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June 21, 2004

Web-Based Transcription: The Future Is Now
By Kate Jackson
Radiology Today

Transcription departments can be expensive. In radiology, speech recognition can cut that cost but shifts more editing and reporting chores to radiologists. Web-based transcription may provide a workable middle ground.

Like many other information industries, medical transcription faces changes driven by the Internet. Hospitals, including radiology departments, can consider Web-based transcription as an alternative to maintaining their own staff or using voice-recognition approaches, which shifts more editing and reporting burdens to radiologists.

Technology History
According to Dale Kivi, vice president of marketing, CyMed, Richmond, Va., Web-based technology for transcription began to gain traction and national prominence approximately five years ago, led by Speech Machines, a company launched in the United Kingdom that was among the first to offer speech recognition for medical transcription. Its speech-recognition technology had been developed by the British military for wiretapping and converting voice captured over the phone to text. Speech Machines, Kivi explains, was formed to pursue a commercial market for that technology and eventually stumbled across healthcare and medical transcription. The first large-scale American customer was the Visiting Nurse Service of New York, which benefited from the company’s ability to capture voice from the nurses’ mobile phones and return completed documents via the Internet.

At that time, the first Web-enabled transcription companies operated through Application Service Providers (ASPs). The physicians would call an 800 number that routed their calls to a voice server managed by the ASP housed in a secure location, such as the offices of a telephone carrier or Internet Service Provider. The physicians’ voice files would then be compressed, encrypted, and downloaded to the home-based transcriptionists, who would listen to the files while they typed the documents directly into the company’s server through an Internet connection. The completed reports were then routed to a batch print queue at the hospital or clinic that contracted for the services.

Through this “thin client” (or Web-based) approach, the ASP company housed and maintained all dictation and transcription applications. This approach is in contrast to that which relies on separate hardware and software technology components residing with the healthcare provider and home-based transcriptionists themselves in a “thick client” (or Web-enabled) environment employed by many of the traditional technology vendors that simply use the Internet as a vehicle to transfer files.

Voice and Text
“Because of the success of the Web-based approach to move transcriptionists away from the hospital and the technology curve for Web enablement,” says Kivi, “now essentially all national technology providers in the transcription industry have the ability to manage voice and text over the Internet.” He says a non-ASP, Web-enabled model “allows for the voice capture component to be housed either by the Transcription Service Provider [TSP] at their locations or alternatively at the hospital or clinic.”

Most of the early clients for ASPs were transcription companies that sought ASPs as their technology platforms because it is a “pay-as-you-go” or “pay-as-you-use” business model that eliminates the need to make capital investments in voice-recording devices, typing platforms, and report distribution servers. “All of that comes with the ASP,” Kivi notes. “Therefore, if smaller transcription companies are under capital restraints that prevent them from scaling their businesses, the ASP model allows them to pay only for what they actually use, as they would for utility services. And by not needing to make that big up-front investment before being able to realize any return on the added capacity, it makes it much easier for such companies to manage their operating expenses.”

When this process was managed through nonintegrated components—a voice-recording platform, workflow management platform, and report distribution system, as well as separate accounting and reporting systems—it wasn’t always easy to accurately track and audit the work volume through the entire production cycle, especially if the healthcare provider owned some components and the service provider owned others.

“One of the early advantages that the ASP models offered was platform integration of the workflow—from voice capture through report distribution,” Kivi explains. “This inherently brought the buyer and service provider together on the same database for workflow management and auditing purposes. In this way, the healthcare providers could actually look at the per-document character count and pricing schemes.”

Previously, he adds, it wasn’t uncommon for large facilities to get a single-line item for one month of transcription—perhaps for 500,000 lines at 15 cents per line. The lack of detail and inability to audit down to the document level for billing purposes were the causes of major frustration and, in some cases, mistrust. Kivi says it more than likely perpetuated some of the industry’s integrity issues with respect to pricing and billing practices.

Billing Issues
In that vein, Kivi cites a long-standing problem in the transcription industry: inconsistent billing practices. “You cannot find two companies that calculate work volume the same way,” he says. “If you pick any 10 TSPs and send them the same 10 documents, you’ll get back 10 different measurements for the work that was done to produce those same documents. I’m not talking about 10 different prices, although you’ll get that, too. I mean 10 different ways to measure exactly the same volume of work. The inability of the industry to agree on a common work-volume measurement standard is a big part of the problem in terms of how billing is viewed by clients.”

Kivi traces the billing practices from the time transcriptionists and services were paid on an hourly rate, then shifted to a production rate pay based on the pages typed, then the number of lines typed, then gross lines vs. 65-character net lines, then competing definitions of what constitutes a character, until now where in more and more cases production is measured only by the number of black characters that appear on the final reports. Regardless of the methods used, the ASP model was the first to integrate all the technology components of the transcription production cycle in a manner that enabled buyers access to the same set of numbers their service providers used to calculate their bills.

Thanks to the advantage provided by Web-enabled transcription, the shape of billing tasks has changed. Whatever the measure of productivity, complete workflow cycle auditing has become standard as buyers can now demand that all calculations and work-volume measurements used to produce their bill be equally accessible to all parties.

Remote Advantage
Among the biggest advantages of Web-based transcription is that it allows medical transcriptionists to work from home—a win-win situation for everyone. Ten to 15 years ago, explains Ray Scott, CEO of Axolotl, Mountain View, Calif., the recording medium for dictation was mostly some form of tape, and the transcribed documents were communicated back to the physicians’ office on paper. Somebody had to pick up the tape and somebody had to deliver the paper, which usually demanded that the service be local.

