Mandatory MT credentialing

I sometimes wish journalists valued responsible reporting as much as I do. I'm not getting paid, and I try to either verify what I'm saying is actual fact or I make sure I present it as my opinion or personal experience. It would please me mightily if the people who get paid and publish magazines would be as careful.

The April 2009 Vol. 19 No. 5 issue of Advance has an article on mandatory certification of MTs (“One Way or Another”). I'd link it but you have to subscribe to see the online issue.

Just the facts, ma'am

Here's the statement that got me fired up:

Woodrow [Dave Woodrow, Vice President of Business Development with DSG, a Jacksonville, FL-based medical transcription service, formerly with SPI and Precyse] noted he sees about half of MTs in favor of mandatory credentialing.

Why would a journalist pass this along in an industry publication without getting or giving more information? The big question pertaining to that statement by Dave Woodrow is: Half of what group of MTs? How was this information gathered?

What's irresponsible about this is that this “fact” will now start floating through the medical transcription community and industry. Shoot, it was published in a well-recognized industry magazine, so it must be correct! Nevermind that we have no information as to how Woodrow obtained this number, so we have no idea whether it's even close to accurate.

Now about that credential…

The mandatory certification being floated is the RMT (Registered Medical Transcriptionist) credential. Of course – because AHDI wants us to think the CMT requires more experience. In truth, the CMT does not require two years of experience – it is suggested. But how would it look if new graduates could pass that CMT test? And you can't require certification and then say only people with 2 or more years of experience can be certified, can you?

How much does anyone think it would add to the profession if the entry-level certification was required of all MTs? Let's get real here – the CMT has been a tough sell and most people will tell you it doesn't add any value for either the MT or the employer. But – this isn't even a CMT we're talking about! This is the RMT, an entry-level certification. All I can say is – I'm less than excited about this and more than a little cynical about the value it adds to the industry as a whole.

AHDI envisions mandatory certification on a state-by-state basis. Pennsylvania has already shot down licensing of MTs, although I'm having a difficult time telling if they were talking about licensing or certification or if a credential would be required to get the license. (You can read the Advance article here.)

Pennsylvania denied the request on this basis:

The Department of State Sunrise Evaluation Team wrote that MTs didn't show a “compelling state or public interest in that there are no identifiable benefits to the public,” and cited that physicians read over the documentation “to prevent misdiagnosis or medical errors and to protect the patient.”

I would certainly agree with that, but Carol Croft, the MT who brought the request to the state of Pennsylvania, disagrees with the findings.

As far as the patient not benefiting, as the state wrote, Croft found that untrue. The patient would benefit the most from having a credentialed MT transcribe the record, she explained, and mandatory credentials would bring a new level of professionalism to the field. “I think we will all benefit, but No. 1 would be the patient,” Croft said.

While that sounds good, Croft doesn't really explain HOW this benefits the public or the patient. If a “new level of professionalism” is the best she could come up with, then I'm not surprised the state of Pennsylvania found as it did. There's absolutely nothing to support any argument that an entry-level certification will add anything of value to patient care.

It seems that AHDI, in its efforts to instill value in the process of medical transcription, is willing to overlook the fact that the physician is the one who provides the care, the physician is the one who documents the record and the physician is the one who is responsible for what is contained in the record. I've noted many times in the past that trying to lay responsibility for accuracy of the record on the transcriptionist is a very slippery slope. If there's a question as to whether or not MTs will support the cost of certification, the bigger question is whether or not MTs – and MTSOs – will support the cost of malpractice insurance.

And what happens if a state does buy into this nonsense and require mandatory certification? That's where the confusion begins. Will it apply to MTs living in that state, or MTs in any state working on an account geographically located in that state? The article does bring this up. Regarding pending action in the state of Washington, Kim Buchanan, Director of Credentialing and Education at AHDI, is quoted as saying:

Buchanan said the best way to do it, if a state were to approve mandatory certification of MTs, would be to have all work for that state's hospitals done by certified MTs, no matter where those MTs might be based.

“[If] you said any health care documents in the state of Washington have to be produced by certified individuals, I think outsourcing nationally could be called into question,” Buchanan said. “We may end up seeing Washington hospitals bring their dictation either back in house or at least more local because they would have more control over it.”

Some of the comments made by MTs in the online forums are directed towards the hope that mandatory certification would mean the end of overseas outsourcing. That would only be the case if the state requirement meant that all health care documentation done for practitioners and facilities in that state had to be performed by a certified individual.

The article then raises the question of how this would affect the work force shortage. Let me go on record as saying that the work force shortage in the US is primarily caused by the work conditions and pay rates in MT, which have been impacted by outsourcing offshore. It simply isn't an attractive career for people with the education level and intelligence required to do it. IF the pay rates and work conditions improved, it's my opinion that there wouldn't be a work force shortage in the US

Woodrow explained that service organizations are already operating under tight budgets and having MTs pay for their own credentials also seems like a difficult choice, as maintaining the credential can be pricey.

OK, so why are budgets and operating margins so tight? Because nobody has the guts to just come out and say “we need to charge more for this service – you simply can't get what you want at that price.” Instead, the ambiguous line game continues to play out and outsourcing companies engage in cutthroat competition, apparently willing to bleed right along with everyone else. Would healthcare facilities be willing to pay more? Ten years ago, when Diskriter was performing benchmarking of what it costs per line to maintain a medical transcriptionist as an employee, the cost per line was 30 cents. So why are MTSOs undercutting to less than half that? If it can be demonstrated that employees cost 30 cpl, then isn't 20 or 22 cpl still less expensive? I simply don't understand the business model that says undercutting has to be drastic in order to be successful – unless the outsourced MT business has also bought into the healthcare model of “we're not making any money, but we're making up for it in volume!” In addition to cutthroat pricing, the outsourced services have practically thrown the kitchen sink into the mix as “added value” to the actual transcription, all while charging less and less. And when an MTSO has to provide ever-increasing technology – or offers it to get a leg up on the competition – without actually charging more for the service, guess where the difference gets made up? It has to come from somewhere and as long as MTs are willing to continue working for less and less, that's where it comes from. Is it any wonder that more and more experienced MTs are walking off the field? This shouldn't come as a surprise to anyone.

