Donna Littrell questioned the use of my time in addressing the issue. I’ve been in the discussion forums online for a long, long time – and questioning someone’s effective use of time in pursuing a line of discussion is intended to stop a conversation, similar to Godwin’s Law:

As an online discussion grows longer, the probability of a comparison involving Nazis or Hitler approaches.

Were I to posit Julie’s Law (well, Laws, since there has to be more than one), it would be that as soon as someone reaches the point where they cannot logically defend their position, they will call into question the use of time of (a) the original poster, (b) other participants in the conversation, and then declare THEY don’t have time for this nonsense, so they’re done discussing it.

So, I decided to address a topic that is surely dear to the heart of the founder of ATA and its members: anti-offshoring attitudes and policies in the medical transcription community.

Let me start by relating an incident that happened to me many years ago, when offshoring first became an issue. At that time, I was paying for a listing in a publication that listed medical trancription services. (I believe this publication is now defunct, but I have the 2003 and 2004 directories, which is like looking through a registration of gravestones.) I received a solicitation in the mail about listing my service, filled it out and sent a check. I was subsequently contacted by the editor, who told me they would be unable to list my business in the directory because they had a policy against listing companies that were involved with offshoring work and they believed I was sending work overseas. I asked the editor to point out to me where in their contract this policy was stated. She stuttered and stammered a bit before admitting the policy wasn’t written. She also couldn’t tell me when the policy had been put into place. Then, I asked her how they were verifying whether or not a company sent work overseas. Signed affadavits? Audit? Not to my surprise, there was no verification process. Obviously, with no verification process and no written policy, the policy was being unevenly applied. In fact, I had the prior year’s directory and I pointed out to her all the companies that were listed that were sending work overseas and/or doing training overseas. I asked her if she really wanted to go down this road, at which point she decided that maybe, in fact, they would allow my business to be listed in the directory.

The editor admitted that her reason for attempting to deny my listing was based on posts I’d made in medical transcription forums that she felt were supportive off offshoring. Aside from that, whether or not I was sending work overseas isn’t the point. Even if this editor had had a written policy, there was no way to verify the accuracy of any information. And, as I’m going to discuss, application of any policy is, by its very nature, difficult to impossible to uniformly apply.

How far is someone who is anti-offshore willing to go to stand by their principles and walk the walk? This is where things get sticky.

First of all, how does an individual or organization verify the uniquely nationalist work ethic and policies of a company or individual? Take their word on it? Ask for copies of contracts? Not having a process in place to verify the truthfulness or accuracy of claims is the same as having a contract with no early termination penalty; it’s a nice framework for working together, but pretty toothless. The organization formerly known as MTIA based its membership categories (and dues) on revenue, and members were required to submit financials. At least they’re asked to prove a positive – how do you prove a negative?

In spite of my belief that absent a method of independent verification, these policies are worthless, I’ll continue…

How far is an organization or individual willing to go to walk the walk and back up their beliefs and/or policies? Refuse to work for a company that sends work offshore? Boycott publications that accept advertising from companies that send work offshore? Boycott websites that are owned by offshore interests and/or have advertisers that are offshore or send work offshore? Refuse to accept advertising from companies that are involved with offshore transcription? Boycott vendors that sell their products and services to offshore companies or companies that send work offshore?

The possibilities seem endless, don’t they?

Over the years, anti-offshore sentiment has evolved to center around privacy and security issues. HIPAA and HITECH have strengthened this argument – and I believe it is a valid concern. Looking at significant HIPAA breaches over the past year reveals that out of over 260 incidents reported that affect 500 or more individuals, only 3 involved transcription services. For more information, you can read Brenda Hurley’s summary. Right now, I’m feeling like I ought to contact Gair Transcription and offer to do some consulting about their online presence – aside from their address (in the US), Google search results returned only information about this breach. But here’s my favorite part – they exposed PHI on the internet for over 2 years! <thud> I don’t even know if any of these companies are involved with overseas transcription, but since these breaches occurred on their servers, it’s really a moot point.

Quite frankly, I’m more concerned about hackers in Russia than I am about transcription contractors in India.

To drive the sticky wicket in even further, we might be able to make an issue over whether or not these companies utilized overseas website maintenance and programming. Whether or not there was a breach, any overseas contractor maintaining the website would have access to the same information a transcriptionist would have – probably more. Is that something medical transcriptionists object to, or are they leaving that issue for the US programmers? In fact, according to Dr. Ahmed, he worked on the website design and programming for MT Stars. Is anyone concerned that their personal information is being exposed to someone in Pakistan who might do God-knows-what with it, or are they all using fake and throwaway e-mail addresses, so they don’t care? Does anyone ever wonder if their company website is programmed overseas? Maybe ATA should add a membership restriction that includes using offshore programmers, since they’re concerned for the security and privacy of American’s data.

