Medical transcription

This article is an allied medical field. For other uses, see Transcription and MT disambiguation pages

Medical transcription, also known as MT, is an allied health profession which encompasses the process of transcription or converting voice-recorded reports as dictated by physicians and/or other healthcare professionals into text format.

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History

The evolution of the transcription dates back to 1960s. The systems were designed to assist the manufacturing process. The first transcription that was developed in this process happens to be MRP (Medical Resource Planning) in the year 1975. This was followed by another advanced version namely MRP2 which is the acronym for Manufacturing Resource planning. None of them yielded the benefit of Medical Transcription.

However, transcription equipment has changed from manual typewriters to electric typewriters to word processors to computers and from plastic disks and magnetic belts to cassettes and endless loops and digital recordings. Today, voice recognition system (VRS) is increasingly being employed, with medical transcriptionists and or "correctionists" providing supplemental editorial services, although there are occasional instances where VRS fully replaces the MT. Natural language processing takes "automatic" transcription a step further, providing an interpretive function that speech recognition alone does not provide (though MTs do).

In the past, these reportings consisted of very abbreviated handwritten notes that were added in the patient's file for interpretation by the primary physician responsible for the treatment. Ultimately, this mess of handwritten notes and typed reports was consolidated into a single patient file and physically stored along with thousands of other patient records in a wall of filing cabinets in the medical records department. Whenever the need arose to review the records of a specific patient, the patient's file would be retrieved from the filing cabinet and delivered to the requesting physician. To enhance this manual process, many medical record documents were produced in duplicate or triplicate by means of carbon copy.

In recent years, things have changed considerably. Filing cabinets have given way to desktop computers connected to powerful servers where patient records are processed and archived digitally. This digital format allows for immediate remote access by any physician who is authorized to review the patient information. Reports are stored electronically and printed selectively as the need arises. Today we have speedy computers with many electronic references, and we use the Internet not only for web resources but also as our daily working platform. Technology has gotten so sophisticated that MT services and MT departments work closely with programmers and information systems (IS) staff to stream in voice and accomplish seamless data transfers through network interfaces. In fact, many healthcare providers today are enjoying the benefits of handheld PCs or personal data assistants (PDAs), and are now utilizing software on them for dictation.

With all that has changed, some things have not. The conversion of spoken medical language to text is a craft that is difficult to learn and takes time to perfect. Some individuals have a "knack" for it; some will never get it. Technology can and does assist in many ways, but transcription still comes down to people. Even with the transition of MTs to editors for VRS documents, medical language interpretation skills will still be imperative for a quality report. MTs welcome this transition as an editor for VRS documents.

Overview

Traditional medical transcription is a form of document creation that the medical industry considers outdated, but necessary as a means of providing the necessary documentation needed to satisfy regulatory and insurance provider requirements. The practice of Modern Medicine dictates that the physicians spend more time serving patient needs than creating documents in order to make financial ends meet. More modern methods of document creation are being implemented through the technology of computers and the internet. Voice Recognition (VR) is one of these new-age technologies. With the power to write up to 200 words per minute with 99% accuracy Voice Recognition has freed physicians from the shackles of traditional transcription services.

Pertinent, up-to-date, confidential patient information is converted to a written text document by a medical transcriptionist. This written text may be printed (and hand placed in the patient's record, archived, and/or retained only as an electronic medical record). Medical transcription can be performed in a hospital, via remote transmission to the hospital, or directly to the actual providers of service (doctors or their group practices) in off-site locations. Hospital facilities often prefer electronic storage of medical records due to the sheer volume of hospital patients and the accompanying paperwork. The electronic storage in their database gives immediate access to subsequent departments or providers regarding the patient's care to date, notation of previous or present medications, notification of allergies, and establishes a history on the patient to facilitate healthcare delivery regardless of geographical distance or location.

The term transcript or "report" as it is more commonly called, is used as the name of the document (electronic or physical hard copy) which results from the medical transcription process, normally in reference to the healthcare professional's specific encounter with a patient on a specific date of service. This report is referred to by many as a "medical record". Each specific transcribed record or report, with its own specific date of service, is then merged and becomes part of the larger patient record commonly known as the patient's medical history.

