Medical Transcription

Evolution of transcription dates  back to the 1960s. The method was designed to assist in the  manufacturing process. The first transcription that was developed in  this process was MRP, which is the acronym for Manufacturing Resource  Planning, in 1975. This was followed by another advanced version namely  MRP2. But none of them yielded the benefit of medical transcription.

However, transcription equipment has changed from manual typewriters to electric  typewriters to word processors to computers and from plastic disks and  magnetic belts to cassettes and endless loops and digital recordings.  Today, speech recognition (SR), also known as continuous speech  recognition (CSR), is increasingly being used, with medical  transcriptionists and or "editors" providing supplemental editorial  services, although there are occasional instances where SR fully  replaces the MT. Natural-language processing takes "automatic"  transcription a step further, providing an interpretive function that  speech recognition alone does not provide (although MTs do)

In  the past, these medical reports consisted of very abbreviated  handwritten notes that were added in the patient's file for  interpretation by the primary physician responsible for the treatment.  Ultimately, this mess of handwritten notes and typed reports were  consolidated into a single patient file and physically stored along with  thousands of other patient records in a wall of filing cabinets in the  medical records department. Whenever the need arose to review the  records of a specific patient, the patient's file would be retrieved  from the filing cabinet and delivered to the requesting physician. To  enhance this manual process, many medical record documents were produced  in duplicate or triplicate by means of carbon copy

In  recent years, medical records have changed considerably. Although many  physicians and hospitals still maintain paper records, there is a drive  for electronic records. Filing cabinets are giving way to desktop  computers connected to powerful servers, where patient records are  processed and archived digitally. This digital format allows for  immediate remote access by any physician who is authorized to review the  patient information. Reports are stored electronically and printed  selectively as the need arises. Many MTs now utilize personal computers  with electronic references and use the Internet not only for web  resources but also as a working platform. Technology has gotten so  sophisticated that MT services and MT departments work closely with  programmers and information systems (IS) staff to stream in voice and  accomplish seamless data transfers through network interfaces. In fact,  many healthcare providers today are enjoying the benefits of handheld  PCs or personal data assistants (PDAs) and are now utilizing software on  them for dictation

Pertinent  up-to-date, confidential patient information is converted to a written  text document by a medical transcriptionist (MT). This text may be  printed and placed in the patient's record and/or retained only in its  electronic format. Medical transcription can be performed by MTs who are  employees in a hospital or who work at home as telecommuting employees  for the hospital; by MTs working as telecommuting employees or  independent contractors for an outsourced service that performs the work  offsite under contract to a hospital, clinic, physician group or other  healthcare provider; or by MTs working directly for the providers of  service (doctors or their group practices) either onsite or  telecommuting as employees or contractors. Hospital facilities often  prefer electronic storage of medical records due to the sheer volume of  hospital patients and the accompanying paperwork. The electronic storage  in their database gives immediate access to subsequent departments or  providers regarding the patient's care to date, notation of previous or  present medications, notification of allergies, and establishes a  history on the patient to facilitate healthcare delivery regardless of  geographical distance or location

The term transcript or "report" as it is more commonly called, is used as  the name of the document (electronic or physical hard copy) which  results from the medical transcription process, normally in reference to  the healthcare professional's specific encounter with a patient on a  specific date of service. This report is referred to by many as a  "medical record". Each specific transcribed record or report, with its  own specific date of service, is then merged and becomes part of the  larger patient record commonly known as the patient's medical history.  This record is often called the patient's chart in a hospital setting

Medical  transcription encompasses the MT, performing document typing and  formatting functions according to an established criteria or format,  transcribing the spoken word of the patient's care information into a  written, easily readable form. MT requires correct spelling of all terms  and words, (occasionally) correcting medical terminology or dictation  errors. MTs also edit the transcribed documents, print or return the  completed documents in a timely fashion. All transcription reports must  comply with medico-legal concerns, policies and procedures, and laws  under patient confidentiality

