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?

The topic at AHDI Lounge is AHDI and MTs. Basically, it’s a highlight for the more in-depth AHDI “Let’s Talk About…” series and Barb Marques’ AHDI and MTs (PDF) talk-about. While Barb Marques’ piece is interesting, for me the most interesting part of this AHDI Lounge post was the comments (as is usually the case).

The first comment refers to the impact the VBC (visible black character) standard (explaining why this isn’t really a standard is another discussion entirely) has had on medical transcriptionist’s pay rates.  To which Laura Bryan responds:

AHDI is not responsible for issuing the “VBC”. This standard was issued by MTIA and AHIMA.

Now, just to be clear: Laura Bryan has no official position with AHDI. As far as I can tell, she never has (and I’m quite certain I don’t need to invite anyone to correct me if I’m wrong, but please let me know if I am). At the very least, however, she’s a very vocal supporter.

To which I asked – why wasn’t AHDI part of the task force on the visible black character?

And Laura responds:

@Julie, the standard was intended to address BILLING, not compensation. The MTSOs and AHIMA are most involved in billing negotiations.

When I noted that billing and compensation are related, Laura elaborates:

@Julie, I didn’t say they weren’t related. But it is common knowledge that billing is not necessarily calculated the same way as compensation. The standard was not intended to address methods of calculating line rates for the purpose of compensation.

The way I understand this statement, Laura believes AHDI wasn’t involved in this task force because it was about billing, not compensation. This is a direct contradiction to the following statement by Barb Marques in the referenced Let’s Talk About… article:

We have few weapons in the arsenal to “force” employers to alter their compensation practices. As I shared above, sometimes the only way to impact something you can’t get your hands on is to chip away at the walls around it in hopes of a breakthrough. For AHDI, that means identifying and addressing marketplace drivers that impact billing, whose inarguable bedfellow is compensation. (emphasis added)

I don’t know about anyone else, but I would certainly classify the VBC white paper as a market driver that impacts billing. And let’s not get confused as to the difference between recommending compensation rates and setting standards. When the organization was AAMT, it most certainly was involved in all kinds of standards setting, including billing.

One goal of the white paper was to provide a standard that would give the customer base the ability to compare apples to apples when evaluating proposals from outsourced medical transcription services. However, that was only one goal.

The goal was to implement a standard for content measurement that health information management (HIM) practitioners can use to evaluate in-house transcription staff and external transcription service suppliers.

And makes the recommendation:

The task force recommends that this definition be adopted by all organizations producing medical transcription, including those using in-house staff to transcribe dictation.

That’s pretty clear intent, wouldn’t you say? Anyone who thought it wouldn’t impact transcriptionists working for the outsourced services is either brain dead or sleeping at the wheel.

AHIMA subsequently issued a FAQ (frequently asked questions) about the white paper, where it states that the white paper does not call for MTSOs to change compensation methods for medical transcriptionists.

Though adoption of the VBC unit for compensation of medical transcriptionists was neither the intent nor recommendation of this paper, we recognize that some will choose to adopt it for compensation and strongly encourage those service owners to engage in the same research and analysis outlined in this paper, as well as dialogue with their transcriptionists, in transitioning to this new methodology.

I read this as AHIMA backing down from what was actually published in the white paper. I question why the white paper would recommend adoption by all organizations and specifically include in-house staff if the intent wasn’t to apply the VBC to calculating compensation.

Additionally, let me point out something maybe Laura has forgotten: not all medical transcriptionists – not all members of AHDI, even – work for a hospital or transcription service. I’m not quite sure how Laura could forget this, since she runs a medical transcription service and is obviously a member of AHDI. The suggestion that AHDI would decide to bow out of a task force attempting to set standards involving billing units because it didn’t involve compensation suggests that AHDI isn’t representing the interests of all its members.

Perhaps AHDI didn’t bow out; maybe it was never invited to the table. If that was the case, it demonstrates the weak position AHDI has in the healthcare documentation community.