Medical transcription encompasses the MT, performing document typing and formatting functions according to an established criteria or format, transcribing the spoken word of the patient's care information into a written, easily readable form. MT requires correct spelling of all terms and words, (occasionally) correcting medical terminology or dictation errors. MTs also edit the transcribed documents, print or return the completed documents in a timely fashion. All transcription reports must comply with medico-legal concerns, policies and procedures, and laws under patient confidentiality.

In transcribing directly for a doctor or a group of physicians, there are specific formats and report types used, dependent on that doctor's speciality of practice, although history and physical exams or consults are mainly utilized. In most of the off-hospital sites, independent medical practices perform consultations as a second opinion, pre-surgical exams, and as IMEs (Independent Medical Examinations) for liability insurance or disability claims. Private practice family doctors rarely utilize a medical transcriptionist, preferring to keep their patient's records in a handwritten format.

Currently, a growing number of medical providers send their dictation by digital voice files, utilizing a method of transcription called speech or voice recognition. Speech recognition is still a nascent technology that loses much in translation. For dictators to utilize the software, they must first train the program to recognize their spoken words. Dictation is read into the database and the program continuously "learns" the spoken words and phrases.

Poor speech habits complicate the process for both the MT and the recognition software. An MT can "flag" such a report as unintelligible, but the recognition software will transcribe the unintelligible word(s) from the existing database of "learned" language. The result is often a "word salad" or missing text. Thresholds can be set to reject a bad report and return it for standard dictation, but these settings are arbitrary. Below a set percentage rate, the word salad passes for actual dictation. The MT simultaneously listens, reads and "edits" the correct version. Every word must be confirmed in this process. The downside of the technology is when the time spent in this process cancels out the benefits. The quality of recogniton can range from excellent to poor, with whole words and sentences missing from the report. Not infrequently, negative contractions and the word "not" is dropped all together. Voice recognition is similar to the voice prompts one hears on dialing "411", when information provides the wrong number and charges for the "411" call. These flaws trigger concerns that the present technology could have adverse effects on patient care. Control over quality can also be reduced when providers choose a server-based program from a vendor Application Service Provider (ASP).

Downward adjustments in MT pay rates for voice recognition are controversial. Understandably, a client will seek optimum savings to offset any net costs. Yet vendors that overstate the gains in productivity do harm to MTs paid by the line. Despite the new editing skills required of MTs, significant reductions in compensation for voice recognition have been reported. Reputable industry sources put the field average for increased productivity in the range of 30%-50%; yet this is still dependent on several other factors involved in the methodology. Metrics supplied by vendors that can be "used" in compensation decisions should be scientifically supported.

Another unresolved issue is high-maintenance headers that replace simple interfaces to become the "platform" of choice. Pay rates should reflect this lost-opportunity cost for the MT.

Operationally, speech recognition technology (SRT) is an interdependent, collaborative effort. It is a mistake to treat it as compatible with the same organizational paradigm as standard dictation, a largely "standalone" system. The new software supplants an MT's former ability to realize immediate time-savings from programming tools such as macros and other word/format expanders. Requests for client/vendor format corrections delay those savings. If remote MTs cancel each other out with disparate style choices, they and the recognition engine may be trapped in a seesaw battle over control. Voice recognition managers should take care to ensure that the impositions on MT autonomy are not so onerous as to outweigh its benefits.

Medical transcription is still the primary mechanism for a physician to clearly communicate with other healthcare providers who access the patient record; to advise them on the state of the patient's health and past/current treatment; to assure continuity of care. More recently, following Federal and State Disability Act changes, a written report (IME) became a requirement for documentation of a medical bill or an application for Workers' Compensation (or continuation thereof) insurance benefits based on requirements of Federal and State agencies.

As a profession

An individual who performs medical transcription is known as a medical transcriptionist or an MT, or (less frequently) a medical transcriber. A medical transcriptionist is the person responsible for converting the patient's medical records into typewritten format rather than handwritten, the latter more prone to misinterpretation by other healthcare providers. The term transcriber also describes the electronic equipment used in performing medical transcription, e.g., a cassette player with foot controls operated by the MT for report playback and transcription. In the late 1990s, medical transcriptionists were also given the title of Medical Language Specialist or Health Information Management (HIM) paraprofessional.

There are no "formal" educational requirements to be a medical transcriptionist. Education and training can be obtained through traditional schooling, certificate or diploma programs, distance learning, and/or on-the-job training offered in some hospitals, although there are foreign countries currently employing transcriptionists that require 18 months to 2 years of specialized MT training. Working in medical transcription leads to a mastery in medical terminology and editing, MT ability to listen and type simultaneously, utilization of playback controls on the transcriber (machine), and use of foot pedal to play and adjust dictations - all while maintaining a steady rhythm of execution.

