There’s at least one technical solution to every problem, then there’s a miracle solution.

For medical transcription, the technical solution would be God coming down and visiting plagues upon the medical transcriptionists’ employers, making them raise pay rates, pay for down time, provide better benefits and paid time off. He’d send a thunderbolt straight into the heart of the speech recognition engines, filling them with unresolvable bugs so they put out the worst gibberish imaginable. He’d tangle the networks hopelessly so that EMRs would constantly be down and doctors would be forced to dictate again. Doctors would suddenly dictate with clarity and without a single um or ah. Medical transcriptionists would be blessed with accuracy and speed, getting twice as much done in half as much time! The work queues would never run dry, but everyone would be in turnaround! Children would be singing in their homes about the joys of a parent who has a legitimate work-at-home job!

The miracle solution would be that medical transcriptionists realize that medical transcription is rapidly changing and they need to change as well, because there’s nothing they can do to turn back the clock of change.

A friend of mine on Facebook who is now a former MT noted that when she announced she took a job at a hospital, working on an EHR, she was told she was a traitor. Well okay – stronger terms were used, but you get the idea.

Ten (or so) years ago, you were a traitor if you had anything to do with overseas transcription. Unfortunately, there are still groups trying to put this genie back in the bottle, as though overseas transcription is the only cause of stagnant pay rates, increased demands and less work and if it would just go away, all US medical transcriptionists would suddenly benefit from increased pay, better working conditions, more work and fewer demands.

Then, there was speech recognition. I wish I had a dollar for every time a medical transcriptionist said it wouldn’t ever be good enough to impact transcription jobs. Now, we have large facilities reducing the volume of transcription by 50% or more with speech recognition and individual doctors using speech recognition in a variety of applications to reduce or eliminate transcription.

The new traitors are anyone who works with EMRs, which have emerged as a bigger threat to medical transcription jobs worldwide than overseas outsourcing and speech recognition combined. Unfortunately for medical transcriptionists, this threat is actually more real. In spite of evidence that doctors spend precious time working on the EMR instead of seeing patients, the cost-benefit has been weighed and apparently the benefits outweigh the costs. In spite of efforts to maintain a narrative in the record, EMRs continue to roll out with slashing or eliminating transcription costs as one of the goals.

Facing the career change fear factor

If you’re over the age of 40, your parents most likely stayed not only in the same career their entire life, but they also stayed with the same employer. According to career planning experts, that has changed drastically in the last 15 years, due to changes in technology and, more recently, the economy. The Department of Labor does not have statistics about career changes; however, career planners estimate that the average person will change careers three to five times in their lifetime. That’s careers, not jobs.

That means if you’re 40+ years old and you’ve doing medical transcription most of your working life, you’d be like any average American if you’re considering a complete career change.

Let’s face it: a career change is frightening, and the older you get, the more frightening it’s going to be. If you’re close to retirement, you just want to hang on for a couple more years until you CAN retire – and in the meantime, you have bills to pay. If you’re younger, paying for an expensive medical transcription education probably isn’t all that far in your past; not only would you like to get your money out of it, you’ve got bills to pay. Whatever group you’re in, you’re struggling more and more to find a company that pays a decent line rate, allows you to be productive so you can make a decent hourly rate, and has plenty of work so you aren’t constantly struggling to get in enough lines to make logging in and working worthwhile. Changing jobs – much less careers – is an exercise in frustration and fear. Can you find a new job before you starve to death because the company you currently work for is always running out of work? Will the new company be any better?

The biggest barrier to career change is money. Any medical transcriptionist who has gone through a medical transcription education program, struggled to get that first job, struggled to get in a couple years’ experience and finally come out the other side can probably expect to pay the rent or the mortgage or whatever other financial obligations the family has determined need to be paid from that paycheck. As long as the volume of work holds, an MT knows how many lines have to be produced to keep the job and pay the bills. A career change means starting all over – possibly schooling and the time and expense associated with that, training and job hunting, during which time there’s uncertainty about how those bills will be paid.

Another barrier to career change is the knowledge that, like medical transcription, many careers require that dues be paid. The dues paid in medical transcription is the steep learning curve, even for those who have a good education. The thought of going through another round of dues-paying with a completely new career is daunting. And, having paid your dues in medical transcription, realizing maybe this career isn’t going to help you accomplish your financial goals and you’re going to have to start over with a new one carries a huge psychic cost.

Switching careers is most difficult for those in the 35 to 55 age group. For most people in this age group, there are more financial and family obligations and considerations. Any change can upset what is already a delicate balance. It’s kind of like sticking your hand into a box and grabbing a handful of sand – you can’t hold onto the sand, but you can’t pull your hand out of the box, either.

After the miracle

Let’s imagine for a moment that the miracle happens and more and more medical transcriptionists say we’re fed up, we can’t work like this, there has to be something better. What happens next? (Hint: a union is not the answer.)

Time to evaluate what career will meet your financial and social needs. When MTs post on the medical transcription forums that they’re working more and more hours just to meet their minimum line requirements or make ends meet, I have to wonder whether they wouldn’t be better off with an office job, even with travel time. I can say from experience that the biggest problem with a home office is you never leave the office.

An office job might require that children be left in someone else’s care all day – but what are MTs who are at their desk 10 to 12 hours a day doing with their children, anyway? Is there any quality interaction going on there? I know there wasn’t in my house. I was stressed and working too many hours. Looking back, I have no doubt I would’ve spent more time with my children if I’d had a job that I could leave at the office. I wouldn’t have made as much money, but I would’ve spent more time with my children. If I was at the same point in my life today, I’m not so sure I could also say the money is better. Maybe it’s time for the MT who wants to be a work-at-home-mommy to evaluate how much mommy the kids are actually getting, and whether a career change – even one working outside the home – would result in more quality time with the children.

