A client sent me a note the other day saying he had received a proposal from another medical transcription vendor and wanted to know if I would match the rate. He told me that while he was very pleased with our document quality, service and turnaround, he felt that the lower price was enough to get him to make a change. I asked him to send over the proposal and I would let him know.
When the proposal arrived, I quickly looked through the terms and confirmed that the rate was indeed significantly lower than ours. As I read on, however, I noticed that the definition of a line included only 55 characters, 10 less than the 65 characters we used. When I "normalized" the rate to 65 characters, the competitors rate was actually higher than ours! Needless to say, we still have our client.
Which leads me to the 3 things to know about medical transcription billing:
- If you're being billed on a line, make sure to understand the definition of the line. As above, it can make a big difference comparing apples to apples. The standard line is 65 characters, which includes all letters, numbers, symbols and spaces in the document divided by 65.
- Avoid the line altogether. The new standard is the black character. Most major companies will be able to provide you pricing using this metric. Rates should be in the $.0020 to $.0025 per black character to be competitive.
- Finally, watch the extras. Things like bolding, underlining and other formatting can be charged, running up the number of characters in your document. You should not be paying for this formatting.
There are, of course, many other things to watch for so read the fine print before signing anything. If you're really in doubt, have your new transcription service type a few documents and tell you how much they will cost. Compare that to what your old transcription company is charging and you'll know if its a good deal.
A friend sent me a link to an interesting article on speech rec, specifically front end speech similar to what is being used in many radiology and ED departments. The study, published in the October, 2011 issue of American Journal of Roentgenology, revealed that breast imaging reports generated using an automatic speech recognition system were 8 times (emphasis added) more likely to contain major errors than those done with traditional dictation/transcription.
In the study, "Error Rates in Breast Imaging Reports: Comparison of Automatic Speech Recognition and Dictation Transcription", co-authored by Anabel Scaranelo, PhD, MD, the authors reviewed 615 complex cases at a breast imaging center in which 308 cases were generated by speech recognition and 307 using dictation transcription. The study revealed that at least one major error was found in 23% of the speech recognition cases against only 4% of the dictation transcription reports.
The study went on to look at relatively more complex breast MRI reports and found that the error rate for the speech recognized documents rose to 35% for speech recognized documents vs. only 7% for dictation transcription documents. The co-author surmised that the more detailed descriptions in these reports resulted in the increased error rate. Interestingly, the native language of the dictator had no effect on the error rate for speech recognized documents.
So what is going on here? The author concluded that the more complex the documents, the greater the need for careful editing on the part of the dictator. She went on to say that there seemed to be a "strong need for standardized templates and use of structured reports." Intuitively, this makes sense. The longer the document, the more likely there will be errors, particularly with long sections of free text dictation. If the physician is not going to closely review these longer documents, it seems obvious that another editor should.
As more EMR's incorporate front end speech into their systems, doctors will be asked to edit more of their own dictation. They'll need to be reviewing these dictations more thoroughly in order to avoid errors that could impact patient care.
The relentless pace of consolidation in the transcription industry continues today with the announcement that Nuance has completed its acquisition of Transcend. With Nuance set to drive full speed into the small to mid-size hospital market, I thought it would be good to take a look at some myths around big transcription companies.
Myth 1: Bigger companies have better technology.
There is some truth to this, particularly with Nuance and their speech products; they're definitely ahead of the curve there. That being said, the technology curve keeps moving out and keeping up requires a huge investment in development. In addition, as companies get bigger, migrating hundreds of large clients to new platforms is time consuming and expensive so companies can be slow to upgrade.
Finally, big companies are loath to customize software or processes for clients so typically you'll get the off-the-shelf version. If you want the off-the-shelf version, that's great. If you don't, be prepared to be disappointed, or to pay more to get what you want, or both.
Myth 2: Bigger companies have better pricing.
