Creating A Documentation Assembly Line

Designing effective documents and learning how to produce them in an assembly-like pattern (so that they end up looking like customized letters and reports), involves a similar process to the one used by the chef who creates customized omelets for a Sunday hotel brunch. The basic parts of the documents to be created should be engineered in advance so that you can assemble data in a modular style and then add in the frills and embellishments necessary to customize each report you dictate.

The key to success is learning how to organize your thoughts. Most physicians are forced to dictate when they are tired, rushed, or stressed out. As a result, they find it difficult to concentrate while dictating.

Frequently, physicians will dial into a digital dictation system and then hang on the line while they try to find the information they are looking for. Often they will skip back and forth through a patient's chart while looking for pertinent details (and making no sense whatsoever).

You would be shocked to discover how many doctors, after dictating thousands of reports, still cannot think on their feet. Listening to them fumble through the same report they must dictate day after day is embarrassing.

When dictating, you must always remember that the person receiving information from you is only getting aural input. Although that person can see what is on the computer screen in front of him, he cannot read your mind. As a result, you have to act like a seeing-eye dog for the transcriptionist by delivering the proper vocal cues each and every time you transmit information.

Next: Practice Makes Perfect

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Changing Work Styles

In the old days, a physician might dictate some reports and leave the patients' charts on the transcriptionist's desk with instructions to glean any additional information from the chart and put it in its proper place in the report.

If a transcriptionist mentioned that the physician had dictated a laboratory value which was obviously incorrect, the physician might wave his hand and casually say "Well, just go ahead and fix it" on the assumption that the transcriptionist had the time, the ability, or the authority to search for a patient's chart, find the appropriate information, and make the necessary correction.

In today's world, this is impractical, inefficient, and more often than not, physically impossible. Because transcriptionists are not necessarily working on-site, they rarely have access to a patient's chart. And, since some transcriptionists work during the evening and on weekends (when a Medical Record Department or physician's office might be closed), they cannot always ask someone to access a patient's chart for them.

Medical transcriptionists are no longer paid to bring productivity to a grinding halt in order to embark on an informational "wild goose chase" in the hope of finding a patient's medical record number -- or the proper mailing address of someone who is supposed to receive a copy of a dictated report.

That's no longer their job.

With computers having changed so much of the work process, let's take a close look at who is responsible for each part of the information chain

Next: Dictating Physician
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Dedication

If a person is genuinely lucky during the course of his life, he will encounter one or two people who help him to believe in himself and inspire him to keep working at whatever he has chosen to do. I was extremely fortunate to cross paths with three remarkable women at crucial turning points in my life.

During the late 1960s, while she was starring on Broadway in the hit musical Mame, I made the acquaintance of Angela Lansbury. Watching her perform the title role many, many times in Broadway's Winter Garden Theater (while managing to keep her performance fresh for each new audience) showed me what it meant to set high standards of professionalism and stick to them.

Offstage, Lansbury demonstrated to all who worked with her what it meant to be a good colleague and a hard worker. Angela and I began to correspond and, shortly after moving to San Francisco, I received a letter in which she wrote "With your talent, I have no doubt you will land on your feet."

Because her letter arrived at a particularly stressful time in my life, I remember being flabbergasted that a "big star" like Angela Lansbury could be generous enough to reach out and give a few simple words of encouragement to someone living in a world which must have been light years away from her daily reality. Her words bolstered my spirits during many emotionally tough moments and Angela has always been an inspiration to me: as a performer, as a professional, and as a human being. Here are two clips of Angela and George Hearn performing Stephen Sondheim's tongue-twisting lyrics from Sweeney Todd: The Demon Barber of Fleet Street.

During my career as a freelance writer I gained a reputation as the only music critic to give serious attention to the growth of regional opera throughout the United States. One of my most stalwart supporters in this endeavor was Ava Jean Mears, who was then Public Relations Director and Archivist for the Houston Grand Opera. A woman with an incredible memory, Ava Jean is a writer's strongest ally (a colleague once opined that if he ever needed to find a one-legged albino dwarf who could swing upside down from a tree limb while singing all four parts of some obscure operatic ensemble in Swahili, that person probably went to school with Ava Jean).

The dozens of professional arts publicists who matured under Ava Jean's guidance learned how to be solicitous without being pushy, how to be concerned without being territorial and, above all, how to be fair when dealing with the press. When I became National Editor of Opera Monthly magazine and needed an additional pseudonym for my writing, Ava Jean's devoted golden retriever, B.J., was hauled into service. Numerous young American opera singers were subsequently interviewed by "B. J. Mears" and were grateful for the opportunity.

In January 1991, after 15 years as a freelance journalist and opera critic, a combination of decidedly unpleasant events knocked the wind out of my sails. Forced to abandon my career as a writer and get a "real job," I was lucky enough to fall back on a skill I had completely forgotten I once had: medical transcription.

Although I had not transcribed for more than a decade, Janet Photinos, who believed in my talent, gave me a chance to sharpen my skills and start transcribing again. Had she not done so, I might have become homeless. A tough-minded, stubborn woman, Janet set extremely high standards for herself and everyone she hired. She believed in fighting for both the patient and the dignity of the English language. Unlike many other transcriptionists, Janet did not hesitate to criticize doctors for their sloppy dictation habits. As a result of her prodding, I eventually joined the American Association for Medical Transcription. AAMT's invitation to speak at its second annual managers and supervisors conference in Las Vegas triggered a curious chain of events, which led to the creation of this blog.

To Angela, Ava Jean, and Janet, my heartfelt thanks for your generosity, inspiration, and encouragement.

Consciousness Raising Exercise #3

One of the most frequent ploys used by physicians to intimidate fellow members of the patient care team is to accuse others of being jealous that the physician received a better education and that he makes more money than they do. Another tactic is to suggest that a doctor, by definition, is a professional and that anyone who lacks a license to practice medicine is not.

When a doctor haughtily suggests that a medical transcriptionist is jealous because the MT's education was inferior to the physician's, the medical transcriptionist is primed and ready to ask the learned doctor this question:

"Would you please tell me why, if my education was so inferior to yours, it has become my professional responsibility to identify and correct the documentation mistakes in your work that endanger a patient's care and make both you and this hospital vulnerable to a medical malpractice lawsuit? I'm really eager to understand this, especially since these are mistakes that you (as a doctor with such a superior education) should not be making!"

In recent years, the health information management industry has insisted on maintaining the highest professional standards of quality assurance with regard to accuracy in patient documentation. Coders, abstracters, and medical transcriptionists must all be held accountable for the accuracy of their work. And yet the accuracy of their work is totally dependent on the accuracy of the data they receive from doctors.

List ten reasons why dictating physicians should strive to meet the same standards of accuracy imposed on the health information management industry's knowledge workers.

1.____________________________

2.____________________________

3.____________________________

4.____________________________

5.____________________________

6.____________________________

7.____________________________

8.____________________________

9.____________________________

10.___________________________

Consciousness Raising Exercise #21

In an effort to save on transcription expenses, a consortium of hospitals decided to pool their bargaining power. Working with a medical practice management consultant, they entertained bids from the largest transcription agencies in the area. The agency that came in with the lowest bid got the contract for several large and lucrative hospital accounts.

Although Agency A's management bid successfully on the contract, Agency A did not have sufficient transcribing talent to meet its obligations. As a result, dictation which should have been transcribed within 24 hours was frequently five days late.

The head of the liver transplant service at one of the hospitals was appalled to discover that a two-page report contained 50 mistakes. When he protested to the hospital administrator about the poor quality of transcription, he was told that the hospital had locked itself into a contract for that price and it didn't matter how bad the reports were -- the hospital was bound to honor its contract with Agency A.

From the hospital administrator's standpoint, the lowest price per line was the driving factor behind the contract. Yet the hospital's risk management advisors might have felt otherwise -- had they understood how vulnerable the administrator's cost-cutting decision would leave them to medical malpractice lawsuits.

In an essay of 250 words or less, explain why the lowest possible rate can also guarantee a higher percentage of errors when outsourcing transcription services:

Consciousness Raising Exercise #37

One of the critical failings of voice recognition is its inability to spot contextual errors. Despite industry claims that artificial intelligence will soon take care of these minor "glitches," artificial intelligence is exactly what it claims to be.

The following headlines are notable for their sexual innuendo and/or typographical mistakes. Whether or not the meanings were intentional, these headlines are reputed to have appeared in the newspapers listed below them.

