Monday, September 24, 2007

Measure For Measure

A long time ago — in a distant galaxy far, far away — a dedicated army of medical transcriptionists kept hacking away at their jobs. For many a year, these determined information drones had been forced to labor on poorly-maintained manual typewriters and obsolete word processors by the rulers of an evil empire that only allowed documents to be produced in 10-pitch Courier font.

Those who supervised the MT drones were quite concerned about setting standards and maintaining credibility (they remembered all too well what had happened when some smart-ass sailor embarrassed them by proving that their planet was round). Although the leaders of the evil empire rigidly clung to definitions which made sense before personal computers became part of the popular culture, they could sense the growth of a dangerous trend.

In an industry struggling to achieve conformity, old definitions were being ignored so often that chaos had taken over the profession. Many medical transcriptionists had rebuked the self-proclaimed authorities and instead chosen to communicate with each other over the Internet. The situation had deteriorated to such a degree that an accurate definition of a line count had become as difficult to nail down as an accurate measurement for a line of cocaine!

Why were the folks in power so scared? Because change can be both frightening and exhilarating.

In 1998, the American Association for Medical Transcription (AAMT) finally threw in the towel and stopped trying to defend the 65-character line as an industry standard. In case anyone missed the significance of that moment, let me state it as bluntly as possible: The fat lady sang. It’s over, folks! The time has finally come for the medical transcription industry to adopt a new standard unit of measurement which can be clearly understood by everyone who participates in the dictation/transcription work process.

In searching for a new unit of measurement, the most important thing to remember is that technology drives change. And that once technology has penetrated a sufficient sector of the population, technology can redefine how things are run and how business is done. Regardless of one’s personal feelings toward Bill Gates, there is no doubt that the computer revolution has had a huge impact on the medical transcription industry. Very few of us are still using carbon paper to make copies or attempting to make corrections with razor blades and chalk.

In an era of electronic spreadsheets, digital file transfers and data repositories that can be mined for the purpose of target marketing, any large hospital system or medium sized medical transcription service that still uses cassette tapes is relying on obsolete technology. In searching for a new standard, we must locate an easily identifiable unit of measurement which is universally understood and available to all. We must also choose a unit which, in being used to measure productivity, can become a reliable standard for cost projections and budgeting purposes.

In the process of searching for this unit, we should always keep our costs of doing business in mind. Why? Because if we can eliminate any unnecessary tasks which add to our overhead or complicate our billing practices, we have a chance to streamline our work flow and make it more cost efficient.

Do you remember the 1992 Presidential election, when Bill Clinton’s forces kept stressing It’s the economy, stupid”? Medical transcription is not about how many words, lines, characters or pages get typed. It’s all about service.

  • Service with a smile.

  • Service with accuracy and quality assurance.

  • Service with reliability and professionalism.

  • Service that meets deadlines.

In short, professional service that should be paid for. How have people been paying for that service?

By the page

This was one of the earliest techniques to be used. Unfortunately, clients don’t like being billed for anything they can’t see -- especially if they’re paying the full page rate for a page that contains only three lines of text. Some become suspicious that transcriptionists are “fudging white space” or forcing the signature block to a second page. For medical transcriptionists, there is no easy way to anticipate one’s earnings since one page of wall-to-wall text takes much longer to type but pays the same as a page with only three lines of text.

By the line

Take the complications of charging by the page and add in the following caveats: How do you define a line? What margins are being used? What size fonts are you using? Do the headers and footers on each page count as billable lines? If a client requests that the transcriptionist insert a boilerplate paragraph, does the client have to pay for each line of that text? What if there are only three words on a line? Does that count? What if there’s a blank line between paragraphs? Does that count, too?

By the keystroke

If a doctor dictates three sentences and then says to delete them, does he have to pay for all those keystrokes that were performed if the text never made it into the final report? Should a transcriptionist be punished for using word expansion software to increase productivity? What about formatting commands? What about macros? Do those count?

By the character

Take all the arguments for payment by keystroke and ask what happens if the client doesn’t want to pay for hard returns or spaces between words? (Don’t laugh, some hospitals have tried to put that in their contracts).

By the minute of recorded dictation time

Complicated — and yet, in the long run, a potential winner. A scientific standard of measurement, the minute is recognized in all cultures. Because everyone tells time by the exact same standard, no one is going to argue about the definition of a minute the way they might argue about the definition of a line!

Other benefits? Measuring productivity by the minute of recorded dictation time is not affected by the same variables outlined above for measurement by layout, keystrokes or characters. Nor is it affected by operating system (DOS, Windows, Macintosh, UNIX). Most important, the new digital media which has begun to dominate the industry incorporates the minute of recorded dictation time as a standard measurement which is taken from the computer’s clock. Using military standards, every computer clock records the time in MMDDYY:HHTTSS format where


Any computer program that saves a file records the time the file was saved according to this standard. Using its computer’s clock, a digital dictation system can be set to measure the length of each report to the 10th or 100th of a minute. Therefore, given the existence of a previously underused common field, what is the potential of the minute of recorded dictation time as a standard unit of measurement with regard to productivity?