I'm not saying it would be easy to find quality MTs here in the US if the pay rates were better or that it would be easy to find outsourced companies doing a better job just because they charge a higher rate than anyone else. Sometimes, all you get is more expensive incompetence. However, the probability of getting better service would be greater and over time, as MTSOs and facilities demanded better performance from MTs in exchange for better pay, there would be more attraction of better candidates overall. In the current environment, there simply is no incentive for US MTs to do a better job than they're doing. By the same token, there isn't any incentive for MTs to get an entry-level credential that presents additional costs to them with no subsequent reward.

MT Credentialing, Round 2

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28 thoughts on “Mandatory MT credentialing”

  1. Julie, very well-written and compelling argument on this subject. I’d like to address just a couple of statements. AHDI has never overlooked the fact that physicians are required to authenticate their records and, thus, are ultimately responsible for the accuracy of the data that is captured. What we have continued to argue (and will be doing so with error data in the near future) is that transcription is a risk management role. Surgeons have a team of techs in the OR who are responsible for ensuring that all surgical supplies are counted prior to the procedure and then recounted prior to closure. Why? Because of the high risk associated with surgeon error and the liability of leaving any of those things inside the patient. The surgeon is still the responsible, accountable party in the OR, but he/she relies on a supportive risk management team to protect the patient, the physician, and the hospital from a devastating error.

    Arguably very few “errors” patient care documentation could be described as potentially “devastating,” but many of them have a high risk for misinterpretation and misapplication from a coordinated care standpoint. It is the role of the skilled MT to provide risk management support to the physician through accurate interpretation and capture. Sure, the physician is ultimately responsible for authenticating that this was done accurately, the reality is…how many of them actually do that? Or do it consistently and well? We can pass the buck to the physician and say, “I’m just typing what you say, doc. If it’s wrong, it’s your problem, not mine.” Julie, if MTs continue to make that argument, we may as well hand the industry over to SRT and template EMRs because we will have given healthcare zero reason to believe we’re necessary.

    If human intelligence is necessary in the data capture process…why? We argue that MTs are ncessary because (a) physicians do make errors in dictation every day (some major, some minor), (b) it takes human intelligence to recognize, correct and/or flag those errors, (c) physicians are dropping in electronic signatures and avoiding consistent record authentication to a great enough degree to cause concern, and (d) healthcare cannot afford to rely solely on the physician for patient safety. The last reason is now why hospitals put tech teams in the OR to count sponges, needles, and instruments. If surgeons had been doing it the way they should, no one would have ended up with a trocar left in the abdomen. MTs function in much the same way, and if we’re not willing to step up to the plate and assume some responsibility for that, then we need to shut down and let technology roll right over us.

    AHDI has been saying for quite awhile now that credentialing is necessary to elevate MT out of a “secretarial” role and into the allied health domain. No one in healthcare sees us as allied health professionals (primarily because we have no entry-to-practice credential) and, wrongly so, assumes we don’t need one because we don’t put our “hands” on the patient. That’s what went wrong in Pennsylvania. The state lacked the understanding of our risk management role and assumed that we provide no benefit to the patient. There isn’t an MT working out there who doesn’t profoundly understand our benefit to the patient.

    Credentialing should not be embraced because it earns you more money or gives you a professional advantage. I’ll step out here and say…if AAMT ever touted that as the reason to get certified, it was the wrong message to put out there. Credentialing is about moving the profession forward, not the individual. It isn’t about getting you more money, a promotion, or a better job (unless it’s a specialty or advanced credential). It is entirely about regulating our own profession, setting the benchmark for who can have entry to practice, and sending a message to healthcare and to legislators that we have the ability to set standards for ourselves. If the entry level credential (RMT) was mandatory for entry to practice, it wouldn’t earn you more money. Everyone would be required to have it just to enter the profession, so it’s not about the money. It’s about what it can do for all of us as an industry…collectively. Until people truly understand that, we will continue to see MTs cross their arms, shake their heads, and say, “I’m not getting it unless my employer pays me more or makes me do it.”

    Well, many employers are making it a requirement. Our CMT numbers are on the rise. Whether we will ever see that evolve to a mandatory credential remains to be seen, but again, it’s about demonstrating a unique value to healthcare delivery.

    MTs can’t continue to speak out of both sides of the mouth. You can’t tell people how valuable we are, how we should be paid more, how important we are, how lost the doctors would be without us….and then refuse to back that argument up with the kind of self-regulatory credential the rest of healthcare has respect for and refuse to accept any responsibility for the patient the way the rest of the allied healthcare team does. You don’t see those players passing the buck to the doctor. They understand that it takes a team to take care of patients, and they assume responsibility for their roles and their scope of practice.

    We should do the same (even if it requires malpractice insurance).

    PS – Julie, I think you’re dead on about MTSOs, though. If they don’t take a stand for the complexity of the services they provide and price accordingly, we won’t see too many folks coming into the profession, at least not domestically.

  2. Julie, thanks for bringing this up. Very well written, and very timely. The American Transcription Association has been discussing this very topic recently.