GATORS TO FACE SEMINOLES WITH PETERS OUT
The Tallahassee Bugle

MESSIAH CLIMAXES IN CHORUS OF HALLELUJAHS
The Anchorage Alaska Times

GOVERNOR'S PENIS BUSY (should have been "Pen Is Busy")
The New Haven Connecticut Register

THANKS TO PRESIDENT CLINTON, STAFF SGT. FRUER NOW HAS A SON
The Arkansas Plainsman

CLINTON PLACES DICKEY IN GORE'S HANDS
Bangor Maine News

STARR AGHAST AT FIRST LADY SEX POSITION
The Washington Times

CLINTON STIFF ON WITHDRAWAL
The Bosnia Bugle

LONG ISLAND STIFFENS FOR LILI'S BLOW
Newsday

ORGAN FESTIVAL ENDS IN SMASHING CLIMAX
San Antonio Rose

PETROLEUM JELLY KEEPS IDLE TOOLS RUST-FREE
Chicago Daily News

TEXTRON INC. MAKES OFFER TO SCREW COMPANY STOCKHOLDERS
The Miami Herald

MARRIED PRIESTS IN CATHOLIC CHURCH A LONG TIME COMING
The New Haven Connecticut Register

GOVERNOR CHILES OFFERS RARE OPPORTUNITY TO GOOSE HUNTERS
The Tallahassee Democrat

WOULD SHE CLIMB TO THE TOP OF MR. EVEREST AGAIN? ABSOLUTELY!
The Houston Chronicle

MONDALE GETS WARM RESPONSE FROM FRENCH HEAD
Champaign-Urbana Gazette (ca. 1978)

In 150 words or less, explain what can go wrong if a medical language specialist is not editing a doctor's dictation during the transcrpition process.

The Currency Of Language

Throughout the history of civilization, human beings have used a variety of means to communicate thoughts and images. Primitive societies depended on gestures, drawings, rhythm, sound, and an early form of telecommunications known as smoke signals. More advanced civilizations developed motion into dance, drawings into art, rhythm into music, and sound into language. Over the years, telecommunications have evolved from smoke signals to semaphore, from wireless to satellite technology.

Many people are drawn to medicine because it promises an exciting career. But what makes medicine so exciting is not just the challenge of helping people manage their health. There is also the element of change. Medicine does not change simply because of new diseases. Nor are changes in the language used by medical practitioners merely influenced by the release of new drugs into the marketplace. New words -- and new uses for old words -- reflect how language is being used in society at large. For example: Since 1970, two new uses for the word waste have entered our vernacular.

1. To get wasted (on drugs or alcohol).
2. To waste (kill) someone.

Quite frequently, new terms and phrases make their way into the vernacular from a variety of subcultural sources. Terms like “hip-hop,” “frug,” “rave,” “scat,” and “reggae” emerged from the music and dance worlds and were popularized through radio. Rock bands like the Dead Kennedys or Butthole Surfers chose their names for shock value and/or marketing purposes. Current events often lead to the coining of peculiar phrases to describe the news of the day. For example: A series of fatal incidents led to the terms “disgruntled postal worker syndrome” and “going postal.”

Slang most frequently originates among teenagers whose sense of alienation from older generations inspires them to concoct words of their own. The ultimate irony is that the words once thought to belong to the cutting edge soon become a mark of how dated a person’s references might be. Terms like “disco bunny,” “feminazi,” “Trekkie,” “shrimper,” “far out,” “Deadhead,” “dudette,” and “Beemer” can pinpoint a person’s age, interests, and sensitivities (or lack thereof) with cruel precision.

A society’s language changes as that language must continue to reflect the population it serves. The more diverse and multicultural a society becomes, the more diverse the language of medicine becomes. With each change in the practice of medicine (as with any changes in our society), words must be created or chosen to define what is happening and to communicate new thoughts. In order to produce a coherent patient record, these words must be clearly articulated by the dictating physician and understood with the same clarity by the medical transcriptionist.

If any profession is filled with people who love words, it would have to be medical transcription. Perhaps even more than in publishing and editorial endeavors, medical transcriptionists form a nationwide army of wordsmiths. People who enjoy seeing how words are put together. People who enjoy seeing how words relate to each other. People who enjoy seeing a word used in its proper context. People who can find the same kind of joy and excitement in the discovery of a new word that they experience upon biting into a chocolate truffle and -- as the soft, creamy filling titillates their taste buds -- savoring the exotic flavor within.

If one were to examine common traits found in medical transcriptionists, they might include:

• Curiosity

• Strong reading skills

• A passion for crossword puzzles and anagrams

• A genuine love of language.

So why not let these people have some fun with their work? During the past 25 years, the words contained in Group A have become assimilated into our common language. Some are medical terms, some are terms from the vernacular:

Group A

ATM machine

gridlock

salsa

AZT

infomercial

satellite dish

BBS

Internet

shrink wrap

compact disk

kiwi

sound bite

condom

megalopolis

spin doctor

cyberspace

microwaveable

sushi

cyclamates

modem

sysop

dissing

nose ring

target marketing

downsizing

on-line service

televangelist

freebasing

outplacement counseling

tofu

freeze dried

outsourcing

upscale

frequent flyer miles

politically incorrect

Wassup

gentrification

relational database

Walkman

global economy

salad bar

wok

Suppose you try an interesting exercise: Spend some time with a physician who is 25 years older or younger than yourself. Analyze these terms by asking each other the following questions:

• What does this term mean to me?

• How does the proper use of this term reflect changes in the world in which I live?

• How does the proper use of this term affect me from a personal standpoint?

• How does the proper use of this term affect me from a professional standpoint?

• If this term did not exist, how would I describe the phenomenon it identifies?

• If this phenomenon did not exist, how would my life be different?
  

While you have your colleague’s attention, tell him you need his help in understanding some words from the following scenario:

“An ‘urban aboriginal’ patient who has been shooting speed comes to the Emergency Room complaining of burning on urination. As the patient is examined, the physician notices a variety of tattoos and body piercings, including a stainless steel stud piercing the tongue, a pair of nipple rings, a gold navel ring, a Prince Albert, and a guiche. In addition to the patient's urinary tract symptoms, there is concern about the possibility of the patient developing an abscess or infection.”

Look the physician straight in the eye and ask him to explain the terms “Prince Albert” and “guiche” to you. Ask him to draw you a diagram, if necessary, and articulate how he would describe any other body ornaments while dictating this patient’s physical exam.

What’s the point? Why bother?

It’s easy to throw words around just to make noise and try to impress people. It’s much more difficult to use words properly. Whether someone is wealthy, self important, or a figure of authority, a critical weakness in language skills can have serious repercussions in the workplace.

One of the main characters in the film The Opposite of Sex is a high school English teacher who has been having an affair with a much younger man. No matter how much emotional pain he is subjected to by his lover’s selfishness and thoughtlessness, the teacher cannot stop himself from correcting the young man’s sloppy grammar. Each time this occurs, there is a peculiar poignancy attached to the teacher’s unwillingness to let the language he loves be abused with such recklessness.

I remember how, when re-entering the field of medical transcription after a 15-year career as a freelance writer, the woman who was mentoring me warned “This is about working on a production basis. If you’re having trouble hearing what a doctor says, listen to it three times and then leave a blank. Move on to the next sentence. This is not about creating art.”

Yet any teacher can tell you that there is a stunning difference between math, science and language arts. One of the most interesting reality checks being delivered to today’s new generation of “knowledge workers” has to do with the use of search engines on the Internet. It’s all well and fine to want to search for information. But if you don’t know what you’re looking for – and don’t know how to define the parameters of your search – you might not get good results.

More to the point: if the word you type into a search engine’s data entry field is misspelled, the results of its search will be meaningless.

This can be a real “bummer” for people who are functionally illiterate and/or driven by a need for instant gratification. But them’s the rules, folks. You have to spell the word correctly if the search engine is going to function properly. If you don’t use a word to communicate its proper meaning, you are failing to communicate. With that thought in mind, let’s examine the terms in Group B that have become part of our popular vocabulary:

GROUP B

African-American

fax

Neptune Society

Amerasian

fiberoptics

PMS

angioplasty

gene splicing

Prolene

artificial intelligence

Gore-Tex

significant other

bionics

Hemlock Society

sky pager

biofeedback

hospice

surrogate mother

CAT scan

intraocular lens

telecommute

cochlear implant

in vitro fertilization

trabeculoplasty

crack head

laparoscopy

ultrasound

cryotherapy

liposuction

uplink

digital sound

Marlex

VCR

Ebonics

MRI scan

virtual reality

extended family

needle exchange

WYSIWIG

Once again, try to spend some time with a physician who is 25 years older or younger than yourself. Analyze these terms by asking each other the following questions:

• What does this term mean?

• Was this term commonly used when I was in medical school?

• How did this term come into existence?

• How did this term become popularized in our culture?

• How does the proper use of this term affect me from a personal standpoint?

What you will soon discover is the power of words to help or hinder communication. The lesson to be learned is that unless we understand the words we are using – and how those words may be interpreted by the person who hears us use them – we may easily fail to communicate with each other.

Compared to how medicine was practiced at the beginning of the century, the technology at our disposal is quite remarkable. Syphilis and polio are no longer major diseases. Organ transplants have become routine procedures. Laser keratotomies can be done in the office. Laparoscopic techniques have had a dramatic impact on the surgical suite.

Despite our technological sophistication, new diseases keep surfacing. Among those identified in the past 25 years have been Legionnaire’s disease, carpal tunnel syndrome, AIDS, chronic fatigue syndrome, and toxic shock syndrome. Although a cure has yet to be found, there is a much more sophisticated understanding of Alzheimer’s disease. Drugs such as Sustiva, Celebrex, Aricept and Viagra have entered the marketplace while many more are undergoing clinical trials.

