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October 26, 2009

On the Hot Seat
For The Record
Vol. 21 No. 20 P. 5

Transcription leaders muse about the state of the industry. (Note: This is the full transcription of our interview.)

There’s a lot going on these days in the healthcare arena. Revolution is just around the corner … supposedly. Putting aside the sweeping speeches, rabble-rousing rhetoric, and trite commentary, For The Record queried three transcription leaders for their thoughts on a variety of subjects. Our panel consists of Jay Cannon, president and chief information officer of Webmedx; Ethan Cohen, president of SPi’s healthcare division; and Peter Durlach, senior vice president of marketing and product strategy at Nuance Healthcare.

For The Record (FTR): What’s the latest on documentation standards?

Durlach: The latest on documentation standards is the continued goal to develop and, most importantly, regulate industrywide guidelines to ensure that as EHR systems are adopted that the data within them is accessible, shareable, and translates across different languages, applications, and locations.

HL7’s Clinical Document Architecture (CDA) has helped the industry to create some consistencies across clinical documentation, such as history and physical and discharge summary, but to date, not all sections of and types of a medical note have been characterized with standards.

The Healthcare Information Technology Standards Panel (HITSP), as well as other developing standards bodies and the current work they have under way, will help further formalize standards in the next one to three years. It is more important than ever before for the industry to implement documentation standards so all captured data can be shared and for interoperable clinical document repositories to be built and utilized across enterprise, regional, and national networks. As standards improve, so will workflow across the healthcare industry, as well as quality, accuracy, efficiency, and patient care.

Cohen: Although there are a number of initiatives under way in this area, we are not aware of any single standard that has gained traction on a national level.

Cannon: Document standards continue to evolve in regard to report type and structure, along with electronic exchange requirements for interoperability.

Standards are being addressed through the Health Story project, a consortium of associations and interested parties creating standard report architectures by report type. Electronic exchange is being tackled by a MTIA (Medical Transcription Industry Alliance) workgroup working on a digital health information highway. The digital information highway is designed to link together clinicians for the secure exchange of transcribed reports and discrete patient information.

FTR: How will the transcription industry be affected by the American Recovery and Reinvestment Act (ARRA)?

Durlach: The HITECH Act, which includes $17 billion of the ARRA, is earmarked to support widespread adoption and utilization of interoperable health information technology, including electronic health records (EHRs). As part of the overall mission to ensure the healthcare industry effectively uses EHRs, the transcription industry will support physicians’ meaningful EHR use.

As part of EHR data capture, dictation and transcription help ensure that the physician narrative (the part of the medical note that tells what the doctor is thinking during the patient encounter) is preserved and not lost to purely point-and-click templates or details that go untyped. While we do believe that legacy transcription vendors will face a challenge with the rise of EMRs, the evolved medical transcriptionist’s role as an editor (to speech-recognized documents) will continue to show value and contribute to EHR meaningful use, helping healthcare organizations earn incentives from the ARRA. Whether a physician leverages real-time speech recognition (Dragon Medical) to capture and input information directly into the EHR or background speech recognition to input information into the EHR (with help from an MT [medical transcription] editor), it has been shown that speech recognition contributes to more detailed electronic medical notes and support meaningful use of the EHR. In fact, productivity tools that would help doctors to better document care within an EHR (beyond the keyboard and mouse) were cited by 75% of the doctors surveyed as an incentive to EHR adoption, whereas 69% cited stimulus money.

Cohen: The ARRA, and the HITECH Act within it, will have far-reaching changes to the structure of the healthcare industry in the U.S. over the long term. Under ARRA, transcription companies must act as business associates and are required to comply with evolving and increasingly stringent privacy and security rules. Notification requirements for security breaches have also been expanded. The HITECH Act also imposes direct civil and criminal penalties on business associates for certain security and privacy violations under HIPAA. These changes mean that transcription services can no longer treat HIPAA guidelines loosely. They need to invest in dedicated personnel and establish formal processes to ensure that they are in compliance with HIPAA and the ARRA. Similarly, healthcare providers need to make sure that their transcription services are following these guidelines and have the appropriate support mechanisms in place. We believe that these changes will drive consolidation, as smaller transcription services cannot afford to make the investments required to comply with these stringent and evolving regulations.

