Vol. 15 •Issue 17 • Page 24
Medical Transcription Forum Industry Experts Speak Out
In our first-ever Transcription Forum, ADVANCE brings together MTs, MT managers and industry experts to discuss the current trends affecting the industry.
There are so many “hot button” issues surrounding the medical transcription industry these days, it was difficult to narrow down the focus for our first-ever forum. But we wanted to get a feel for the current state of the industry, so we let some of the big questions fly.
Read on to get some interesting opinions and perspectives on everything from offshore transcription to mandatory certification for MTs. And, is there really a shortage of qualified MTs? Most of our panel members agreed with a resounding, “Yes!”
One of the biggest, and most controversial, topics surrounding medical transcription today is offshore outsourcing. What are your thoughts on this practice? Has it affected your job directly?
McSwain: I guess you could say offshore outsourcing has affected my job: I have actually worked in India, for an Indian company, helping to upgrade their MTs’ skills. Therefore, I am very aware, on a personal level, of the talents, problems and life stories of Indian MTs. In the context of that vast, crowded and still poor country, I can’t help but applaud those folks who put out the time, trouble and money to become MTs. Their training, intelligence and contact with the world outside India are good things for India and the world.
None of which, arguably, has anything to do with the question of whether Indian medical transcription is good for U.S. MTs or the medical transcription profession. Except possibly this: in India I learned that it is just as hard to find a good MT offshore as it is in the United States, if not harder. They’re there, but they’re rare and valuable. Furthermore, many people trying to do medical transcription in India are not well trained and have a shaky command of English. (Unfortunately this sometimes seems to be true in the United States as well!) I don’t believe that even full acceptance of Indian MTs would lead to a glut of MTs: the number of people willing and able to be excellent MTs will remain limited globally.
Simpson: As a company that provides outsource services and technology for medical transcription, we listen closely to our clients and respond with solutions customized to their needs. The health systems, hospitals and practices we work with are facing a capacity issue: an escalating demand for digital clinical documentation and a shortfall of MTs. That’s the reality. They’re also asking for off-hours coverage and true around-the-clock service. After 2 years of discovery, Spheris decided that providing a global workforce—in addition to increasing our U.S.-based MTs—was in the best interests of our clients. As a result, we immediately increased our capacity by more than 1,000 MTs by acquiring a global operation with a successful 10-year track record.
Martin: I would definitely prefer to keep all work in the United States. Offshoring has affected me directly. A medical transcription service organization (MTSO) I was an independent contractor with lost a major hospital account to an offshore company. My pay was cut almost half of what it had been previously.
Iwinski: The outsourced medical transcription industry is expected to grow to $4.2 billion by 2008. Considering there are approximately 101,000 MTs employed in the United States, we face a daunting challenge—how do we supplement the current manpower to cope with this increasing demand? I believe the answer to this challenge is to offer customers a menu of services blending technology with domestic and offshore capabilities based on their needs. This is not at the expense of the American MT, whose employment opportunities are expected to grow faster than most other occupations. Offshore MTs bring other benefits to the picture as well, most have college degrees and pride themselves in highest quality performance and the commitment to meet increasing turnaround time demands.
Frame: Whether we approve or not, I believe offshore transcription is here to stay. Therefore, the best thing we can offer the transcription profession/industry is to assure the MTs in other countries receive the best training possible. This, of course, takes time; and I don’t believe the offshore MTs have had enough time to be trained adequately. But aside from all that, offshore companies are making pretty compelling offers to employers in the United States. Just recently, I had the opportunity to be involved in a presentation/demo from an offshore company out of India, along with several of the larger dictation/transcription vendors in the United States. In terms of money, the offshore company won hands down. With the cost of health care today and everyone needing to cut corners, offshore transcription is very tempting.
Howe: Competition from offshoring both from pricing and availability perspective, has forced us to closely examine the way we deliver services to remain as cost efficient and cost effective as possible. I believe that globalization of business markets is inevitable and growing and that these pressures will ultimately improve the skill set of U.S.-based MTs.
In the last 3 years, what have you seen as the biggest change in transcription?