Accompanying all of these medical breakthroughs are new words -- and new uses of old words -- to describe and enhance the practice of medicine. My suspicion is that if physicians, risk managers and hospital administrators were more impressed with the power of language -- and the love medical transcriptionists share for words (which, after all, are the basic building blocks of language) – then medical transcription itself might be regarded very differently by the powers that be.

First Walk A Mile In My Shoes

In the 1995 film entitled Swimming With Sharks, Kevin Spacey delivers a bravura performance as Buddy Ackerman, a spoiled, brutally selfish Hollywood executive who takes great delight in making his underlings miserable. Anyone who has worked as a legal secretary, medical transcriptionist or administrative assistant for a megalomaniacal monster like Ackerman will recognize each sadistic bit of needless humiliation, power tripping and job-related abuse. Viewers may swallow their horror long enough to cheer when Ackerman’s assistant Guy (played by Frank Whaley) turns the tables on his boss and proves how sweetly detailed revenge can be.

Those who have never worked for such prima donna personalities can’t believe that people actually behave that way in the workplace. However, the poor souls who have hung onto their jobs through thick and thin – suffering constant streams of invective mixed with daily doses of humiliation -- often find it difficult to describe the personal hell they have endured.

Medical transcriptionists often find themselves in a similar situation. And there is little solace in knowing that only people who transcribe on a regular basis truly understand what they are subjected to while trying to do their work. It’s the folks who are in the trenches day in and day out – listening to some muckmouth doctor’s mumbling, screaming, or other distorted attempts at dictation -- who know what professional MTs must listen to in order to produce a finished report.

It doesn’t matter whether doctors are dictating onto cassette tapes, using a cell phone (which broadcasts their dictation over radio frequencies and thereby compromises patient confidentiality), or dictating over a secure phone line. Their constant lack of attention to the acoustics of the environment in which they are dictating causes severe problems for medical transcriptionists which can impede productivity and dramatically increase job stress.

Here are some real life examples (taken from my own experiences as well as from colleagues in the industry) of what MTs are forced to listen to as they attempt to work:

• The doctor who insists on dictating next to ringing phones, high-impact printers, beeping cardiac monitors, vacuum cleaners, or simply prefers to hold his pager next to the telephone as he dictates reports. This has the same effect as someone holding a highly sensitized microphone next to chalk that is repeatedly being scraped against a blackboard.

• The physician who dictates reports while sitting in his jacuzzi.

• The physician who dictates reports over his cell phone from an airport lounge or from the first class cabin of his plane (either while in flight or on the ground) knowing full well that his voice is in direct competition with the public address system, the noise from the plane’s engines and the general hubbub in the cabin.

• The physician who tries to dictate over a cell phone while driving to work and can’t understand why transcriptionists are unable to hear every word of dictation while the doctor is driving through a tunnel.

• The physician who tries to dictate in English while holding a conversation in Mandarin with someone else in the office.

• The physician who tries to make the most of his time by dictating while he eats his lunch.

• The physician who loudly sneezes, belches, coughs and burps throughout his dictation.

• The physician who dictates while seated next to his pet parrot (who has a nasty habit of making loud – and lewd – comments which drown out the doctor’s dictation).

• The physician who, not wanting to waste a moment of time, carries his microcassette recorder into the bathroom and continues to dictate while urinating, defecating, wiping himself and flushing the toilet.

• The physician who watches The Late Show With David Letterman while trying to dictate reports.

• The physician who attempts to cook dinner, feed her infant and dictate reports while her two other children scream at each other and watch television in the background.

• The physician who is too busy comparing dating techniques with her fellow residents to pay attention to the report she is dictating and thus keeps mixing up all of the information about the patient’s surgery.

• The physician who is trying to dictate on an office phone, talk to her boyfriend on a cell phone and hold a conversation with someone in the hallway at the same time.

If you talk to other transcriptionists about how such problems affect their work, they knowingly shake their heads and start to share their war stories with you. However, when you talk to managers who don’t transcribe – and don’t have a clue about how seriously bad acoustics on the dictator’s end of the conversation can affect the quality assurance of transcribed reports – it becomes obvious that most transcriptionists’ complaints and criticisms fall on deaf ears.

Management typically thinks that transcriptionists make up these little stories because they have nothing else to complain about. Or because they’re unhappy. Or because they think these stories are funny. A standard clueless reaction recently came to me from a HIM manager who contacted me by e-mail. The fact that this person would not even sign her name to her correspondence told me that she had some problems with cowardice and insecurity. Here are some excerpts from her e-mail:

• “I am an RHIA and manage a middle-sized hospital department, including 4.5 Transcriptionists. I have never typed a report outside a classroom (okay, I tried it once). However, I do not believe this makes me any less of a good manager.”

• “Just as my boss has enough Health Information Management knowledge to make him dangerous, direct work experience is not always necessary to get the job done.”

• “You are very knowledgeable in your area of expertise & I feel that the Transcriptionists who work in my department would find your articles a good resource for information. However, due to the constant unfounded negative comments & suggestions towards administration and management, I feel that more harm than good would be done to the self-esteem and self-worth of the Transcriptionists.”

Her comments would be laughable if they were not so pathetic. By taking on the role of the superprotective schoolmarm, this RHIA insults the intelligence of her medical transcriptionists as a means of covering up for the fact that other people know more about their work process than she does. Not only does this RHIA exhibit serious control issues, she obviously does not trust her transcriptionists enough to allow them to read and digest information about their work (what they do every day) without her censoring their reading material.

This is the kind of manager who does not know how much she does not know. And certainly doesn’t want anyone pointing out that the Empress is wearing no clothes. But what about some of the real problems facing her transcriptionists? Who can they seek help from when confronted with such an ignorant and unsympathetic supervisor? Who can they turn to who will challenge the doctors at this facility to improve the quality of their dictation?

Often, when medical transcriptionists complain to management, no one seems to care or want to ruffle the feathers of “the poor doctors.” Unfortunately, many doctors have reached a level of success where they are no longer interested in learning how to do something better. The chances of making them change their dictation habits are really very slight.

How can the problem be fixed when the people who are capable of initiating change are in such a strong state of denial that they refuse to admit a problem even exists? In situations where a transcriptionist or MTSO has a casual, personal relationship with a doctor, progress can often be made over drinks or dinner as part of “continuing medical education.” If you are a doctor’s patient, a fail-safe technique is to grab his attention in the examining room when you can lock eyes with him.

For those who lack such options, let me offer a fantasy scenario akin to the treatment Buddy Ackerman receives from his vengeful assistant in Swimming With Sharks. Some might call it “Paybacks Are A Bitch.” I prefer to think of it as a consciousness-raising exercise that should earn credits for continuing medical education. Here’s how it works:

• Insist that your doctor make a deal with a male teenager who is not a member of the physician’s immediate family. The doctor must give the teenager an apple, a can of warm soda, a copy of the daily newspaper's sports section and promise to pay the teenager with a $100 bill as soon as he acts out the following script.

• The teenager goes home and gets ready to place a phone call to the doctor. Before he dials the physician’s number, he makes sure that a radio or television can clearly be heard in the background. He then drinks the can of warm soda as quickly as possible.

• The teenager then calls the doctor on the phone. As soon as the doctor answers, the teenager says "Testing, testing," and spits into the mouthpiece three times. The teenager then starts to eat the apple as he reads the sports page aloud.

• After reading the first paragraph, the teenager taps the phone's mouthpiece five times with a pen.

• After reading the second paragraph, the teenager belches as loudly as possible into the mouthpiece. Once he has finished belching, the teenager positions the mouthpiece near his forehead and mumbles a set of game scores as quickly as he can while finishing off the apple.

• When he has finished, the teenager slams the phone down without any warning and quickly returns to the physician’s house. Upon storming into the physician’s home, he grabs the $100 bill from the physician’s hand and screams: "Whaddaya mean you couldn’t understand my dictation and had to leave blanks? How dare you criticize a teenager! You've got a lot of nerve, biting the hand that feeds you. Why, if it weren't for us teenagers, you wouldn't have a job!"

• At this point, the physician must apologize profusely to the teenager, tell him how sorry he is to have upset him, and promise never, ever, to upset him again.

Managers like the RHIA who wrote to me may not understand this. They may think it is a horrifically rude and petulant assault on physicians. So would anyone who lacked real life experience working as a medical transcriptionist. However, the medical transcriptionists reading this article will know exactly what I’m talking about.

Fools Rush In

There’s an old joke about the businessman who became a multimillionaire and, with his newfound wealth, purchased a large and very impressive yacht. Bursting with self-importance, he flew his little old Jewish mother out to visit him and arranged to have her met at the airport by a stretch limousine. When the chauffeur delivered the old woman to the dock, she saw her son proudly standing by the gangplank in front of his yacht, decked out in the flashiest maritime uniform he could find. “Look, Ma. I’m a captain!” he boasted.

His mother (who was no fool) instantly sized up the situation. Taking her son’s hand reassuringly, she leaned over, kissed him on the cheek and whispered to him: “Darling.......By me, you’re a captain. And by you, you’re a captain. But, trust me on this one. By a captain? You’re no captain!”