Cannon: I believe the impact of ARRA will be very good for the transcription industry in three ways. First and foremost, all service providers will be forced to reevaluate their HIPAA privacy and security protocols as stronger rules are introduced. Secondly, the push to meet meaningful use criteria will drive adoption of data abstraction capabilities and integration. Transcription providers will need to develop new tools to mine data from transcribed reports for quality reporting and EHR fulfillment. Finally, I believe ARRA will place greater emphasis on accuracy and quality; it has already increased the demand for more rapid turnaround time.

FTR: What is the industry’s relationship with EHR vendors?

Durlach: In general, the legacy transcription industry has had little to no relationship with EMR vendors. This is due to the fact that a common promise of EMRs has been to eliminate traditional transcription and its associated cost and, as a result, the transcription industry has felt the threat of eventually being replaced by EMRs. As a speech-enabled clinical documentation company, we have very strong partnerships with the major EHR vendors as we jointly work to provide speech enabled clinical documentation solutions to clinicians.

Because dictation is oftentimes a preferred method for physicians to document their clinical notes, it will remain in practice through speech recognition solutions even as the EMR is broadly adopted. While not all physicians want to (or are willing to) use real-time speech recognition because of the editing responsibilities, background speech recognition will be increasingly utilized with the support of transcriptionists as editors. To support the real-time workflow, we retain relationships with more than 150 EHR vendors and have a Dragon Medical EHR Certification program, which helps to ensure that Dragon Medical works out of the box to populate the physician’s dictation directly into the EHR. Whereas for the background speech recognition workflow, our solutions integrate with EHRs via the phone or embedded dictation markers to allow for transcriptionists to upload final and structured documents (edited, approved speech-recognized dictation) into an EHR.
In both workflow scenarios, we are working to support physicians’ meaningful use of the EHR by creating interoperable technology for high-quality data capture, which ultimately results in high-quality electronic patient medical records.

Cohen: I cannot comment for the industry as a whole, but personally, I see immense potential for partnerships between EMR vendors and transcription companies. Implementation of an EMR system is a daunting task, and medical transcription is an integral part of the documentation process. Accordingly, the successful rollout of an EMR system requires a collaborative effort between the EMR vendor and the transcription provider. Even if the EMR vendor believes that its product will reduce the need for transcription, cooperation between both parties is essential for a smooth transition. By working collaboratively, both parties have the greatest chance for success over the long term.

Cannon: I think the relationship with EHR vendors will be increasing as operational phases of implementation begin. It has been disappointing to date that attention from EHR vendors has been lacking within our sector, but that has probably always been the case between the selling and the servicing cycles of products.

In time, I think these relationships will be very functional and the associated processes seamless for documentation creation processing and improvement. Our goal is to work together with EHR vendors to deliver hybrid clinical documentation solutions that give physicians flexible choices for input, along with discrete, reportable data output for the EHR.

FTR: The Power of 10 campaign is designed to give the industry more of a voice in Washington. Why does the transcription industry need lobbyists?

Durlach: First off, we are not part of the Power of 10. In our opinion, the transcription industry contributes to helping preserve the physician narrative (the unique patient story that can not fully be captured as part of a point-and-click template alone) as part of the EHR. As policymakers continue to work to create rules and guidelines surrounding meaningful EHR use, it is our opinion that the value and quality of the narrative information that is captured in the EHR should be accounted for. Therefore, the transcription industry is lobbying for their role in preserving the physician narrative to be recognized. In the move to make patient’s medical records electronic, we can’t forget about preserving note detail and quality, as it is central to the delivery of high-quality care especially as healthcare becomes a more interconnected continuum of care.

