August 6 , 2007

Why India?
By Suresh Nair
For The Record
Vol. 19 No. 16 P. 6

Why is India so popular among high-tech companies looking to supplement their American workforce with employees in other countries? The most common answer is cost reductions. However, there are other driving forces that are equally, if not more, important. After all, India is not the least expensive source of labor in the modern, globalized world. Other countries with a lower standard of living and a less-educated population would likely offer more significant savings.

Fortunately for businesses, India offers more advantages beyond the financial. First and foremost is the size of its English-speaking population. For historical reasons, approximately 150 million Indians were educated in schools that continue to teach in English. According to the United Nations, there are more English speakers living in India than any other country. The sheer number of potential workers able to communicate in English is not possible anywhere else.

Merely speaking and writing the same language is, of course, not enough to qualify for high-tech jobs such as those offered by American companies. Over the past few decades, the Indian government has invested heavily in higher education to produce a number of engineers, programmers, and other technology professionals. Unlike the rest of the developing world, India’s workforce is educated on par with the United States, thus able to fill highly skilled positions.

Investment in education has paid off for India. In an effort to reduce labor costs, software development companies were the first to turn to India in the 1990s. Taking advantage of communication technology improvements that made electronic data exchange cheap and reliable, programming could be performed anywhere in the world without significantly slowing down the development process.

Indian programmers quickly became the bulwark of the software industry. By the turn of the millennium, credit card companies and other financial institutions were looking to India for data processing jobs. Soon, legal firms, architectural and design agencies, and insurance companies were hiring workers in India. In the past five years, clinical documentation vendors have followed this lead.

Clinical Documentation
The clinical documentation industry has specific needs that make India well-suited to supplement the domestic workforce. First, the number of qualified medical transcriptionists (MTs) in the United States is shrinking. Each year, more MTs retire than enter the profession. This has created a strain on healthcare organizations trying to maintain an in-house MT staff and subsequently fueled an increase in outsourcing.

Unfortunately, U.S.-based medical transcription service organizations (MTSOs) face the same problem. Filling all positions with a shrinking American workforce is simply not a sustainable solution for a large organization. Hiring enough MTs for the daytime shift is increasingly difficult, and second- and third-shift positions are virtually impossible to fill.

A few decades ago, when a turnaround time (TAT) of 48 to 72 hours was commonplace and acceptable, there was little need to maintain a large third-shift MT staff. Healthcare facilities and MTSOs could wait until the morning to begin work on dictation files that arrived overnight. This is no longer possible.

Today, approximately 40% of all dictation files in the United States arrive after 4 pm, and TAT requirements are more restrictive. Physicians and patients demand complete medical records be available without hours of dictation. Administrators also require a quick TAT because the billing cycle depends on fast, accurate clinical documentation. Joint Commission requirements and other hospital bylaws and regulations create additional pressure to accelerate TAT.

The answer to filling the third shift is found in India, which is practically on the opposite side of the planet. Overnight hours in the United States are prime daylight hours in India. Furthermore, MT positions in India are highly sought out, allowing American companies to be selective in their hiring practices.

Concerns About India
The top concern of American healthcare facilities about medical transcription staffing in India is the security of protected information—whether patient or financial—once it leaves U.S. shores. The Indian government has enacted strict laws, similar to those in the United States, to protect the privacy and security of electronic information and healthcare data. All major Indian clinical documentation companies are HIPAA-compliant and require continuous training for all staff.

For additional security, American healthcare organizations should make certain that any facilities in India handling their electronic data are ISO-9001:2000 certified operations. ISO-9001 is an internationally recognized Quality Management System standard that promotes customer satisfaction through continual improvement of a facility’s systems and processes effectiveness.

Also, consider partnering with a U.S. MTSO that directly employs its MTs in India rather than one that uses foreign subcontractors. This allows the MTSO to maintain strict control of all protocols, processes, training programs, and technologies. The MTSO can also control, monitor, and manage all electronic files at every stage.

Another concern is the quality of the finished product. Fortunately, this is easily tested and verified. An MTSO should demonstrate clearly and objectively that accuracy scores are the same or higher with Indian MTs as with domestic staff. Furthermore, many companies link the pay of Indian MTs to the accuracy of their documents, so workers are encouraged to place equal emphasis on quality and speed.

Although overall quality should remain unchanged, performing medical transcription services in India generally slows down the process significantly because each completed document is subjected to more rigorous quality checks. However, this should not compromise TAT because the majority of work in India is performed during U.S. overnight hours. By combining Indian and American workforces for true around-the-clock service, an MTSO is able to deliver exceptional TATs that a company with a completely domestic or overseas workforce would never be able to accomplish.

Advantages
As mentioned, U.S. companies typically expand to India for four primary advantages: labor costs, population size, language, and education levels. India is a good fit for the clinical documentation industry for two additional reasons: workforce shortages in the United States and the need for 24-hour staffing.

The Internet and other advances in electronic communication make it possible to fully integrate an Indian workforce into the workflow of a U.S. company with a large domestic staff of MTs. The two groups working on opposite sides of the globe ensure clinical documentation services continue day or night. The security of the data and accuracy of the finished report should remain unchanged no matter where the medical transcription was performed.

It is important to note that there is not a shortage of medical transcription jobs or work volume for MTs in the United States. In fact, there is an overabundance. The number of MTs available domestically cannot keep pace with the volume of clinical documentation required by modern healthcare facilities. This is the driving force for the globalization of the clinical documentation industry.

— Suresh Nair is CEO of Spheris India.