In a professional world that has been flooded with inflated resumes transforming waiters into“beverage service managers” and fast food outlet counterboys into “nutritional counselors,” it has become increasingly difficult to identify and hire “the real thing.” Many job applicants, consultants and entrepreneurs feel confident that, by inflating their resumes, they can make their achievements sound more impressive and, as a result, ace out the competition. The cynics and fact checkers who know how to read between the lines no longer find much humor in such pathetic exercises in self-aggrandizement.

Recently, a friend with 14 years of experience handling affirmative action complaints for a state university described how, as part of yet another bureaucratic reorganization, the people in her department had been demoted and forced to report to a 26-year-old woman with no experience in affirmative action (who came to the job following six months as the marketing director for a winery). “The terrible thing about this situation is that she doesn’t even know what she doesn’t know! Unfortunately, the rest of us do!”

Another colleague (who has enjoyed a 20-year international career as a leading coloratura soprano) recently transitioned to teaching voice at the university level. A competitive professional singer who always learned her music and arrived prepared for any job, she is appalled by the lack of initiative and professionalism she encounters in her students. “They don’t learn their languages and they’re not musically prepared. To make matters worse, they seem to think that all they have to do is just show up and get a grade so they can then magically move on to a big money career,” she groans. “You know what makes this whole thing so pathetic? These students are suffering from delusions of adequacy!”

That term – delusions of adequacy – keeps coming to mind each time I receive a new -- and utterly ridiculous – e-mail from some Third World entrepreneur trying to convince me to subcontract work to a firm that has no experience in medical transcription. Because you have to see some of these messages to believe them, here’s a tasty little sampler of what many MTSOs have been receiving:

• “Let me introduce myself,i am jayakeerthi,an engineer.,working with my father in interior decoration firm, I am setting up medical transcription service in india very soon, i am looking for orders from usa countries for mts We have dedicated people,having training in good medical transcription school, We will assure you of 98.5% accuracy min all the time,with 24hrs to 48hrs turnaround tim,with well documented with 5 cents per line. looking forward for your positive reply from u”

• "Dear Sir, I have man & mechinary & big basement to start Medical transction work. Please give me all guidence.”

• "well , i am on my way toset up a MT unit in Delhi which i have already mentioned in my last mail now i am facing couple of problems regarding the information technologies requirements. I am not much aware of the the software requirements in this field. it would be a kind enough jesture if u can let me know bout this aspect."

• “I'm a Graduate from Pakistan. For the last week I was searching transcription companies and have found you. I'm willing to work for you, I have heard a lot about you on the internet. Although I have got no experience in the past but have good typing skills and can very well understand the American English accent. I'm sure I'll be able to this job.

• “Today, I was browsing about the [web site]. I m very much intrested in becoming a quality transcriptionist. could please help me about voice recognition and other important features in becoming a competitive transcripitonist. And i m intrested work in u.s.a, how about the posibality? can I make it. Please help me by sending to my e-mail adress. I hope, I get some positive replay.”

• “We would like to introduce ourselves as Exporter of Marine Products mainly to Japan with an annual turnover of approximately INR 150 milion. Now we are interested in starting Medical Transcription Business through you from India with 10 pc's. As we have to start from scratch, we need total guidance as to how to go about it including the requirement of Hardware & Software.”
  

When I looked at this last person’s website, I discovered that he was actually a shrimp farmer. But, what the hell! India is rapidly becoming known as the virtual back office to the world. Airlines, banks and other businesses are using Indians for data entry and customer service support calls. The logical assumption would be that, as long as you have a computer, who says you can’t do medical transcription for Americans?

Maybe some people who know what they’re talking about?

Perhaps those professional MTs who have been doing this for a living?

I am deeply indebted to Renee M. Priest, CMT, and Carole J. Gilbert, ART, for their willingness to offer proof to America’s health information management industry of the ludicrous sales pitches and piss-poor quality of work they encountered when trying to deal with offshore subcontractors. I urge every person who reads this article to point their web browsers to www.optitron.com/offshore/ to see just how outrageous the situation has become. Once you’ve finished reading the sales pitches, do be sure to click on the “Discussion” link to view the proofreading log!

Why did Priest & Gilbert feel a need to post this information on the web? “We see endless posts online assuring people that offshore services are not as bad as the massive volume of badly worded e-mail letters we all receive each day––the e-mails that are touting how much more cheaply and accurately offshore transcription can be provided. It is our hope that by sharing these files with you, you will realize that there is a great deal of important information being left unsaid about the pitfalls of utilizing an offshore company, or any company for that matter, whose sole purpose is using our profession as the latest get-rich-quick scheme for global entrepreneurs.”

Rest assured that the same problem exists in America. Throughout the past decade, business magazines have consistently touted medical transcription as a major growth industry, luring many unqualified people to the field. A client who is an attorney sent me a postcard he recently received announcing an upcoming seminar at the Learning Annex. The pitch was short and sweet. “If you know how to type and like the thought of starting a business without much hassle, medical transcription may be the business for you!......If you want to have a business at home, find employment easily, and make a living on your own, this class will get you started!”

Whether aimed at American or Third World entrepreneurs, these types of solicitations give people the false impression that all they need to do is purchase a computer and the rest will happen by magic. Having bought into the fantasy, these MTSO wannabes further assume that doctors, hospitals, clinics and experienced professional MTs will automatically want to give them tons of work (regardless of whether they are the slightest bit qualified to perform the services required). Nor do they seem to be concerned that so many similar start-up ventures have crashed and burned with astonishing rapidity.

Several years ago, an aspiring MBA who was planning to start a medical transcription business sought my counsel. She had crunched all the numbers and figured out how to make it work. She was sure of it. Besides, she was great at selling and knew how to get new clients. The fact that she had no experience transcribing didn’t seem to matter to her because, as she proudly told me, a friend of hers could do some part-time editing and she was confident that would take care of any and all problems.

How did she plan to manage her subcontractors? “Well, if a doctor wants his documents in MSWord, I’ll tell the transcriptionists to type it in Word. And if he wants it in WordPerfect, then I’ll tell them to type it in WordPerfect.”

She was supremely confident, very sure of herself and, without a doubt, dressed for success. Guess what? Six months later she called to inform me that things had not quite worked out and, since her return on investment didn’t materialize fast enough (and she was getting married), she had decided not to continue in the field of medical transcription.

Her future business plans? Spending six months honeymooning in Europe.

And what did she expect her clients to do? “Whatever!”

I mention this incident to counter some accusations of racism that have come my way as a result of my having taken such a vehement stand against offshore transcription. There are certain human traits which transcend racial and/or national boundaries. These include (but are certainly not limited to):

• Greed

• Arrogance

• Incompetence

• Ignorance

• Stupidity

• Deceit

• Failure to produce

• Lack of responsibility

• Lack of professionalism
  

Doctors have been known to display these qualities with startling regularity. With industry analysts now estimating that one in every five doctors practicing in America is an Indian import (and managed care putting the squeeze on every doctor’s earnings), some physicians have decided to invest their money in the healthcare information management industry as a means of developing a secondary revenue stream.

More than one Medical Records Director has already complained about Indian physicians on staff who are constantly pressuring their hospital administrator to award transcription contracts to companies that are owned by themselves, their friends or their relatives.

This is definitely not a means that justifies the end.

Several years, ago, it was determined that potential conflicts of interest should prevent doctors from owning their own medical laboratories. With news items constantly surfacing about doctors who have been indicted for double-dipping on travel expenses -- or fraudulently overbilling Medicare – the concept of allowing doctors to be involved in the ownership of medical transcription services makes as much sense to me as permitting drug dealers to set up rehabilitation programs.

Forgive me for asking such a simple question. But exactly who is America’s healthcare system supposed to be taking care of? The patient? Or some staff physician’s relatives overseas?

San Diego MT Discovers Missing Link

In 1962, when Who’s Afraid of Virginia Woolf? premiered on Broadway, playwright Edward Albee used new dramatic techniques to bore a hole into the American psyche. Unlike classic Greek dramatists who favored the use of a “deus ex machina” -- or mystery writers who thrived on revealing hidden pieces of evidence – Albee shattered the illusions of an alcoholic couple trapped in a miserable marriage by allowing one partner to call the other’s bluff with devastating accuracy. As an evening of drunken debauchery and dysfunctional party games (Humiliate the Host, Get the Guests, Hump the Hostess, Bringing Up Baby) wound down, Albee’s shrewd and shrewish Martha sighed “Truth or illusion, George. Doesn’t it matter to you...... at all?”

A pertinent question, indeed! In April, the Medical Transcription Industry Alliance held its annual conference in Seattle, a city that had recently been rocked by a sizable earthquake. Over at Seattle’s Pacific Science Center, “Titanic: The Artifact Exhibit” invited visitors to touch a wall of ice upon which a series of hand prints had been fashioned. The bone-chilling sensation made it shockingly clear that, instead of drowning, most of the 1,509 people who perished in history’s greatest maritime disaster succumbed to hypothermia after being exposed to the icy waters of the North Atlantic. As the MTIA conference got underway, an unsettling theme started to emerge through a pattern of acutely painful reality checks. Like Albee’s searing drama, the conference forced participants to confront some appalling truths and/or prepare to dump a bunch of tired illusions that have haunted the transcription industry.