McSwain: I suppose most people will respond “technology.” However, I think the change with the most impact recently has been the increasing dominance of national transcription services. Some of us were thinking, 5 years ago, that issues of quality and control would prompt many health care clients to abandon services and take transcription back in-house. As far as I can see, this has not happened to any significant extent. That it has not happened is a tribute to the ability of the services to adapt to clients’ demands. It appears that in the last 3 years the movement toward outsourcing has taken on increased momentum.
McMann: Turnaround times (TATs)! It was not uncommon at one time to put in a 72-hour TAT for a clinical resume; however, now, with the advent of hospitalists, the TAT for clinical resumes is now 12 to 24 hours. We are finding that all reports have to be turned around in a shorter timeframe. These TATs are a huge challenge for our transcription team to meet.
Howe: The biggest changes I have seen are advancements in speech recognition technology (SRT); fierce competition from offshore agencies; a growing interest in quality initiatives and improved documentation workflow through electronic systems. In our facility, once the transcribed note is electronically signed, it is immediately available in our clinical information systems as well as uploaded to the many alliance facilities throughout the state.
Iwinski: The concept of valued pricing is one that has shifted from different perspectives. The trend of transcription providers moving toward an industry standard line count methodology, the Virtual Black Character is a positive move. This allows customers to verify and compare companies based on an “apples-to-apples” comparison. However, a negative trend I see occurring in the industry is health care professionals selecting a transcription provider based solely on the lowest price. Customers often end up regretting this decision in months to come when they realize that these companies usually fail to deliver—whether it is their quality measure, TAT or lack of customer service support excellence.
Are you or is your facility using SRT?
Frame: We are not using SRT yet, but I’m sure we will see some form of it in our facility in the next couple of years.
Howe: Yes. We have used back-end speech recognition technology for 4 years. It has greatly improved our productivity and our TATs, allowing us to handle a growing volume of dictation.
Minor: Speechvantage has been providing speech automation for the last 5 years. We have been focused on delivering solutions to the health care and insurance verticals. Many of our clients are interested in using speech automation to help improve the quality of their inbound phone calls and to better leverage the people, resources and/or call centers. For example, one of our clients was experiencing significant inbound call growth in the call center. We built a speech recognition system that has saved them at least 15-20 people from being hired in the call center and transferred that money to more critical needs in the hospital.
What are your thoughts on SRT?
How is it affecting the industry?
Minor: SRT has been around for a long time and has made many promises that have fallen short. Today, however, SRT and the horsepower needed to run the systems have become more affordable for health care organizations. A $250,000 system can now be put into place and used by a health care provider for less then $100,000. We are now seeing the tip of the iceberg. The return on investment (ROI) is large. SRT is affecting our industry in a very profound way. The key to any good speech system is an effective voice user interface (VUI) and to start with the simple applications first.
Cameron: SRT, as introduced years ago, was largely still a technology being tested within health care. In recent years, technology improvements have led to greater adaptation and less frustration. We currently see a trend where health care organizations are utilizing SRT as an alternative to offshore transcription, in which they have better control over their own destiny with regard to the security and turnaround of transcription. Organizations are seeking a co-existence between dictation, point-and-click, transcription and SRT to address the increase in documentation as the health care needs of baby boomers steadily increase.
McMann: I have heard for 20 years that SRT would be coming and none of us would have jobs. I have seen the most recent SRT products, and I still do not feel that I will be displaced. I believe that my job will definitely change into more of an editor, but I do not doubt that I will have a job.
Martin: I think it’s going to play a larger role as the technology improves. This has been an issue in the medical transcription industry for years and only now is it becoming more reliable and affordable for hospitals and clinics. I do not think it will eliminate MTs.
Howe: SRT is elevating the value of medical transcription by shifting focus from a “typing” mentality to one of the role of “editor.” When health care providers prove to themselves that their time is best utilized when focused on patient care, documentation practices will shift toward information processing and a rising need for expert language specialists to edit, review and ensure clean data in our information systems. There will always be the need for an expert MT to partner in the documentation process and SRT validates that.
Frame: I think SRT will be the MT’s savior, so to speak. It will allow an increase in production and decrease health issues such as carpal tunnel syndrome. With the average age of MTs being in their mid to late 40s, this is vitally important. The MT’s role will change to more editing functions rather than high speed impact typing, but this means that the MT’s medical knowledge will need to increase. And I’m not sure a lot of MTs are ready for that change.