While medical transcription does not mandate registration or certification, individual MTs may seek out registration/certification for personal or professional reasons. Obtaining a certificate from a medical transcription training program does not entitle an MT to use the title of Certified Medical Transcriptionist (CMT). The CMT credential is earned by passing a certification examination conducted solely by the Association for Healthcare Documentation Integrity (AHDI), formerly the American Association for Medical Transcription (AAMT), as the credentialing designation they created. AHDI also offers the credential of Registered Medical Transcriptionist (RMT). According to AHDI, the RMT is an entry-level credential while the CMT is an advanced level. In addition to their certifications, AHDI also offers training programs to aspiring transcriptionists. In lieu of these AHDI certification credentials, MTs who can consistently and accurately transcribe multiple document work-types and return reports within a reasonable turnaround-time (TAT) are sought after. TATs set by the service provider or agreed to by the transcriptionist should be reasonable but consistent with the need to return the document to the patient's record in a timely manner. Whether one has learned medical transcription from an online course, community college, high school night course, or on-the-job training in a doctor's office or hospital, a knowledgeable MT is highly valued.

A medical transcriptionist is constantly challenged to learn in a very exciting occupation with interesting, ever-changing subject matter. There are always new medications and new procedures, previously unstudied specialties to learn, and new doctor-specific phraseology, accents and ESL to master.

As of March 7, 2006, the MT occupation became an eligible U.S. Department of Labor Apprenticeship, a 2-year program focusing on acute care facility (hospital) work. In May 2004, a pilot program for Vermont residents was initiated, with 737 applicants for only 20 classroom pilot-program openings. The objective was to train the applicants as MTs in a shorter time period. (See Vermont HITECH for pilot program established by the Federal Government Health and Human Services Commission).

Curricular requirements, skills and abilities

• High school diploma or GED, plus range of 1 to 3 years' experience that is directly related to the duties and responsibilities specified, and dependent on the employer (working directly for a physician or in hospital facility).
• Knowledge of medical terminology is helpful.
• Average to above-average spelling, verbal communication and memory skills.
• Ability to sort, check, count, and verify numbers with accuracy.
• Skill in the use and operation of basic office equipment/computer; eye/hand/foot coordination.
• Ability to follow verbal and written instructions.
• Records maintenance skills or ability.
• Good to above-average typing skills.

Basic MT knowledge, skills and abilities

• Knowledge of basic to advanced medical terminology is essential.
• Average to above-average verbal communication and memory skills.
• Ability to sort, check, count, and verify numbers with accuracy.
• Demonstrated skill in the use and operation of basic office equipment/computer.
• Ability to follow verbal and written instructions.
• Records maintenance skills or ability.
• Average to above-average typing skills.
• Knowledge and experience transcribing (from training or real report work) in the Basic Four work types.
• Knowledge of and proper application of grammar.
• Knowledge of and use of correct punctuation and capitalization rules.
• Demonstrated MT proficiencies in multiple report types and multiple specialties.

Duties and responsibilities

• Accurately transcribes the patient-identifying information such as name and Medical Record or Social Security Number.
• Transcribes accurately, utilizing correct punctuation, grammar and spelling, and edits for inconsistencies.
• Maintains/consults references for medical procedures and terminology.
• Keeps a transcription log.
• Foreign MTs may sort, copy, prepare, assemble, and file records and charts (though in the United States (US) the filing of charts and records are most often assigned to Medical Records Techs in Hospitals or Secretaries in Doctor offices).
• Distributes transcribed reports and collects dictation tapes.
• Follows up on physicians' missing and/or late dictation, returns printed or electronic report in a timely fashion (in US Hospital, MT Supervisor performs).
• Performs quality assurance check.
• May maintain disk and disk backup system (in US Hospital, MT Supervisor performs).
• May order supplies and report equipment operational problems (In US, this task is most often done by Unit Secretaries, Office Secretaries, or Tech Support personnel).
• May collect, tabulate, and generate reports on statistical data, as appropriate (in US, generally performed by MT Supervisor).
• May take minutes of transcription department meetings (seldom).
• Performs miscellaneous job-related duties as assigned (seldom).