The other reality is that there are probably as many medical transcriptionists who have to work at home as there are ones who want to work from home. Those in rural locations, those who have health issues, those who care for elderly parents… there are a lot more reasons for working at home than just staying at home with the kids. My point is that if you have options, it’s probably not a bad idea to see what they are and whether or not a career change would be an improvement.

My husband has been pushing me to learn coding, so I’m going to put this one out here. Medical transcriptionists have skills that are transferable to coding. Coders are in demand and that demand is expected to continue. Coders have always made more than transcriptionists. There are telecommuting coding jobs. ICD-10 is being rolled out in the US, which means experience is going to be less of an issue for new coders – ICD-10 is radically different from ICD-9. I am told the current average coder is near retirement age and many of them are planning on retiring, rather than learn ICD-10. This will mean an increase in demand for coders. My hesitation about this career is that it is/will go in the same direction as transcription; i.e., overseas, commoditized, with shrinking pay rates. I am assured by many people that this is not a concern. I feel it’s something for MTs to look at, at any rate.

It takes a lot of focus and commitment to successfully change careers. It also takes planning, developing short-term, intermediate and long-term goals, and the support of your family. And in an economic downturn, it can feel like jumping out of a burning airplane. But let me pass along some wisdom my 25-year-old son imparted to me one day. We were talking about education and he said that what convinced him he needed to finish college is someone saying to him in two years, do you want to just be two years older – or two years older with a degree?

So I’ll ask the medical transcriptionists who are struggling with their fistful of sand in the box: In two years, do you want to just be two years old and still struggling as a medical transcriptionist – or do you want to be two years older with the skills to start a new career?

Related information:

1. How to switch careers in a recession
2. How to change careers without going broke

In case you aren’t up on the book publishing business and missed Borders’ bankruptcy filing and shuttering of over 200 stores, the traditional book publishing establishment is going through the pangs of change; i.e., the change from paper to digital.

Sound familiar?

The change from analog to digital forced a change in the music industry and how it does business. Likewise, the change from paper to digital is forcing a change in the publishing industry. The change from analog to digital has also forced a change in the medical transcription industry and continues to change as medical records move to fully digitized medical records.

I was reading a long (too long) discussion online about the digital revolution in the book business and this got me thinking about similarities in the medical transcription industry.

Medical transcription as a niche market

One point the authors make that resonated with me was a discussion about niche markets. Before the invention of electricity and electric lighting, candlemakers were in the lighting business. We all enjoy candles but most of us don’t use them as our primary source of lighting. Candles are now used primarily for decoration and scent. Candlemaking is no longer the major industry it was and it is no longer in the lighting business; it is in the niche market of candlemaking. Candlemaking is still a business and it still generates significant revenue, but not nearly as much as it did when it was in the lighting business. That means fewer companies making candles and fewer employees making candles and fewer people selling candles.

I could go on and on about how major industries have become niche markets, but I think you get the idea.

Likewise, medical transcription is becoming a niche market. As some industry sectors are fighting for preservation of the narrative record, larger forces are fighting for a point of care digital record and its numerous advantages over traditional documentation methods. Even if the narrative record fight is won, what will most likely to retained as traditional transcription will be a niche market. The consultant will no longer dictate a past history, medical history, medication list, allergy list, surgical history, etc., when it’s already readily available and easily accessed in the digital record. The discharge summary will no longer summarize all that, plus all the labs and studies that were done during the admission because they’re already readily available in the digital record. The narrative portion of the record will shrink significantly. I’m not sure what that niche market will look like, but I know it will be a fraction of what the medical transcription market has been in the past. Like the candlemaking business, that will mean fewer companies doing transcription and fewer employees doing transcription.

Medical transcription is not dictation/transcription

In the 1930s, automobile travel began to cut into the railroad’s passenger travel market, but freighting was really the meat and potatoes of the rail system. The development of the interstate highway system dealt a blow to the railroad industry, followed by the extra punch of air travel and freighting in the 1950s and 60s. Add onerous federal regulations and stagnant labor unions and the railroad industry was on its knees. Railroad industry leaders thought they were in the railroad business, but the railroad industry wasn’t in the railroad business – it was in the transportation business. The inability to grasp the concept nearly killed the industry. In 1939, there were 132 class I (freight) railroads. Today, because of mergers, bankruptcies and major changes in regulatory classification, there are only 7.

Except for the labor unions, that sounds pretty familiar, doesn’t it?

The railroads were ultimately saved by your tax dollars, in the form of Amtrak and ConRail. ConRail subsequently privatized and the railroads were deregulated, making it possible for railroads to operate free of government regulations that had made them unprofitable.

(You can read all this at Wikipedia – I’m just summarizing for you).

In spite of the similarities between the two, don’t look for a government bailout of the medical transcription industry. The US government, in fact, is aggressively pushing digital records. If it supports any industry, it will be the electronic records industry. (Conspiracy theorists, start your engines!)

Which brings me to the publishing business. The blog I was reading noted that, similar to the railroad industry, the publishing industry thought it was in the business of publishing. With the development of digital books, it’s becoming apparent that the publishing industry is actually in the business of distributing printed information and entertainment (thanks for the refinement, Moriah Jovan!). As self-publishing becomes easier and more acceptable, the necessity for a publishing company that distributes books (paper or digital) is further eroded. The publishing industry is trying to preserve its place by attempting to suppress self publication and digital book distribution, a move that just about everyone in that industry can see is a last-gasp effort that isn’t going to work. Amazon (and now Barnes and Noble) are staying viable by embracing digital books, as well as self publication. In 5 or 10 years, will anyone care that an author’s work has never gone through the gatekeeper of a publisher? Probably not.

