Overview
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 encompases 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 edits 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 upon that doctor's speciality of practice, although history and physical exams or consults are mainly utilized. 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, quite a few medical transcription dictators may send their dictations by digital voice files and some even utilize a slowly-developing, somewhat unreliable method of transcription called speech recognition. Speech recognition is not popular with most transcriptionists as they feel this method loses much in translation. In order for any dictator to use a speech recognition software, they must first train their speech recognition program to recognize their spoken words. This involves reading many words into the database in order for the recognition program to "recognize" their spoken words in the reports. This has always been a problem (understanding what the dictator just said) and transcribing it correctly. An MT, who is unable to recognize what the dictator has just dictated, simply flags the unintelligible dictation, but the computerized speech recognition program misunderstands the spoken word and mistypes a wrong word on the spot. This is the downfall with speech recognition. There is concern among the MT community that it could have adverse effects on patient care. Voice recognition is similar to the voice prompts one hears on dialing "411" nowadays, when information often gives you the wrong number to call, and then charges you for the "411" call.
Medical transcription is currently the primary mechanism a physician can communicate clearly with any other healthcare providers who also access the patient's record, advising them about the state of health and past/current treatment of their patient - to provide continuity of medical care. More recently, after Federal and State Disability Act changes, a written report (an IME) became a requirement for documentation of a medical bill or in application for Workers' Compensation (or continuation of) insurance benefits due to requirements of Federal and State agencies.
MT 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 a typewritten format rather than a handwritten format which could be misunderstood by a subsequent healthcare provider. The term transcriber may also refer to the electronic equipment used in performing medical transcription such as the cassette player that has foot controls the MT uses for report playback and transcription. As of the late 1990s, medical transcriptionist are also known by the title, Medical Language Specialist or a HIM (Health Information Management) paraprofessional.
There are no "formal" educational requirements to be a medical transcriptionist. Education and training in medical transcription can be obtained through traditional schooling, certificate or diploma programs, distance-learning, and/or on-the-job training which is offered in some hospitals, although some non-US countries, which are now employing transcriptionists, require 18 months to 2 years of specialized MT training. Working in medical transcription leads to a mastery in medical terminology and editing. The ability to type while listening, and utilizing the playback controls on the transcriber (machine) and the medical transcriptionist's use of a footpedal to play dictations while not breaking the typing or rhythm.
Medical transcription does not require any sort of registration or certification. However, there are individuals who seek registration or 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 only earned by passing a certification examination conducted solely by The American Association for Medical Transcription (AAMT), as this is the credentialing designation they have created. The AAMT also offers their credentialing of Registered Medical Transcriptionist (RMT). According to the AAMT, the RMT is a lower-level credential than the CMT. The AAMT also offers training programs to aspiring transcriptionists in addition to their certifications. In lieu of any of the AAMT's certification credentials, MTs who can consistently and accurately transcribe multiple document work-types, and return their reports within a reasonable turn-around-time (TAT) are sought after; with TATs set by the provider of service or the transcriptionist, and which are reasonable but necessary to return the document to the patient's record in a timely manner. Whether one has learned MT from an online course, a community college, a night highschool course, or on the job training in a doctor's office or hospital, a knowledgeable MT is highly sought after.
A medical transcriptionist must constantly learn the occupation with very interesting, ever-changing subject matter. There will always be new medications, new procedures to learn, previously unstudied specialties to work on and conquer, and new doctor-specific phraseology and accents to learn and master.
As of March 7, 2006, the MT occupation became an eligible US Department Labor Apprenticeship, which is a 2-year program focusing on acute care facility (hospital) work. In addition, as of May 2004, a pilot program for Vermont residents was initiated, with 737 applicants for only 20 classroom pilot program openings, to train as MTs in a shorter period of time (see: Vermont HITECH for the pilot program established by the Federal Government Health and Human Services Commission).
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 will do a physical examination, may request various laboratory or diagnostic studies, will make a diagnosis or differential diagnoses, and then decides on a his plan of treatment for the patient, which is then discussed and explained to the patient with instructions provided to the patient. 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 to make a 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.
Some Doctors, however, 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 will not speak clearly or voice files are garbled, and some doctors are (unfortunately) time-challenged and need to dictated their report quickly (as in ER Reports). In addition, there are many regional or nationality accents and (mis)pronunciations of words for the MT to 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 "flag" a report. A "flag" on a report requires the dictator (or his designee) to fill in a blank on a finished report that 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 (at times) tenaciously research (quickly) in order 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.
Medical Transcription Reports and Specialties
- Re Out-of-hospital transcription/Directly for Doctor transcription: The MT transcribes and self-edits from recorded or written material: Patient History and Physical Examinations, Consultations, Physician Letters and Office Notes, Medical Records Reviews, and IME Reports.
- Re In-Hospital dictations add to above, Operative Reports, Discharge Summaries; Tests, Biopsies, and Studies; ER Reports, Autopsy Reports, X-ray Reports, Clinic/Progress Notes and SOAP Notes. Hospital dictations can range in the specialties being dictated (in any order of presentation in any given day) such as: Cardiology, Cardiopulmonary, Developmental Medicine; Ear, Nose & Throat; Endocrine, Gastroenterology, Gastrointestinal, General Psychiatry, General Surgery, Genetics, Genitourinary, Geriatrics, Geropsychiatry, Hematology/Oncology, Internal Medicine, Neurology, Obstetrics/Gynecology, Ophthalmology, Orthopaedics, Otolaryngology, Pediatrics; Physical Medicine & Rehabilitation, Podiatry, Psychiatry, Psychology, Pulmonary, Radiology, Rheumatology, Urgent Care, Urology, and Workmen's' Compensation.