• After 18 years as the driving force behind the American Association for Medical Transcription, news of Executive Director/CEO Claudia Tessier’s sudden resignation provoked emotional outbursts ranging from deep concern about AAMT’s future to ecstatic war whoops (a former AAMT President was seen clicking her heels in the air to express her delight). However, finding someone who can replace Tessier and breathe new life into AAMT will be a daunting task. What will the future bring for AAMT? Truth or illusion?

• News spread quickly that, as a result of acquiring an ASP company named Speech Machines, industry giant Medquist had gained access to competitors’ client information which had been resting on the Speech Machines servers. As Medquist tries to redefine itself as a technology company, many MTIA members wonder how soon that company’s definition of “free market competition” will start to resemble Microsoft’s monopolistic arrogance. Will MTIA’s Board of Directors take action with regard to the predatory practices of the industry’s largest medical transcription service? Truth or illusion?

• In yet another demonstration of the supposed wonders of speech recognition technology, a representative from Dictaphone/Lernout & Hauspie went through the text she had dictated three times without catching a simple grammatical error. When asked why she had not fixed this error, she stated that she had seen it and should have corrected it, but was in a rush to finish her presentation. Truth or illusion? MTs don’t have that luxury. For a real eye-opener on the continued woes of Lernout & Hauspie and the future of speech recognition, read about Lernout & Hauspie's Continued Woes.

• Joe Weber’s article entitled “Speech Recognition: Is It Ready for Docs?” raised an important question: Can users of speech recognition safely rely upon statistical analysis of performance if SR fails to understand context? Editing SR-generated documents can easily cause a lazy eye syndrome among editors which leads to easy distraction and diminished concentration. If mistakes such as the one missed in the above-mentioned demonstration keep getting missed, will more serious mistakes metastasize throughout a patient’s medical record? Truth or illusion? If such mistakes are not caught in the process of editing SR-generated documents, could patients be harmed – or die -- from the use of speech recognition technology?

• After more than three decades of the women’s rights movement, and AAMT’s never-ending struggle to gain professional respect for medical transcriptionists, there are still female MTSOs who refer to their transcriptionists as “my girls.” Truth or illusion? Are service owners (instead of doctors) the real reason why MTs can’t get no respect?

A particularly hot topic was whether companies should look toward combining coding and transcription services as a way to broaden profits (the assumption being that medical transcriptionists already know enough to do coding). Truth or illusion? Unlike medical transcriptionists, coders have to pass a variety of exams and continuing education courses in order to maintain their licenses. Medical transcriptionists might not wish to embark on another learning curve with no guarantee of being financially rewarded for their efforts. There might also be strong resistance from the folks in AHIMA and other parts of the coding industry.

In one of the keynote sessions, William Young (President of Market Trends, Inc.) explained how the market assessment commissioned by MTIA to determine the size and scope of the medical transcription industry had tried to evaluate the different types of medical transcription services and the relationships they held with their clients. Estimating that the current market ranges up to $25 billion -- with an estimated 30% increase in volume predicted over the next two years -- Young tried to demonstrate how questions of satisfaction with regard to accuracy, quality, responsiveness, turnaround time, and cost often determine whether a national, local, or independent MTSO will offer the best match of services for a particular client. Young’s presentation left MTIA’s membership struggling to decide whether, once again, they were dealing with truth or illusion.

• In examining overall satisfaction with outsourced transcription, the sample size of Young’s market analysis found the impact of offshore transcription firms too small to allow for any future projections. Truth or illusion? Nearly 10% of MTIA’s membership now consists of offshore firms aggressively marketing their services to American hospitals and MTSOs while seeking positions on MTIA’s Board of Directors.

• If the rate at which companies represented on MTIA’s Board of Directors keep disappearing into Medquist’s hungry maw continues unabated, MTIA’s board will have a tough struggle to stay true to the organization’s rank-and-file membership. Truth or illusion? Now that Medquist has swallowed most of MTIA’s large members, small to medium-sized companies may have trouble finding the time and/or funds to participate at the board level. MTIA may soon face an identity crisis.

• Despite exhortations that the medical transcription industry must catch up to other industries which have quickly and easily surpassed us in embracing new technology, MTIA’s conference demonstrated with truly appalling visuals that an industry which stresses accuracy in healthcare documentation is doing a very poor job of proofreading its own materials. MTIA’s conference binder was filled with numerous mistakes and outdated information about its membership. Slide presentations and placards outside the conference rooms contained typos which should have been caught. Do we practice what we preach? Truth or illusion?

• An article by MTIA Board member Joe Weber which appeared in the conference binder included the statement “We wanna get the draft text as accurate as possible, so that minimal editing is required.” Truth or illusion? Any MT who submitted that text in a report would probably be fired. That kind of grammar causes MTSOs to lose credibility and lose accounts.

• Outgoing MTIA President Steve Dunkle’s presentation on the opportunities technology might bring us in the future resembled the Pentagon’s approach to spending billions on an unproven missile shield program. Is this the future MTSOs should embrace? Most of the people in the room represented small to medium-sized MTSOs that would be bankrupted by attempting even one small portion of Dunkle’s Star Wars vision. Truth or illusion? When push came to shove, Dunkle confessed that only one or two big hospital chains were thinking about this approach and that his presentation was mostly hypothetical.

In what may well have been her farewell appearance before the MTIA membership, Claudia Tessier (speaking with an adrenaline-induced fervor bordering on a Florentine frenzy) outlined the work being done by ASTM’s transcription committee and the relationships spawned with other organizations that impact the future of healthcare information management. The most eagerly awaited session, however, was Kathy Rockel’s superb and concise presentation about the new HIPAA regulations that had just gone into effect a week prior to the MTIA conference. Discussing the political process which brought HIPAA to its current state and HIPAA’s specific impact on the transcription industry, Rockel outlined key issues confronting MTSOs:

• Criteria for determining HIPAA compliance include low development and implementation costs relative to the benefits of using the HIPAA standard.

• The question of whether an MTSO is considered a business partner or a clearing house might have a huge impact in determining the size of penalties for failure to comply with the HIPAA regulations.

• The issue of claims attachments and how they are dealt with under the HIPAA rules and regulations will have a major impact in focusing attention on transcription’s role in profitability and reimbursement. Within two years there may be no more handwritten notes in patients’ charts with the possible exception of nursing entries and vital signs.

• In order for MTSOs to protect themselves and their transcriptionists from having patients knocking on their doors and insisting on their right to make changes in their medical records, revised contracts must stress that the MTSO and/or transcriptionist does not hold the final record.

• The financial impact of HIPAA compliance for MTSOs is expected to be 1-3 times the costs of preparing for Y2K. Most transcription services will find themselves needing to draft written policies and making changes in some operational procedures. One of the most pressing issues involves developing policies and practices for those who work at home.

• Compliance with the new HIPAA regulations will be enforced by the Office of Civil Rights. Truth or illusion? Since the Bush Administration has yet to allocate any extra funding to this office, the actual enforcement of the HIPAA regulations may result in nothing more than a photo opportunity for political purposes.

• A bill has subsequently been introduced to say that no rules are final until all of the final rules have been published except for the individual identifier rule or until 2004 (whichever is sooner). Truth or illusion? “It will be interesting to watch Congress respond to the cries from business about the cost of HIPAA and see where this one goes,” says Rockel. To stay abreast of further developments, she advises subscribing to a mailing list that can be found at HIPAA listserv.

A panel designed to demonstrate how educating MTs can increase the bottom line for hospitals and service owners was aided tremendously by the hard data provided by Elaine Olson of Stat Enterprises, Inc. This may have been the first time that anyone has actually tracked productivity in a work environment based on the impact of continuing education of MTs. Using her experience consulting with a regional hospital, Olson described the transformation of an in-house transcription team from a group of lethargic, unmotivated, underachieving MTs with a bad attitude to people who had more respect for themselves, were taking more interest in their work, and whose productivity had jumped as much as 80%! While the results of her presentation were inspiring, the question still remains: How long will the learning curve take to accomplish such results?

The answer was found in a small booth in the exhibit area where I came across a product that justified my trip to Seattle. In the process of touring vendor exhibits, one becomes a little numb to the strutting and hype coming from sales teams that make great promises but don’t always deliver the goods. When you come across the real thing, the blunt truth behind the product is so daring and refreshing that you sit up and pay close attention.

I don’t usually flip out over new software, but I think that Chad Francisco, the creator of Keymaster, should be given an industry award for the most innovative and thoughtful use of technology to help medical transcriptionists. I would urge everyone reading this article to visit the Keymasters website and order his demo CD. After viewing the intelligently designed and coherently scripted multimedia presentations on the demo CD, you will understand why Keymaster – a product designed by an MT who has an acute appreciation for how an MT works – truly represents this industry’s “missing link.”

