MEDICAL TRANSCRIPTION(MT)-OFFERING A BRIGHT FUTURE FOR TECH-SAVVY KERALITES

Medical Transcription – a high-end career in service sector
In the 1990s, there was a great deal of hype around expectations that the electronic medical record (EMR) and speech recognition (SR) would likely replace nearly all of medical transcription by the year 2000. To the distress of investors, developers, and early adopters, both EMR and speech recognition technologies saw dismal numbers as we rounded the millennium, while the medical transcription industry experienced considerable growth. Regardless of the promises, hopes, and advances of these new technologies and vendors, it appears that the replacement technologies may even be losing ground in the healthcare industry as some users retreat to the comfort of a process that has been around for generations – medical transcription.

Predicting the future of medical transcription in 2003 may yield results no different than those from the predictions in the 1990s. This author may have to follow the example of early fortunetellers and eat his words; however, it is again time to step up to the line, pick up the darts, and take aim at the target. It is hopeful that these predictions may come closer to the mark by learning from past projections, examining early replacement solutions, understanding the industry as it exists today, and making an objective and educated prediction on the evolution and longevity of the medical transcription industry.

PAST PROJECTIONS AND EARLY REPLACEMENT SOLUTIONS

Healthcare industry and technology experts, almost unanimously, predicted and believed that electronic medical record and speech recognition applications were sure to replace medical transcription as the primary, and in many cases, the only method of documenting the clinical encounter. Vendor marketing materials and salespeople went so far as to promise cost savings through the creation of paperless offices and increased practice efficiencies, increased revenues through higher coding, real-time access to data, and reduced personnel costs and headaches by “getting rid of the medical transcriptionists FTEs” (full-time equivalents).

Whether EMRs or speech recognition, the race was on to build the biggest and best set of products. Vendors competed to see who had the most bells, whistles, and flashing lights. Companies surfaced everywhere — either through new company birth or through mergers and acquisitions. In every product and with every vendor, developers all built their applications on the same basis. The industry believed that point of care documentation by the physician was the key to successfully delivering on the promises of reduced costs, increased revenues, and reduced FTEs. In all of the hustle and bustle, one very important factor was forgotten – the physician is central to both the delivery of care and, by industry creation, the immediate capture of data for the systems.

As physicians and organizations began to purchase these systems and try to implement them, an unexpected wrinkle emerged. Physicians who began using the systems found them difficult to learn, cumbersome, and significantly more time-consuming to document an encounter than dictation. Physicians are the foundation and conduit for the vast majority of all revenues in health care. These new technologies turned these revenue generators into data entry personnel and added cost center functions to the duties of the individual with the highest cost per hour.

Physicians quickly recognized that their productivity and efficiency were dramatically decreased — they were seeing fewer patients and still dictating records, all resulting in equal or higher costs, reduced revenues from fewer patients, and increased frustration and anxiety for themselves and their staff. Physicians also pointed out that real-time access to data was a nice benefit, if the data were there, but that they really only needed real-time access to historical data, which their paper charts easily provided. The wrinkle quickly became a canyon that has been nearly impossible to traverse.

These technologies have even seen some legal issues arise that have deterred adoption. Both EMRs and speech recognition use standardized content. It is well documented that creating and modifying a report using these technologies typically takes more time than physicians would like. Concerns exist that physicians may accept templates or predetermined “normal” values as is, rather than take the time to note the exceptions. This has led to overly standardized patient records and records that look exactly the same from patient to patient. Investigators have been concerned that exact and even very similar reports could mean that physicians aren’t documenting actual findings. These investigations have resulted in disciplinary actions against physicians.

Although adamantly denied by industry players, as the millennium neared its end, the EMR and speech recognition landscape had a dramatic new look. Of the hundreds of companies who were industry pioneers, the majority of them are lying on the roadside with arrows in their backs from unsuccessful products and unhappy customers. Finally, as the millennium turned, some companies began to acknowledge low industry penetration and user adoption and utilization.

However, denial still rears its head in some companies, as claims of users and installations are not always as portrayed. Still today, in 2003, the companies offering these products, who are considered the best in the industry and award winners, are charging off revenues as contracts with customers are canceled due to low or no user utilization.

Most current research and beliefs about EMR and speech recognition (SR) market penetration point to 5% to 8% for EMR and 1% or less for SR. Some industry experts contend that, in actuality, a current negative net exists as providers ceasing the use of these applications exceed the number that are purchasing and implementing them. Clarification is important here: these figures are for actual user utilization and not users registered on the system or simply using non-core functionality such as content, contacts, or general calendars.

Although riddled with low adoption, decreasing user bases, and floundering technologies, both the EMR and speech recognition systems do promise benefits in the future. As technologies evolve, processes change, and needs arise, these applications will, at some point in time, offer many of the benefits that were promised in the 1990s. History has shown that for these applications to succeed, they must not interfere with the physician’s ability to practice medicine. This author feels strongly enough about this prediction that, even as a transcription company executive, he recognizes the potential in the EMR industry and has founded a new technology company to build an EMR that addresses the problems of the past and focuses on physician clinical workflow as key to successful and mass adoption.