If you want a blueprint for what’s happening and what will continue to happen in the medical transcription industry, just take a look at the music and publishing industries. The music industry has survived, but it’s not the same as it was before. Apple iTunes has become the #1 seller of music in the US. I’m not sure the traditional publishing industry will survive; at the very least, it will be radically transformed and the people who work in that industry will have to carve themselves a new place in the niche markets that spin off the publishing industry.

Like my transition to digital books, doctors are kicking and screaming and swearing they won’t like it, but they are adapting digital records and they are becoming accustomed to the advantages. The technology is improving and will continue to improve; at the same time, it will become less expensive. The users are becoming more adept at the technology. I think we can count on the trend to continue. Likewise, transcriptionists are kicking and screaming and swearing – speech recognition editing, overseas competition, low pay rates – can we expect any of this to change? I don’t think so. I think that as the medical transcription industry responds to changes it’s undergoing, some medical transcriptionists and transcription companies will carve out a place in developing niche markets, others will move to related healthcare fields where some or all of their skills can be applied, and a lot will leave the industry altogether. The speed at which technology moves makes it nearly impossible to see where the medical transcription industry may end up. Right now, it seems that smaller companies are losing out, as they don’t have the financing to support the technology requirements – or even rent them. I’m hearing from more and more independent transcriptionists that even their long-term accounts have stopped dictating entirely, in favor of an EMR (regardless of well it works for them). I think the larger companies have already started making the move from the business of transcribing dictation to the business of providing technology to document healthcare records. In the meantime, the Department of Labor keeps reporting that medical transcription is a good career option (I think it’s time for an update on that one), the medical transcription schools continue to do a booming business, churning out people who soon discover that they cannot get a job or, if they do, they struggle to make minimum wage – if they finish the program at all. I think more and more transcriptionists are looking at – or have already implemented – other options because they cannot tolerate the financial instability of the shrinking market and deteriorating pay rates. You have to ask yourself – in 5 or 10 years, will anyone care that doctors used to dictate and someone transcribed the dictation?

So what is the medical transcription business? Traditionally, we’ve thought of it as the business of taking recorded dictation and turning it into typewritten records. The upheaval in the market is redefining how we think of the business of medical transcription. I’m not sure what the medical transcription business is really – I’m only certain that it’s no longer taking recorded dictation and turning it into typewritten records. 

The light at the end of the tunnel may, unfortunately, be a train.

I’m soliciting comments: what do you think the business of medical transcription is, really?

This is an interesting question now being frequently posed in the medical transcription community on Facebook, in the forums, and elsewhere. It’s one I am frequently asked, as well.

And my answer is no – it’s not a career choice I encourage. This position has been questioned by some, especially when I say it in forums like MT Chat, because I own several websites for medical transcription (and, obviously, I blog about the medical transcription industry). My response to that is that I spent over 20 years in the medical transcription industry. I know a lot of people in the industry and support them, regardless of how I feel about the career.

But – if you’re someone looking for career choices, I am going to tell you to really do your homework before plopping down thousands of dollars on a medical transcription education.

Follow the money

For several years, my impression that medical transcription pay rates are going south has been anecdotal. Then, my friend Kathy Nicholls (who is much more data oriented than I am) did an excellent analysis of numbers, which you can read at MT Tools Online: A Salary Perspective Over 11 Years.

It doesn’t take a rocket scientist to read that information and see the writing on the wall for the working MT. Medical transcription pay rates haven’t kept up with even cost-of-living increases over the last 11 years. I don’t see that this trend is going to change. There are increasing reports from medical transcriptionists that pay rates continue a downward slide, with speech recognition editing paying half or less, while not delivering a breakeven proposition with increased productivity.

The line count pay rate isn’t the only factor affecting how much a medical transcriptionist can make. There are more and more MTs telling me that they fight a daily battle to eke out their daily line count minimum when there isn’t enough work in their employer’s system. These employees are expected to not only be available to work their scheduled hours, but to sit around and wait for work to be available on the system – without any compensation if there isn’t.

Whiners and winners

My decision to write on this topic came out of a Facebook discussion. Fortunately, you don’t have to be on Facebook because Kathy also wrote a blog post at her MT Tools site – Medical Transcription on Facebook: A Case Study. In my opinion, the most interesting response to the question posed came from Ava Maria George, the president-elect of AHDI.

In order to assure that pay is commensurate with our talents, we have to get out there and educate ourselves (yes, I mean bachelor’s degrees) and advocate for our profession. One cannot simply sit back and say, “Please Mister, give me more” and expect that will happen. Obviously, not advocating or speaking out has literally made us obsolete. So, what are we willing to do about it? Get out there or leave. Simply, those are your choices.

Call me crazy, but if someone told me I needed a bachelor’s degree to do medical transcription, I’d be laughing so hard, I’d be speechless. I mean really – if you had the time and money to get a 4-year degree, would you get one so you could be a medical transcriptionist?? I wouldn’t even do it if I had to get a two-year degree.

Now, the case might be made that even Starbucks pays more if you have a college degree and therefore we may draw the conclusion that medical transcription would pay more if practitioners had a college degree. However, it is not the degree itself that is driving higher pay rates – it’s the employers. Starbucks simply states that employees who have a college education are paid more than those who do not. It does not give preferential hiring to degreed applicants, but it does reward them for having a degree. (And it’s kind of a sad statement on the economy and the value of a college education when people with college degrees are working as baristas.) And employers in the medical transcription industry have not supported either higher education or credentialing.

Get out there or leave – seems to me that’s a predictive statement, especially when it comes to AHDI membership. Oh sure – they can point to growth, due to the KB membership, but their practitioner level membership numbers are shockingly low, just over 3000 members at the end of 2010. When I left the organization, the practitioner membership was over 7000 members. Apparently the answer to not finding your sweet spot in serving actual people is to come up with a product you can sell and tie it to a non-voting membership category so you can tell the people you used to represent that you’re tired of their whining and they can just go away.