The first thing to understand is that, as soon as we start using digital dictation technology, we can and should abandon the line count.

  • Line counts are based on wildly inaccurate and obsolete standards.

  • Line counts vary dramatically depending on the dictation skills of each physician.

  • Line counts should never be used as a means of forecasting for purposes of budgeting.

  • Line counts also represent a phenomenal waste of time.

By changing our industry’s standard unit of measurement we can eliminate an entire level of accounting and, with it, a wealth of unnecessary stress. How so?

As personal computers have leveled the playing field (digital dictation systems that were once only affordable to hospitals are now within the budgets of many home-based MT businesses), one fact has become crystal clear. Contracts based on a unit price per line, character, word or page count punish medical transcriptionists for the poor language skills of doctors who are poor dictators. If medical transcriptionists are to be viewed as professionals, then why should they be forced to absorb any penalties that translate into lost income? Why should they transcribe the same amount of dictation with a variance of nearly $40 in the amount of money they earn from one day to the next?

By switching the unit of measurement from the line count to the minute of recorded dictation time, one immediately lifts the penalties for poor dictation skills off the transcriptionist's shoulders and puts them exactly where they belong: on the shoulders of the dictating doctor. Top transcriptionists will still have an incentive to make more money because, if they've tweaked their computers with Shorthand For Windows or InstantText and are using as many templates and macros as possible, they'll be turning over more minutes of dictation each day. Their productivity, however, will be measured accurately because they won't be penalized for someone else's bad dictation habits.

Any statistician can tell you that if you extrapolate the data over a year's time, the numbers will play out in a similar fashion. But think, just for a minute, of the stress you will eliminate! If a transcriptionist commits to turning over a certain number of minutes of recorded dictation time at X dollars per minute, he knows what he will get paid. That means:

  • Less anxiety about line counts

  • Less apprehension about being able to pay the rent

  • Less trepidation about meeting productivity quotas

  • Less tension about cash flow.

  • And last, but certainly not least, less undermining of a transcriptionist’s self-esteem.

With more economic stability in their daily lives, medical transcriptionists can be much happier workers. Happier workers contribute to a healthier business environment that earns bigger profits. What are some of the other potential benefits of adopting the minute of recorded dictation time as a standard unit of measurement?

Value-Added Formatting

Once you start charging by the minute of recorded dictation time, you don’t have to argue about whether or not anyone is going to pay for three words on a line. Or whether clients are going to pay for spaces and hard returns. Or whether people are going to count bold, underlined or italic codes as part of a 65-character line count. Instead, value-added formatting allows you to present clients with a compelling reason to include every item required for hospital report sections (like Review of Systems and Physical Examination) in pre-formatted templates. By giving your clients value-added formatting, you empower risk managers and medical records directors to confront dictating physicians with incomplete reports and require them to supply the missing data.

Paying for Appropriate Levels of Service

One of the most pressing reasons to charge by the minute of recorded dictation time is that it can dramatically simplify billing and accounting. There is no need to confuse clients by making your pricing structure as complicated as the offers being touted for various cellular phone services. Nor should your definition of a unit of measurement be as difficult to decipher as someone’s order for a cup of coffee at Starbucks.

If your clients are using a digital dictation system, they are essentially paying for access to an "online” or“telephony” service. Whether clients are accessing a legal database like Lexis or dialing 1-800-STUDMEN for phone sex, billable time is a professional concept that is universally understood. If you don’t believe me, ask an attorney or computer consultant.

With the minute of recorded dictation time as your standard unit of measurement, you can still offer clients multiple levels of pricing on a very creative and competitive basis.

  • For $X per minute, the client gets 48-hour turnaround time.

  • For $Y per minute, the client gets 24-hour turnaround time.

  • For $Z per minute, the client gets a stat report delivered in three hours along with a pepperoni pizza.

Regardless of what levels of service you choose to define, the unit of measurement remains the same throughout the industry. This makes it much easier for purchasing agents to shop around for transcription services. It helps vendors compete while basing their proposals on an industry standard that is universally understood.

Budgeting and cost projections

When hospitals measure transcription by the line count, they have no accurate way of budgeting the cost of the work performed. They can only “guesstimate” the costs they might be billed for after the transcribed reports (with appropriate line counts) are delivered to them.

By contrast, when the minute of recorded dictation time is used for billing purposes, a hospital administrator will know exactly how much it should cost to have a certain volume of work transcribed. A digital dictation system has the capacity to sort jobs by transcriptionist, author, job number, job type, job length, date of dictation and time of dictation. With those capabilities, an MIS director can design so many computer-generated reports that there is no need to use line-counting software. Using the data culled directly from the digital dictation system, a department head can extrapolate costs over a budget year in order to forecast trends in dictation volume and transcription costs with much greater accuracy.

The truth is out there. May the facts be with you.

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