In  transcribing directly for a doctor or a group of physicians, there are  specific formats and report types used, dependent on that doctor's  speciality of practice, although history and physical exams or consults  are mainly utilized. In most of the off-hospital sites, independent  medical practices perform consultations as a second opinion,  pre-surgical exams, and as IMEs (Independent Medical Examinations) for  liability insurance or disability claims. Some private practice family  doctors choose not to utilize a medical transcriptionist, preferring to  keep their patient's records in a handwritten format, although this is  not true of all family practitioners

Currently, a growing number of medical providers send their dictation by digital  voice files, utilizing a method of transcription called speech or voice  recognition. Speech recognition is still a nascent technology that loses  much in translation. For dictators to utilize the software, they must  first train the program to recognize their spoken words. Dictation is  read into the database and the program continuously "learns" the spoken  words and phrases

Poor  speech habits and other problems such as heavy foreign accents and  mumbling complicate the process for both the MT and the recognition  software. An MT can "flag" such a report as unintelligible, but the  recognition software will transcribe the unintelligible word(s) from the  existing database of "learned" language. The result is often a "word  salad" or missing text. Thresholds can be set to reject a bad report and  return it for standard dictation, but these settings are arbitrary.  Below a set percentage rate, the word salad passes for actual dictation.  The MT simultaneously listens, reads and "edits" the correct version.  Every word must be confirmed in this process. The downside of the  technology is when the time spent in this process cancels out the  benefits. The quality of recognition can range from excellent to poor,  with whole words and sentences missing from the report. Not  infrequently, negative contractions and the word "not" is dropped all  together. Voice recognition is similar to the voice prompts one hears on  dialing "411", when information provides the wrong number and charges  for the "411" call. These flaws trigger concerns that the present  technology could have adverse effects on patient care. Control over  quality can also be reduced when providers choose a server-based program  from a vendor Application Service Provider (ASP)

Downward  adjustments in MT pay rates for voice recognition are controversial.  Understandably, a client will seek optimum savings to offset any net  costs. Yet vendors that overstate the gains in productivity do harm to  MTs paid by the line. Despite the new editing skills required of MTs,  significant reductions in compensation for voice recognition have been  reported. Reputable industry sources put the field average for increased  productivity in the range of 30%-50%; yet this is still dependent on  several other factors involved in the methodology. Metrics supplied by  vendors that can be "used" in compensation decisions should be  scientifically supported

Another  unresolved issue is high-maintenance headers that replace simple  interfaces to become the "platform" of choice. Pay rates should reflect  this lost-opportunity cost for the MT

Operationally,  speech recognition technology (SRT) is an interdependent, collaborative  effort. It is a mistake to treat it as compatible with the same  organizational paradigm as standard dictation, a largely "standalone"  system. The new software supplants an MT's former ability to realize  immediate time-savings from programming tools such as macros and other  word/format expanders. Requests for client/vendor format corrections  delay those savings. If remote MTs cancel each other out with disparate  style choices, they and the recognition engine may be trapped in a  seesaw battle over control. Voice recognition managers should take care  to ensure that the impositions on MT autonomy are not so onerous as to  outweigh its benefits

Medical  transcription is still the primary mechanism for a physician to clearly  communicate with other healthcare providers who access the patient  record, to advise them on the state of the patient's health and  past/current treatment, and to assure continuity of care. More recently,  following Federal and State Disability Act changes, a written report  (IME) became a requirement for documentation of a medical bill or an  application for Workers' Compensation (or continuation thereof)  insurance benefits based on requirements of Federal and State agencies

An  individual who performs medical transcription is known as a medical  transcriptionist or an MT. The equipment the MT uses is called a medical  transcriber. The individual who performs medical transcription should  always be called a "medical transcriptionist." A medical  transcriptionist is the person responsible for converting the patient's  medical records into text from recorded dictation. The term transcriber  describes the electronic equipment used in performing medical  transcription, e.g., a cassette player with foot controls operated by  the MT for report playback and transcription. There have been industry  discussions centered around whether or not medical transcriptionists  should be called something else; no other industry-wide term has been  adopted