Are the physicians you work with using handheld technology for dictation? If yes, how is it affecting your work?
Cameron: Yes, we are seeing a steady increase in the number of physicians adopting this technology. In fact, studies have shown that provider organizations are earmarking a larger portion of their budget for clinical applications including mobile technologies.
Personal digital assistant (PDA) solutions allow busy physicians who practice at multiple sites to easily monitor schedule changes from home or office. They also allow physicians in a clinical setting to “roam” while dictating, which typically increases the volume of dictation because the physician is not tethered to a telephone wall mounted unit.
Howe: Our residents receive IPACs at orientation. They are able to download patient schedules, demographics and a variety of test results to have on hand. They do not dictate using handheld devices.
Frame: We’re not using handheld devices yet, but I’m sure we’ll see some form of it come into our facility within the next couple of years. From my conversations with physicians, they’re ready and willing to try anything that allows them mobility.
Is there a shortage of skilled MTs? If yes, what are your opinions on how the shortage can be rectified?
Simpson: Based on forecasts from the U.S. Bureau of Labor Statistics, the American Association for Medical Transcription (AAMT) and the Medical Transcription Industry Alliance (MTIA), there is a widening gap between the supply of qualified MTs and the demand for clinical documentation. A true solution will take a large-scale and collective effort from transcription companies, educational institutions, health care providers and MTs themselves. We have to attract talented new people to the profession and support them with appropriate advancements in technology. At Spheris, we’re working to shape and partner with educational programs, fund scholarships, invest in our technology infrastructure and build rewarding, innovative career paths. We’re also working with our own MTs to become ambassadors for the profession.
McMann: Yes; there’s definitely a shortage. We have to get more students coming into the field and graduating from transcription schools. I think we really need to visit high schools on career day and maybe have our AAMT chapters put some flyers out to high school guidance counselors to help educate the younger students on what we do and give them another career to choose from. While in Washington, DC for AAMT’s Lobby Day, we were told the average age of the congressional intern is 23. We were able to do a lot of education while we were up there by explaining what we do; these younger people had no idea who we were or what we do. We must do a better job at this.
Martin: Absolutely. I think the industry has been overrun by people who want to “work at home and take care of the kids” while still earning money. They haven’t received the on-the-job training necessary to be skilled in this profession. I think the shortage could be rectified by requiring some type of training (either through a qualified school or training program) and higher pay.
Howe: Yes, there is a significant shortage of qualified MTs and there has been for the last 10 years. I have a current position that has been open for more than a year. I appreciate that AAMT is now approving educational programs to help address this problem. For too many years, substandard educational facilities have turned out substandard MTs that ultimately produce substandard work and significantly injured the reputation of the medical transcription profession.
Frame: Yes, I believe there’s a definite shortage of skilled MTs. To rectify it is going to take time and possibly even a change in thought processes and hiring practices. If employers require applicants to have 2 years of experience as an MT to even apply for a job, then why should the prospective MT put all that time and money into school if they know they can’t get a job? Personally, I think it would help if full-scale transcription courses were put back into the community colleges. A 6-week segment of transcription as part of a medical assisting course is not enough. But to take it one step further, I think it would be awesome if the colleges, medical facilities and/or transcription companies could work together to provide practicums for students, which would help give beginning MTs a jump-start.
The other side of the coin, however, is that people think that learning medical transcription is a quick fix—that all they need is to be able to type fast. I serve as an advisor to a self-study transcription course offered through our allied health program here at the medical center, and time and time again I see students start the course and drop out in a few weeks because they have to do too much studying and it’s taking too long.
Grebin: I do believe that the population of skilled MTs is aging but can not actively or statistically agree to a shortage. The work for MTs is increasing in every facility that we deal with, so perceptively it seems there is an MT shortage. I do believe that with work going offshore, there is more work for U.S.-based MTs. The MTs that are coming to our company are telling of losing their jobs to offshore operations and because companies are losing clients or scaling down their U.S. operations. If every MT in this country trained one MT, we could double our work force. MTs and workers in general are seeking job stability. At our company, we are getting a huge volume of applicants because we provide an employee-based, stable environment with a good strong work flow. When an employee’s dollars depend solely on your ability to provide consistent work flow, you need to be with a stable company. If a worker believes that you have a shortage of work because you send most of the work offshore, a company can experience a shortage of qualified MTs.