Which brings me to the next statement made by Ava…

I’m not talking about staying traditionally an MT…we’re evolving. We will be looking at changing not only what we do, but hopefully in the process elevating our profession to one that is compensated at a professional rate. Think about it. Coders were in our position years ago. They decided to educate up, credential, and their salaries followed (higher). Now, they are at the same crossroads that we currently find ourselves…we either grow or go. It can be scary or it can be exciting. I’m betting on exciting….

I have a couple observations to make about this. First of all, I don’t know where Ava Maria George gets the impression that coders educated up. The requirement is, and always has been, a high school diploma or equivalent education.

And I’m going to argue with the interpretation of history here… coders did not, by themselves educate up and credential. AHIMA was successful in getting employers of coders to recognize the value of the credential and start demanding that coders be credentialed. The recognition of the coding credential was not a grassroots movement by the coders, but a top-level-down marketing campaign by AHIMA.

The same is true at HFMA. In the Southern states, more employers require their finance people to have an HFMA credential; therefore, there are more credentialed HFMA members in the Southern states. In the Western states, fewer employers require the credential and therefore there are fewer HFMA members in the Western states who are credentialed.

My daughter is a personal trainer. To get hired at a reputable gym, she must have a credential. No credential, no job. In addition, at the gym where she works currently, she must participate in additional inservice training in order to advance in pay. If she doesn’t participate or participates and doesn’t pass, she loses her job at that gym. Her reward for participating and doing well is not only higher pay, but continued employment.

I have a friend who works in the HIMS department of a major university hospital. She was given a drop-dead date for finishing her AA degree and passing the RHIA exam. If she did not, she was out of a job. She took the test on the Saturday and fortunately passed because after many years of working at this hospital, she would have been terminated on Monday if she hadn’t passed. And – she didn’t get a raise or a promotion, she just got to keep her job.

What AHDI seems to be missing in the entire credentialing discussion is that successful credentialing takes place from the top down, not the bottom up. The problem in the medical transcription industry is NOT that transcriptionists haven’t supported credentialing and education – it’s that employers haven’t supported it. How long do you suppose MedQuist would last if they terminated all MTs who didn’t get a credential by a certain date? The plain truth is that the transcription industry doesn’t have the guts to place such a stringent requirement on its workers, even if it had a financial incentive for doing so. And let’s face it – there’s no financial incentive. For the Record recently did an article on The MT Credentialing Debate, and this statement is indicative of why credentialing for medical transcriptionists has never gotten off the ground:

Dale Kivi, MBA, business development manager at FutureNet Technologies Corporation and a member of the board of directors for the Clinical Documentation Industry Association (CDIA), says he understands and appreciates the efforts of industry organizations that promote credentialing. However, he says organizations that purchase transcription services don’t seem to care whether the labor force is credentialed. Their interest lies in stipulating quality expectations and holding vendors to those levels, regardless of whether the staff are credentialed.

It seems all the blame doesn’t go to AHDI, but I’m tired of them point a finger at medical transcriptionists for not supporting the credential. A better use of their time and energy would be to use their partnership with CDIA (the organization formerly known as MTIA) more effectively.

Winners never quit

You know that saying: Winners never quit and quitters never win.

If you examine successful business people, you’ll find the above statement is erroneous. More than anyone else, winners know when to quit.

What really sets winners apart from quitters is the ability to escape dead ends quickly, while staying focused and motivated when it really counts. They don’t waste time and energy on a dead end. Winners do not keep chasing unprofitable ventures.

The biggest difference between quitters and winners is that when quitters quit, it’s an emotional decision. When winners quit, it’s a rational decision, based on objective data and analysis. Seth Godin has some interesting things to say about quitting and winning in his book: The Dip: A Little Book That Teaches You When to Quit (and When to Stick). Guy Kawasaki interviewed Seth about the book and asks:

Question: Other than hindsight, how does someone know when it’s time to quit?

Answer: It’s time to quit when you secretly realize you’ve been settling for mediocrity all along. It’s time to quit when the things you’re measuring aren’t improving, and you can’t find anything better to measure.

Smart quitters understand the idea of opportunity cost. The work you’re doing on project X right now is keeping you from pushing through the Dip on project Y. If you fire your worst clients, if you quit your deadest tactics, if you stop working with the people who return the least, then you free up an astounding number of resources. Direct those resources at a Dip worth conquering and your odds of success go way up.

What’s the worst time to quit? When the pain is the greatest. Decisions made during great pain are rarely good decisions.

Research and make your choice

Basically, medical transcription has been the one reliable (or, lately, semi-reliable) legitimate work-at-home opportunity. It works for people who don’t have other choices; they must work at home or they must have a more flexible schedule than a traditional office job allows; or they live where there aren’t many work opportunities. For those reasons, medical transcription will remain a career choice for some, while those with more and better options will choose something else. Blaming medical transcriptionists by telling them they’re a bunch of whining losers won’t make medical transcription a higher-paid career. Not only is that a lousy marketing tactic, it’s just putting lipstick on a pig and trying to convince everyone the pig is a something desirable.

This is my surprise face

The discussion at the AHDI Lounge has taken on a life of its own. As usual, the more AHDI representatives talk, the more questions get raised.

Over the past couple of days, the conversation has raised some questions in my mind about why AAMT changed its name to AHDI. While telling medical transcriptionists they need to be forward-looking, prepare for change… blah blah blah… it becomes clear in some of the comments here that AHDI itself isn’t doing the same.

