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.

In an effort to help doctors make sense of this mess, The AMA News collaterally helps out business associates, so it’s a good idea to follow along if you are interested in what the doctors are being told and how it applies to medical transcription services. Attorney Steven Harris, reporting in the AMA News, writes:

Those agreements you signed to comply with the Health Insurance Portability and Accountability Act probably need to be torn up, rewritten and re-signed.

One of the most significant changes that HITECH makes to HIPAA is that the relationship becomes bilateral. Under HIPAA, medical transcription service providers were not covered entities. Under HITECH, they are. Under HIPAA, the physician was responsible for monitoring business associates for breaches. Under HITECH, the business associate must also monitor the physician’s compliance.

In another article, Stimulus package alters HIPAA rules for business associates, Mr. Harris goes into some informative detail about what business associates are supposed to be protecting:

A business associate is someone who, on behalf of a covered entity, performs an activity involving the use of disclosure of individuals’ health care information.

…Under the stimulus bill, several HIPAA security provisions now apply to business associates in the same manner that those provisions apply to covered entities. That means business associates of covered entities will now have an affirmative duty to protect the confidentiality of electronic protected health information created, received, maintained or transmitted in performing services for or on behalf of covered entities.

Even if you are only providing services 1:1 to a physician, read the article by Mr. Harris and take steps to protect yourself. He suggests that a contract should outline what steps the physician will take if there is a suspected breach, so that both parties know what to expect and for reporting purposes.

At this point, other than to say it’s probably time to start looking at the contractual relationship you have with your clients, regardless of how little you think you are and/or whether or not you believe HITECH will impact you in any significant way. I’m not going to go into detail about what MTs may or may not be required to do as a result of this legislation; I will suggest that you follow Mr. Harris’ articles at the AMA News. They’re written for doctors, but MTs and MTSOs will be able to apply much of what he writes about.

Thanks for your comments. I was curious what your take is on the state of the profession in light of the trend to offshore transcription work. Do you think there are enough nightmare overseas transcription stories to keep work stateside or will the trend only get worse? I ask, as I have seen others whine and complain about their jobs being shipped overseas, but their work product leaves a lot to be desired.

As you’ve noted, there are enough nightmare stories stateside to keep it going overseas. There’s nothing you can say about offshore companies/MTs that you can’t say about US companies/MTs. This gives rise to (one of) my mantra: If people are going to get crap, they’re going to go for cheap crap.

The fact is demand remains high for QUALIFIED transcriptionists and it will remain high, although I don’t predict we’ll see better pay rates. There seems to be a weird bubble in the supply/demand theory when it comes to MT. This is only partly attributable to the overseas companies, something US MTs don’t seem to understand or don’t want to take the time to understand.

In my opinion, at least half of the US MTs who decry the poor quality of overseas transcription and pound their breasts in nationalist fervor would be surprised (and outraged) if you tell them they aren’t doing that great a job themselves. They have jobs, they’ve been MTs for years (many of them) – how could they possibly NOT know what they’re doing? (See my prior post: Not so dark, just cloudy, side of medical transcription). When I was trying to find another MT company to subcontract some work to a couple years back, we trialed 6 transcription services and found only 1 that met our standards. I was told I was too stringent, that words that didn’t change the medical meaning shouldn’t be counted as errors (even though they were quite plainly spelling or English word errors), that the client’s requirements were picky, etc. etc. – yet all I was asking was: (1) all the words be the RIGHT ones, (2) all the relevant words that had been dictated be included in the transcription, and (3) all the words (English and medical! radical concept, I know) be spelled correctly. That was “crap” on a large scale – if the MT company owner has the attitude that the work they do is fine and my service is “just too picky,” then you can bet they have X number of MTs whose work wasn’t all that great, too. Extend that down to the finer level – only 1 out of every 10 MTs we trialed made it through the initial QA process. Unfortunately for the medical records industry, those other 9 had no trouble going out and getting a job with someone else who “wasn’t as picky” – and trust me, most of them had no problem letting me know that the problem was not THEM – it was ME.

Want samples? I have plenty. In the “just plain sloppy typing” category:

T: She feel about a month ago
E: She fell about a month ago

T:  loss of vision of acute eye pain
E:  loss of vision or acute eye pain

T: see my noted from
E:  see my note from

T:    difficulty with bend forward
E:    difficulty with bending forward

T: some ibuprofen and Vicodan.
E: some ibuprofen and Vicodin.