There are healthcare providers who don’t have a problem with the privacy and security issues of sending transcription overseas. There are medical transcription companies that feel the privacy and security measures they have in place meet the requirements, even for overseas employees and/or contractors. The fact that there has been no large breaches involving overseas contractors supports the confidence these companies have in their policies and procedures for dealing with offshore workers. Where I do feel problems may arise are in situations where a small MTSO or an independent MT may not have adequate measures in place when transmitting PHI to small MTSOs or independent contractors offshore. Ultimately, however, the US entity will be the one on the hook – and the US entity will have to decide whether or not the risks are worth the benefits.

When I look at the So What Can We Do? recommendations in the ATA’s open letter on offshoring, I see an effort that is well-intentioned, but rather naïve. In reality, what Americans (in fact, most people worldwide) are willing to give up in terms of privacy is changing at an incredible rate of speed. You could close your social network and e-mail and all other online accounts and log off the internet permanently – and there would still be a huge volume of information about you available on the internet. It might even all be contained on servers within the borders of the United States of America. The fact is, you can’t control what others do and how they conduct their business. Your information is being tracked in hundreds, if not thousands, of different ways. If we limit the conversation to only your medical information, your doctor, the hospital, the laboratory, the pharmacy and your healthcare insurance carrier are only the starting point. The largest reported HIPAA breach so far this year is being reported by HealthNet – a large insurance carrier.

When we bank online, watch the pharmacist verify our insurance information and medication record on the computer and watch the doctor send our records to the hospital with a push of the button, pay a credit card online, hand a discount card to the cashier at the grocery store – and a host of other electronic events that have become ubiquitous in our day-to-day lives – we are relying on the company we’re entrusting with our personal and financial information and that it has made every effort, even extraordinary efforts, to safeguard that information. Not just because they can be sued, but because their interests in safeguarding that information align with our own. Even though we are aware that there is a possibility that our information could be stolen, we have consciously or unconsciously weighed the risks and decided the benefits are greater than the risk.

Which brings me back to that sticky wicket. It’s pretty obvious to me that at some point we have to accept that in the medical transcription industry, we can’t possibly boycott everything that touches the offshore transcription industry. And we can’t prove a negative. At whatever point a person or organization comes to that realization, they have to either set limits they can live with – or start rationalizing and defending the inconsistency between their actions and their stated principles.

I hadn’t even discussed this with Nae, so when she posted that thread, she was not aware of this MT’s e-mail to me.

Let me preface this by saying there are usually 2 sides to a story and I only have one, so my conclusions are going to be based on that. I’m not going to name names, but if any MTSOs have had a similar experience from their side, or if you’re in management and you think this is your company, I’d like to hear the “other” side.

In a nutshell, an MT who was being paid a premium line rate because of her experience and skills on multiple accounts, was demoted due to “potential reportable events” (PREs) involving privacy and security breaches.

The reason? Selecting the wrong doctor as attending, and sending a copy to the wrong physician. In the first case, the error was noted by the MT, but too late – the report had already been sent in, at which point it was immediately distributed. Even though the MT sent an e-mail, noting the error, this error was counted in the disciplinary action that was taken against her. In the second instance, the name dictated sounded almost exactly like another name – and the MT selected the incorrect name.

As amusing as it is to say “we can’t read your mind, doc,” I’m wondering if some of the people responding to that post at MT Chat want to rethink their answer. Although Nae’s example is “send a copy to Dr. Patel,” in a case where there are multiple doctors with that name, it could have easily been “send a copy to Dr. Smith,” where there are not only multiple Dr. Smiths on a list, but Dr. Smyth, Smythe and etc. All it takes is one large university hospital or VA account to realize there are many, many ways to spell names we all thought had a common spelling, for both patients and physicians. With no training and no physician list, it would be obvious to an MT that picking the correct one among a number of Dr. Patels is impossible and needs to be flagged to QA – but what about Dr. Carter v. Karter? If someone says “send a copy to John Carter” and you find a John Carter on the roster – would you look any further to see if there was also a John Karter and therefore flag the report to someone up the food chain?

In my opinion, there were a couple of errors that occurred prior to the MT making the error.

1. It was a new account and no training was given.
2. No physician list was provided, including a list of attendings and their fellows or residents.
3. The MT company has no written policy regarding PREs and how they will be handled.
4. The MT company has no written policy regarding disciplinary action to be taken in the case of MT errors of this kind.
5. No software safeguards are in place.
6. As is usually the case, training for dictators at the facility also appears to be substandard – GIGO.

Some of these seem like no-brainers, don’t they? I don’t know how anyone can be expected to perform with minimal errors on a new account without any direction or instructions, regardless of how experienced they are. An experienced MT may be able to pick up and transcribe any dictator at any facility – but years of experience is going to give an MT the ability to somehow instinctively grasp account specifics.

This is not a small company, this MT is not an independent contractor. The disciplinary action taken cut the MT’s pay by 20% to 25% yet there’s no written policy in place. No inservice on HIPAA, no training on the account, no written disciplinary policy – but with no warning, the company takes action that cuts pay 25%.

Hello, MT employees – have you asked your employer what the written policy is for your company? What happens when a mistake like this happens? What are your responsibilities? What disciplinary action may be taken against you? What recourse do you have?