What type of measuring stick does your employer use to gauge productivity and quality? Are there cases in which productivity pressure compromise quality?
Minor: SRT to be considered successful must be effective while delivering at least 90 percent or better automated responses. We design our systems around these parameters. Another metric is based on service level agreements (SLA). For example; our emergency response system at one of our clients has to deliver more than 500 phone calls and e-mails within 15 minutes. The system has to deliver within the allotted time frame and provide a complete audit trail for compliance. We are about improving the productivity of the staff and call center and not comprising the quality of the work that our clients are providing.
Grebin: At Silent Type we provide each employee with our general practice guidelines. Transcription methods, techniques and measuring system are given at the beginning of the employment process, reviewed with the employee by our orientation team and the employee has a handbook to take home for reference. Daily and monthly audits are conducted randomly. Biannually a full audit is conducted based upon these standards. Quality/production bonus is tied to the results of these audits. Everyone knows what the expectation is before starting work and then throughout the evaluation process. This has reduced our error rate for our entire staff to 0.47 percent. The audit results are sent to each client to ensure client satisfaction.
Productivity never compromises quality because we depend upon each MT to do a regular and full work load, and we handle increased volume with “float staff” thereby not pressuring staff to compromise their case load quality.
McSwain: My company recently did away with the bonus/incentive program for quality. Although the company still requires (rightly) 98 percent quality, they no longer pay anything for it. In addition, the company recently raised the minimum production requirement (lines per 2-week pay period). So what is the trend here in terms of quality/quantity issues? What is the message? “Quantity counts. Quality is nice, but we’re not going to pay for it.”
Productivity pressure definitely compromises quality. And unless you pay for quality, you’re not going to get it, period. We know that is true in our personal lives—plumbing fixtures, windows, cars, accounting services—and it applies equally to medical transcription. You might occasionally get a bargain, but by and large, you get what you pay for.
Iwinski: At Acusis, productivity is never given priority over quality; in fact, our MTs are compensated based on the quality of the reports they transcribe rather than quantity. Our Affinity Solution is a process that assigns MTs to focus exclusively on one account after implementation, which greatly improves familiarity, consistency and delivery. In the event an increase in transcription volume occurs, buffer production capacity is built in our system and due to a healthy pipeline maintained by our recruitment department, any permanent increment in volume is handled on a proactive basis.
Frame: At BryanLGH, we measure productivity in lines (base is 160 to 180 lines/hour), and quality checks are done monthly or quarterly. Our average quality of work as a whole runs around 98 percent accuracy. With the demands for increased productivity being placed on the MTs, quality of work can take a downward slant in an instant if we don’t stay on top of it all the time. I believe quality assurance specialists are vital to the success of an organization that provides transcription services. Because of changes being made in our facility, I have revised our QA standards and loosened them up slightly in terms of formatting, punctuation, sentence structure, etc. It’s been difficult for me to let some of that go, but I have to keep asking myself what’s really important here? Is it having proper sentence structure and perfect punctuation, or is it having accurate and complete patient documentation?
What type of compensation does your facility provide?
Are you paid hourly? By the line? Do you get production or quality bonuses?
McMann: We are paid an hourly rate and do get production bonuses. We are also given an extra 25 lines per report for a predetermined list of difficult dictators. We have found that our MTs are much more willing to tackle these difficult dictators with this extra line bonus.
Martin: The MTs on my team are paid by the line. There are incentives in place for the full-time employees after reaching a predetermined line volume.
Howe: Our facility has three job classifications for MTs, which provides a career ladder for these professionals. The Master MT classification is saved for those who achieve and keep a valid certification through the AAMT. We pay our MTs hourly plus incentive that allows us to keep a strong focus incorporated in the quality of the documentation.
How accountable are practitioners for the quality of medical transcription (i.e., bad dictation habits, ESL physicians, etc.)?