Education  and training can be obtained through, certificate or diploma programs,  distance learning, and/or on-the-job training offered in some hospitals,  although there are countries currently employing transcriptionists that  require 18 months to 2 years of specialized MT training. Working in  medical transcription leads to a mastery in medical terminology and  editing, MT ability to listen and type simultaneously, utilization of  playback controls on the transcriber (machine), and use of foot pedal to  play and adjust dictations - all while maintaining a steady rhythm of  execution

While  medical transcription does not mandate registration or certification,  individual MTs may seek out registration/certification for personal or  professional reasons. Obtaining a certificate from a medical  transcription training program does not entitle an MT to use the title  of Certified Medical Transcriptionist (CMT). The CMT credential is  earned by passing a certification examination conducted solely by the  Association for Healthcare Documentation Integrity (AHDI), formerly the  American Association for Medical Transcription (AAMT), as the  credentialing designation they created. AHDI also offers the credential  of Registered Medical Transcriptionist (RMT). According to AHDI, the RMT  is an entry-level credential while the CMT is an advanced level. AHDI  maintains a list of approved medical transcription schools[1][2]

There  is a great degree of internal debate about which training program best  prepares a MT for industry work[3]. Yet, whether one has learned medical  transcription from an online course, community college, high school  night course, or on-the-job training in a doctor's office or hospital, a  knowledgeable MT is highly valued. In lieu of these AHDI certification  credentials, MTs who can consistently and accurately transcribe multiple  document work-types and return reports within a reasonable  turnaround-time (TAT) are sought after. TATs set by the service provider  or agreed to by the transcriptionist should be reasonable but  consistent with the need to return the document to the patient's record  in a timely manner

As  of March 7, 2006, the MT occupation became an eligible U.S. Department  of Labor Apprenticeship, a 2-year program focusing on acute care  facility (hospital) work. In May 2004, a pilot program for Vermont  residents was initiated, with 737 applicants for only 20 classroom  pilot-program openings. The objective was to train the applicants as MTs  in a shorter time period

Curricular requirements, skills and abilities

experience that is directly related to the duties and responsibilities specified,  and dependent on the employer (working directly for a physician or in  hospital facility)

* Knowledge of medical terminology

* Above-average spelling, grammar, communication and memory skills

* Ability to sort, check, count, and verify numbers with accuracy

* Skill in the use and operation of basic office equipment/computer; eye/hand/foot coordination

* Ability to follow verbal and written instructions

* Records maintenance skills or ability

* Above-average to excellent typing skills

Basic MT knowledge, skills and abilities

* Knowledge of basic to advanced medical terminology is essential

* Knowledge of anatomy and physiology

* Knowledge of disease processes

* Knowledge of medical style and grammar

* Average verbal communication skills

* Above-average memory skills

* Ability to sort, check, count, and verify numbers with accuracy

* Demonstrated skill in the use and operation of basic office equipment/computer

* Ability to follow verbal and written instructions

* Records maintenance skills or ability

* Above-average typing skills

*  Knowledge and experience transcribing (from training or real report  work) in the Basic Four work types: History and Physical Exam,  Consultation, Operative Report, and Discharge Summary

* Knowledge of and proper application of grammar

* Knowledge of and use of correct punctuation and capitalization rules

* Demonstrated MT proficiencies in multiple report types and multiple specialties

Duties and responsibilities

* Accurately transcribes the patient-identifying information such as name and Medical Record or Social Security Number

* Transcribes accurately, utilizing correct punctuation, grammar and spelling, and edits for inconsistencies

* Maintains/consults references for medical procedures and terminology

* Keeps a transcription log

*  In some countries, MTs may sort, copy, prepare, assemble, and file  records and charts (though in the United States (US) the filing of  charts and records are most often assigned to Medical Records Techs in  Hospitals or Secretaries in Doctor offices)