Keymaster goes far beyond most word expanders. Its owner did a spectacular job of putting together the pieces of an MT’s work process puzzle and understanding the big picture. A Windows-based word expander that will work with any Windows application (it does not need to be linked to your word processor in order to function), Keymaster combines the use of established shorthand techniques for building short forms with a database of more than 450,000 transcription words and phrases which it calls the MEDb or MED Brain. Owners of MEDb receive daily electronic updates containing new drug names and other emerging medical terminology which can be added into the database with several keystrokes. Drugs appear with standard dosages; definitions are accessible from your keyboard.

Whereas traditional publishers of medical transcription reference materials have dragged their feet and been reluctant to publish their word list books in electronic format, Keymaster incorporates the vocabulary and definitions into a huge database that matches your keystrokes. Its suite of products shows people how to systematically create and use short forms so that they can earn as they learn.

I can’t speak highly enough of this product. But what excites me even more is what it can do for this industry.

• If incorporated into the curricula of medical transcription courses, Keymaster can probably do a faster job of training more people to become medical transcriptionists so that they are able to enter the workplace ready to perform at decent levels of productivity.

• Medical transcriptionists who are individual contractors will find this product boosting their productivity while saving them time researching new drugs and medical terms on the Internet.

• MTSOs and Transcription Departments that train their employees on this software will be able to process larger volumes of work with greater accuracy. If their employees have an incentive program, they will earn more money. Happier, more loyal employees build better team morale. Get it? Got it? Good!

• Quality assurance people will find their work at lot easier to perform; clients may also get greater accuracy in their documentation.

• As more and more productive MTs enter the American labor market, there will be less need to send transcription offshore.

In short, Keymaster offers a cost-effective, easily affordable, win/win solution for many of the problems facing America’s medical transcription community. In terms of earning a return on your investment, I would suggest budgeting for this product before anyone budgets for the cost of an AAMT membership. Why? Because embracing Keymaster’s technology will give MTSOs and medical transcriptionists the tools with which to quickly generate sufficient revenue to pay for AAMT memberships.

Truth or illusion? Don’t take my word for it. Check out this product yourself.

Till There Is A Cure

We’ve all heard of PMS. Will someone please tell me why no one wants to talk about PJJ syndrome? PJJ occurs on a regular basis in hospitals throughout America. Most medical records personnel anticipate the onset of PJJ months in advance. The pre-JCAHO jitters can have a devastating impact on workplace stress, staff morale, employee health, and productivity. But no one has found a way to tame this bizarre form of administrative seizure activity which precedes an audit by the Joint Commission for the Accreditation of Healthcare Organizations.

While the folks in IT and other departments have no trouble understanding the classic GIGO formula (garbage in, garbage out), risk managers, Chiefs of Staff and physicians on the Medical Records Committee seem to suffer from an occupational blind spot. If nurses and medical transcriptionists can easily identify the chronic conditions which provoke PJJ, why can’t those with medical licenses diagnose the problem? As Bill Maher (the host of TV’s Politically Incorrect) would say, it’s like watching people trying to ignore a 500-pound pile of elephant dung located smack in the middle of their living room!

If a patient required treatment with antibiotics, anti-inflammatories, antacids or a change of diet, everyone would know what to do and the problem would quickly be solved. So let’s not kid ourselves. The “garbage in” factor can often be traced to known sources. The culprits can often be quickly identified.

Why can’t the pre-JACHO jitters be avoided? To answer the question, let’s look at certain news stories which are guaranteed to appear every year. Will there be stress at the nation’s airports over Thanksgiving weekend? You’d better believe it. Will the first baby born in the New Year make it onto the local news? Without a doubt. Will everyone wonder if Punxsutawney Phil sees his shadow on Groundhog Day? Easy story to cover.

Come April 15th, will the news media have their cameras out as taxpayers rush to the post office to file their returns before the midnight deadline? You can bet money on it. Planning a story about people who wait until the last minute to do their taxes is a no-brainer for news editors. It makes for good copy and touches a universal fear button. The story is a sure shot for the 11 o’clock news because there’s always some poor schmuck who will wait until the last minute to file his tax returns.

But what about the story that does not get written? What about the millions of people who file their tax returns on time because they were doing what they should have done all along? I’m not just talking about people who are employees, but also about those freelancers and business owners who maintain the financial discipline necessary to track their income and expenses using programs like Quicken and/or Quickbooks.

These people dutifully log all transactions, balance their checkbooks, and deliver reliable financial data to their accountants in plenty of time to meet each year’s April 15th deadline. Whether running a hospital or a restaurant, they pay their employer’s taxes on time. Their W-2 forms are delivered to employees and their 1099 forms appear in contractor’s mailboxes on time.

Not only do these people understand the responsibility to store and maintain data so that they are ready to print W-2 and 1099 forms by mid-January, they also know that other people are expecting these forms to arrive on time in order to prepare their taxes and avoid any penalties for late filings.

That seems pretty straightforward, doesn’t it? It’s the kind of process that someone with a medical degree should be able to understand. And yet, when it comes to creating valid clinical documentation, too many physicians think that their patient’s right to a clear and concise medical record has nothing whatsoever to do with the timeliness and quality of a physician’s dictation.

Suppose we compare maintaining a patient’s medical record to handling a company’s accounting functions. In the financial world, data has to be clean. If you make the kind of mistake that moves a decimal point three digits to the right, it can have stunning economic repercussions. If, for some bizarre reason, you decide not to record any transactions that occur on Fridays, how can you know how much money you have in the bank? How can you plan a budget without sufficiently solid data to forecast income and expenses? How many people in your accounts payable department are allowed to issue blank checks?

No one in the business world can tolerate that kind of ineptitude when profit margins are tight and management needs to maintain a desperate grasp on reality. But look at what we tolerate in the world of medical transcription. There isn’t a hospital in this country that doesn’t have at least one doctor whose dictated reports contain enough blanks to look like a piece of Swiss cheese. Or a handful of physicians who are notorious procrastinators. Not to mention the doctors who don’t bother to read their transcribed reports in order to check for errors and/or make corrections.

When people don’t know how much of a mess has been made – or don’t care – there’s good reason for the person in the hot seat (usually the Medical Records Director) to get a bad case of the pre-JCAHO jitters. Suddenly, there is a heightened awareness of the need for quality control in transcription. Like a bolt out of the blue, there is a demand for perfect transcription with no blanks in any reports. Extra employee hours must be devoted to making sure that past records are complete and can withstand the scrutiny of the JCAHO’s auditors. As the pressure starts to build and employees are asked to work longer hours, management’s expectations become more and more unreasonable.

Like someone who has “found” religion, a clinic or hospital that once wasn’t very concerned about quality assurance suddenly executes a 180-degree turnaround in policy and procedures. With a JCAHO audit looming on the horizon, there is a newfound urgency for all charts to look pristine and complete. Is this any more of a joke than the stereotype of the stewardess who, on April 14th, shoves a box full of receipts at her accountant and says “I don’t know what these are for, but I saved all of my receipts this year. Just make sure you get my taxes done on time, Buster.”

While working in the arts, my friends and I used to compare the long-term health of large dysfunctional nonprofit institutions to that of problem drinkers. In many cases, the management and staff of these institutions resembled adult children of alcoholics who desperately kept trying to “make their parents get better” without being able to face the horrid fact that their parents didn’t want to get better. Is there a corollary between a hospital’s pre-JCAHO jitters and an alcoholic’s delirium tremens? You tell me.

The people at the bottom of the ladder are not fools. Nurses know which doctors make sloppy, illegible entries into patients’ charts. Medical transcriptionists know which doctors are continually contradicting themselves while dictating because they’re lost in space, dictating so fast that they can’t help but make errors, or are simply too pooped to pay attention to what they’re doing. Accountants know who’s been doing a responsible job of tracking expenses. Even Santa Claus knows who’s been naughty or nice.

But in the medical field, everyone keeps dancing around the truth about doctors like a bunch of co-alcoholics who are terrified to perform an intervention. God forbid someone should nail a physician to the wall, tell him he has sloppy work habits and force him to sober up and learn the proper techniques for creating a coherent medical record. That might require people to risk losing their jobs by accusing a doctor/alcoholic figure of not doing his work properly and being a hazard to those around him. Even worse, it might mean that in a medical peer review, doctors might actually have to accuse their colleagues of being incompetent slobs whose poor work habits continually jeopardize the accuracy of their patients’ medical records.

So what happens? Each year, we see the same news stories on television and witness the same song and dance in the HIM industry. The variations are easy to spot from one year to another. In one instance, a hospital installs a new piece of software which is supposed to guarantee that physicians follow certain procedures for templating their reports. In another, hospital administrators decide that by outsourcing transcription to India they can get faster turnaround with a lower price per line. With new advances in Internet technology, ASP entrepreneurs trumpet claims that they have solved all the problems of creating and maintaining an electronic medical record.