Unless you're a huge hospital system, don't think you're getting the best price from a large MTSO. And don't be lured by a low line rate. Be prepared to pay for things like maintainanc, software licenses, training, interfaces, autofaxing and other "options" that you might consider important. Also, don't be locked into a long term agreement. Anything longer than a year limits your flexibilty. You probably won't make a change but it's nice to know you could. Read the fine print in the agreement.
Myth 3: Big companies are the "safe" option.
There's an old saying that goes "No one ever got fired for going with IBM". There is certain amount of that in transcription vendors. If you go with an M-Modal or Nuance and things go bad down the road, it's no big deal. Go with a smaller vendor and it goes wrong, you get fired.
But in reality, there are lots of good options outside of the big players and more often than not, the smaller companies provide better service and are more responsive than their larger counterparts. You can confirm this by checking references on recent installations.
So if you're looking to make a change in MTSO vendors, take a look at MTSO's not named M-Modal or Nuance. You'll be glad you did.
The Clinical Documentation Industry Alliance (CDIA), formerly known as the Medical Transcription Industry Alliance (MTIA), quietly closed it's doors on March 7, 2012. Read the announcement here.
I've always known it as MTIA and was never fond of it's new name. When I worked at Secrephone in the 80's, Secrephone's President, Ed Samek, was a big proponent of the organization and later received a Lifetime Achievment Award for his efforts. Another employer, MedQuist, was always a big and vocal supporter of the organization. I attended the annual meetings for many years where I met many wonderful people and established some lasting friendships.
But as the owner of a transcription company, I always wrestled with the idea of paying my dues to the organization. When money got tight, it was one of the first things to go and when money became less tight, we never went back. I felt the organization drifted away from the small business owner and focused too much on the larger organizations that paid most of the bills.
Unfortunately, as the relentless consolidation in the industry continued over the past few years, there were fewer and fewer companies left to foot the bill. At this point it's probably too early to know what MTIA's legacy will be but for me, I'll always remember the the friendships I was able to make as a result of my membership in the association.
Got an email from an old collegue and friend today, John Suender of Suender Advisors. John is the former General Counsel for MedQuist (now M-Modal) and helped guide the company through a period of tremendous growth during which it went from $30 million in revenue to over $500 million in revenue. He now runs an investment advisory group and has worked on many of the recent acquisitions in the MTSO space.
In his email (you can read the text here) John discusses the evolution of the MTSO business and how the industry has survived despite technological advances (i.e. speech recognition) that many observers felt certain would bring an end to the industry. The reason the industry has survived, according to John, is that MTSO's have a deep and powerful understanding of their client's clinical documentation needs and have therefore been able to adapt their service offerings to meet these changing needs.
The most recent threat to the MTSO business has been the rise of the Electronic Medical Record (EMR). EMR vendors and MTSO's have had what can be chararacterized as a stormy relationship. Years ago the main selling point for many EMR's was that by going to an EMR, you could eliminate transcription costs altogether. What the EMR companies found out was that doctors felt their skills were better suited to caring for patients than data entry, so adoption was slow. Then the government stepped in and essentially mandated the use of the EMR and provided the financial incentives to make it happen, which in the long run is a good thing for health care. EMR vendors soon realized that allowing doctors to dictate portions of the report added to the clarity of the documentation and helped speed adoption.
Again, because they understood what their clients wanted (better documentation, multiple means of data input including dictation, electronic integration with their existing systems) MTSO's have been able to adapt to the EMR and have improved the rate of adoption.
MTSO's, including Landmark, are in some ways ahead of the EMR's in meeting their clients needs. Several MTSO's have been among the leaders in developiong technologies such as Natural Language Processing (NLP) that will generate the discrete data from the clinical documentation that the EMR's need to fully meet Meaningful Use Requirements. More on this in a later post.
As many of you know, Nuance continued it's torrid pace of acquisitions by agreeing to purchase Transcend Services for roughly $300 million in cash. Read the press release here. Over the past couple of years there has been a rapid consolidation in the transcription industry as CBAY/MedQuist/M-Modal and Nuance/WebMedx/Transcend/MDI(MD) have all partnered up, exchanging vast sums of money to expand their footprint in the transcription business.