First, Lea Sims (remember, the Director of Professional Programs), states:

I think the challenge is that as an association, we don’t know enough about the scribe role to conclude that a 6-month training program is either too long or too short for this position.

Clearly, as pointed out in comments made by Kathy Nicholls, using medical scribes to facilitate physician use of an EMR isn’t a new concept. And also clearly, this occupation falls squarely within the mission statement of the organization. So why is it, at this point, AHDI doesn’t seem to know very much about medical scribing and it’s place in healthcare documentation integrity? Forget how it relates to medical transcription. The purported reason for the name change was to adapt to changes in how healthcare documentation is accomplished, and to lead those changes. But it seems that AHDI is as stuck in the medical transcription mindset  as the people it purports to lead and instead of taking a leadership role, it’s continuing to grope in the dark for relevance within the narrow definition of “as medical transcriptionists, where are we going?”

Lea goes on to say:

We certainly COULD represent the scribe occupation and most of us agree that this new role falls well within our mission, goals and objectives as an organization, but I think you’re missing the fact that we can’t just walk over to an independent workforce group that formed on its own, stamp an AHDI logo on their heads and say, “Shazam, scribes. We own you.” LOL

Here’s my question: Why not? They seem to have no qualms about claiming to represent the entire medical transcription industry. Taking a leadership role would entail identifying potential careers in healthcare documentation integrity and taking a lead in developing the job description, education and training requirements and credentialing for those careers. In fact, I was under the impression when AAMT changed its name to AHDI that doing this was the whole point. Whether or not medical scribing is a career that medical transcriptionists can transition to isn’t really the point; the point is, it falls within the mission, goals and objectives of the organization and therefore the organization should be leading the way in setting the standards. If it was leading the way, there wouldn’t be a need to tell medical scribes we own you; medical scribes or people looking into medical scribing careers would be coming to the organization, looking for information and direction.

In a press release (PDF) dated August 10, 2006, the following was given as the reason for the name change:

The House of Delegates voted on August 2, 2006, to change the name of the association to Association for Integrity of Healthcare Documentation and open the membership up to a broader sector of healthcare professionals involved in clinical documentation and data capture.

Sounds good on paper, doesn’t it? And in reading this, one would certainly conclude that the organization intended to take an active role in the broader sector of clinical documentation, not limited to medical transcription or what medical transcription might become. It was, in essence, saying “we own you” to the entire healthcare documentation sector. In spite of its own mission statement, the organization still seems mired down in the medical transcription of it all. One would think the leaders behind the name change had a plan in mind that extended beyond a different name for medical transcription.

In terms of leading the way, AHDI gets a big fail on the medical scribe issue. Medical scribing is nothing new. In July 2008, the AMA News published an article about medical scribes (One answer to EMR data entry: Hire a scribe to do it).

Scribe companies, which previously had concentrated on hospitals, say they are finding demand for their services from individual practices.

Obviously, Scribe America not the first medical scribe company. I don’t know how long they’ve been in business, but their domain name was registered in 2004. Abbott Northwestern Hospital launched a physician scribe program in 2006.

So where is this change leadership we keep hearing about? You can’t say on the one hand that you’re leading change, then turn around and say you “don’t know enough about the scribe role,” a healthcare documentation career that’s been around for over four years. What other healthcare documentation careers has the organization not identified, not taken the lead on, not informed its members about? Four years is certainly enough time to evaluate the broader sector of healthcare professionals involved in clinical documentation, but maybe they’ve been too busy trying to decide whether or not to keep the House of Delegates and otherwise restructuring the organization of the organization.

It all apparently started with this article at Advance for HIM, Big Transcription… which got picked up and posted at the AHDI Lounge… which generated a lot of comments… which got Chad Sines thinking, so he wrote a blog post, Style Over Substance… which again got linked at AHDI Lounge.

Whew! And now, of course, I’m going to write a blog about it, because it seems my comments at AHDI Lounge never quite make it to publication – plus, I am going to be a bit long-winded.

So what’s the big deal?

The big deal is the English errors made in the original Advance for HIM article. Chad Sines seems to think MTs need to cool off a bit and pay more attention to the substance of what’s said and stop picking on the errors.

What struck me as off was that the comments seemed to suggest that since this MT made “glaring” errors, the substance of the article was not worthy of reading. The author apparently was to be shamed and discarded as seemingly irrelevant simply because of “mute” versus “moot” and other simple oopsies. While reading the comments I was almost yelling “WHO CARES??? Get off your pedestal and listen to the message!!”

Here’s the thing for me: there’s a reason for those big fat books on the shelf called “dictionary” and “Gregg Reference Manual” and that slim but oh-so-potent “Strunk & White.”

Errors such as mute instead of moot can certainly be overlooked – but as is obvious from the discussions at these websites, they’re distracting. It’s the equivalent of watching a period movie set in the 1800s and seeing an airplane fly across the sky in the background. Suddenly, you can’t pay attention to anything but the airplane, in spite of the fact that it’s a few seconds of a 90-minute film and a relatively minor event. And if you’ve ever watched TV or a movie with someone in the TV/movie business, you’d know that these types of errors are very obvious to them. Errors in spelling, grammar and punctuation are distracting and detracting for most readers, whether it’s a fiction novel or a professional journal – or a medical record.

If the Big Transcription article had been a blog post or a post in a forum or some other type of casual venue, errors could be written off – the author was tired, in a hurry, etc., whatever. But this isn’t a blog or a forum post, it’s an article in a professional publication that is widely read by everyone in the health information management chain. Is Advance for HIM no longer running articles past an editor? Or are the editors no better than the author?

Moving on, Chad compares this to the medical transcriptionist’s obsession with grammar and punctuation while overlooking glaring errors in the medical record.