Technology being what it is, why doesn’t the EMR software – that same software that immediately routes the transcript to all interested parties upon completion by the MT unless it’s flagged – have some safeguards built in? I realize that EMR technology is evolving, but is anyone doing anything to ensure that copies don’t go to Dr. Carter if he’s not involved in the patient’s care and Dr. Karter is? If not, why not? You’d think that while everyone is out spending money on streamlining the process and reducing labor costs, they’d also be doing something to ensure security is more automated. Even a delay of a certain number of minutes would be helpful (something like the 7-second delay on newscasts), so if errors are caught shortly after the report is completed, there’s some hope of rerouting it before it’s gone out for distribution.

Are MTs paid enough to take on this kind of responsibility? Are YOU paid enough to take on this kind of responsibility? What I see happening is that more and more MTs will send every questionable physician name to QA or to the hospital staff to deal with. Then, someone will get mad – probably at the MTs. Because it seems nobody is willing to hold the dictators responsible. So here’s a tip for all you working MTs out there – unless you’re 100% certain, flag that report. The sooner these questions start piling up on the desks of people who are actually paid enough to deal with PREs, the sooner the problem will be resolved.

This situation was a FAIL of epic proportions, primarily on the part of the transcription service for not having policies in place, by not having in-service sessions for employees to train in HIPAA compliance and on account specifics. Well, shame on management for taking its shortcomings out on the transcriptionist.

Just a little bit about AHIMA. It’s a great organization in many ways and I’ve met a lot of people I really like. Now for the big HOWEVER… as a business in the transcription industry and a member of AHIMA, I felt like the red-headed stepchild of medical records and I know I’m not the only one. It was a recurring theme among the MTSOs and MTs I talked with who were also members of AHIMA. Ms. Looney’s feeling that MTs are undervalued in the medical records cycle is, in my opinion, validated by the way AHIMA – and its members – ignore transcription.

Case in point – back to that meeting I attended…

At that time, digitalization of records was advancing and there was talk of perhaps expanding the available pool of (very much in demand) coders by allowing telecommuting of jobs and how that might successfully take place. There then ensued a long discussion between particpants in the conference about the possible issues for coders telecommuting: isolation, child care, supervision, compensation. The conclusion? “We’ll have to study this and proceed very carefully.”

I wanted to stand up and wave my hands in the air and say, “Hey, over here! All you have to do is look at transcription!” At that point, MTs had been telecommuting for years. And yes, experienced all the problems associated with working remotely from home. And yet – not one person acted as though they had any idea that all they had to do was talk to the transcription industry, with its many years of experience!

Moving on – same meeting – I happened to be giving a presentation on speech recognition. During the presentation, I did a live demonstration of how speech recognition works for both live dictation and recorded (back end) recognition. I used a snippet of actual physician dictation for the demo. After the meeting, more than one person came up to me and said they’d never listened to a recorded dictation before! I was absolutely floored.

Is anyone still confused as to why MT is undervalued and misunderstood?

Flash forward to 2009 and I’m at another conference on electronic medical records, personal health records, Health 2.0 and health information technology in general and not much has changed except we’re more digitized. Still commoditized and marginalized, but digitally. I didn’t get the sense so much from people who asked questions in the transcription-related sessions that THEY felt this way – but everyone pretty much agreed that at most facilities, the general feeling is: (1) anyone can do transcription and (2) even if they believed it takes special skills to do transcription, those skills are no longer necessary when editing speech recognition. In fact, Nick van Terheyden showed, in his presentation, that the intrinsic value of a medical transcriptionist is that s/he isn’t the equivalent of a “dumb terminal,” but what we do is taken for granted because we do it so well. We make sense of the jumble, garble, frank dictation errors (well, most of us do) and turn it into a usable document which the doctor then looks at and says “Yes, that’s what I dictated!”

Wouldn’t they be surprised if we actually transcribed verbatim?

Part of the problem in the transcription industry is the upside-down supply/demand model. Even though demand is high, pay rates have gone down. (And yes, I do plan on getting around to commenting on the Advance salary survey one of these days.) Because demand remains high, even the worst MTs have no problem getting jobs as MTs, which doesn’t do a lot for the overall impression of the value of MTs. Top that off with the fact that the better MTs are better because they have higher levels of motivation, skill, intelligence – whatever constellation of assets you want to put together – which means they are also more employable in other sectors that utilize the same or similar skill sets. If someone who has been an MT for 20 years gets offered the same rate per line as someone fresh out of school, what is her incentive to remain in the transcription industry? And yes, I know I shouldn’t suppose that 20 years ipso facto makes one a better MT, but let’s just pretend it does. Why did she enter MT? Because she had children at home and wanted flexibility in her work. Twenty years later, those children are grown and she no longer needs the flexibility, which gives her more options when it comes to looking to take her skills to other jobs. The MT whose skills are marginal is more likely to remain in the industry, leaving behind the reluctant and unqualified, regardless of years of experience. In what other industry can someone be completely unable to do the job well and still remain employed at that job?

No wonder medical transcription gets no respect.

I’m not pointing the finger at any one group – there are plenty of factors that led medical transcription down this dark path. I do feel Ms. Loosey pretty much hit all the nails right on the head. I just hope those nails weren’t going into the lid of a coffin.