This represents a tremendous narrowing of options for hospitals and practices that outsource transcription which is not necessarily good for the client's of these recently acquired companies. As the acquirers move to consolidate the operations of the acquirees, many facilities will be required to change technology platforms as existing technology gets phased out in favor of a single platform.
For hospitals and practices in this situation, this can be a great opportunity to assess all of the options available. Some may benefit from the expanded technology offerings that these combinations can provide. However many others lose the service, pricing and customization that brought them to a particular vendor in the first place.
We've updated and expanded our guidelines for evaluating medical transcription services. Here are some things to think about when evaluating those proposals:
- Pricing can be confusing. Ask questions about how lines are measured, how many characters are on a line and what is a character? If you're still not sure, send the same document to each company and ask them to give you a price for that document.
- Make you're getting Quality and Turnaround Time audits on a monthly basis. Quality reports should cover at least 2% of the total lines transcribed.
- 100% US based staffing results in exceptional quality reports and superior client services.
- Mobile dictation options, including iPhone applications, are critical to physician satisfaction.
- Ensure your facility receives true 24/7/365 US based client service from a live person who knows your account.
- Make sure your work is not being pooled with work from other hospitals. You should have a team of transcriptionists assigned specifically to your account. This improves quality and productivity.
- Make sure you have access to onsite training for your staff and physicians if you need it. Training should be free and unlimited.
- Make sure there are no extra fees for licenses, interface development for your EHR or HIS or electronic signature.
- Contracts should be simple. They should be for one year, have no minimum volume commitments and not more than a 30 day cancellation clause.
Follow these suggestions and you'll have a solid foundation for your transcription search.
If you’re associated with a physician practice, you’ve probably been the target of at least one EMR/EHR vendor’s sales pitch in the past few months. And the pitch is a good one: EMR/EHR implementations can make practices more efficient, provide better patient outcomes and best yet, make you eligible for a portion of the federal incentives tied to EMR/EHR implementation.
But before you charge off on an EMR/EHR implementation, consider how the the system will impact the content and quality of your clinical documentation. Most EMR/EHR’s rely on clinicians to manually input the majority of the patient information. The clinician sits at a terminal, usually in front of the patient, and types in only the most basic of information on the encounter in an effort to move as quickly as possible to the next patient.
While this may work for some practices in certain environments, many physicians feel that this inability to thoroughly document their diagnosis and treatment plans in detail is a serious drawback of the EMR model. As noted in a recent study of physicians done by Nuance Healthcare Solutions, over 74% of physicians surveyed felt that the “cookie cutter templates” used by most EMR’s in documenting patient encounters are a serious challenge to realizing the full potential of the EMR.
So how best to thoroughly document the patient encounter? In the same study, physicians cited the ability to speak the patient narrative directly into the EMR as being one of the top 5 most important features of the EMR. And this makes sense; most physicians are used to dictating and in fact, prefer dictation to any other form of documentation.
So how to bridge the gap between the template based efficiency of the EMR and the physician’s desire to more thoroughly document the patient encounter by dictating a narrative portion of the report? What is required is a seamless method of allowing the physician to dictate the narrative section of the report without having to pick up the phone, type in a text box or login to a separate system.
Landmark’s Integrated Dictation Solutions allow clinicians to dictate directly from the PC while accessing the EHR using a handheld speech microphone. There is no need to log into a different system or enter any patient or demographic information. The resulting dictation is sent electronically to our servers where it is run through our speech recognition engine. Physicians can choose to edit the speech recognized document themselves or have Landmark provide the editing. The narrative appears in the templated document and is ready for signature.
Best of all, there is no hardware or user licenses to buy. You purchase only what you need, when you need it.
The Wall Street Journal ran an interesting story the other day that caught my eye. “Caterpiller Joins “Onshoring” Trend” (Kris Maher and Bob Tita, Wall Street Journal, 3/12/2010) pointed out that Caterpillar, the Fortune 500 manufacturer of heavy equipment, was planning on bringing significant portions of its heavy equipment manufacturing back to the US from overseas.