There had been some early movement for home-based transcription through which someone could dial in work through a direct telephone connection, but it was limited by the range of a local telephone call.

“As soon as you introduce the concept of being able to digitally record the voice and communicate it anywhere in the world across the Internet and to produce or transcribe the report and communicate it similarly, you’ve removed that local restriction and turned what was a local business into something that can become a global business,” Scott says.

For the medical facility, having an operating platform that is attractive to remote transcriptionists helps recruit and retain the best workers. This is especially true, says Kivi, for those hospitals and clinics in second- or third-tier types of markets—for example, the only hospital in the middle of a rural Iowa community. “Finding qualified medical transcriptionists who can support that hospital might be quite difficult because that community is not likely to always have an abundance of residents with that skill set readily available,” says Kivi. Scott says it’s enabled many hospitals that previously had their own transcription staff to outsource because they’re no longer dependent on local labor.

The benefits work both ways. “At CyMed, we have a variety of work-at-home transcriptionists who have great skills but live in the middle of nowhere with no local employment opportunities,” says Kivi. If not for this technology, he explains, their options would be to work in another field or for a small practice that would underutilize their skills. Being able to work from a remote location offers a lifestyle bonus as well.

Many transcriptionists find it easier to meet family responsibilities while working from home and others enjoy living outside metropolitan areas where the cost of living is more reasonable.

The ability for transcriptionists to work remotely also translates into potential savings for physicians and facilities. “Physicians are no longer going to be subject to local expenses or expense differences,” says Scott, “and they can take advantage of cheaper rates wherever they may be. It allows the market forces to set new levels in terms of price, quality, and turnaround time.”

Privacy Issues
Kivi says some of the initial reluctance about Web-enabled transcription centered around security and privacy issues. However, legislation and technology have eased the concerns. HIPAA is clear about the requirements for home-based or outsourced transcription. Although Kivi acknowledges that there’s been a great deal of concern recently about offshore transcription, the focus for privacy and security needs to be the same whether the transcription is sent across the street or across the ocean. “The company or person who has the business contract with the hospital or clinic must sign a business associate agreement,” he says. “Such agreements are required by HIPAA and clearly define the security and privacy laws that must be adhered to while managing that work.” If a TSP accepts work, it accepts the responsibility to manage its business according to HIPAA. If the company disregards the law, the Office of Inspector General will more than likely get involved.

Security issues, says Kivi, were initially a roadblock to the acceptance and adoption of Web-based transcription technology. “Obviously, the perception is that it’s much easier to control privacy and security inside the four walls of the hospital or clinic, and there’s a greater sense of comfort when it’s managed that way,” he says. Outside of those four walls, there is uncertainty over what exactly the transcriptionist is doing with that information. For example, one doesn’t know, suggests Kivi, whether an at-home transcriptionist’s 16-year-old son is going to use the computer during off hours and start surfing the Internet and in some manner enable the transcription reports to be inappropriately exposed to someone who is not authorized to have access (although there’s never been a published report of anyone hacking into a home computer in search of medical reports).

The ability to audit every form of access provides a great security advantage, too. The best software now provides an audit trail that reveals who has created, altered, viewed, updated, or rerouted a document in any way. Furthermore, says Scott, people have become assured that the technology, along with encryption, can appropriately safeguard information while it’s in transit. Similarly, he says, they’re confident that if information should end up at the wrong destination, encryption will prevent it from being misused. “They weren’t three or four years ago, but people are comfortable with that now,” he says.

Flexibility for Physicians
The benefits extend to physicians as well. It’s not uncommon these days for doctors to be associated with a hospital, have a private practice at a remote clinic, and have another office in their home. In such a scenario, they may want access to their transcription at each of those locations. “The ability of the Internet to enable that in a secure manner is definitely how healthcare will be practiced in the future, and technology that enables the physicians the flexibility to accommodate their working lifestyle is going to be required if technology vendors or service providers are going to survive,” Kivi says.

On the Horizon
Although some hospitals and clinics have been slow to adopt Web-enabled transcription technology, industry insiders seem confident that it is the way of the future. “The automating of workflow and dovetailing with electronic medical records is key to any and every transcription provider to succeed in the next decade,” says Scott. “Isolated systems are no longer going to be acceptable, and interfacing is going to play a much larger role.” For many customers, Axolotl is already delivering transcribed documents and interfacing with their existing information management systems. “The ability to integrate between these types of systems through the Internet is definitely going to play a major role,” concurs Kivi. “Fortunately, interface automation engines, such as those supplied by InterFix [www.interfix.biz], can seamlessly and securely connect such disparate platforms and provide total workflow visibility, regardless of who owns the individual components.”

Kivi continues: “The mom-and-pop landscape of the medical transcription industry, with its more than 1,500 providers, has to change because of Web technology. In another five years, the number of providers will be significantly less because smaller service providers will not be able to afford to keep up with the technology required for the auditing, privacy, and security issues.”

The technology sophistication and economies of scale have already begun to force smaller companies to consolidate or take on risky debt to keep pace. Five years from now, Kivi suggests, everyone expects there to be fewer transcriptionists working in hospitals and clinics and more to be working from home. “If that’s the future,” he asks, “how do you, as an individual or organization, make certain you’re on the thriving end of that equation instead of sitting on the outside remembering the good old days?”

— Kate Jackson is a staff writer for Radiology Today.

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