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November 21, 2011

An Uncertain Future
By Selena Chavis
For The Record
Vol. 23 No. 21 P. 10

As the healthcare industry becomes increasingly electronic, medical transcriptionists are trying to find a new identity.

Like many facets of the healthcare industry, the medical transcription field is evolving around the electronic movement. Many questions are being raised as to how transcription will redefine itself to work alongside speech recognition technology and EHRs. As it stands, the verdict is still out as to what exactly the future holds for this field as it attempts to adapt and morph into something new.

Opinions on where transcription is headed run the gamut. Some industry professionals predict its demise, while others see an elevated role for medical transcriptionists (MTs) that will coincide with decreasing demand and the elimination of some jobs.

But what is certain, according to many MTs, is that it’s high time for the industry to become proactive about its future.

“The entire industry is in a huge state of flux,” says Kathy Nicholls, CMT, AHDI-F, owner of Nicholls Consulting Services and founder of an academy for MTs adjusting to life in an EHR environment. “What I don’t think we can do is sit around and wring our hands and just say, ‘We don’t know what the future will look like.’ If we don’t get proactive, all those roles will be redefined for us.”

While much anxiety exists within the transcription industry, savvy professionals are gearing up to meet the challenge. From redefined roles as editors to new careers as coders, MTs have a vast amount of medical knowledge that can be leveraged, according to industry experts.

“I’m not sure what direction to go in, but we cannot wait here for everyone else to decide our fate,” says a 16-year medical transcription veteran who requested anonymity.

A Challenging Outlook
According to Kathy Lengel, manager of transcription services for Pennsylvania-based Lancaster General Health, the comprehensive health system that operates one of the state’s busiest hospitals, has witnessed a huge change in its workflow over the past two years. She attributes the makeover to the deployment and use of the organization’s EHR.

“We had 74 transcriptionists in 2007 [in the health system’s central transcription department]. Currently, we’re down to 66,” she notes. “We do 75% of the work we used to do. I’m expecting huge decreases in staffing going forward.”

The challenging outlook is not just reserved for the hospital environment. Staffing decreases are the expectation across the industry whether an MT works directly for a hospital, a large transcription services company, or a mom-and-pop operation.

Carole Gilbert, RHIT, owner of Gilbert Medical Transcription Service, a small company that has been in business since 1984, has experienced some downsizing over the past two years after two of its hospital clients moved to speech recognition software. “We’re very cautious in hiring staff. Staffing has become much more difficult to manage, but we don’t want to overstaff,” she says.

Some of the challenge is directly related to the changing dynamics of the transcription function that is moving MTs away from their traditional responsibilities into more of an editing role. As speech recognition technology becomes more mainstream, the delivery of physician dictation becomes automated, requiring a different skill set—one that edits computer-generated documents for accuracy and quality.

Hospitals and healthcare organizations are capitalizing on the efficiencies speech recognition software creates within an EHR through automation. Industry experts predict that it will continue to enhance data-sharing efficiencies as EHRs integrate with established systems for interoperable healthcare reports that conform to standards for information exchange. The standardization and adoption of these electronic documents are expected to enlarge and improve the flow of data, including narrative documentation, into the EHR.

As this industry movement continues to evolve, experts suggest MTs will need to hone their listening skills, and adopt a more critical-thinking approach to their work. Such attributes will require a broad knowledge of medical terminology and processes, making certified MTs a valuable commodity while diminishing opportunities for those who lack this expertise.

Alongside decreasing demand and a need for more advanced skills, another issue clouds the future of MTs: declining pay rates. The drop in salary is creating anxiety in the industry as to whether a career as an MT will remain financially viable.

“Some [MTs] have gone from 9.5 cents per line to 3.5 cents per line,” says Gilbert, adding that productivity demands tend to be unrealistic in the new editing positions. “The jury is still out as to whether you can make the same income editing. The premise for speech editing is that it would be more efficient, but MTs should still be able to make the same amount. We’re finding that’s not necessarily the case.”

The 16-year industry veteran, who works for a large transcription services company, has dealt with pay decreases over the past few years. Alongside the EHR challenge, she points out that competition with offshore labor in countries such as India continues to drive down medical transcription salaries. “We’re either going to be zapped by India or EHRs,” she says. “The time expectations are not in line with what is really required for editing.”

Besides dealing with wage woes, owners of small transcription companies such as Gilbert Medical Transcription Service are finding that scheduling is becoming an increasingly difficult challenge. Because the workload varies and is more inconsistent than in the past, Gilbert says companies and staff have to be much more flexible.

“The variance in workload really affects us. People have to be ready to go at a moment’s notice,” she points out. “In order to meet clients’ needs, we have to work flexible shifts rather than set shifts.”

Unrealistic Claims?
Decreased demand for MTs may be a reality going forward, but some industry vendors and professionals have even suggested that speech recognition and automation can ultimately eliminate the need for transcription. However, those in the transcription trenches debunk this assertion.

“These claims are disingenuous,” says the longtime MT. “There are too many things that the software is not able to do without human intervention.”