* Distributes transcribed reports and collects dictation tapes

*  Follows up on physicians' missing and/or late dictation, returns  printed or electronic report in a timely fashion (in US Hospital, MT  Supervisor performs)

* Performs quality assurance check

* May maintain disk and disk backup system (in US Hospital, MT Supervisor performs)

*  May order supplies and report equipment operational problems (In US,  this task is most often done by Unit Secretaries, Office Secretaries, or  Tech Support personnel)

* May collect, tabulate, and generate reports on statistical data, as appropriate (in US, generally performed by MT Supervisor)

When  the patient visits a doctor, the doctor spends time with the patient  discussing his medical problems, including past history and/or problems.  The doctor performs a physical examination and may request various  laboratory or diagnostic studies; will make a diagnosis or differential  diagnoses, then decides on a plan of treatment for the patient, which is  discussed and explained to the patient, with instructions provided.  After the patient leaves the office, the doctor uses a voice-recording  device to record the information about the patient encounter. This  information may be recorded into a hand-held cassette recorder or into a  regular telephone, dialed into a central server located in the hospital  or transcription service office, which will 'hold' the report for the  transcriptionist. This report is then accessed by a medical  transcriptionist, it clearly received as a voice file or cassette  recording, who then listens to the dictation and transcribes it into the  required format for the medical record, and of which this medical  record is considered a legal document. The next time the patient visits  the doctor, the doctor will call for the medical record or the patient's  entire chart, which will contain all reports from previous encounters.  The doctor can on occasion refill the patient's medications after seeing  only the medical record, although doctors prefer to not refill  prescriptions without seeing the patient to establish if anything has  changed

It  is very important to have a properly formatted, edited, and reviewed  medical transcription document. If a medical transcriptionist  accidentally typed a wrong medication or the wrong diagnosis, the  patient could be at risk if the doctor (or his designee) did not review  the document for accuracy. Both the Doctor and the medical  transcriptionist play an important role to make sure the transcribed  dictation is correct and accurate. The Doctor should speak slowly and  concisely, especially when dictating medications or details of diseases  and conditions, and the medical transcriptionist must possess hearing  acuity, medical knowledge, and good reading comprehension in addition to  checking references when in doubt

However,  some doctors do not review their transcribed reports for accuracy, and  the computer attaches an electronic signature with the disclaimer that a  report is "dictated but not read". This electronic signature is readily  acceptable in a legal sense. The Transcriptionist is bound to  transcribe verbatim (exactly what is said) and make no changes, but has  the option to flag any report inconsistencies. On some occasions, the  doctors do not speak clearly, or voice files are garbled. Some doctors  are, unfortunately, time-challenged and need to dictate their reports  quickly (as in ER Reports). In addition, there are many regional or  national accents and (mis)pronunciations of words the MT must contend  with. It is imperative and a large part of the job of the  Transcriptionist to look up the correct spelling of complex medical  terms, medications, obvious dosage or dictation errors, and when in  doubt should "flag" a report. A "flag" on a report requires the dictator  (or his designee) to fill in a blank on a finished report, which has  been returned to him, before it is considered complete.  Transcriptionists are never, ever permitted to guess, or 'just put in  anything' in a report transcription. Furthermore, medicine is constantly  changing. New equipment, new medical devices, and new medications come  on the market on a daily basis, and the Medical Transcriptionist needs  to be creative and to tenaciously research (quickly) to find these new  words. An MT needs to have access to, or keep on memory, an up-to-date  library to quickly facilitate the insertion of a correctly spelled  device

Due  to the increasing demand to document medical records, countries started  to outsource the services of medical transcription. In the United  States, the medical transcription business is estimated to be worth  US$10 to $25 billion annually and growing 15 percent each year[4]. The  main reason for outsourcing is stated to be the cost advantage due to  cheap labor in developing countries, and their currency rates as  compared to the U.S. dollar