The medical transcription process

When the patient visits a doctor, the doctor spends time with the patient discussing his medical problems, including past history and/or problems. The doctor performs a physical examination and may request various laboratory or diagnostic studies; will make a diagnosis or differential diagnoses, then decides on a plan of treatment for the patient, which is discussed and explained to the patient, with instructions provided. After the patient leaves the office, the doctor uses a voice-recording device to record the information about the patient encounter. This information may be recorded into a hand-held cassette recorder or into a regular telephone, dialed into a central server located in the hospital or transcription service office, which will 'hold' the report for the transcriptionist. This report is then accessed by a medical transcriptionist, received as a voice file or cassette recording, who then listens to the dictation and transcribes it into the required format for the medical record, and of which this medical record is considered a legal document. The next time the patient visits the doctor, the doctor will call for the medical record or the patient's entire chart, which will contain all reports from previous encounters. The doctor can on occasion refill the patient's medications after seeing only the medical record, although doctors prefer to not refill prescriptions without seeing the patient to establish if anything has changed.

It is very important to have a properly formatted, edited, and reviewed medical transcription document. If a medical transcriptionist accidentally typed a wrong medication or the wrong diagnosis, the patient could be at risk if the doctor (or his designee) did not review the document for accuracy. Both the Doctor and the medical transcriptionist play an important role to make sure the transcribed dictation is correct and accurate. The Doctor should speak slowly and concisely, especially when dictating medications or details of diseases and conditions, and the medical transcriptionist must possess hearing acuity, medical knowledge, and good reading comprehension in addition to checking references when in doubt.

However, some doctors do not review their transcribed reports for accuracy, and the computer attaches an electronic signature with the disclaimer that a report is "dictated but not read". This electronic signature is readily acceptable in a legal sense. The Transcriptionist is bound to transcribe verbatim (exactly what is said) and make no changes, but has the option to flag any report inconsistencies. On some occasions, the doctors do not speak clearly, or voice files are garbled. Some doctors are, unfortunately, time-challenged and need to dictate their reports quickly (as in ER Reports). In addition, there are many regional or national accents and (mis)pronunciations of words the MT must contend with. It is imperative and a large part of the job of the Transcriptionist to look up the correct spelling of complex medical terms, medications, obvious dosage or dictation errors, and when in doubt should "flag" a report. A "flag" on a report requires the dictator (or his designee) to fill in a blank on a finished report, which has been returned to him, before it is considered complete. Transcriptionists are never, ever permitted to guess, or 'just put in anything' in a report transcription. Furthermore, medicine is constantly changing. New equipment, new medical devices, and new medications come on the market on a daily basis, and the Medical Transcriptionist needs to be creative and to tenaciously research (quickly) to find these new words. An MT needs to have access to, or keep on hand, an up-to-date library to quickly facilitate the insertion of a correctly spelled device, procedure, or medication dictated.

Outsourcing of medical transcription

Due to the increasing demand to document medical records, other countries started to outsource the services of the medical transcriptionist. In the United States, the medical transcription business is estimated to be worth US $10 to $25 billion annually and growing 15 percent each year^{[citation needed]}. The main reason for outsourcing is stated to be the cost advantage due to cheap labor in developing countries, and their currency rates as compared to the U.S. dollar.

It is a volatile controversy on whether work should be outsourced, mainly due to three reasons:

1. The greater majority of MTs presently work from home offices rather than actually IN Hospitals, working off-site for "National" Transcription services. It is predominantly those Nationals located in the United States who are striving to outsource work to other-than-US-based transcriptionists. In outsourcing work to sometimes lesser-qualified and lower-paid non-US MTs, the Nationals unfortunately can force US transcriptionists to accept lower rates, at risk of losing business altogether to the cheaper outsourcing providers. In addition to the low line rates forced on US transcriptionists, US MTs are often paid as ICs (Independent Contractors); thus, the Nationals save on employee insurance and benefits offered, etc. Unfortunately for the state of healthcare administrative costs in the United States, in outsourcing, the Nationals still charge the hospitals the same rate as they did in the past for highly qualified US transcriptionists, but subcontract the work to non-US MTs, keeping the difference as profit.
2. There are concerns about patient privacy, with confidential reports going from the country where the patient is located (the US) to a country where the laws about privacy and patient confidentiality may not even exist. Some of the countries that now outsource transcription work are the United States, Britain, and Australia, with work outsourced to Philippines, India, Pakistan, and Canada.
3. The lack of quality in the finished document is concerning. Many outsourced Transcriptionists simply do not have the requisite basic education to do the job with reasonable accuracy, much less additional, occupation-specific training in Medical Transcription. Many foreign MTs who can speak English are unfamiliar with American expressions and/or the slang doctors often use, are apparently unfamiliar with medical reference books, and are unfamiliar with American names and places. An MT Editor, certainly, is then responsible for all work transcribed from these countries and under these conditions. These outsourced transcriptionists often work for a fraction of what transcriptionists are paid in the United States, even with the US MTs daily accepting lower and lower rates.