Gilbert concurs, noting that computer-generated transcription “would be a completely inaccurate report without speech editing.”

In a study published in October by the American Journal of Roentgenology, researchers found dramatically higher rates of major errors in patient records created using front-end speech recognition technology compared with reports that were dictated and transcribed. The study’s abstract reveals that at least one major error was found in 23% of the reports generated with speech recognition as opposed to a 4% error rate in reports that used conventional dictation transcription, making speech recognition eight times more likely to result in major errors.

“The whole purpose is to have an accurate, timely report. That’s what the push is for the EHR,” Gilbert notes. “What is the sense of having an inaccurate record transmitted faster? It doesn’t make sense in the context of patient care.”

Nicholls points out that the errors found in documents transcribed in speech recognition would never pass the test in a traditional transcription environment, adding that there will always be the need for some type of quality follow-up.

“If we allow [the elimination of transcription] to happen, then we are going to have some serious errors,” she says, admitting that while there will always be some need for MTs, it is inevitable that the industry will shrink. “I think there will be much less transcription. We can’t hang our hats on the narrative.”

Leveraging Potential Opportunities
Gilbert notes that the industry needs to have a united voice that promotes the value of editing skills and the need to elevate pay scales to a livable wage.

Until editing becomes more prominent, MTs need to look at other skills, suggest industry experts.

For example, the transcription department at Lancaster General Health has started to redefine its role, even going so far as to consider changing the department’s moniker. “I’m hearing a lot more talk of data-quality checks in the industry now,” Lengel says, suggesting that such a change presents an opportunity for MTs to take their knowledge and expand it in a new direction. “That’s where I’m seeing the momentum going. We’re working with physician champions to roll out a data-quality program.”

In Lengel’s department, 15 MTs have been cross-trained to perform abstracting in the organization’s physician offices to get information into the EHR and eliminate errors. The department has also been involved with validating quality on a broader scale as the entire organization implements a new EHR.

In these roles, Lengel acknowledges that certified MTs (CMTs) definitely have an edge on their noncertified colleagues. “CMTs have the advantage because they have the general knowledge,” she says. “You need to have experience with the patient record. We will require CMTs in this role.”

Some MTs at Lancaster General Health are taking courses to broaden their knowledge base, and Lengel is working with hospital staff to determine other areas where MTs may be a good fit. In fact, two transcriptionists have successfully made a transition into the coding department.

“My director and I are just very honest with our staff. At least they know where things stand,” she says. “I strongly believe there’s going to always be a need for transcription … just decreased demand.”

— Selena Chavis is a Florida-based freelance journalist whose writing appears regularly in various trade and consumer publications covering everything from corporate and managerial topics to healthcare and travel.


A Two-Sided Perspective
A physician assistant (PA) since 1982 and a medical transcriptionist (MT) since 1992, Sherry Roth, PA-C, DF-AAPA, CMT, AHDI-F, has been able to make the transition to working with an EHR without too many headaches. She attributes the ease of her metamorphosis to a background in the medical field and IT experience—two skill sets that will be important from a quality perspective going forward.

“Being a PA has been invaluable because I have such a broad knowledge of medical terminology and the field,” she notes. “Plus, technology is something I’ve always been interested in. Expanding the skill set from there becomes another step.”

Not all MTs will make the transition as easily as Roth, but she believes the skills that helped her adapt to a changing environment will be important to maintaining quality as more MTs become editors of computer-generated documents. Unfortunately, the industry appears to be moving in a direction that undervalues and underpays this skill set, she points out. As a result, the best MTs will begin to look for greener pastures.

“They are paying 3 cents a line for editing. It’s ridiculous and demeaning,” Roth says. “I think you don’t get the quality of people you need. They don’t realize our value as transcriptionists to promote good patient care and patient safety.”

As a PA, Roth sees firsthand how an EHR can improve patient care and outcomes. To that end, the availability of accurate documentation in a timely manner is essential to having the complete patient picture the industry is striving to capture. Without quality editing that draws from broad industry and medical knowledge, Roth fears the content in patient records will suffer, and it will become increasingly difficult to recruit qualified MTs.

“Unless and until 100% accurate documentation is produced, natural language processing [NLP] will be less effective in data mining and will miss or misinterpret things. The less human involvement you have in these processes, the more important it is to make sure that the information provided to the software program is accurate,” she says.

For example, Roth recalls going through a patient’s chart and finding a progress note with a physician’s interpretation of a slightly elevated troponin as being indicative of a non-ST segment elevation myocardial infarction (STEMI). Two pages later, however, a note from a cardiologist said it was not a non-STEMI and was related to coronary heart failure leak.

“How will NLP interpret this discrepancy? I’ve seen human coders make mistakes; how much more so a computer program?” Roth asks. “This is not to say that NLP is useless; on the contrary, it can be fantastic because of the speed with which it can fly through records and pull out information. However, data is not the same as information or knowledge. Humans must still be involved from beginning to end.”

— SC