The article in question isn’t a medical report. It’s a regular column published in a professional online magazine. By any publishing standard, the grammar and punctuation should be correct. Asking a group of people whose daily bread is the written word to ignore them is like asking a production assistant to ignore the airplane flying across the sky in a movie set in the 1800s.

The discussion at AHDI Lounge takes a turn in that direction, which then raises the question about Book of Style Bootcamps. Lea Sims defends the BOS as something other than a grammar and punctuation manual.

We can’t raise a fist at the use of a contraction and turn a blind eye to the clinical inaccuracy in the record that may impact care decisions. Both are necessary, but of the two, clinical accuracy can’t be sacrificed for style.

This really isn’t an either/or. There are few – very few – instances where clinical accuracy would even have to be sacrificed for style. Correct me if I’m wrong, but proper grammar, punctuation and spelling  are not exclusive of accuracy of medical terms and terminology. I can think of many instances, however, where improper punctuation, grammar and spelling have impacted the clinical accuracy of a record.

Feel the need to defend the BOS a bit (I’m biased, I know), but there is ONE chapter on grammar in the entire BOS and ONE chapter on punctuation.

The BOS is not about clinical accuracy of the medical record. It is about style. No big surprise there, given the title of the publication. As part of the MT Desk online style guide wiki project, I’ve been through the Book of Style for Medical Transcription with a fine-tooth comb. It’s a style guide, not a laboratory values reference or a word list or an anatomy guide, or anything else that would guide a medical transcriptionist to recognize accurate clinical documentation. Let me just open this book at random in some of the sections  and give you some examples – you tell me if this helps medical transcriptionists identify clinically accurate documentation. I’m going to identify Section 2, Chapter 4 (Grammar) as the ONE chapter Lea identifies as being devoted to grammar and Section 2, Chapter 6 (Punctuation) as the ONE chapter devoted to punctuation – everything else is fair game.

Section 3 is devoted to Measurement & Quantitation; i.e., numbers, percents, proportions, ratios and ranges, units of measure. I see how to decide when to use arabic numerals, Roman numerals and ordinal numbers. I don’t see any explanation of the clinical use of these numbers or how to determine whether or not what’s being dictated is within the accurate range. And oh look – there’s an entire section on punctuation when expressing numeric values in the record, covering days and times, among other things. Lots of clinical significance there. There’s another section on how to form plurals, use of numbers in proper names, use of numbers at the beginning of a sentence….

Section 4 is devoted to Specialty Standards. Surely, there’s something in this section that would help a transcriptionist make decisions about a clinically accurate document. Let’s see… commonly encountered elements in the periodic table and their symbols, how to write chemical compounds, how to write chemical names and concentrations… nothing there that would help me make decisions about whether or not the dictation was clinically accurate. The Pharmacology section devotes an entire page to the FDA approval process; while interesting, not especially helpful from either style or clinical accuracy point of view. As long as we’re being obsessive-compulsive about the little things, we could start a discussion about the clinical importance of capitalizing brand name drugs and not capitalizing generic drug names. There’s a section on the different DEA drug classes, but there’s only a short list, given as an example, of some of the drugs in that class. And while I would say it’s useful for an MT to know the forms of administration of a drug, as outlined on page 302, what would be helpful insofar as the clinical accuracy is knowing which drugs are administered by each method – but that information is missing.

I could go on and on, but you get the idea.

The Book of Style for Medical Transcription is a style guide. It may have only one chapter devoted solely to grammar and one chapter devoted solely to punctuation, but that doesn’t mean the rest of the book isn’t full of instructions for grammar and punctuation and (gasp again!) style as applied to the medical record. What it is not about is what drugs are administered by inhalation and what drugs are tablets, or what laboratory ranges are normal, or what diagnostic studies might be performed on specific parts of the body, or to rule out a specific diagnosis. In other words, it has nothing whatsoever to do with clinical accuracy. As the self-claimed author of the BOS, Lea Sims surely knows that.

The Book of Style does what it’s supposed to do – other than general grammar and punctuation, it provides a framework for how to format the terms found in medical records. The terms themselves, the anatomy, the physiology, the pharmacology, the diagnostic studies – in other words, the clinical aspect of the medical record – are not the purview of a style guide. For one thing, it would take several volumes to cover the amount of information required to ensure the clinical accuracy of a document. The medical transcription school an MT attends, subsequent training, reference manuals, quality assurance, etc. – those are the appropriate venues for ensuring that a medical transcriptionist has the information to assess the clinical accuracy of the document. And I’m not even going to climb on my soapbox (again) about the dangers of attempting to make medical transcription more important by claiming that MTs are or should be responsible for the accuracy of the medically relevant portions of the record.

As far as I’m concerned, the bottom line concerning the errors in the Big Transcription article is that this is an article by a transcriptionist, in a professional publication for health information management professionals, and therefore it represents – or should represent – the standards of the industry. Starting with the transcriptionist who made the mistakes and ending with the editor who didn’t correct them, it’s a poor reflection of the kind of skills a medical transcriptionist brings to the table. Really, if MTs can’t demonstrate that they know the difference between they’re/their/there, moot/mute, or any number of other common English language errors, how can anyone be confident that they have the ability to protect the clinical accuracy of the document? I recognize that nobody is saying the English language component isn’t as important as the clinical accuracy of the document; however, my opinion is that we have to view this in the broad spectrum. You don’t trust someone with advanced skills – and the clinical accuracy of a document is certainly an advanced skill – when they can’t even demonstrate mastery of their native language.