    I’m not going to go on and on in my comment 🙂 The point I would like to make about mandatory credentialing is how can any one organization “create” a credential and hold the keys to that credential without it looking suspicious? And to make the statement that most transcriptionists support this is wrong. Most transcriptionists do not support mandatory credentialing. They might like you to believe that, and if you say anything enough times, people start to believe it as fact, but it’s just not true.

    The CMT, and now RMT, looks to be nothing more than a profit center created by an organization trying to justify their support of off-shore transcriptionists. If credentialing should ever become mandatory, many excellent US transcriptionists who have been employed for years would simply fade away or lose their jobs because they would not want to go through the process of becoming “credentialed” (or maintaining their credential — also another profit center, nice huh) for a job they have been performing perfectly well their entire lives. Something is very wrong about this.

    You can speak all you want about risk management, etc. There is not an MT that I have spoken with who does not take their job seriously or understand the importance of patient safety. They understand the importance of education in our field and enjoy the continuous learning experience this industry offers. They do not need to buy a credential to prove this. The fact is, it does ultimately fall to the physician to make sure their report is accurate and conveys the message they are trying to send. I do not know any physician who would want to let their reputation ride on anyone’s credentials other than their own.

    Finally, here is something to think about… The push for a mandatory credential further opens the door for off-shore players. When an argument is presented about the quality of off-shore work, etc., one can come back with “well even though we utilize off-shore transcriptionists, they are all CMTs just like the US transcriptionists you currently use, so the quality will be the same and your costs are lower.”

    I think those who support this need to open their eyes and look a little deeper and see how this would really affect them in the long run. Read between the lines and see how credentialing and off-shoring go hand-in-hand. This is not something that anyone who is concerned with keeping our jobs in the US should be supporting.

    1. Thank you Donna, you’ve expressed wonderfully my exact sentiments about the CMT, RMT. Its a sham the AAMT, now AHDI, created to keep from going bankrupt several years ago. Now, in the interest of full disclosure, I am an RMT, only because my now former employer paid the cost for me (and several others) to sit for the AHDI’s beta test late last year. Now, whether or not I decide to keep the RMT has yet to be decided…I was one of the unfortunate who had a lot of technical problems with the test. It is an expensive credential to maintain and I am not wealthy, so time will tell….

  3. I have to agree with Donna above. What concerns me is that the AHDI seems to hold all the controls so of course they are pushing for it as they get the money for it. If it going to come to regulation, it needs to be done on a local and/or state level without the profits lining the pocket of the very organization that is pushing for it.

    In addition, if you are pushing MTs to incur all these costs and even mention malpractice insurance, you are indeed going to force the very MTs that you want to keep in the field out of practice. In addition, how many hospitals and physicians would be able to pay the MT what they would have to earn to cover the credentialing (since it is an ongoing thing), licensing and potential malpractice fees??

    You can also take the argument of responsibility to insane levels further increasing the costs of healthcare at a time when millions cannot afford it as is.

    I think that, until the issue of credentialing is broken out of the AHDI (so that they do not have any monetary gain), it is very difficult to debate regulation. The regulation would need to come from a local/state level and be controlled on the local/state level with an impartial board instituting these tests and regulations.

    However, I don’t think it would offer a thing to the industry. MTSOs currently employ fairly intense testing prior to hiring an MT and then follow with probationary periods under intense scrutiny with QA, etc. If all of this doesn’t fairly well guarantee accuracy, I don’t see how an entry-level credential is going to do so. I agree that it becomes suspect for justifying and/or opening the door for more off-shore outsourcing.

  4. Lea wrote: “It is the role of the skilled MT to provide risk management support to the physician through accurate interpretation and capture. Sure, the physician is ultimately responsible for authenticating that this was done accurately, the reality is…how many of them actually do that? Or do it consistently and well? We can pass the buck to the physician and say, “I’m just typing what you say, doc. If it’s wrong, it’s your problem, not mine.” Julie, if MTs continue to make that argument, we may as well hand the industry over to SRT and template EMRs because we will have given healthcare zero reason to believe we’re necessary.”

    Why, then, does there seem to be so much more emphasis on verbatim transcription than ever before?

  5. Lea said: MTs can’t continue to speak out of both sides of the mouth. You can’t tell people how valuable we are, how we should be paid more, how important we are, how lost the doctors would be without us….and then refuse to back that argument up with the kind of self-regulatory credential the rest of healthcare has respect for and refuse to accept any responsibility for the patient the way the rest of the allied healthcare team does. You don’t see those players passing the buck to the doctor. They understand that it takes a team to take care of patients, and they assume responsibility for their roles and their scope of practice.

    Exactly how many members does AHDI have these days? Last I heard it was between 7-8000. The last figures I saw (a couple of years ago now) put the number of CMTs at less than 3000 total world wide. I have no idea how many RMTs there are so far. Is it more than 3000?

    Given that MTIA estimated the number of working MTs as over 300,000 just in the U.S. I guess many could be forgiven for wondering why a group with such a very, very small representative number of working MTs in it should presume, or, be allowed to dictate what anyone should be required to have to work as an MT?

    If AHDI truly feels this credential is so necessary for furthering the profession then why is anyone allowed to be a member or to serve in any sort of leadership capacity within that organization without it? Why is AHDI asking/expecting nonmembers to be willing do what the majority of its own membership won’t?

  6. Great article Julie. On-the-job training with extensive proofing and feedback is integral to development of MTs including those starting out in a doctor’s office with little training or experience as well as for the growth of specialties and work types for experienced MTs. Would mandatory credentialing not inhibit on-the-job training and thus present a barrier to those entering the profession?

  7. Margie, I don’t know if there are any definitive statistics that would show that there is more emphasis on verbatim transcription across the healthcare field in general. I’m sure there are anecdotal instances of this happening. But assuming what you say is correct, I can tell you a major reason for this could be that the clients are moving to speech recognition. With SRT, it’s very important for the dictation to be transcribed verbatim in order for the speech recognition engine to “learn” the doctor’s voices.