And in the “it doesn’t make sense to me but that’s what it sounds like so I’ll guess” (aka “brain off, fingers on”) category, which assumes that the MT even knows enough to realize what’s being typed is complete and utter nonsense:

T: Advair discuss,
E: Advair Diskus,

T: in case it might be the beginning of adult palsy.
E: in case it might be the beginning of Bell palsy.

T: finger reveal a nondisplaced volar placed, avulsion fracture
E: reveal a nondisplaced volar plate avulsion fracture

T: Favors test is negative bilaterally.
E: FABER test is negative bilaterally.

T: TMs are clear, with cerumen.
E: TMs are occluded with cerumen.

T: minimal form rotation
E: minimal forearm rotation

T: transit history
E: transient history

T:    with modality with unstretch exercises.
E:    with modalities and stretch exercises

T:  is no lag of thalamus noted
E:  is no lag ophthalmus noted

Now I bet anyone reading this would not disagree with me that – sloppy or ignorant – these are errors, plain and simple. So why is it most MTs blame QA when errors like this are pointed out to them?

And what really gets me is this: probably only 1 in 10 MTs was appalled. The other 9 became defensive and argumentative. If someone pointed out errors like this to me, I’d sink straight into the ground. In fact – someone did at one time. At a point when I’d been out on my own for several years, I went to work for a small company. I thought I knew my stuff – until QA got done with me. I was mortified, not only at the errors they pointed out to me, but at the realization that my training hadn’t been as complete as I’d thought and that I had, for years, been making these mistakes. I took as much correction as they were willing to give me, for as long as they were willing to give it to me. I learned a LOT from those 2 QA experts and I thank them for it.

But what happens to the other 9 MTs who become defensive and argumentative? They move on to a company that’s “not so hard to work for,” that’s what. Do they learn anything from it? (No.) The fact that they can get another job with someone else who doesn’t tell them they do a crappy job only reinforces their belief that the problem isn’t them. This delusion continues despite the fact that they know nobody is actually looking at their work.

OK, back to the topic of overseas transcription – anyone who still wonders why hospitals and doctors went for the cheap crap overseas, feel free to comment.

On another note, do you see voice recognition really making inroads in the field or is the technology still too far off and too annoying to “train” to make a difference in the business?

There have been no significant advances made in speech recognition technology in the past 10 years (or more). There are technologies that make it easier to use, but the recognition engines themselves haven’t changed much over that period of time. Companies like M*Modal and e-Scription require a certain (and significant) volume in order to make it worth their time to do the preliminary work required to achieve any kind of success. It will be used to increase productivity for MTs in certain sectors, but it won’t eliminate jobs.

There are doctors who use it to dictate directly and there are studies that show this slows them down, resulting in either fewer patients seen or more time spent in the office. I’m not going to take the time to dredge up the references, but the information is available. From my own observations of CSR used this way, most of them aren’t using it properly, which only increases the errors and the amount of time required to fix them.

The EMR is more likely to eliminate transcription jobs, especially as younger doctors enter the field. They’re used to keyboarding and using computers. As the EMR software developers incorporate more blended technologies – speech, touch screen, templates, point and click – all in one package, there will be a higher adoption rate. Right now, EMRs are struggling to sell themselves. Unfortunately for them and us, they’re using elimination of transcription costs as a sales point, pointing out that the system pays for itself because overall it will cost less than the practice or hospital spends on transcription. The fallacy in this is that highly-skilled, highly-paid professionals then perform the task of a medical transcriptionist – which makes absolutely no sense. Physicians struggle enough with the financial justification for an EMR; coupled with resistance to change, it has pretty much guaranteed slow adoption of EMRs, especially in smaller practices. I suggest reading the Accelerating Adoption of Healthcare IT blog, by Nick van Terheyden, MD. He made this point in his presentation at the recent TEPR conference. To put a point on it, you wouldn’t find Jack Walsh typing his own annual reports or Warren Buffet manually entering stock values into the computer (well, maybe Warren does – but I’ll bet Jack doesn’t). Ultimately, however, the technology and programming will improve and the number of younger doctors who haven’t spent the past 20 years dictating will exceed the number of physicians who have – and we’ll see a greater impact on our business.

To answer the question, I see technology making inroads, but slowly. I see the cost of technology, as well as privacy and security regulations, making it more difficult for small MT services and independent MTs to stay in business.