Larry Abernathy, the President of Digital Voice, Incorporated, claims that “Philips speech recognition technology is being married to our dictation system, to give birth to DVI SpeechPower. Without changing physicians’ dictation behavior, we can run their DVI VoicePower dictations through the speech engine, produce a draft text report, and then provide this text – along with a synchronized voice playback – to a ‘medical editor.’ We anticipate dramatic improvements in productivity since correcting a small number of mistakes will be considerably faster for your transcriptionists than transcribing the entire document. And it also expands the pool of personnel from which you can recruit, since fast keystroking is no longer a required skill.”

Abernathy’s statement blithely ignores the fact that fast keystroking is not the issue which keeps bringing medical transcriptionists to their knees. The problem is the incoherent garbage spewing forth from the mouths of physicians with absolutely no intention of improving the quality of their dictation.

In its mission statement, the American Society of Tests & Measurements (ASTM) claims to be the foremost developer and provider of voluntary consensus standards, related technical information, and services having internationally recognized quality and applicability that:

"promote public health and safety, and the overall quality of life; contribute to the reliability of materials, products, systems and services; and facilitate national, regional, and international commerce."

In recent years, an ASTM committee supervised by AAMT’s Claudia Tessier has been hard at work developing new standards for medical transcriptionists to follow. Although doctors initially said they wanted to be told how to dictate, it soon became obvious that the transcriptionists would have to make all the adjustments in their work habits.

It’s interesting to note that some 85 years after the Titanic disaster, analysis of the wreckage retrieved from the ocean floor helped scientists determine that the use of a cheaper grade of steel (which became brittle at low temperatures) was a major factor in causing the ship’s hull to buckle when the Titanic collided with an iceberg. Will ASTM, which supposedly sets standards for raw materials used in the manufacturing process, insist that doctors deliver a higher quality of dictation (the basic raw material that transcriptionists must process in order to create a coherent patient record)?

The reason it will be a cold day in hell when that happens is best articulated by Robert I. Field, the director of the graduate program on health policy at the University of the Sciences in Philadelphia. In his comments about the challenges faced when two or more hospitals try to merge, Field notes that basically “you have a large number of prima donnas who are used to taking orders from no one."

In her superb essay in the New York Times entitled Teaching Old Dogs New Medicine Can Be Some Trick, Dr. Abigail Zuger explains that the wealth of important new information offered to doctors during continuing medical education sessions is often forgotten soon after physicians settle back into their professional routines. And so the dance of denial continues. It doesn’t matter that the good doctor drools, has two left feet, and keeps stepping on his partner’s toes. He’s not going to change.

Which means that you’ll just have to keep dancing with the folks what brung you (and try to avoid stepping in that 500-pound pile of elephant dung in the middle of the dance floor). Think about that the next time you attend a conference sponsored by AHIMA, AAMT, HIMSS, MTIA, or any other healthcare information management-related organization. Because once you go back to work, you’re going to face the same old problem.

Garbage in, garbage out.

What's In A Name?

A favorite cartoon shows a physician’s tombstone with the epitaph “He never spelled the patient’s name.” Many transcriptionists have experienced the nightmare of listening to a doctor dictate “This is a report on John Kryzmanowski. That’s J-O-H-N.”

Have you ever listened to a Russian physician with an accent thicker than mud dictate that “The patient is having trouble pronouncing names.” Or a Chinese doctor try to pronounce and spell a Russian patient’s name? What about the Chinese physician who dictates a letter to Dr. Tse but refers to him as “Dr. Cho”?

Amusing is not the word that comes to mind.

Late one night, about a year after I had entered the field of medical transcription, I found myself pacing back and forth in the medical records department of a local hospital. A word was bothering me (a phenomenon well known to medical transcriptionists). What bothered me about this word was that I could not find it in a medical dictionary. Or any other available medical reference book, for that matter. I knew I had heard that word before. I was almost sure I had typed it that week. But for the life of me, I couldn’t remember what it meant. And I was mad at myself for not being able to remember.

There wasn’t much help at hand. By that time, only the swing shift crew was present in our department. Ken, a very polite African American file clerk, didn’t mind when people “axed him questions,” but didn’t have too many answers. Lillian was an elderly transcriptionist who was legally blind and smoked like a house on fire. Caroline was the image of an aging cheerleader who was rumored to be screwing one of the OBGYN surgeons. And Maryann, bless her soul, was a prim and proper librarian type (a superb transcriptionist who worked a second job to pay for her mother’s medical bills) who pretty much minded her own business. I couldn’t get any answers from them.

The word that was driving me nuts was “Ochoa.” But it wasn’t until two weeks went by -- and another patient named Ochoa got admitted to the hospital -- that I realized I had been obsessing over a patient’s name rather than an item of medical terminology.

That was back in 1974. Although the hospital where I worked had a large number of Filipino and Hispanic employees, it had never dawned on me that Ochoa might have been a patient’s name. I never would have guessed that my answer could have been found in a telephone directory because I was only thinking in terms of medical and pharmaceutical terminology.

Doctors often like to think that, without their godly presence, people like medical transcriptionists wouldn’t have jobs. But the truth is that without patients there would be no practice of medicine, no health information management industry, and a major dent in the world’s economy. Since 2000 is a census year, it’s important to understand how changes in America’s demographics affect the knowledge base of a professional medical transcriptionist.

When I was a child, it was a pretty fair assumption that the doctor who treated you would be a Caucasian male. It has taken many years for the demographics of physicians and medical transcriptionists to catch up with the demographics of the population at large. But the times, they are a-changing! A sure indicator of the altered face of medical care in America is to examine the names of the patients who are being treated and the healthcare providers to whom they turn for their care.

Most medical transcriptionists wouldn’t be expected to know the names of the Native Americans who welcomed the first wave of immigrants. Some patients are indeed named Pocahontas and Hiawatha. Many towns in New England (Matunuck, Pawtucket, Narragansett, Chepachet), were named after local Indian tribes. Street signs and business names in the American Southwest often include tribal names like Pima, Osage and Navajo. But few transcription courses offer clear instructions on the proper hyphenation of a patient’s name when that name is “Benjamin Brings-Plenty.” I doubt there are any medical transcription courses which teach that a contaminated quahog could be a source of food poisoning. Yet these words are part of the language which forms our American heritage.

Recent years have seen huge numbers of immigrants arriving in the United States to seek a better life. Whether they came from Europe, Mexico, Central America, or countries along the Pacific Rim, these people have had a tremendous impact on America’s healthcare services. Be honest: Until the Elian Gonzalez story hit the news, how many women named Marisleysis were a part of your daily life?

Whether recent immigrants have been Haitian boat people attempting to enter the country illegally or relatives being brought to the United States by naturalized Filipino-American citizens -- whether they were newly-free Russians or families that fled Hong Kong before it came under Communist rule -- they all brought their past medical histories, healthcare needs, and ethnic vocabularies with them. Some have created a need for physicians who speak a foreign dialect. Others have created a growing market for interpreters.

Many cities now have large ethnic populations. And, for many minorities, the desire to keep the money flowing “within the community” is matched by a distrust of people from other backgrounds. For these reasons, a Hispanic physician is likely to attract a Latino-identified patient base the same way that a black physician might attract a largely African-American patient base.

However, searching a database for a patient named “Chan” in San Francisco, “Hernandez” in Los Angeles, or “Schwartz” in New York might reveal hundreds of patients with the same last name. A medical record number may be the only way of finding the correct “Carlos Hernandez,” “John Chan,” or “Paul Schwartz.” Other, more subtle variations, must also be recognized. In many ways these reflect the language of a subculture and, to a certain extent, the musical rhythms with which that language is spoken.

• Is the proper spelling of a patient’s last name Gonzalez or Gonzales? Does that change in spelling indicate a different heritage or country of birth?

• Should a Hispanic woman’s first name be spelled Ofelia or be spelled the same way as Shakespeare’s Ophelia?

• Should another patient’s name be spelled Mohammed? Muhammed? Or Mohamet?
  

The further one delves into the spelling of family names within ethnic subcultures, the more difficult it is to be sure that a medical record is referring to the proper person. Especially when doctors continue to dictate names without spelling them.

For example: San Francisco has a huge Asian population. With an increasingly large number of Asian patients in many cities, it is often difficult to identify which word represents the patient's first, middle, or last name. Names like Boon Hang Ling or Fang Nguyen can easily be transposed to read Ling Hang Boon or Nguyen Fang. Once again, a medical record number serves as a crucial identifying marker.

The term “Asian,” however, is no longer restricted to people from China and Japan. It also encompasses the Korean, Thai, Burmese, Vietnamese, Cambodian and Filipino subcultures. Under this huge umbrella of nationalities stand endless numbers of patients whose names sound alike but may be spelled very differently.

• Is the patient’s last name Wu or Woo?

• Li or Lee?

• Low, Lo or Lowe?

• Young, Yang or Yong?

• Chen, Chan, Tsang or Tsiang?

• Leung, Leong or Liang?

What about the Chinese physician who pronounce things very differently than a transcriptionist might expect? Suppose he is dictating a letter to a physician named Dr. Kwok? Could he really mean to dictate a letter to Dr. Quock (whose office is in the same building as Dr. Kwok’s)? What about the physician who sends referral letters to both colleagues but pronounces their names “Dr. Kwa”? Or refers to Dr. Hsu as Dr. Shoe? How is speech recognition going to make these distinctions when the medical transcriptionists who are familiar with this doctor’s work can barely figure out what he is trying to say? Should we be demanding equal rights for homophones?

