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Outsourcing
Transcription: Is It for You? By Robbi Hess For The Record Vol. 18 No. 9 P. 14 At what point does it make sense to relinquish transcription to a vendor? Whether an organization begins investigating outsourcing as a way to handle overflow, balance staffing needs, centralize transcription services, or as a cost-savings measure, outsourcing can be a great solution when medical transcription volumes vary. Outsourcing allows the HIM director to minimize the staff’s idle time during slow periods, avoid stress and overtime during peak periods, tackle seasonal fluctuations, and account for vacation coverage. Whether it be on a department-by-department basis or a wholesale switch, many facilities find that outsourcing some—or all—of its transcription makes the most sense. In fact, the numbers show that there is a good chance
it will become more popular. The International Data Corporation
reports that U.S. spending on medical transcription outsourcing
services totaled approximately $2.3 billion in 2004 and forecasts
that the market will increase to more than $4 billion in coming
years. “In most facilities, there isn’t a single ‘ah-ha!’ moment to make the switch to outsourcing,” he says. “It usually happens gradually, and maybe the first step is because someone is going on an extended leave or maternity leave and the department will be short staffed. The HIM director says my department will be short staffed, service levels will be impacted, discharge summaries and operating reports are getting behind. When a department is falling short on its service level requirements they may consider bringing someone in on a temporary basis. That leads the shift toward a more permanent outsourcing arrangement.” Lee Tkachuk, CMT, CEO of Keystrokes Transcription Service, Inc., also views the move to outsource transcription as a gradual process. “It is getting more difficult to find qualified transcriptionists to work on site, as well as the cost factor involved,” he says. “When a facility outsources their transcription, they no longer have to pay for the overhead in the transcription department, the computers, the network connection, IS [information system] support, taxes, benefits, or office furniture. In addition, they can use the space for something else; most hospitals view space as a premium.” Acusis CEO David Iwinski, Jr says one criteria for considering outsourcing is fundamental: Is the healthcare facility able to fulfill its mission with appropriate turnaround times (TATs) and offer both quality and cost effectiveness? “If I, as an HIM director, think I’m not getting the job done and I need more transcriptionists to get it done, I might turn to outsourcing,” he explains. “Some people step back and ask, ‘What’s the mission of the hospital? Providing healthcare or spending money on transcription?’ They need to determine if they are cost-effectively providing healthcare and allocating funds if they are spending substantial amounts of money on clerical services.” If a facility hires an outside vendor to fill in on a temporary basis and is duly impressed with the service, it becomes more comfortable with the idea of outsourcing. The seed is planted, and it grows from there, likely blossoming into a more comprehensive outsourcing arrangement. “Those in charge need to remember they are in the business of providing healthcare, not staffing a transcription department,” Hopkins says. “Is staffing our own transcription department really vital to providing patient care?” According to Hopkins, making a switch to an outsourcing vendor depends on the level of “pain” the hospital is experiencing—pain being defined as cost vs. service level. “We have a client that started outsourcing in a small way; they were three months behind on discharge summaries and they started asking themselves if that was acceptable. If it is, then the idea of outsourcing to get caught up is no big deal. If being three months behind is unacceptable, you need to find a solution,” he says. Outsourcing is a viable solution to the problem, but Hopkins knows that some facilities may have had a bad experience with outsourcing, whether it be from a service or cost standpoint, two areas in which HIM directors need to be well versed. “Are you running below or at budget, or are you exceeding budget levels? Once that’s determined, then you need to ascertain what’s going on to cause those costs to be so high,” he explains. “Are you spending considerable time and resources searching for staff than you are making sure the typing and transcription is being completed in a timely fashion?” Hopkins says facilities must determine the following: • whether they are meeting service levels; • whether their financial metrics are at acceptable levels; and • whether the HIM department’s job and time requirements are being met. The wake-up call for many hospitals and clinics, Iwinski says, is backlog. “The HIM director says, ‘Holy smokes, we have a ton of work, our staff is over stressed, we’re spending a lot on overtime, and we’re still behind,’” Iwinski says. “That’s typically when outsourcing is considered.” Iwinski says most of Acusis’s clients seek assistance because they are experiencing a dramatic backlog. “This backlog creates two kinds of problems—delays in therapy and treatment because the physicians don’t have access to reports, and the more prosaic problem is getting paid. Every file sitting in backlog is a pot of money waiting to be grabbed, “ he says. Tkachuk says an HIM director can determine whether the department is functioning efficiently by monitoring signs of burn-out among staff who may be covering shifts for other MTs. Other indicators include a jump in overtime pay and TATs, and physicians complaining about a lack of responses or a failure to complete reports in the charts. “No one in administration seems to think about
transcription until there is a problem,” Tkachuk says. “At
that point it becomes a panic situation. Oftentimes, temps are brought
in at a premium cost, quality can be sacrificed in the rush to get
