Medical Transcription Introduction

Introduction to Medical Transcription

Medical Transcription is the process of converting voice dictation (typically either cassette or digital format) into a permanent written record utilizing word processing equipment and software.

Each day in hospitals all over the country, thousands of patients are admitted and discharged. Examinations are conducted, procedures are performed and recommendations are made. It is not uncommon for multiple physicians to be involved in a simple procedure for a single patient. Radiologists, Pathologists, Anesthesiologists, Surgeons, and a host of other medical specialists must all coordinate their efforts to ensure that patient care is both adequate and appropriate.

Underpinning all of these activities is a complex web of medical and patient information. Each patient-related activity and procedure must be meticulously documented and then added to the patient's permanent record. Physicians and medical record handlers alike must be extremely careful to ensure that detailed patient identification information accompanies each procedure and examination report to avert potentially disastrous mix-ups. Over time, all of this information accumulates in a centralized medical records repository where it serves as a critical resource for patient care - facilitating accurate diagnoses and appropriate treatments. Indeed, timely patient care often hinges on the ability of Radiology, Pathology, and other specialty departments to quickly conduct their examinations and report their findings.

Evolution and History of Medical Transcription

In the past, patient medical charts consisted of a series of abbreviated handwritten notes that were funneled into the patient's file for interpretation by the primary physician responsible for diagnosing ailments and prescribing treatment. Ultimately, this hodge-podge 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. Walls of filing cabinets have given way to desktop computers connected to powerful mainframe systems where patient records are prepared and archived digitally. This digital format allows for immediate remote retrieval by any physician who is authorized to review the patient information. Reports are stored electronically and printed selectively as the need arises.

While the transition from a paper based to an electronic format will take years to complete, considerable progress has been made. Handwritten reports are largely a thing of the past. Verbal dictation is now by far the most common method for documenting and reporting the results of examinations and procedures. Physicians generally use either a cassette based voice dictation system or a digital voice dictation system to record their findings. Dictating reports verbally not only allows physicians to be more thorough in their reporting, it also saves them a great deal of time. The Wall Street Journal recently reported the results of a study conducted by the Association of Legal Administrators suggesting that verbal dictation is the fastest way to create a document. The study states that "a 245-word document takes 9.34 minutes to create with an electronic dictaphone, compared with 16.46 minutes on a personal computer and 16.49 minutes by hand." (WSJ, Tuesday, October 22, 1996, page A1, column 5). Given the salaries of most physicians, the cumulative productivity savings associated with these technological enhancements is considerable.

The process of converting voice dictation to a typewritten format is known as transcription. Traditionally a staff of skilled medical transcriptionists working in the medical records department of the hospital has accomplished the work of transcribing medical records. In the early years of medical transcription it was not uncommon for very large hospitals to have staffs of 40 or 50 medical transcriptionists working one or more shifts. A transcription supervisor, who in turn reported to the Medical Records Director, generally oversaw these transcriptionists.

The Medical Transcription Outsourcing Trend

Increasingly, traditional hospitals are coming under competitive attack by more efficient managed care organizations. In an effort to remain competitive, many hospitals have turned to outsourcing as a means of cutting costs. Many of the processes that were previously performed internally are now being contracted out to third parties. Medical transcription is no exception. The outsourcing of transcription and other functions relieves hospitals of the administrative headaches and overhead burdens associated with internal production and allows them to focus their attention on improving service and lowering costs.

This new competitive climate has driven many hospitals out of business. Those organizations that have survived have done so by becoming more efficient and cost-conscious. There is considerable evidence to suggest that contracting out medical transcription is a much less costly alternative to producing reports internally. Most savvy healthcare providers today understand this and are responding appropriately. The significant cost-cutting pressures which continue to drive the industry toward consolidation, managed care and capitation virtually guarantee that the outsourcing trend will not only continue but accelerate in coming years.

This proliferation of outsourcing agreements has spawned a new generation of small medical transcription companies intent on carving out a piece of the pie. Interestingly, in spite of its rapid growth, the medical transcription industry is still considered a cottage industry. While there are a few truly national players, the industry is at this point still dominated by the hundreds of small local transcription companies located wherever hospitals are found.

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