    I’m on record as being opposed to mandatory credentialing for MTs. But Lea’s point cannot be so easily dismissed, IMHO. There is an argument to be made that SRT and/or template-based EMRs are “just as good” as manual transcription that does not include anything in the way of “interpretation,” i.e., corrections, which is a form of risk management any way you slice it. The problem is that at this point in the discussion we MTs get sidetracked because we KNOW how bad unedited SRT or strictly verbatim manual transcription really is. BUT NOBODY ELSE KNOWS THAT! So as far as everyone else but us is concerned, SRT or verbatim transcription isn’t a big deal, since they have no idea just how bad it can get. Until there is a widespread understanding of just how much “cleaning up” MTs do, and how bad medical records would be without that human intervention, we are whistling in the wind. Where I disagree with Lea and others at AHDI is in the assumption that mandatory credentialing would accomplish that goal. I believe it will take something much more dramatic and eye-opening to get people’s attention. My next ADVANCE blog post, as a matter of fact, will be advocating for a National Verbatim Transcription Day, where every MT transcribes records twice, one “official” version, and one absolutely verbatim version. The results could be compiled, de-identified, and made public to show just how different the two versions are. Now THAT would be something that would get some attention!

  8. Lea Sims wrote: “Arguably very few “errors” patient care documentation could be described as potentially “devastating,” but many of them have a high risk for misinterpretation and misapplication from a coordinated care standpoint.”

    I agree with this statement. What I don’t understand is why you think MTs wouldn’t have the same potential “for misinterpretation and misapplication.”

    Why wouldn’t the risk potential be worse for the MT? Have you considered that many MTs don’t have the luxury of being able to refer to the rest of the patient’s chart? Have you considered that they don’t have the patient in front of them to talk to? That they don’t have access to the nursing notes and other information involved in patient treatment?

    How can you acknowledge these very real coordinated care issues but ignore them in the one member of the healthcare team that is the furthest removed from the patient?

  9. Me, let’s say for the sake of discussion that all things were equal, and an MT does NOT have access to additional information about a patient’s care. If it were YOUR medical record, would you feel more comfortable having your encounter recorded by a physician with 30 other people to see that day who is hunting and pecking on a laptop, using an EMR he/she likely doesn’t like, while he/she is supposed to be listening to/examining/treating you, or alternatively, by a speech recognition computer program trying to make sense of dictations by that same harried physician whose primary desire is to get through all the dictations as quickly as possible? Or would you rather have a real, live human being with a brain capable of critical thinking and deductive reasoning listening to and transcribing your report? All things being equal, there’s no question in MY mind which I would trust the most!

  10. I’m not saying “don’t flag errors or inconsistencies.” I’m saying that ultimately, whether they read it or not before they sign off on it, the physician IS the one responsible for what’s in the record, just as they are ultimately responsible for what happens when one of their surgical techs – who are covered by the physician’s or the hospital’s malpractice and as a result don’t have to buy their own separate policy – makes a mistake. Licensed professionals working alongside physicians at a hospital are covered by the hospital.

    Pushing MTs into a position where they “provide risk management support to the physician through accurate interpretation and capture” requires that everyone – dictators and HIMS staff – join the team. How long have we been trying to get dictators to dictate better? MTs working in the “mass market” (large companies) and large facilities can probably confirm that their questions are rarely answered and the same blanks are left over and over again because there is no “team” here.

    “Sure, the physician is ultimately responsible for authenticating that this was done accurately, the reality is…how many of them actually do that?” I really don’t care how many of them actually do it! That’s not the point. The point is that they are the ones being paid to do it and they have a responsibility to do it. I didn’t go to med school, I didn’t do a residency and an internship, I’m not the one seeing the patient and coordinating patient care. That’s like saying an MT is supposed to know that a doctor actually means “right” when s/he dictates “left” throughout the entire report, with no indication that s/he is taking about the wrong side. The record is still wrong and it’s still the physician’s responsibility. I personally don’t want to be responsible for enabling the irresponsibility of the person who is actually paid to be responsible. If they sign without reading, any errors are – and should remain – their problem.

    Lea, I’ll be impressed with the commitment to credentialing when AHDI’s partner, MTIA, uses its influence to get the big employers like MedQuist, Spheris, SPI/Focus, Precyse, etc. to not only REQUIRE a credential, but to undertake an effort to get all their MTs credentialed and pay the fees, even if they don’t increase the MT’s pay. That would send a clear signal that these companies – which employ thousands of MTs in the US and abroad – are committed to “moving the profession forward.” According to the numbers I’ve seen (again, unsupported “facts”), there are 150,000 MTs in the US. The last time AHDI published numbers, there were only 3000 CMTs. That means only 2% of the estimated workforce is credentialed. Does anyone believe that an employer getting 100 applicants for a job is going to give preferential hiring to the probable 2 CMTs who apply? Until the employers themselves back up their “preference” with action, it’s a meaningless gesture – and I think most of us are smart enough to see it for what it is. And yes, these same companies need step up and be the ones demonstrating the value to the rest of the industry.

    I’m not opposed to credentialing but I am opposed to licensure and mandated credentialing. Go find out how AHIMA got its credentials so widely accepted and “required.” It’s very difficult to get a job in HIMS without the credential, yet there is no mandate that these people have one. Mandated credentialing and licensure is a can of worms and I believe if it actually happens, even the people who pushed for it will regret it.