In all fairness, Laura does make the point that the “standard” is being applied in a detrimental way that was most likely not intended and that AHDI did say it was not in favor of the VBC without adjusting equivalent pay. This is, in fact, stated in the white paper:

Financial analysis must be completed to establish the equivalent VBC pricing in comparison with the existing rate and unit of measure. The company must then ensure the counting and financial applications are properly configured to support the new method for consistency and verifiability. As mentioned previously, comparative modeling showing each method side-by-side on invoices will more than likely be required.

The same problem came into play when the 65-character standard was enacted. But that doesn’t excuse AHDI from taking a back seat in any attempt to set standards that impact the industry. The fact that there were problems associated with the 65-character line standard, which AAMT ultimately backed away from as a result of these issues, isn’t a reason to bow out of any further attempts to set standards that will impact transcriptionists, the industry and compensation. I would argue, in fact, that it was an opportunity (now lost) to take the lead to make sure billing standards that could impact compensation would not be used to the detriment of transcriptionists.

I’ve been pretty retrospective lately about my career in transcription and these posts take me way back. They highlight both what hasn’t changed and what has changed.

What hasn’t changed is the quest for independence. This is part of the true entrepreneurial spirit. Quite honestly, MTs who strike out on their own to do a couple of local office accounts are my toughest competitors. They are almost always willing to provide a level of service I can’t match at a price I don’t want to match.

If this is what you want to do, there are a couple of things you need to take into consideration. All this advice, of course, assumes that you are good at what you do and your clients will be happy with your service.

Know what you’re getting into

When you’re on your own, you’re really on your own. You’re on the hook to meet your commitments and you have no backup. Sometimes you may have very little work and sometimes you may have more than you can handle. If you want to take time off, you have to decide whether the account is the type where you can suspend service while you’re gone or if they will expect you to cover. Usually, this means you won’t be taking as much time off as you might like and you may be working longer hours/more days than you’d like. That’s part and parcel of having your own accounts.

I know some MTs have pooled together with other MTs in their area to back one another up. If you do it right, this can work. However, you need to make sure the people you’re cooperating with can be trusted. Not only do you not want them soliciting your accounts, you want them doing the job the way you would do it. Make sure everyone has a clear understanding of what’s expected and what the compensation will be – and put it in writing.

Don’t promise the world

This is probably the #1 mistake made. We all make it. I made it. I don’t know anyone who hasn’t. We’re so eager to land that first account that we’ll say yes to just about anything. If you do a good job, you may have that account long enough to regret making those promises.

It’s very difficult to go back and revise client expectations. Take a good, hard look at what the client is asking and ask yourself if you will be willing to provide the service on those terms for the next 5 years. Ideally, you will keep your accounts for years and years. Although this is less certain with advancements in technology, keeping your accounts for as long as possible should be a goal you set for yourself. It’s easier and less expensive to service existing clients than it is to be constantly looking for new ones. So again – ask yourself if you want to be providing the expected level of service over a long term.

That’s not to say you can never renegotiate with a client. If they are extremely happy with your service, they may be more willing to make requested changes. It’s expensive and difficult for them to find a replacement for you, as well. It’s always easier to start out with reasonable expectations from one another, however.

Always be willing to let an account go

As tempting as it is to have one really good account that keeps you as busy as you want to be, it puts you in a bad position if you have to renegotiate anything. If you are willing to concede anything to keep the account, the client will sense this. Not only will your negotiation fall apart, you may lose ground.

Never ever go into a negotiation with a client without being willing to let the account go. Ever. Ever.

That means no account should constitute more of your business than you can afford to lose. Typically, the number is 30%. It’s easier if it’s lower, around 20%. You can afford to lose 20% to 30% of your business – but can you afford to lose 50%, 75% or even 100%? Most likely not.

The downside to this is that you may have more work than you really want to do in order to keep all clients at a lower percentage level. It’s also more work to maintain multiple accounts instead of 1 or 2 accounts – which is why so many independent MTs are tempted to just stick with 1 or 2 accounts.

As always, advice to be taken with a grain of salt and an eye towards what works best for you. All comments welcome.