- Some reports a Hospital Transcriptionist may transcribe in any given day include reports on: Acute croup, acute viral syndrome, ADHD, allergic rhinitis, altered level of consciousness, angioma, bacteremia, cadaver transplant recipient, cardiac catheterization, cellulitis, cervical spasm, congestive cardiac failure, choledochojejunostomy, Crohn's disease, CVA, dermatitis, dermatology biopsies, dislocated shoulder, dobutamine stress echo, echocardiogram, EEG, epigastric pain, eustachian tube dysfunction, fecal impaction, fibro-epithelial polyp, GI bleeding, glucose intolerance, Holter monitor, ischemic optic neuropathy, lentigo, leukocytosis, lumbar laminectomy, manic depression, melanotic nevus, modified barium swallow, multi-nodular goiter, nerve conduction studies, neuro sleep study, nuclear medicine, occipital headaches, osteoarthritis protocol study, otitis, otoacoustic emission, pervasive developmental disorder, pleural effusion, polysomnogram, pterygium, pulmonary function, radicular pain, radiographic interpretation, renal colic, seborrheic keratosis, seizure disorder, small bowel obstruction, spinal cord stimulator revision, spondylolisthesis, squamous cell carcinoma, status-post adenoidectomy and bilateral tube placement, status-post liver transplant, stomatitis, urethral calculus, urodynamic studies, venous duplex ultrasound, viral gastroenteritis, and xanthoma to name a few.
Standards in the Medical Transcription Industry
Within the medical transcription industry and in healthcare documentation, the lack of standardization of our systems and our processes, challenges us all - the users, practitioners, vendors, healthcare providers, and patients. Standardization is important in our professional and personal lives. When we make purchasing decisions for standardized items, we can do so with confidence that they will fit and work for our needs. Imagine how complicated it would be if faxes could only be sent and received specific to the same manufacturer, or email could only be sent and received specific to the same internet provider service. Standards allow for systems, regardless of the manufacturer, to work together. In order to provide procedural consistency and proficiency in performance, processes can also be standardized. This saves time and aggravation, rather than repeatedly taking resources to re-invent the wheel.
The ASTM subcommittee E31.22 Health Information Transcription and Documentation was formed in 1995, with the scope to develop standards for the systems, processes, and management of medical transcription and its integration with other modalities of report generation. Since its inception, this subcommittee has created important standards that are useful and significant to the medical transcription industry and in healthcare documentation.
This standards developed within E31.22 represent the collaboration and hard work of many dedicated volunteers with a wide diversity of experiences and skills, committed to making a difference in the MT industry.
HIPAA
The Health Insurance Portability and Accountability Act (HIPAA) was passed on August 21, 1996. Among other things, it included rules covering administrative simplification, including making healthcare delivery more efficient. Portability of medical coverage for pre-existing conditions was a key provision of the act as was defining the underwriting process for group medical coverage. It also provided standardization of electronic transmittal of billing and claims information.
Congress recognized that standardizing the electronic means of paying and collecting claims data increased the potential for abuse of people's medical information. So a key part of the act also increased and standardized confidentiality and security of health data. HIPAA privacy regulations require that access to patient information be limited to only those authorized, and that only the information necessary for a task be available to them. And finally that personal health information must be protected and kept confidential.
Congress did not get around to finalizing the actual regulations on the time schedule set up. Instead they passed that responsibility to the Department of Health and Human Services. The final version of the HIPAA Privacy regulations were issued in December 2000, and went into effect on April 14, 20012. A two-year "grace" period was included; enforcement of the HIPAA Privacy Rules on April 14, 2003. So HIPAA has been to law since then. The April 14, 2003 deadline is when the penalties can be applied for non-compliance.
The Rules are not set in stone; periodically the Department of Health and Human Services will propose changes or issue updates, clarifications, and explanations (aka "guidances"). When a change is suggested, it is followed by a period of public comment. During the comment period, the suggested changes may be modified or withdrawn. After the comment period, the change may be put into effect.
Prior to HIPAA , there was no uniformity; rules and regulations varied from state to state, and even from one healthcare organization to another. If an organization was doing business in multiple states, were they subject to the rules of the state where each office was located, or by the rules of the state where the headquarters was located? Should they follow state regulations, or federal?
HIPAA provides for a uniform, basic level of security and privacy throughout the country. (Where existing state laws are more strict, they supercede HIPAA .)
For example, when sending a referral to another office they only need to know the medical history, and not the billing information. Therefore they should only be given the medical history. Or, when sending items to accounting for billing purposes, only the information necessary to process that should be sent; there is no need to see the whole medical history, just the codes for current work, possibly a few notes, and the patient identifier.
Some of the regulations are straight forward and very black and white. However, many of the regulations are very subjective. Basically, a healthcare provider needs to examine the requirements, take a look at current way things are being handled, particularly the personal health information, and apply the regs how they make the most sense.
When the day comes and the question is asked, is your firm HIPAA compliant, can you say your firm did the best job possible? If you can document that with our HIPAA manual, you probably won't have any problems. If you can't, or worse made no effort to be compliant, beware, the fines are potentially immense.
Think of HIPAA as legislated common sense when it comes to protecting the personal, private and confidential information relating to the client's of your firm. How would you want your personal information protected? That is what we provide on this web site. A step by step proceedure to assist you in the this process. When you have completed all the modules, you will have a HIPAA manual for your firm. It is up to you to implement the procedures in your firm. All your employees must be trained in the importance of protecting PHI. Ultimately the principals of a healthcare firm will be held responsible for the actions of the firm and its employees.
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