  11. Jay, I think you missed the point I was trying to make. That being, MTs don’t have a link into the mind of the doctor. An MT is just as likely as anyone else on the team to misinterpret or misapply what’s being said. Let’s not kid ourselves. We can’t say that a highly educated doctor or an RN is likely to misinterpret or misapply the data in a report, but an MT won’t.

    I’m sure Lea’s statements ring true within the echo chamber of AHDI headquarters, but in real world very few people give any weight to an MT’s medical decision making. Even if it as simple as a drug dosage or whether the sex of the patient was dictated correctly.

    That doesn’t mean that I think MTs need to step aside and let SR or the EMR take over. It does mean that MTs need to realize their place in the process. They can call attention to what may be an error without taking on a risk management role. A good MT saves the doctor valuable time by doing this. That’s where the true value of MT comes in.

    MTs who don’t save the doctor time should get out of the profession and let them use SR or the EMR. If the doctor doesn’t think his time is that valuable or if he thinks the accuracy of records is unimportant, then he should fire his MT and deal with the consequences (if any) of DIY medical records.

  12. Lea says “AHDI has been saying for quite awhile now that credentialing is necessary to elevate MT out of a “secretarial” role and into the allied health domain. No one in healthcare sees us as allied health professionals.”

    Where I work, the medical secretary starting pay is higher than the MT starting pay. How’s that for elevation?

    Lea says “Sure, the physician is ultimately responsible for authenticating that this was done accurately, the reality is…how many of them actually do that? Or do it consistently and well? We can pass the buck to the physician and say, “I’m just typing what you say, doc. If it’s wrong, it’s your problem, not mine.” Julie, if MTs continue to make that argument, we may as well hand the industry over to SRT and template EMRs because we will have given healthcare zero reason to believe we’re necessary.”

    Yes, bottom line, the physician IS responsible. My husband is a veterinarian and he has friends in his field who have lost their license to practice, and it was always because they let someone who worked for them try to do their job. If you asked any of those doctors if it was his fault or the person he relied upon to do something that put his license to practice in jeopardy, they would all say something to the effect of “bottom line, the buck stops here.” The doctors know who is responsible, and they want it that way. When you ask “how many of them actually do that?”, my response is, the ones who want to keep their license actually do that. Or if they don’t, they know what the consequences are for taking risks like that.

    One more question I have – if they license state by state, would we need to be credentialed in the state of the MT service we work for, the state where the hospital we are typing for is, or the state we live in? I see some confusion there. Not to mention cost, since I have transcribed for hospitals in several states all in one day, working for one service. But since my husband’s licenses (all 9 of them) are issued by each state, I would guess the same type of state entity would issue our credentialed document? If it’s not run by a state entity, I don’t see how you can enforce it.

  13. Me, I think perhaps we’re arguing over semantics.

    You said, “An MT is just as likely as anyone else on the team to misinterpret or misapply what’s being said. Let’s not kid ourselves. We can’t say that a highly educated doctor or an RN is likely to misinterpret or misapply the data in a report, but an MT won’t.”

    Depends on what we define as “misinterpreting or misapplying.” I would say that in fact an MT, having the advantage of being removed from a potentially emotionally charged situation (even if the emotions are fatigue, stress, etc.) is in a much better position to catch inconsistencies WITHIN THE DICTATION. That’s what we’re talking about here. Neither Lea nor anyone else at AHDI is inferring that somehow MTs should be able to make judgment calls about information OUTSIDE the dictation itself.

    You said: “I’m sure Lea’s statements ring true within the echo chamber of AHDI headquarters, but in real world very few people give any weight to an MT’s medical decision making. Even if it as simple as a drug dosage or whether the sex of the patient was dictated correctly.”

    I don’t think you have enough information to make a sweeping statement like that. You know what you yourself have experienced, or what you yourself have observed or heard from others, but that doesn’t qualify as an accurate picture of what happens throughout the healthcare continuum. There are just as many anecdotal instances where “catches” by MTs have been very much appreciated and heeded.

    You said, “MTs need to realize their place in the process. They can call attention to what may be an error without taking on a risk management role. A good MT saves the doctor valuable time by doing this. That’s where the true value of MT comes in.”

    Again, we’re disagreeing on the meaning of words. “Calling attention to what may be an error” is an act of risk management, whether you care to define it as such or not, or whether it is recognized as such by others. Catching errors before they cause broader consequences is a function of risk management. But regardless of what we call what we do, it is, as you say, “where the true value of MT comes in.” I think it would be a shame for that point to be lost in bickering over buzz words and phrases. It’s the end result that matters, not what the process is called, and the end result is that without the active intervention of skilled MTs, literally millions of patient encounter records every year would be significantly more inaccurate than they are. THAT is the point we all should be able to agree on, surely.

  14. Lots of great debate here. I unfortunately don’t have time to address every response to my post (not to mention, it wasn’t my intention to hijack Julie’s post), so I’ll just address a couple here.

    1. AHDI does not make money on credentialing…never have, never will. We actually subsidize that program through other revenue streams. We don’t make money from it.

    2. AHDI would not oversee a mandatory credentialing scenario. That has to occur on a state-by-state basis and would be administered by the state. Our goal would be to work with those states to adopt our RMT exam (that’s how this typically happens…no state wants to reinvent the wheel) as their state licensing/credentialing exam.

    3. Julie – the first step was getting MTIA to release their position statement in support of credentialing. A small step, certainly, but an important one. Since that paper was released, we have seen a big influx of employer-sponsored RMT and CMT study groups. Webmedx, for example, has made the decision to get every one of their MTs credentialed by next year and to hire only credentialed MTs after that (or so I’m told). That’s not necessarily a trend, but all trends start small. I can absolutely tell you that credentialing was on the lips of every employer I talked to at the MTIA conference last week.