Unfortunately, I don’t have the original draft I had submitted, which got sent back to me for some editing because the PTB at AAMT didn’t feel I was being positive enough about the future outlook for medical transcription. That draft would have more accurately pinpointed my predictions for the industry and how I felt about the future of medical transcription. With that caveat…

Although many transcriptionists work through the internet, they may be unaware of the scope of technological changes and the jockeying for position currently taking place. Many see a threat from offshore labor, when they should be looking at the technology that resides on their own desktop. The very tools we use to enhance productivity are also available to the computer-literate physician, especially if packaged nicely and marketed aggressively by a far-sighted company. The advertising claims that physicians can replace their transcriptionists are not far-fetched. Some physicians have, in fact, done just that and are perfectly satisfied with the results. The number will increase exponentially over time, in much the same way the technology has advanced. Transcriptionists need to prepare themselves to work within the new model of  business that will be created by the available technology and the changing environment of business brought about by the internet.

I’m pretty sure that last sentence was part of the edit. Notice that I don’t say HOW MTs need to adapt. Quite frankly, if memory serves, I couldn’t think of a way they could that would keep them in this picture. After all, I just predicted that technology would give physicians more tools to facilitate reducing or completely eliminating medical transcription.

At the time the article was written, the AMA reported that 59% of physicians weren’t even using computers. I wasn’t able to find a recent study, which suggests to me that there’s an assumption that medical practices and healthcare facilities are using computers, including mobile devices.

My updated prediction is that this trend will continue and we’ll see an even bigger spike as more computer-literate physicians enter practice. They will not only be less resistant to entering data into the computer directly, they’ll be more proficient at it than their predecessors.

I also predict that as more computer-literate patients enter the system, and as technology advances, we’ll see patients entering their history directly into an EMR, either at the doctor’s office or online. Or, if interoperability issues are resolved, retrieved from a PHR. I predict updates will take place the same way, so you can review the history the physician or facility has for you and enter any updates or changes. As EMRs evolve and improve, the information you give the doctor will be available to any other facilities or offices in the system. There are already systems that share information with providers across the system. As always, the technology will only improve over time. Young adults who have used computers most or all of their life won’t wonder why they’re being asked to type in this information themselves – they’ll wonder why it isn’t available, or why they have to enter the same information multiple times in multiple places. I think there will even come a point when speech-to-text is so accurate that this data entry will take place in the form of speech, combined with touch screen and keyboarding.

A new tool becoming available to the individual transcriptionst and smaller business owners is the application service provider (ASP)… The purpose is to provide an “enterprise” solution for physicians (in plain English – one-stop shopping). By giving physicians access to something everyone knows they utilize, the portals hope to entice them to take advantage of other services and/or goods being sold through the portal. The advantage an ASP can give transcriptionists as a by-product is more equal footing with the large services. Access to both physicians and other transcriptionists becomes a possibility, at a price that is not beyond reach. It will no longer be necessary to take a deep breath, hyperventilage, then sign a five-year lease agreement for $60,000 worth of digital dictation equipment that will be obsolete before the lease is up. ASP networking will allow transcriptionists to work with each other to coordinate coverage for peak periods and time off… The ASP model provides state-of-the-art networking and upgrades inclusive with the other services offered.

I’m not sure the ASP model has been of great benefit to the independent MT, working solo or in small groups to provide service to select physicians. I think it has been of benefit to small transcription services looking for growth opportunities. In the past ten years, a model used by some ASPs is to do the marketing and sales, then contract with various independent MTs and small MTSOs to perform the work. In this scenario, the ASP sets the price to the client, not the MT or the MTSO. Like everything else, the ASP market has continued to evolve, with multiple acquisitions, change of ownership, mergers, and some winners and losers. Very few of them partnered with portals; instead, they became transcription platforms, with interfacing on the client end for compatibility with whatever technology the client used. Companies like InterFix made it easier to interface the ASPs with the multiple hospital IT systems and recently, in partnership with AHDI, created the Benchmark KB, a desktop application for transcriptionists that interfaces with various transcription platforms. The value of the Benchmark KB is that it reduces training and learning curve for transcriptionists working for a company that uses more than one platform.

Although currently many physicians remain blissfully ignorant of templates, macros and normals, that will change as doctors become more computer literate and money gets tighter. I predict more transcriptionists will be requested to discount or not charge for templates or normals.

I think I got this one right. What I missed completely was that anyone would not count spaces! I also missed that there would be transcription services (in my experience, predominantly overseas services) that would use this as a selling point, not only discounting the characters contained in templates, macros and normals, but also undercutting prices at the same time, further eroding the rates charged by US-only companies and the earning ability of medical transcriptionists here in the US.

The next level for speech recognition will be speaker-independent recognition. Translated for the technophobe, the technology will be able to understand the dictator who is your worst nightmare, with very little user training.

This prediction was accurate, in fact. Not that no training at all is required, but companies providing server-based (also known as back end) speech recognition do train the speech recognition engine, but they do it using a library of digital dictation files obtained from the system. Physicians are not required to sit and train the engine. Most of them are told they don’t need to change their dictation habits, which is more for the purpose of getting them to adapt to the system than anything else because there certainly would be a benefit to the accuracy of the documents if the physicians were willing to make some changes.

The question for transcriptionists is: will it matter if recognition accuracy is 100% when grammar, punctuation, syntax and language usage are not (how shall I say this?) – exactly representative of a strong foundation in English? My prediction is that it won’t. I believe as long as the document says what the dictator means it to say in a relatively clear (i.e., defensible) fashion, it will be accepted… While we may wring our hands that the quality of patient care is being compromised, who is actually compromising it – the physician, the transcriptionist, or the software used to create the transcript? Ultimately, the responsibility belongs to the physician. The more we try to take ownership of this responsibility, the more liability we expose ourselves to – a questionable tactic for assuring job security.

Well, I feel my crystal ball was working really well on this one and I probably don’t need to add anything to this.