the work caught up, and transcription is the topic of many meetings.” “If you say we need help with ‘X’—be it discharge summaries, a specific work type, evening or weekend coverage, radiology, or other specific departments—they might not have the correct equipment or systems in place to support an outsourcing arrangement,” Hopkins explains. “You may need to upgrade your HIM systems, in which case you wouldn’t necessarily want to bring in an outsourcing company.” To best make an outsourcing arrangement work, Hopkins says, if possible, the vendor should integrate its systems with the facility’s platform. “As a hospital, you might want to own the system and have someone come in and work on your platform—that would be more of a labor supply issue,” Iwinski says. “The facility could say we don’t want your technology, just your labor force. It gives the HIM department an added measure of control because they don’t have to strip out the transcription technology piece they have in place.” Conversely, a healthcare facility may want the vendor to provide everything. Hopkins urges any HIM director or facility that is considering a move to an outsourced vendor to have a plan. “You should tell the vendor what you want, what you need, and what you expect,” he says. “You need to interview vendors with a focus and tell them to give you a proposal rather than being bombarded with vendors offering services you may not need, want, or even understand.” When it comes to software and operating platforms, Iwinski says before deciding whose platform to use, the status of the hospital’s infrastructure must be determined. “If it’s obsolete and no longer under warranty, I would think a hospital would have no problem switching to a new platform,” he says, adding that this is the least common practice. “What happens more often is you go into a department and adapt your equipment to interface with theirs.” Having a baseline and metrics for evaluating the services being offered is crucial. “Once a vendor is brought on board, the HIM director needs to be able to evaluate its services and point out this is what we wanted, this is what you actually delivered,” Hopkins says. “Are they living up to what you expected? Are the costs in line with what you anticipated?” Ideally, it is best to make the switch to outsourcing by slowly integrating one department at a time. “A massive overall change is disruptive,” Iwinski says. “If you find out you picked the wrong vendor, you are in trouble because to go out and try to find a new vendor while dealing with the old one could be disastrous.” Iwinski also believes that making a piecemeal change employee by employee is not the way to go, either. “The best way to make a change is to take a whole department at a time,” he says. “If you give an outside vendor jobs on a file-by-file basis, the quality will likely not be what you are getting with your in-house staff who have relationships with the physicians and understand their idiosyncracies.” A department-by-department deployment gives inside staff breathing room and also offers the outside vendor a fair chance of proving its capabilities. “We guarantee that at the end of the time, if they are happy with the services we provide, we’d like a shot at the whole hospital,” Iwinski says. “Many times, a hospital medical services grows faster than its ability to keep up with transcription.” Both men agree that the outsourcing vendor should
adapt its services and technologies to the hospitals’. “It’s all relative,” he notes. “I could build a model to show you are paying 10 times more than you are now but that may or may not be true for every facility. And, honestly, outsourcing is not for everyone. It’s not a panacea for every problem an HIM department may be facing. In some cases, though, it definitely helps.” Getting your money’s worth is an issue hospitals and clinics face when looking to outsource, says Iwinski. “The range of providers out there and the services they offer is incredibly wide and there are no credible, across-the-board industry standards applied to the vendors,” he explains. “I really suggest talking to references, visit the production facility, talk to the manager, and do some homework. Make sure that claims of quality, service, and price by the vendor can be verified.” Tkachuk explains the way a facility may be able to determine whether it was getting its money’s worth could come in the form of decreased TAT with equal or better quality. “Many services, especially the larger ones,
have the manpower to put several MTs on an account to get it caught
up and to keep it that way,” he says. “The next indication
takes a little longer, but the director will notice that the physicians
are no longer being vocal about transcription and that the topic
is no longer a focal point in staff meetings. Long term, budget
will show the savings, which is the final indicator and, unfortunately,
the one that the number crunchers like to see the most.” “It really doesn’t matter where the transcription is provided, the technology is the same. It’s the idea of getting the work completed that matters to the bottom line,” Hopkins says. Iwinski, who frequents Acusis’s Indian facilities, says “excellent” work is being done offshore. “What you have to watch for are those providers who say they are doing all the work in the United States and then outsource it,” he cautions. “The problem isn’t with going out of the country, it’s having a middleman involved who might be unscrupulous or not use secure enough measures. With Acusis, the files aren’t out of our hands for a microsecond.” Tkachuk says looking for a provider with a proven track record, solid references, adequate resources to complete the work in a timely fashion, a supportive IS department that can work in tandem with the facility’s, and a good infrastructure are crucial items to seek in a vendor. “What are the company’s QA [quality assurance] requirements and how do they implement them? Do they have a solid disaster recovery/back-up plan? Can they handle your volume and provide the TAT you are looking for?” Tkachuk says, adding, “Are they easy to reach by phone? Can they provide coverage during the hours that you are looking for?” Making
It Work “Facilities need to do a thorough internal inspection to see where they are and where they need to be, get a handle on the situation before looking to an outsourcing vendor,” Iwinski says. “Try outsourcing a department or a specialty at a time and see how it goes.” —
Robbi Hess, a journalist for more than 20 years, is a writer/editor
for a weekly newspaper and a monthly business magazine in western
New York. Reasons
to Consider Outsourcing - Focus on what you do best - Leave noncore activities to the outsourcing vendor • Save time: - Cut back on downtime and backlogs because of vacation or sick days - No work time lost in training and educating staff - Quick turnaround • Save money: - You incur no payroll taxes, worker’s compensation insurance, sick pay, or medical benefits - You may not need to purchase hardware or software — RH
• Staff quality • Process quality • Vendor quality • Create a vendor evaluation matrix • Use the reference process ambitiously • Seek contractual and operational transparency • Be aware of processes for service activation • Thoroughly understand the pricing structure • Seek prelaunch comforts • Privacy and confidentiality procedures • Are you allowed flexibility (is there an exit plan)? — RH .
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