    4. Nae, you love to tout our membership numbers. Membership is not reflective of the impact of any association. Almost all associations carry less than 5% of an industry on their membership rosters. The membership experience is not for everyone…but it doesn’t have much to do with the work associations do in the arenas of credentialing, advocacy, and standards-setting. Ultimately, AHDI is not going to be the one to decide if a mandatory credential is necessary. The states will evaluate the role of the MT in healthcare and make that decision. We can’t force it, but we will continue to explore, discuss, and advocate for it.

    I would love to address the comments about risk management and the physician’s responsibility, but I don’t have time, and I believe we’d only continue to debate it from the corners.

  15. Donna said: “…If credentialing should ever become mandatory, many excellent US transcriptionists who have been employed for years would simply fade away or lose their jobs because they would not want to go through the process of becoming “credentialed” (or maintaining their credential — also another profit center, nice huh) for a job they have been performing perfectly well their entire lives. Something is very wrong about this…”

    I have said that same sort of thing for years, anytime I discuss credentialing with anyone. What would credentialing bring to my transcription/job that I don’t already bring to it, and that I haven’t brought to it for these 34-or-so years?

    Lea said, “…Ultimately, AHDI is not going to be the one to decide if a mandatory credential is necessary. The states will evaluate the role of the MT in healthcare and make that decision. We can’t force it, but we will continue to explore, discuss, and advocate for it…”

    Lea, with all due respect…Though what you said is technically true, that AHDI is not going to be the one to decide if a mandatory credential is necessary, WHO else is PUSHING for a mandatory credential??? That says a lot. The average transcriptionist out there isn’t pushing for a mandatory credential. It’s AHDI that is pushing. So, even though what you say is true, that’s not really the main thrust of AHDI (to NOT decide for mandatory credentialing). The main thrust of AHDI IS TO PUSH for credentialing AND, IF AHDI was able, I’m sure they would decide to mandatory credentialing (if it was within their capability).

    Thanks for listening

  16. Vicki, I definitely said AHDI advocating for it, though we’re very realistic in understanding that our sector is divided over the value. Again, there is a lot of focus here about what credentailing would or would not do for you as in individual (“what will it bring to my job that I’m not already bringing to it”) and I can’t stress enough that this is not why industries embrace credentialing. This is not about earning you more money or doing something for you individually. Allied healthcare professions that carry a credential do not do so for the purpose of earning those workers more money or better opportunities. They exist and are adopted because of what the credential says about the profession – that we are able to regulate and set standards for ourselves, that we’re willing to be held accountable to a measurable scope of practice, etc. I have never been able to understand why MTs are so opposed to a benchmark credential, one that tells healthcare that we actually do have standards and we’re willing to demonstrate them in a measurable way. You don’t see nurses, therapists, techs, etc, balking about their mandatory licensing/registry exams. They understand that it is a standard practice for professional accountability. What I’m seeing here from many responding is a desire to avoid professional accountability. Even if we can argue how responsible we are for patient safety and risk management, we are accountable for our own scope of practice. If we can’t step up to healthcare and be willing to say that, then we have no scope of practice to demonstrate and no ability to convince healthcare delivery that we’re something more than a giant speech rec engine.

  17. I also wanted to post in follow up to what you said, Julie. I personally would prefer a scenario like AHIMA’s – where widespread adoption of a voluntary credential (like we see with coders) would essentially make it “mandatory” without having to go through the red tape and headache of an actual state licensure process. AHIMA will tell you that one of the reasons they’ve had success with their credential was because their members are the hiring managers positioned to make that a requirement and they’re working inside the hospital – where professional credentials are highly valued. It’s one of the reasons, even of the modest CMT numbers we do have, we see a great percentage of those CMTs working in the acute care setting where the professional culture favors credentials.

  18. “I have never been able to understand why MTs are so opposed to a benchmark credential, one that tells healthcare that we actually do have standards and we’re willing to demonstrate them in a measurable way.”

    Maybe that’s part of the problem, your inability to understand why MTs are so opposed. I don’t mean that in a mean-spirited way, but it seems obvious to me why a radiology MT wouldn’t see the need to sit for the CMT. I don’t need to tell you that the CMT measures acute care MT skill, how would passing that help someone who doesn’t transcribe acute care or multispecialty?

    Okay, there’s the RMT. Same thing. Does the RMT provide for specialty transcription? Since it’s an entry-level certification, why couldn’t it be covered by an entry level test the potential employer administers? Even better, the employer could use their test to see how the MT handles the specific specialty they’ll be working in. Why bother with the RMT when any employment test, which the industry is already widely using, can be easily substituted to cover basic and specialty skills?

  19. Lea wrote: Membership is not reflective of the impact of any association. Almost all associations carry less than 5% of an industry on their membership rosters.

    No argument from me there. I would say the reluctance of the majority of its own members have so far shown to become credentialed/licensed amply demonstrate just how little impact the “association” has had in this regard.

    Lea wrote: “Ultimately, AHDI is not going to be the one to decide if a mandatory credential is necessary. The states will evaluate the role of the MT in healthcare and make that decision. We can’t force it, but we will continue to explore, discuss, and advocate for it.

    Obviously the folks in one state, PA, decided it was not necessary to require this benchmark/standard. It will be interesting to see what happens in other states. Unless something pretty remarkable happens … maybe along the lines of the miracle of Lourdes or something … I would have to say the outlook is not exactly promising.

    I do think though, that if the organization, not the “membership,” is going to continue trying to push for a benchmark/standard that even many members of its own profession don’t seem to think necessary they should probably come up with a better sales pitch because the one they are using right now is not working very well.