The Philippines has recently attracted increased amounts of MT outsourcing from the United States. Due to high literacy in the English language (spoken as a second language and also used in business, education, and government), the Philippines is trying to position itself to become a world leader in this field. Historic connections with the US ensure that the average Filipino is perhaps capable of understanding idioms and slang used in Colloquialism, making them one of the few peoples outside the US to possibly be able to transcribe accurately. This is very concerning to the US MTs. Stricter policies in compliance with [HIPAA] are implemented in such companies to enable security and confidentiality of work involved in such practices.

HIPAA (Health Insurance Portability and Accountability Act) governs outsourcing of MT work.

AHDI (Association for Healthcare Documentation Integrity) is one of the world’s largest association for medical transcription. AHDI's mission is to lead the evolution of medical transcription, represent and advance the profession and its practitioners. AHDI has a summary of rules in medical transcription that guide companies in facilitating seamless and workable transcription processes.

The future of medical transcription

The medical transcription industry will continue to undergo metamorphosis based on many contributing factors like advancement in technology, practice workflow, regulations etc. The evolution toward the electronic patient record demonstrates that, over time, documentation habits will change either through standards and regulations or through personal preferences. Until recently, there were few standards and regulations that MTs and their employers had to meet. First, we had the Health Insurance Portability and Accountability Act (HIPAA). It wasn't long ago "experts" stated that HIPAA would not have any effect on the medical transcription industry. Either in a state of denial or ignorance of the law, many transcriptionists and companies have continued on their existing course of providing medical transcription. Many providers are concerned that the majority of the transcription industry will not be able to meet several specific requirements: namely, access controls, policies and procedures, and audits of access to the patient information. Without the knowledge or resources to comply, many in the industry are claiming to comply and signing their Business Associates Agreements without taking the security measures required. Many are uninformed, and some are choosing to remain so, believing that the world of transcription cannot possibly be expected to make these adaptations. The fact is that the employers will demand HIPAA compliance and will change employees and contractors when they don't get it. There will also be demands to enhance patient safety, increase efficiency, and reduce costs. It is mandatory for service providers and healthcare practices to migrate to a HIPAA compliant environment.

The evolution in this industry will continue, as it has already. The best companies will identify and promote new technologies in health information management in order to continue to build their business. Only the ones that will leverage technology in their processes and business will continue to grow. Some already have adopted technologies such as speech recognition and application service providers (ASPs) in order to adopt new ways of providing services that will keep up with the demands of regulations, standards, and cutting-edge leaders in health care. Furthermore, medical coding will become embedded within documentation thus saving cost.

Transcription will increasingly be measured against such criteria as the Principles of Documentation developed by the Consensus Workgroup on Healthcare Documentation & Report Generation. These criteria include unique identification of the patient, accuracy, completeness, timeliness, interoperability, retrievability, authentication and accountability, auditability, and confidentiality and security. Newer documentation methods and technologies have some advantage over transcription in this regard because they can address these criteria early in their development and implementation. Thus the service providers will be attracted to documentation methods that offer the criteria as part of their "package."

The move away from traditional, free-text, plain-Jane medical transcription is inevitable, given the improvements in speech recognition technology and natural language processing, and other ever-evolving, yet, nascent technologies.

Medical Transcription, as a profession, will continue for many years to come; Medical transcriptionists can rest assured that there is enough transcription work to keep them busy through their lifetime, but they have to be open to changes that will occur quite frequently in the healthcare industry. They should be of the mindset that these changes will make them more adept as a MT. As for the well-read, well-informed; ahead-of-time professionals, they are already part of the evolution and will grow because they are willing and even eager to make changes and embrace technical advancements in this industry. We should not want medical transcription to become stagnant and resistant to changes. We should build around these changes and leverage technology to give impetus to the MT industry.