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Journal of the Academy of Hospital Administration

Medical Transcription: Coming of Age?

Author(s): Sidhartha Satpathy, Shakti Gupta, Rajiv Kr. Jain, S.K. Mathur, Sunil Kant

Vol. 12, No. 2 (2001-07 - 2001-12)

Introduction

Health care industry is one of the fastest growing and most expensive fields in the developed nations, and administrators are perpetually on the look out to control costs. As doctors time becomes precious, it is advantageous to ride the boom in information technology and to use other cheaper resources for transcribing medical information.

Medical transcription is the process whereby one accurately and swiftly transcribes medical records dictated by doctors and other medical professionals. The material transcribed includes, amongst others, patient history and physical reports, clinic notes, office notes, operative reports, consultation notes, discharge summaries, letters, psychiatric evaluations, laboratory reports, x-ray reports and pathology reports and other similar kinds medical records.

Medical transcription may be carried out for any medical professional operating out of a small clinic or a large hospital. These transcribed records are used for purposes of archives, reference or for serving as a legal proof of medical advise.

Evolution

Ancient cave writings attest to the earliest forms of healthcare documentation. While the medium changed from metal plates to clay tablets, to hieroglyphs on temple walls, to papyrus, to parchment, to paper, and most recently to electronic files, the reasons for maintaining records have always been the same - to record an individual's health care and the achievements in medical science.

Until the twentieth century, physicians served as both providers of medical care and scribes for the medical community. After 1900, when standardization of medical data became critical to research, medical stenographers replaced physicians as scribes, taking their dictation in shorthand.

The advent of dictating equipment made it unnecessary for physician and scribe to work face-to-face, and the career of "medical transcription" began. As physicians came to rely on the judgment and reasoning of experienced medical transcriptionists to safeguard the accuracy and integrity of medical dictation, medical transcription evolved into a medical language speciality.

Now, at the dawn of the twenty first century, medical transcriptionists are using speech recognition technology to help them create even more documents in a shorter time. Medical transcription is one of the most sophisticated of the allied health professions, creating an important partnership between healthcare providers and those who document patient care.

In the USA, medical transcriptionists have formed a professional organisation, the American Association for Medical Transcription (AAMT) which has developed a model curriculum for transcription educators; as well as a model job description.1 Though its efforts, Medical Transcriptionists have become recognised as healthcare professionals with expertise in medical language. It was only in 1999 that the US Dept.. of Labour assigned a separate job classification viz standard occupational classification 31-9094. India provides a platform and large storehouse of human resources which is available at comparatively lesser costs and hence is much sought after by the hospital/doctors there. As for as requirement of medical transcription for Indian Hospitals is concerned, it is still at a nascent stage and may well become an allied branch or discipline in the future health care scenario.

Pre-Requisites

Medical Transcription requires a practical knowledge of medical language, anatomy, physiology, disease processes, pharmacology, laboratory medicine, and the internal organization of medical reports. A medical transcriptionist is truly a medical language specialist who must be aware of standards and requirements that apply to the health record, as well as legal significance of medical transcripts.

Reports of patient care take many forms, including histories and physical examinations, progress reports, emergency room notes, consultations, operative reports, discharge summaries, clinic notes, referral letters, radiology reports, pathology reports, and an array of documentation spanning more than 60 medical specialities and sub-specialties! Thus, the medical transcriptionist, or medical language specialist, must be well versed in the language of medicine.

In addition medical transcriptionists require

  • above- average knowledge of English punctuation and grammar;
  • excellent auditory skills, allowing the transcriptionist to interpret sounds almost simultaneously with keyboarding;
  • advanced proofreading and editing skills, ensuring accuracy of transcribed material;
  • versatility in use of transcription equipment and computers, since transcriptionists may work in a variety of settings; and,
  • highly developed analytical skills, employing deductive reasoning to convert sounds into meaningful form

In India, the business of Medical Transcription has been classified as an IT enabled service, i.e. it does not require specialised Information technology inputs or software technology. The primary skills necessary for this are extensive medical knowledge and understanding, sound judgement, deductive reasoning, and the ability to detect medical inconsistencies in dictation. Besides, one must be able to work for long hours and have aptitude to work under pressure.

Organization of Services

In intercontinental medical transcription, doctors in the USA dictate their findings, general information and diagnosis along with the management into a telephone/dictaphone/digital media system/voice data file. These voice messages go into a central computer, and is then converted into digital signals, which are compressed and encrypted; to be beamed upto a telecommunications satellite Intelsat. In India, the data received from the satellite is uncompressed and sent to different workstations for transcription into a written form with the help of qualified medical transcriptionists. Subsequently, these 'transcribed' reports are bounced/beamed back to the satellite as digital signals; from where the central computer reviews it. After being processed by the central computer again, it is converted into written report and is submitted to the doctor. It is estimated that because of significantly lower costs, India has the potential to tap at least 10% of the total business in USA, where there are about 7 lakh doctors.2,3

Quality Standards

In the USA, as in many other developed nations, the medical transcription is a legal document, based on which payments are made. As per the Joint Commission for Accreditation of Healthcare Organisation (JCAHO'S) stringent quality guidelines regarding maintenance of medical records (standard IM-7.6) each indoor patients medical history and physical examination findings have to be documented within 24 hours of admission.4,5 This necessitates the availability of medical transcriptions facilities even on weekends and holidays. In pursuance of these objectives and also as a safeguard against potential litigation, the AAMT has also developed a competency profile. The abstracting requirements are time and cost intensive and the burden of data collection lies with the health care organisations as majority of "core" measures are obtaind from medical records. As a result, Hospital Information Manag ement Dept. is involved in almost all activities going on in the hospital.6,7

Indian Scenario

Although India is serving as one of the leading destinations for intercontinental transcription, medical transcription in the true sense of the term is yet to take off in the Indian Hospitals. Even though medical record departments exist in most of the major hospitals; and training courses are available for medical record technicians; most of the doctors especially in the public sector prefer to act as scribes themselves and either note down or feed in the findings themselves. However, it is felt that with passage of time, this practice is likely to grow and in the future the erstwhile medical record departments / sections may have to be merged or assimilated in the Health / hospital information management system.

Conclusion

It seems to be a reasonable certainty because health care industry is gradually but surely moving towards electronic health records, allowing storage of individual health records, so that it can be accessed by physicians and other health care providers at different sites. The advent of overseas players in the insurance sector is also likely to hasten this process and the management of change in the existing hospital scenario would by the most tricky part, as far as hospital managers are concerned.

References

  1. URL : http://www.aamt.org- the official website of AAMT.
  2. Subhadra M. Transcription, Medical Manna- India Today, Aug. 4, 1997;75.
  3. The Hindustan Times, 2000 Nov. 22; Tides of medical transcription.
  4. URL : http://www.jcaho.org The official website of JCAHO.
  5. URL : http://www.himinfo.com
  6. Dougherty M. Measuring up - Keeping an eye on Joint Commission new 'core' measures. Journal of AHIMA 2000;71(5):59-60.
  7. Blumenthal JE. Speaking up for HIM. Journal of AHIMA2000; 71(5): 84.

Sidhartha Satpathy - Assistant Professor, Department of Hospital administration AIIMS, New Delhi.
Shakti Gupta - Additional Professor, Dept. of Hospital Administration AIIMS, New Delhi
Rajiv Kr. Jain - Registrar Cum Secretary, Delhi Medical Council
S.K. Mathur - Consultant, Hospital Planning and Management, New Delhi
Sunil Kant - Medical Office, MH, Dehradun

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