  20. Great article, as usual, Jules. I miss your writing.

    This discussion is interesting to me. I wear two career hats. I’ve been an MT since the late 70s. No formal education. No tests. Still pretty damn good despite being a tad slower these days. In my job as a drug and alcohol counselor, I’m educated, met minimums in that education, satisfied tenure requirements and became certified.

    I admit to not staying abreast of MT political issues, preferring these days to transcribe my work, do it well, collect my check, and call it a day. But has MT ever been defined? Have educational minimums ever been defined? Has our impact on public HONESTLY been defined?

    As a counselor, I get paid more for my certification. I also am ultimately responsible for my actions in DIRECT client care. When I dictate my records, slowly and clearly of course, I don’t get to hang the phone up secure in the knowledge that the MT on the other end is qualified, sane, certified, or has a clue. When I get a record on my desk, or electronically on my computer, it’s my job to review these records and make sure that what I said is what appears on the record. I personally really don’t care if the person on the other end is certified….I want accuracy. I want my own arse covered. I want my clients to have accurate follow through.

    MTs do not provide direct patient care, and I’m pretty sure very few states will bestow upon them, the responsibility of such. ADHI, it seems, does not represent the majority of MTs in the country, and in my own experience has done more to down-grade the role of MTs. How can one take their advocacy serious if they are not a true representation? Why would states even listen when if you truly state the situation– We want you to require a credential which will make MTs responsible for accurate patient care. Just sounds ludicrous to me.

    And I had to work 2 years as a drug and alcohol counselor before I was given permission to take a test for certification. I had to have supervision and have my supervisor say I had successfully achieved A, B, C, D. I had to take classes in HIV, confidentiality, and several other topics, some that had little to do with the job, actually. So when someone walks into my office and sits down in the chair across from me, they know they are getting someone who has jumped through the hoops, who will directly impact their care, and who is deemed– RESPONSIBLE.

    I’m just not so sure Mr. and Mrs. American Citizen really give a hoot who puts the words on the page, just that their doctor has a license and is ultimately responsible for their care.

  21. So, just for the sake of argument (and clarity), am I hearing you say that you perceive the role of the MT to be primarily secretarial? One only of administrative support to the physician? If that’s the case, then I would agree that no credential would be necessary. I would also argue that such a role is the least valuable to healthcare right now and the most likely to be marginalized and automated. And explains why SRT and EMR vendors have been able to quite easily convince our end-users that MT can be replaced (afterall, it’s just a secretarial/clerical role). If MTs are content to be pigeonholed in that role, then I doubt AHDI (or anyone else) will ever be successful in convincing healthcare that we’re a legitimate partner in allied health. Like it or not, they want to see more than a clerical worker. They’ll take us seriously when they see us as a standards-setting, self-regulating allied health profession. And that means having an accountable scope of practice and a credentialing process.

    For the purposes of history, very few professions willingly seek regulation and credentialing. AAMT/AHDI has always known we would have our work cut out for us by going down this road. But history has also shown that professions that are unwilling to self-regulate will either be (a) forced into regulation by the government or (b) forced out of relevance by technology and automation. Any unregulated, noncredentialed profession that can’t demonstrate a significant value-add is bound for marginalization. And unless you’re completely isolated from what’s going on in our industry right now, that is exactly what’s happening to our profession. Enabling technologies (not offshore outsourcing…FYI) are squeezing us out of healthcare documentation. We get three times as many emails at AHDI from people who are being displaced by template EMRs and SRT than we do from those worried about offshore. We now have a sliver of opportunity to remain relevant in the EHR – how do we demonstrate to healthcare that the tacit knowledge and interpretive skill of the MT is still needed in the narrowing arena of complex narrative capture?

    I’m certainly not blind to the sentiment of many MTs about the value of AHDI. I have come to understand that no matter how AHDI went about advocating for MTs, the vast majority would prefer to complain than engage. We’re trying to convince healthcare that your role as an interpretive knowledge worker is a value-add solution to a healthcare delivery system interested SOLELY in solutions that (a) cut costs, (b) protect patients, and (c) assist with clinical decision-making. They don’t care about preserving secretarial or clerical roles. Our statements about workforce shortage, compensation challenges, and offshore competation fall on deaf ears in healthcare. Period.

    So…it’s really up to every MT, not to AHDI. How long can you count on your behind-the-scenes, no-credential, no-accountability, low-visibility role to sustain you in healthcare? Most experts say that within the next 5 to 10 years, a great deal of what you are doing will be automated (if you don’t believe that, you should be attending HIMSS) and all healthcare might need an MT for is to capture some complex narrative at the acute care level. All “normals” will give way to automation. All “templates” will give way to automation.

    So, what value will you demonstrate to healthcare of the future? What cost-saving solution can you demonstrate? What ability to protect the patient can you market? What assistance with clinical decision-making can you offer? Instead of arguing with me here about what you are NOT, how much time are you spending thinking about what you ARE? You can say “no” to “risk management” as a value-add role, but what are you willing to say “yes” to?

    That’s all healthcare is going to listen to, folks.

  22. I have read this entire blog and the only phrase I can come up with to describe my reaction is utter dismay. I simply do not understand why MTs, especially those who have practiced in the field for years and KNOW the incredible body of knowledge that it takes to do this job well, would not want to demonstrate in a tangible way that they possess a defined body of knowledge and that they are committed to patient care and patient safety.

    Based on the comments here, those who argue against it seem more interested in snubbing their nose at AHDI than actually demonstrating that MTs are trained, knowledgeable practitioners with enforceable standards of practice . That’s the most incredible (and I mean unbelievable) and downright shallow reason to argue against credentialing.

    But here’s the real question in my mind: Why are we OK with there being NO BARRIERS to entry into a field that impacts patient care? (And don’t even bother telling me it doesn’t!)