Grebin: According to some of my clients, their facilities are creating a subcommittee of the medical records committee called the “legibility committee.” Although it formerly examined written communication, they are presently examining legibility issues as they relate to poor dictation habits and English as a second language (ESL) physicians. I would encourage all MTSOs to reach out to the HIM directors to include this subcommittee among the functions of the medical record committee. This places the responsibility for poor dictation where it belongs—with the authors who might be abusing the system and compromising high quality transcription.
McMann: We have a very large physician population who are ESL physicians. We had more than 1,200 different dictators in the month of February alone. If a physician is a continuous problem dictator, we are able to send letters asking them to please change this bad dictation behavior. If they do not, we are able to send our documentation on to our medical records committee where the dictator will be brought before this committee and dealt with in this manner. This has been successful in past cases.
Howe: We are currently working on a project to attach a monetary value to poor dictation habits. In particular, our standard “too long” notice brings the actual cost of an unusually long document to the attention of the provider. We try to work closely with our residents and our SRT physicians to further enhance our areas of productivity and thus, our ability to be cost conscious. It doesn’t always work, but it’s a start.
How important is certification in the medical transcription industry? Do you think credentials/licensure should be mandatory?
Cameron: We see the potential for certification in the medical transcription industry to become necessary in the near future, but it will be an effort that will require MTSOs and AAMT to work together cooperatively. Universal acceptance of certification within the industry will promote standardization and convey a standard value level to prospective employers and clients. At this time, we do not envision that licensure would be made mandatory.
Frame: My opinion of medical transcription certification/credentialing has changed quite drastically over the years. I used to think certification was a waste of money and time because it didn’t mean anything. It has only been in the last 5 years or so that I’ve changed my mind about credentialing. Part of that change comes from my role reversal from MT to manager; the struggle to find qualified, experienced MTs; and a changing and much improved philosophy of AAMT. As a manager, I would sit up and take notice of an applicant coming in with a certified medical transcriptionist (CMT) credential behind his/her name. Because the exam is difficult and really tests your skills as an MT, these credentials would tell me that this individual is pretty knowledgeable in the profession and is a motivated individual.
In the facility I work at, there is no compensation for being a CMT, and our MTs are still categorized as clerical staff. And I’m sure we’re not unique. Clearly, the profession is highly underrated. I’m still on the fence as to whether or not certification should be mandatory, but if mandatory certification is what it takes to bring about how MTs are viewed in the medical community, then I would be one of its strong supporters.
Howe: I think certification is becoming increasingly more and more important; albeit a bit late for what it should have been. CMTs demonstrate a commitment to continuing education and thus a pledge to evolve over time, as the industry changes. CMTs abide by a Code of Ethics and demonstrate knowledge of safe record keeping practices, confidentiality and security. Anyone involved with the sensitive nature of health care documentation should demonstrate this level of professionalism. Why is it your cosmetologist is licensed to do pedicures but those who access your personal and sensitive health information need no more than a high school GED?
Martin: I believe that certification should be required of entry-level MTs. There needs to be some sort of standard for a person to claim to be an MT. At this time, the only credential that is available is the CMT, which usually can’t be obtained until after several years of wide-ranging experience in multiple specialty fields. The CMT credential should not be mandatory but it should be rewarded.
McMann: I’m probably going to take some heat for this one, but I do not think it should be mandatory. There simply are not enough MTs as it is. I was an MT for a lot of years before I got my CMT, and while I did learn a lot while studying for the test, I do not believe I am a better MT since I passed the test. I do believe that by getting my CMT it has made a dramatic difference in my self-esteem and attitude toward myself. I have gone out and done things (publishing articles, running for FAMT office, etc.) that I do not think I would have done before I got the CMT. Also, the hospital that I work for will only hire CMTs for the management team of which I am now a member. For this reason alone, I am a huge supporter of certification.
McSwain: It would be a good thing if there were some reliable measure of an MT’s qualifications. A logical first step would be to develop an accreditation system for medical transcription training programs and schools. I don’t think “mandatory” accreditation is a very likely development in the near future. Licensure, for example, typically has to be accomplished on a state-by-state basis, which sounds like it could complicate things for the national services. I also fear that the costs of licensure would be entirely borne by MTs, most of whom are not making a lot of money to begin with.
Lisa A. Algeo is editor of ADVANCE.