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.

However, medical transcriptionists everywhere can rejoice, knowing that AHDI now has a manual of ethical best practices available for us healthcare documentation sector workers.

And signaling that yes indeed, the practitioner member is once again not as important as the practitioner MTs themselves would like to think, there is no special pricing for practitioner members. Should you decide you can’t live without knowing why there’s a section for AHDI Code of Ethics and another for MTIA Code of Ethics, this baby will cost you a whopping $4,000.

Which is, I’m sure, just the start of the confusion.

After stating (very convincingly, I might add) that this is much, much less expensive than you’d pay if you put this together yourself or pay someone to do it for you (can you put a price tag on the AHDI Code of Ethics or the MTIA Code of Ethics? I think not), then setting you back on your heels with the $4,000 price tag – they soothe your ruffled feathers by letting you know that everybody except practitioner members can get this for less than $1,000.

Damn – I sure hope practitioners don’t actually need this for anything because at a reported average annual income of $30,000/year, the cost of this is just over 13% of an MT’s annual pay.

The pricing on this package (and possibly even the package itself) signals that not only is AHDI still floundering when it comes to offering anything of value to this membership group, they also don’t mind spitting in their faces. Because just in case you missed the part where you’re paying more than anyone else, there’s this friendly reminder:

It’s comforting to know that Gold Members of MTIA – which I’m sure includes companies that could actually afford to develop this information inhouse – don’t have to pay a dime. I’m sure this contributes mightily to the credibility of the claims that the relationship between AHDI and MTIA is good for both. I wonder how many Gold level members are on the MTIA Board. Just wonderin’, that’s all.

Isn’t it nice to know that AHDI knows which side its bread is buttered on? I’m looking on their web site and trying to find some indication as to who they think is going to pay the dues to keep the organization afloat if they piss off enough practitioner members, which still constitutes the largest membership group. Maybe AHDI has given up trying to find something of value to offer to the practitioner members.

Since I’m never going to pay $4,000 (or, let’s face it, $250, $750 or $950) to actually take a look at this manual of ethics and best practices, I really shouldn’t can’t say much about the package itself. I am, however, going to latch onto the term production location transparency. It’s a whole lot catchier – and easier – than “where is this work being transcribed?” I guess I’m just going to have to wither away with curiousity as to the difference between AHDI’s code of ethics and MTIA’s code of ethics.

In short, the Economic Times article sums up the pertinent issue:

…investigations conducted by a British TV channel have come up with the stunning revelation that confidential medical records sent to India for computerisation are being offered for sale, triggering heightened concerns about breach of data security here.

I expect a pretty instant reaction. The BPO business in India is too lucrative to be threatened by something like this. In fact, an English-language Indian blog site posts a response from NAAVI (a portal on Indian cyber law). Unfortunately, whatever NAAVI has to say about this is not available due to some glitch at the web site, but the blogger posts an article related to it (or it’s the NAAVI article, reposted – hard to tell when I can’t read the original): Medical Transcription Industry in India needs to tighten its security.

Ya think?

However, it is possible for sections of the International Community which is opposed to outsourcing business to India to pick up the current incident and blow it out of proportion. They may actually try to get sanctions passed against outsourcing of business to India through the Data Protection Act in EU or through HIPAA/HITECH in USA. The problems will not stop at the small medical transcriptionists. It is likely to affect the image of the country as a “Security Conscious” country and would hurt even the larger companies.

This should be an interesting development to keep an eye on!