Cohen: Major changes are happening within the healthcare sector. In particular, the government’s efforts to encourage the adoption of EMR/EHR systems have significant implications for medical transcription. Accordingly, AHDI (the Association for Healthcare Documentation Integriy) and MTIA are working with lobbyists to make sure that the concerns and needs of the industry are given due consideration and are taken into account when laws are drafted.

Cannon: The industry has felt a need for a voice in Washington due to the pace at which the meaningful use dialogue has progressed. It is critically important that Washington understands the role of transcription in achieving EHR adoption. Practical use must be achieved before meaningful use can be demonstrated. Transcription, speech and voice technologies are practical steps in the operational deployment of EHRs; it’s important that national leaders understand this.

FTR: Measuring line counts. What’s fair? Is the visual black character (VBC) method effective?

Durlach: Any line count is fair as long as the measurement and details are understood and transparent between the customer and vendor. Fair line counts are both transparent and auditable. Based on the way they are measured, any type of preagreed-upon line count should not deliver surprises on either side. Again, VBC is fair as long as it aligns with customer expectations. At Nuance, we make all of our counting procedures clear up front. We also provide customers with reports to audit the line count and activity on a monthly basis.

Cohen: From SPi’s perspective, measuring line counts is all about ensuring transparency; both the client and the vendor must have a common and consistent understanding about what is being counted. SPi advocates the use of a VBC count since we believe that this method is transparent and easy to understand. Accordingly, it allows us to build trust and confidence with our clients.  At the same time, we are willing to use other counting methodologies and believe that they are acceptable as long as the client and the vendor have a clear understanding regarding which characters are counted in every report. In some cases, we are even willing to agree on a flat monthly rate with our clients in order to simplify the billing process and ensure 100% transparency.

Cannon: I am so thankful for the excellent work provided by MTIA and AHIMA in creation of the VBC white paper. This is an area of extreme confusion for our customers. The VBC standard has helped clear the air and provide a standard by which all counting methodologies are compared. It is safe to say that 90% or more of the request for proposals (RFPs) and service agreements we process contain the VBC.

FTR: Is offshoring still a touchy subject in industry circles?

Durlach: While, yes, it is considered touchy among some industry circles, for many healthcare organizations, it is a proven and effective way to obtain the same high-quality transcription service as they are used to in the U.S. at a much lower cost. In fact, we are seeing more and more provider organizations looking to offshoring as a critical element in their transcription sourcing strategy, especially as the overall economy has weakened. From our perspective, offshoring is as good as the organization that you are working with. Our service for example, Focus Infomatics is U.S. based, as well as U.S managed, and has quality standards that align with, or surpass, most onshore services.

Many of our customers are participating in what’s referred to as our “follow the sun”’ model, in which they invest in a combination of both onshore and offshore transcription to ensure that they get the quality of service they need at the price they can justify. We expect offshoring as a trend to accelerate as more and more provider organizations get experience with high-quality offshoring service and as reimbursement rates continue to put pressure on operating costs.

Cohen: The industry’s thinking has evolved quite a bit over the last few years as offshoring has advanced from a niche offering to a mainstream component of medical transcription. Today, many healthcare providers are keen to take advantage of the benefits of offshoring. In particular, these providers find that offshoring allows them to significantly reduce their transcription costs while improving their turnaround times, especially during evenings, weekends, and holidays.  From an MT service provider’s perspective, the larger, more sophisticated players, like SPi, have taken steps to ensure that the quality standards of the work sent offshore are comparable to the quality achieved from domestic transcription.

Cannon: It is my opinion that the interest and visibility for the offshoring of medical transcription has definitely decreased. A majority of the RFPs we receive are now very clear in the prohibiting of offshoring. Furthermore, I believe the heightened awareness with ARRA will bring further scrutiny of global production processes in relation to privacy and security. This is not to say some global companies are not or cannot provide compliance, however the extent of subcontracting as a standard business practice in many global operations remain an area of concern.