There can be no doubt that the medical transcriptionist who works on an account with a high percentage of patients and physicians from any ethnic background must tune his ears to the finer shadings of words which will never be found in medical reference books. These words reflect the community served by the hospital as well as the subset of physicians from the same ethnic background.

However, there are times when not even a knowledge of a community’s ethnography can prepare a medical transcriptionist for coping with the kind of name recognition that accompanies fundraising for nonprofit organizations. In certain healthcare facilities there are rooms, wards, and entire wings that have been named in honor of philanthropic donors. Building-specific names like the “Krietzler Ward,” “Magrob Unit,” or “DeSantis Wing” would never be found in medical reference books. How does an MT properly enter “The Artist Formerly Known as Prince” into an electronic field limited to a specific number of digits?

The Hippie era witnessed the birth of children with names like Unicorn, Atom and Chastity. We now have performers who have adopted single-word names like Cher, Carrottop and visual artists named Stephan and Pumpkin. A transcriptionist in the Midwest once told me of a new (and rather illiterate) mother who, when presented with birth certificates that read “Twin A” and “Twin B,” was utterly relieved and profusely thanked the confused hospital staff for saving her from having to decide what to name her children.

The piece de resistance, however, is a story once told to me by a woman who transcribed for a hospital near Detroit. “One family was extremely well known to the medical records staff because we could never figure out how or why the mother gave her children their names,” my friend chuckled. “Her kids were named Park, Drive, Second and Neutral. My theory has always been that each child was named after the gear the car was in at the moment of conception!”

Who Would I Work For?

Anyone who studies gambling learns a quick lesson: The odds are on the side of the house. So if you’re wise, you find a way to become the house. Things are pretty much the same in medical transcription. If you want to earn more money and have greater control over your work process, you start your own service and take the responsibility for making things happen the way you want them to happen.

Alas, not everyone is in a position to make that move. The majority of medical transcriptionists are women. Some are single mothers and, as the sole wage earners in their household, are doing everything they can to keep their heads above water. Others may be raising children with the luxury of a second income in the family. Others may simply be single (male or female).

Whatever the domestic situation, not everyone is cut out to run a business. Some MTs are at their best simply transcribing. That’s what they do. They do it well, they do it efficiently, and they enjoy doing it. Unless, of course, people are trying to make their professional lives miserable (a wealth of dysfunctional behavior can be found in the field of medicine).

With the industry facing a critical shortage of qualified medical transcriptionists – and the Internet making it easier for MTs to check out a wide variety of job opportunities – it has truly become a seller’s market for talented medical transcriptionists. With one qualifier: Technology is what is driving change. Thanks to technology, MTs no longer have to go where the work is. Instead, the work can come to them. Although medical transcription cannot be done without the human resources necessary to do the job properly, too many entrepreneurs, MBAs and venture capitalists have been seduced into thinking that the professional MT has become a vestigial part of the process.

Having gone through various stages of working as a medical transcriptionist (hospital employee, independent contractor, and owner of a medical transcription service), I think it would be wise to examine the financial, professional, ethical and practical ingredients of an employment package which are going to make a seasoned medical transcriptionist want to work for any employer.

Compensation:

With competition from offshore transcription firms increasing the pressure to lower the cost of transcription, it’s difficult to find qualified MTs who are willing to work for peanuts. Why should they? No matter what formula or unit of measurement is used to determine earnings, experienced transcriptionists have been doing this kind of work long enough to know when they’re getting screwed. Thanks to the Internet, it is now much easier to shop around for transcription services that might place more value on their skills and experience. In an age where corporate loyalty has become a joke (sometimes the corporation is no longer in existence by the end of the year), there is no reason for experienced MTs to take any job unless it is worth their while.

Corporate culture:

Is this company run by people who have experience transcribing and will understand the professional and ethical values of a medical transcriptionist? Or is it being run by a bunch of cowboys and jocks with MBAs who want to pay transcriptionists as little as possible? Does this company believe in protecting the confidentiality of a patient’s medical records? Or is it sending work overseas to offshore transcription firms in an effort to make a quick buck? Will I feel I can be proud of the work I do for this company? Or will I be ashamed to admit that I work for this company?

Employee versus independent contractor status:

MTs who choose to work as independent contractors take on certain responsibilities for which they get certain tax breaks. Unfortunately, some MTSOs want all the advantages of treating an MT like an employee but don’t want to pay the taxes that come with having so much control over someone’s work situation. If being a “statutory employee” means I must sacrifice all the benefits of being an independent contractor in return for a big fat nothing, why would I want to work for your company?

Formats:

Do your documents follow a standard format? If not, how many different formats must I work with? How often am I going to be asked to switch from one format to another? How many different accounts am I going to be working on?

Hardware:

Will I have to perform all work for your company on a separate computer? If so, will you furnish the computer at no cost to me? If not, how much is my investment? How much of that investment can I salvage if we part company?

Leaving blanks:

Does the management of your firm understand why medical transcriptionists leave blanks? Or are they trying to deliver “cosmetically appealing” documents to their clients – regardless of the risk of compromising patient care?

Lost Time=Lost Money:

I’m willing to work on a production basis assuming that a steady flow of work is available. But what about when the work dries up? What kind of compensation can I expect if your servers are down and I can’t receive any work?

Manuals:

Will I receive a manual which clearly outlines procedures and responsibilities? Has this manual also been written in HTML format so that I can access it from my desktop? When was the last time this material was updated by someone who really knew what was going on?

Medical Benefits:

More than line rate or salary, one of the most crucial issues for information workers is medical benefits. Some transcriptionists have hopped from job to job without being able to maintain coverage; others have a spouse whose employee benefits cover the entire family. But for those who are single – or single parents – medical benefits can make or break an employment offer. Sometimes the benefits package offered by an employer isn’t as sweet as it sounds. My prediction for the future is that information workers will shoulder the costs of their own health plans as they take on work from more than one source. In the end, “bennies” will no longer be the golden handcuffs that can keep employees in place.

Prompt payment:

Will my check arrive on time? That’s not as funny as it sounds. If you – or one of your partners – is an alcoholic (or snorting cocaine), I can’t afford to let it affect my ability to pay my bills. I don’t want to hear lame excuses about a client being late with payment or be forced to listen to any long, sad tales of woe about the problems you’re having with cash flow. If you expect me to work tight deadlines and deliver for you, then I expect you to deliver a check to me. On time. Every time.

Quality assurance:

Medical transcription is very difficult work which requires lots of judgment calls (always remember that the quality of an MT’s transcription is directly related to the quality of any doctor’s dictation). If I have to leave blanks because some bozo can’t -- or won’t -- speak clearly, I need to be assured that my professional expertise will be respected. If I am not hearing things correctly, I don’t want to be reprimanded like a child. And if the folks doing quality control are prone to retaliatory strikes against MTs because of personality conflicts, unhappiness with their own failed careers (or perhaps some particularly evil bouts of premenstrual syndrome), I want to be told about this situation before I sign on to work for your company.

Respecting boundaries:

We’ve all heard horror stories about MTSOs who call transcriptionists at 6:00 a.m. and scream “Get out of bed and start typing -- there’s too much dictation on the system.” I still remember the transcription manager who told me I was not allowed to leave my own home without her permission. Medical transcription is a profession, not a religious cult. If I say that I’m unavailable between certain hours, don’t call me. If I say that I’m going on vacation for several days, don’t call me. Never forget that lack of planning on your part does not constitute an emergency on mine.

Software:

How much training is required to understand your software and get up to speed on it? Will off-the-shelf applications like word expanders, drug indexes, and medical dictionaries work with your software? Do you furnish those to your transcriptionists?

Technical support:

With more and more proprietary software systems in use, a common complaint is that “the software is great – when the servers are working.” If I have to rely on your software, are you going to have tech support people available during all of the hours that I’m scheduled to work? Because if you want me to work evenings, graveyards or weekends, I need to know that there’s someone I can call when things go wrong.

Toxic work environment:

I’ve got enough drama in my life without unnecessary egomaniacal tantrums and unprofessional nuclear meltdowns getting in the way of my work. If your managerial staff is prone to screaming at each other, having fights in the hallways, or laying the blame for management’s stupidity on the transcriptionists who work hard to earn the administrative staff their salaries, then I don’t want to work for you. Is that clear?

When confronted with voice recognition technology and constant pressure to decrease the earnings of medical transcriptionists in order to pay for expensive technology, there is a lot to be said for MTs having a solid sense of self worth -- and knowing that every job offer they receive will not necessarily be their last. Any experienced medical transcriptionist worth his/her salt has put a lot of effort into developing the skills and vocabulary necessary to do this kind of work.

In a thriving economy, the smartest employers will treat their transcribing talent well because happy workers are more productive workers. Stupid, selfish and uncaring employers will quickly learn that unhappy workers can vote with their feet and warn others about their experiences in an unhappy work environment.