If you don’t know the difference between DOS and Windows programs, it’s a reasonable conclusion that brushing up on your tech knowledge is necessary. I predict a future where computer literacy will be tested along with English literacy, and not just in the MT profession.

I found the following excerpts in current job listings for medical transcriptionists:

Cerner experience preferred. No satellite.

Meditech Client experience.

Are you reasonably computer literate? (This may be tested.)

Familiarity with transcription platforms (M*Modal, eScription, DocQScribe, and Spantel) a plus.

We are looking for editors who have had experience with the M*Modal platform.

You must have the necessary software (EditScript MT) and equipment (IN-DB9 or IN-USB pedal) in place with Microsoft word and a current electronic medical spell check loaded, ready to work.

Computer that is no older than 3 years. High-speed cable or DSL connection. Air card and satellite will NOT be supported. Internet service with AOL is not supported. RAM (memory) – 512 MB minimum. Hard Drive – 40 GB minimum. External computer speakers with volume control knob and headset plug-in. Good quality headset. USB port foot pedal. CD-ROM drive.

You MUST know how to use a FTP program to download and upload work. … Please DO NOT APPLY if you do not hve the required equipment or know how to use a FTP program.

I think it’s pretty obvious that computer literacy has become an essential part of the job, and we’re way past having to differentiate between DOS and Windows! What’s also become important is having a computer that has up-to-date software and current software. It would be difficult to find a job listing that doesn’t include software and hardware requirements, as well as internet connection requirements.

The article also completely neglected any mention of how technology would impact US medical transcription by facilitating overseas competition. Because digital technology and file transfer was available in 2000, I know overseas competition was a big concern for US MTs at that time. I’m not sure why I left out any mention of it – whether I was asked not to, or whether it was based on my opinion that there’s nothing you could say about overseas medical transcription that you couldn’t also say about onshore medical transcription, or whether I felt it had no place in a discussion that was about technology – I’m not sure. My memory isn’t what it used to be.

My crystal ball says that medical transcription as we know it will continue to deteriorate in both value and pay, and that advances in technology and a burgeoning population of computer literate physicians will contribute to that. We keep hearing that medical transcriptionists need to change their skill set and adapt in order to survive, and I agree with that. However, I see it evolving to an increasingly clerical position, with pay rates comparable to a clerical position. What MTs need to decide is whether or not they want to continue to work in the evolved position, at the evolved pay rates.

Hopefully, I’ll be around in another 10 years to see if the predictions I’m making here will take place.

Is the medical transcription profession doomed?

Just reading the title, I thought maybe AHDI was finally going to take off the rosie-colored glasses they wear in public. During the whole decline of the industry, they’ve insisted that there’s a place for medical transcriptionists in whatever new world health information documentation evolves to. (The other blog post there, Doctors weigh in on the use of scribes, is another worthy of its own separate rant.) So I eagerly went to read the entry, thinking maybe maybe AHDI is going to come out of the closet about the future of medical transcription.

Boy, was I disappointed when I read the blog entry. And surprised not only at the apparent cluelessness at what practitioner MTs (their base membership) go through on a daily basis, but the direction AHDI seems to be willing to take with the tone of this blog entry.

First of all, is it really standard practice for MT recruiters to not respond to those who are applying for jobs? Even if the applicant bombed the test, common courtesy would be to at least thank them for the effort, wouldn’t you think?

Is it really standard practice for the World’s largest professional association representing and advocating for healthcare documentation professionals (MTs, editors, and QA coordinators) (that’s what their Twitter profile says) not to know that yes, indeed, this is standard practice in the industry? That every day, recruiters receive hundreds of applications, solicited and not, and can’t possibly respond to all of them? That MTs take tests all the time – and never hear back a peep from the testing company? That common courtesy isn’t so common? That sometimes recruiters not only don’t know what they’re talking about, but they lie, don’t give direct answers to questions, set up phone calls they blow off, and are even downright rude?

Not that I think that’s a huge factor in what is happening to “doom” the medical transcription industry.

But here’s the part that blew me away:

It’s a tad ironic for someone so concerned about communication skills to criticize someone for not being “atriculate” and having poor “dictation.” And as anyone knows who has participated in online MT forums for any length of time, this scenario is all too common.

Let’s put aside for a moment that anyone who has participated in online MT forums for any length of time should know that the common response to this: I’m not at work so spelling, grammar and punctuation aren’t a priority. (And since I’m putting it aside for a moment, that’s all I’m going to say about it.)

How professional is it for the world’s largest professional association to slam a medical transcriptionist for spelling and grammar errors in an online forum? And a forum that isn’t even theirs?

AAMT/AHDI has never seemed to understand that nonmembers are still potential members and that’s demonstrated again in this blog post. It’s probably not a good idea to alienate your prospective membership base if you expect to recruit and grow – unless, of course, AHDI is happy with the number of members it currently has. However, by claiming to be the world’s largest professional association representing and advocating for healthcare documentation professionals (MT’s, editors and QA coordinators) it’s painting the MT world with a very large brush. I guess it wouldn’t sound so great to be the world’s largest professional association representing and advocating for a very small percentage of healthcare documentation specialists – but it would be a more accurate representation.

It’s one thing for a blogger with no affiliations to blow off steam about whatever they want. Heck, I do it all the time! But I don’t represent the professional association. Matter of fact, I don’t represent anybody but me. Call me old-fashioned, but the official blog of the professional association should be – well, professional! And in my opinion, being professional means you don’t slam MTs posting in forums for their spelling and grammar, even if they are anonymous.

AHDI had an opportunity to focus on something that’s wrong in the industry and actually advocate for the practioner MT – and they blew it by losing focus and attacking the messenger.

So if we’re looking at factors that doom the medical transcription profession, I have to say – AHDI, look at the mote in your own eye.