    It doesn’t matter who is “responsible” folks! The mother who loses her child because somebody made a decision based on an error in the record has still lost her child—assigning responsibility does not bring that child back.

    The argument should not be about assigning blame, it should be about “How do we improve care and make the system better for ALL OF US?” We are patients too!

    In my opinion, speaking out against standards of practice, regardless of ultimate culpability, is the most irresponsible stance a person can take.

    If there is a better way to define and enforce standards of practice outside of credentialing, please describe.

  23. At a time when the healthcare delivery system takes a stance to incorporate change into practice promoting patient care, safety, and outcome, the role of a highly skilled MT into that equation needs to be clear. We provide significant value to the process crafting a well-documented story. The American Recovery and Reinvestment Act (ARRA) calls for new efficiencies to be defined, setting industry standards. As professionals, it is up to us individually to understand the need to be credentialed. We have an opportunity in healthcare to create a value-driven system.

    The industry will transform and we must be an active participant. Currently there are 18 education-approved schools within AHDI. The RMT credential is well positioned to serve as the exit exam. There is a push from the current administration to elevate education (certifications, degrees, etc.) to drive our country into the 21st Century to recapture jobs and secure our future for the nation. With increasing complexities in the present healthcare model, we need to participate fully to raise the bar and enable solutions. The education foundation we bring forward can open the doors to possibilities for our future.

    Working together, united, will benefit our sector to solve the complex problems we are now faced with.

  24. I find it ironic that, in the “bad old days” before AAMT/AHDI was trying to hard to get “recognition” for MTs, we were actually paid quite a bit more, even though most MTs used to get trained on the job.

    I briefly worked for this one MTSO where, although I was only being paid 8 cents on character count, the owner was bragging to me that she used to pay her people 10 cents line-for-line. Apparently it was quite common at one point to get paid that much, even as an employee. And ICs got paid more, especially those who got their own accounts.

    Frankly, I’d rather get paid 10 cents line-for-line than get “recognition” for which I’d have to shell out hundreds of dollars (for AHDI credentials) or even thousands of dollars (licensing). I’m totally against mandatory anything.

    In the Jusinski article, it was stated that Pennsylvania was estimating that the charge for licensing would be over $2,100 every two years. I don’t know about you, but there’s no way in h3ll I’d pay that kind of money for “permission” to do a job I’ve already been doing for over 20 years very well, thank you very much.

    I also asked AAMT/AHDI about the numbers of MTs, members, and CMTs, some time ago. There were about 101,000 MTs in the States, and about 3,000 CMTs.

    If all of those 101,000+ MTs were forced to get credentialed at over $200 a pop, well, there’s a nice pile of money. Someone’s gonna benefit, and it’s not going to be the individual MT. Someone’s after the money. Someone’s gonna get a nice salary without having to transcribe a single line of dictation.

    Also… I’ve read that Peter Preziosi is the CEO of both AHDI and MTIA… isn’t that a conflict of interest? Seems to me that it is.

    I got trained on the job. I was already very literate (won spelling bees as a kid). I had already done a lot of other kinds of transcription and word processing. I competed for, and won, a trainee job at a major Southern California teaching hospital, over 20 years ago, at a time when on-the-job training was getting to be a rare thing.

    I was in college as an art major. I wanted to get into MT partly because the flexibility would allow me to work my way through the rest of college. If I had been required to drop everything, plop down money I didn’t have, and take some kind of training program, instead of getting on-the-job experience, I’d never have done this.

    IMO, there is nothing wrong with doing a job which can be learned on-the-job. I’ve never had any trouble getting hired… the quality of my work speaks for itself. And I have to prove my worth every night on the job. And I’m definitely NOT inferior to someone who has a degree and credential… in fact, not only does my boss state that his best MTs were trained on-the-job, I’m personally not impressed with the CMTs I’ve met so far.

    I also have to say that I’ve met all sorts of degreed people, with degrees up to and including Ph.D. and M.D., who are not nearly as literate as I am. They cannot spell, and they can’t string together sentences in a coherent manner. They often have someone else write or heavily edit their theses and dissertations.

    As far as I’m concerned, I do NOT have to prove myself to the satisfaction of anyone other than the people for whom I actually do the work–my boss and his clients. I certainly do not want AAMT/AHDI telling me what I can and cannot do–it’s frankly none of their business.

    In the past few years, I’ve suffered a 30% pay cut, while none of my bills went down in the slightest.

    BOTTOM LINE: There’s no way I would be caught dead forking over hundreds of dollars (to the AHDI) or thousands of dollars (to some damned state-level licensing bureaucracy) for the “privilege” of doing a job which I’ve already been performing very well.

    Is this job “just” secretarial? Not really. But it has a lot in common with secretarial work. And I see nothing wrong with that. Respect might be nice… but none of my creditors accept “respect” and “love” as payment for the bills.

  25. One more thing: If there were new licensing bureaucracies in every state, as the AHDI is advocating, it will certainly eat up more and more tax dollars. Bureaucracies rarely shrink. Instead, they grow… at the expense of the taxpayers.

    Has anyone heard: There’s a recession, possibly a depression, on, possibly getting deeper. People are having a hard time paying bills; they’re losing their jobs, even their homes. Why make it harder for people to support themselves?

    And at the AHDI, in the midst of all the self-congratulation going on, has anyone ever heard of “unintended consequences”? Because I’d bet there’s going to be a whole lot of them.

    I don’t like plummeting wages more than anyone else does. But with the way the industry is going, the choice may be between getting to work at lowered wages versus getting no work at all.

    Because for a lot of jobs, the market won’t bear more than a certain amount, and beyond that, people WILL look for ways to automate jobs, whether or not the quality is as good as was happening with humans doing the job.

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