There is a volatile controversy on whether medical transcription work should be outsourced, mainly due to three reasons:

1.  The greater majority of MTs presently work from home offices rather  than actually in hospitals, working off-site for "national"  transcription services. It is predominantly those nationals located in  the United States who are striving to outsource work to  other-than-US-based transcriptionists. In outsourcing work to sometimes  lesser-qualified and lower-paid non-US MTs, the nationals unfortunately  can force US transcriptionists to accept lower rates, at the risk of  losing business altogether to the cheaper outsourcing providers. In  addition to the low line rates forced on US transcriptionists, US MTs  are often paid as ICs (independent contractors); thus, the nationals  save on employee insurance and benefits offered, etc. Unfortunately for  the state of healthcare-related administrative costs in the United  States, in outsourcing, the nationals still charge the hospitals the  same rate as they did in the past for highly qualified US  transcriptionists, but subcontract the work to non-US MTs, keeping the  difference as profit

2.  There are concerns about patient privacy, with confidential reports  going from the country where the patient is located (i.e. the US) to a  country where the laws about privacy and patient confidentiality may not  even exist, which was overcome as HIPAA (Healthcare information  portability and accountability act) became mandatory for all the  providers from the outsourced countries. Some of the countries that now  outsource transcription work are the United States and Britain, with  work outsourced to Philippines, India, Sri Lanka, Pakistan, Canada,  Australia and Barbados[5]

3.  The quality of the finished transcriptions is a concern. Many  outsourced transcriptionists simply do not have the requisite basic  education to do the job with reasonable accuracy, as well as additional,  occupation-specific training in medical transcription. Many foreign MTs  who can speak English are not familiar with American expressions and/or  the slang doctors often use, and can be unfamiliar with American names  and places. An MT editor, certainly, is then responsible for all work  transcribed from these countries and under these conditions. These  outsourced transcriptionists often work for a fraction of what  transcriptionists are paid in the United States, even with the US MTs  daily accepting lower and lower rates. However, some firms choose to  employ American transcriptionists as they believe the quality of work is  better.[6]

Among  outsourcing countries, the Philippines has recently attracted increased  amounts of MT outsourcing from the United States due to the fact that  aside from the Filipino language, English is one of the official  languages used in almost all government transactions in the country and  the high literacy in the English language and perhaps, the capability of  average Filipino to understand American idioms, colloquialism, and  slang used in medical transcription. This is very concerning to the US  MTs. The Health Insurance Portability and Accountability Act (HIPAA)[7]  governs outsourcing of MT work. Stricter policies in compliance with  HIPAA are implemented in such companies to enable security and  confidentiality of work involved in such practices

The  medical transcription industry will continue to undergo metamorphosis  based on many contributing factors like advancement in technology,  practice workflow, regulations etc. The evolution toward the electronic  patient record demonstrates that, over time, documentation habits will  change either through standards and regulations or through personal  preferences. Until recently, there were few standards and regulations  that MTs and their employers had to meet. First, we had the Health  Insurance Portability and Accountability Act (HIPAA). It wasn't long ago  "experts" stated that HIPAA would not have any effect on the medical  transcription industry. Either in a state of denial or ignorance of the  law, many transcriptionists and companies have continued on their  existing course of providing medical transcription. Many providers are  concerned that the majority of the transcription industry will not be  able to meet several specific requirements: namely, access controls,  policies and procedures, and audits of access to the patient  information. Without the knowledge or resources to comply, many in the  industry are claiming to comply and signing their Business Associates  Agreements without taking the security measures required. Many are  uninformed, and some are choosing to remain so, believing that the world  of transcription cannot possibly be expected to make these adaptations.  The fact is that the employees will demand HIPAA compliance and will  change employers and contractors when they don't get it. There will also  be demands to enhance patient safety, increase efficiency, and reduce  costs. It is mandatory for service providers and healthcare practices to  migrate to a HIPAA compliant environment.