The article indicated that while this trend was small, a growing number of manufacturers were bringing work back to the US, citing a weak dollar which makes it costlier to do work overseas. According to the authors, companies were seeing growing disadvantages in offshore production, “including shipping costs, complicated logistics, quality issues, political unrest and theft of intellectual property.”
Now, don’t get me wrong, this movement is not a tidal wave, its more a trickle right now. But the reasoning behind it makes sense and is applicable in a lot of ways to the US transcription industry. Two of the issues cited above, quality and theft of intellectual property, are directly applicable to transcription. For years, hospitals and practices have put up with poor quality in the name of cheap transcription. As the standard of living rose in India and the Philippines, their costs have risen commensurately. Add to that the fact that the dollar has deteriorated in value and the overseas cost advantage is just not that overwhelming anymore.
The second issue related to transcription, theft of intellectual property, is analogous to the theft of protected health information (PHI). Countries such as China and India have little regard for US and European notions of intellectual property protection. And while companies can put as many safeguards and controls around our personal information as they want when they send it overseas, we all know that no one is going to stop a really determined thief; if they want our information, they’re going to get it. Put these two ideas together and I think we can see why respected companies such as Caterpillar are worried enough about protecting their multi-billion dollar investments in research and development that they are bringing work back onshore.
It’s my opinion that the onshoring trend will continue to advance for at least the next few years as the US economy continues to be slow keeping the dollar weak. The good news is that with the growing use of speech recognition and editing technology, the US based transcription industry should be well prepared to handle the increased work load without driving up labor costs.
You have made the decision that it is time to look for a new transcription vendor. There are a number of reasons that you might be unhappy with your present vendor such as poor document quality, slow turnaround times, outdated technology, or perhaps you are just shopping to see if what you are currently being offered is competitive in today’s marketplace. Regardless of the reason, here are 5 Quick Tips on what to look for in finding the right transcription service for your organization.
1) Take Advantage of Free Trials-All transcription companies are going to claim that their technology, quality, turnaround times and customer service are second to none. You can only really verify if these claims are true by “test driving” their service. While you should always check references provided by the company, the best way to really get a sense of what your experience will be with a particular company is to have them type some of your dictation for a couple of days. It is a little more work up front but in the end, you will have a great idea of what it’s going to be like working with your chosen company.
2) Ask About Their Transcription Process- Will you be assigned a dedicated transcriptionist(s) or will your work will be pooled with work from other clients. Will your work be sent overseas or done here in the US? Will the work be speech recognized? Pooling of work, overseas transcription and speech editing are all means that companies use to keep costs down. With conscientious review and editing, document quality is usually not an issue. However, quality problems are more likely to crop up with these approaches if there is not a sound QA process in place.
3) Check Out Their Technology- Make sure to get a demonstration of their dictation and document management software. Describe how your office works and understand how their technology will impact your processes. The dictation system should be flexible enough to mirror your current system to minimize the changes for your physicians. The document management system should be internet based so you can access it anywhere, be HIPAA compliant, and easy to use. Find out how long documents are stored in the system and are accessible by staff.
4) Read Their Contract- Many companies will try to lock you in to using their services by putting clauses in their contracts that restrict your ability to leave, even if the level of service has deteriorated significantly. Three year contracts, 90-180 day cancellation clauses, exclusive arrangements and minimum volume commitments are all ways that transcription companies will try to lock you in to using their services. You should stay with a company because they offer great service at a reasonable price, not because you’re locked in to a contract. Read the contract thoroughly and keep an eye out for clauses that can result in problems for you down the road.
5) Don’t Pay Extra Fees- Many companies will try and charge for things like interface development, licenses for using their software, long distance fees for utilizing their dictation system, fees for STAT reports, training and other “extra’s” that are part of their cost of doing business. Some companies charge $5,000 or more for developing an interface to your systems. If a company wants your business, they should be willing to cover these costs.
Follow these tips and you will be well on your way to finding a top notch transcription partner.