opportunity for medical transcription to take the lead when it comes to advocacy for the integrity of the documentation. In a paper-based environment, an error in a record remains isolated in that specific chart. However, in an electronic health record environment where one document will be the foundation of a patient's care and will be viewed by multiple practitioners, the spotlight must turn to the accuracy of the information in the record. I believe there is a permanent role for the skill set of MTs in an electronic healthcare environment. Their knowledge base makes them an ideal fit for risk management and quality assessment. Transcriptionists have adapted as technology has evolved, but the one thing that has remained constant is their commitment to the accuracy of the documentation. MTs have always been advocates for the integrity of the healthcare record, and I don't see that ever changing.

KH: A few months ago, I wouldn't have even known how to address this question, but now I have a few thoughts. The healthcare information initiatives are affecting transcription by complicating the issues we used to take for granted. For instance:

• In the best scenario, elevating MT status to medical editor status (ie, medical language specialist), which to me appreciates the brain power of MTs. On the other hand, from the "business/money" end, the trend toward paying less for edited lines than "typed lines" is working against this.

• By standardizing the language (ie, templates, SNOMED, etc), a lot of the drudgery of MT work can be taken care of, freeing the MT to focus on consistency within reports that truly affect patient care, and to save their wrists/backs from the real physical consequences a working MT had always dealt with.

• Protecting U.S. MT jobs—hopefully the privacy laws and quality standards will curtail outsourcing offshore.

— Robbi Hess, a journalist for more than 20 years, is a writer/editor for a weekly newspaper and a monthly business magazine in western New York.