The latest comment that drew my interest is Lea Sim’s response to one of my comments, where she says:

…unless we can make a solid argument to someone like CMS or HHS or the Joint Commission that there is at least SOME risk to the patient in having unqualified hands in a health record, considering how inconsistently physicians actually read the records they put their signatures to.

I have disagreed with this position in the past and I’m going to keep disagreeing with it.

I want to know if there are any other highly educated, highly trained professionals preparing medical-legal documents who wouldn’t be expected to ensure that those documents are accurate before they sign them. Oh heck – I don’t know of many professionals, highly trained or otherwise, who don’t understand it’s their responsibility to ensure the accuracy of the documents they sign.

I was a secretary for years and not only are non-medical professionals as a whole more conscientious and courteous about their dictation, they all also understood that they needed to actually read the transcribed document before they signed it. After all, that’s their name on it, not the transcriptionist’s. Whoever is going to receive the document doesn’t know – and frankly doesn’t care – who typed it. If there’s a problem with it, they call the person whose signature is at the bottom, they don’t start hunting down the person who typed it.

I’ve had insurance adjusters read a transcribed letter telling a claimant that their case has been settled more carefully than some doctors read an operative report before they sign it. That’s not a reflection of how much either professional trusts the person who transcribed their dictation, either.

Now, I understand that doctors are busy. But really – what special power relieves them of the responsibility of making sure that the medical records they create and have responsibility for and to which they affix their signature are an accurate representation?

Let me quote myself, from a prior post Whose medical records are they anyway?

Let me review, in case anyone missed my comments a couple years ago in Advance for HIM. The average medical transcriptionist has a high school education. The average physician has a high school education, plus 8 years of higher education. The average medical transcriptionist is trained on the job. The average physician spends three to six years in internship and residency training programs. The average medical transcriptionist makes less than $30,000/year. The average family physician makes over $130,000 a year, and that’s the lowest-paid group; specialists can make up to $800,000 a year. Physicians are one of the highest-paid occupations in the U.S. The physician is trained, licensed and paid to make medical decisions; the medical transcriptionist is not. The records belong to the physician, not to the medical transcriptionist. When the physician signs the document – with a pen or electronically – he or she is verifying that it is a medical-legal document that is true and accurate to the best of his/her knowledge.

Which one of these people do YOU think should be responsible for making sure the documentation is correct?

As long as AHDI keeps beating this drum, I’m going to keep repeating myself. This is a dangerous, slippery slope. Making transcriptionists responsible for the accuracy and completeness of the medical record does not make medical transcription more valuable in the healthcare community.

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

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

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

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

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

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

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

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

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

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

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

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

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

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.

Organized to emphasize the necessary return of United States citizens’ patient information to United States-based Medical Information Specialists, Medical Transcriptionists and Medical Language Specialists, furthering the continuation of these health care careers, furthering education, and providing appropriate compensation and job benefits for Medical Information Specialists, Medical Transcriptionists, and Medical Language Speciaists, thereby fostering our status as vital links in the chain of quality health care delivery and the protection of patient privacy.

Don’t go searching the WHOIS registry to find out who is behind this – it’s got a privacy shield on it. And the domain name is freshly registered this month (January 9th).

The medical transcriptionist in me is finding all the grammatical and typographical errors in this site and I’m trying really hard to concentrate on the stated purpose of the site – but c’mon people. Basically what this site is showing people is that they were right to go overseas for cheap crap (see my Quotes section) if this is the best USMTs can do!

The United States Medical Language Speciaists Union Initiative was conceived by a group of independent Medical Language Specialists, Medical Transcriptionists, and Certified Medical Transcriptionists, who cannot sit idly by as sensitive United States’ citizens’  patient  information, and U.S. jobs, disappear beyond U.S. borders, beyond U.S. legal and HIPAA enforcement jurisdiction, beyond our control.

(Pssst! If you’re looking for someone who will find and fix all the errors in your site, I can refer you to a very excellent web site editor!)

Moving on to the issues – this is one of my favorite parts:

As patient privacy has been disregarded, so have Medical Language Specialists.  We have been manipulated by fear tactics, threatened that our work will be sent overseas if we do not accept drastic pay and benefit cuts.  We have been forced to work as independent contractors, when we are actually employees, to save service owners the cost of Social Security contributions, and we are one of very few technically skilled trade groups who earn only half of what we earned 15 – 20 years ago while the cost of living has continued to rise.

Folks, nobody has forced you to do anything. You chose to accept the conditions. Do we need to send everyone to Al-Anon?

The cascade of circumstances that have led us to the current condition in medical transcription would take a series of blog posts, but let me point to a major contributing factor: nobody can take advantage of you unless you give them permission.

This seems to be an organized group of determined people so I’m really disappointed to see this kind of codependent – and yes, juvenile – whining.

I have to say that while usually you can’t get 10 MTs to agree to leave a burning building, these people are to be applauded for getting together 50 MTs to promote their agenda in front of decision makers in Washington, DC.

Fifty independent American MTs are traveling to Washington during the last week of January.  We have been invited to present proof, to health care administrators, clinicians, patient omsbudsmen and members of Congress (who are patients themselves) of the horrific “quality” of overseas medical record transcription, revealing the “before U.S. MT QA” product which MTs edit for pennies from offshore companies every day.

My primary concern here is – where are they obtaining these records and do they have permission to use them in this case?

My secondary interest is whether or not they will also present evidence of the kind of work done here in the U.S. Maybe they aren’t aware that there are plenty of MTs here in the U.S. doing crappy work that has to be cleaned up by extensive editing. Or maybe they are – it’s certainly in their best interest to present a one-sided story, isn’t it?

Another concern I have is why this group has chosen to remain completely anonymous. The domain name registration has a privacy shield and there is absolutely no information at the web site about the principles in this organization or whether it’s an organization with a legally recognized structure. Hopefully, someone involved will come forward with some information.

I’d like to wish them the best and encourage everyone to join the cause but I’m afraid it’s a lost cause without a lot of merit. Oh, and then there’s the codependent whining factor that makes us all look bad.

Folks, overseas transcription is here to stay. It isn’t going to go away. I’ll make every effort to blog my thoughts on why transcription pay (and rates) have gone down but it doesn’t have as much to do with overseas transcription as US MTs would like to think. And I’ve always said everything you can say about overseas transcription can be said about US transcription, so there isn’t a moral high ground here. Proponents of US-only transcription need to stick with one issue and ignore all the other shiny objects. If the issue is privacy, then make that the issue and don’t bring in pay rates and quality.