THE MEDICAL TRANSCRIPTION INDUSTRY TODAY

Today’s medical transcription industry eludes detailed definition. It has only been in the past several years that there have been any real attempts at examining the size of the industry. Even with these efforts, the industry size still escapes detailed examination and precise estimation. Although fairly well understood, attributes of the industry such as composition, technology position, personalities and concerns have received very little formal discussion. These attributes, along with industry size, are likely to hold important information that will help us to predict the future of the medical transcription industry.

Industry Size Within the past few years, the Medical Transcription Industry Association (MTIA), the industry’s vendor-centric association, conducted a survey for the purpose of determining the size of the industry. The results of the survey yielded a very large industry, but most felt the findings were substantially low. Questions abound around the method of the survey, classification criteria of the intended audience, and the organizational representatives who were presented with the survey. The survey was a brief telephone survey, segmented by small and large facility, and often directed to chief information officers (CIOs). Many believe that facility size should have had more and better distributed classifications, that CIOs were unlikely to know the cost of transcription for their facility, and that a fifteen to thirty minute survey likely resulted in guesses at the cost of transcription. Later, the survey results were adjusted much higher after reexamining the data. The resulting size of the industry was determined to be in the vicinity of $25 billion per year. Other methods of extrapolating the size in dollars of the industry yield a similar result and even show $25B to be a bit conservative. It is also generally accepted by transcription company executives that the industry is growing by an annual rate of 10% to 15%. Consensus is that this growth is due to increasing documentation demands to support reimbursement, risk management, and the need for more data. Of significant interest is the company size fragmentation of the industry. The medical transcription industry is the epitome of a “cottage industry”. The industry has one massive company with revenues at $400M, 3 to 4 companies with revenues each of $100M to $200M a handful of companies in the $10M to $100M range, and a couple of handfuls of companies in the $3M to $10M. The combined revenues of the $10M to $400M companies total between $800M and $900M. The remaining $24.1B resides with transcription departments, employee transcriptionists, individual contract medical transcriptionists, “mom & pop” transcription companies, and the 200 or so companies with revenues ranging from $500,000 to $3M. Industry Composition Again, the industry has not seen adequate research into the number of active medical transcriptionists. In the 1990s, the American Association for Medical Transcription (AAMT), the industry’s practitioner-centric association, estimated the number of medical transcriptionists in the industry at 250,000. Today, industry executives and experts feel this number, too, is a bit conservative. It is now believed that the industry is likely to have between 350,000 and 400,000 FTE transcriptionists, with the total number, including part-timers, near 500,000. Many also contend that there may be as many as 80,000 to 100,000 additional transcriptionists who have entered the market without adequate experience or education to obtain a job or who are working as interns or under mentors. Here too, “cottage industry” fragmentation can easily be seen as the largest transcription company in the industry has between 7,500 and 10,000 transcriptionists, then the employee base of the remaining transcription companies spirals downward to 4,500, then 2,500, then 1,500, ending with the companies with 1-5 transcriptionists. A very large number of transcriptionists still work as employees within provider organizations and many work as full-time provider employees and part-time or independently for transcription services or themselves. Industry Demographics Medical Transcriptionists Well above 90% female with an average age of 49 Most were on-the-job trained for years prior to the development of formal transcription curricula Majority of new entrants receiving too little education and/or training Retiring faster than qualified transcriptionists are entering the market The vast majority resides in the US; however, increasing quantities of entrants are from offshore including India ,Pakistan ,Philippines , the Caribbean, etc. Numerous quality problems suggest that a large number of offshore transcriptionists have language barriers or do not have adequate training or transcription/medical education. Upper Management – Companies larger than “Mom & Pop” Majority male with ages generally above 35 Most with at least a 4-year college education, management experience, and often moderate to good information technology knowledge. At least one with detailed HIPAA knowledge Likely to have corporate counsel for compliance issues Middle Management – Companies larger than “Mom & Pop” Mixed female and male with ages generally above 35 Most are likely to have some formal education and on-the-job training in transcription. Management - Mom & Pop Company or Contract Transcriptionist Majority female with ages ranging from 18 to 70+ Experience and education is hit and miss. Most are likely to have been on-the-job trained as a medical transcriptionist. Most likely to have a high school education and possibly some junior college or vocational technical school Some may have a 4-year college education A frightening number have as little as a few months of transcription education and no transcription experience of substance. Likely to have little or no HIPAA knowledge and many have inaccurate understanding of HIPAA. Participation in industry organizations is spotty at best. If you include the number of individual transcriptionists who claim to be a transcription company and mom and pop companies, MTIA probably has a membership of 1% of the industry’s companies. This number is not scientific and only speculative, as there is no way to formally determine the number of individual transcriptionist companies and mom and pop companies that exist. AAMT has less than 10,000 members and has seen several consecutive years of declining membership, resulting in a 1% to 3% representation of the industry participants. There is a notable history of conflicts between medical transcriptionists and their employers, whether healthcare providers or transcription companies. There have also been notable conflicts between medical transcriptionists and replacement technologies such as EMRs and speech recognition and between US-based transcriptionists and offshore companies. There is a valid basis for the medical transcriptionists’ positions and animosity. Medical transcriptionists have striven for increased respect from their employers. Early on, they were referred to as medical secretaries, then became medical transcribers, then medical transcriptionists, and in the past five years were designated as “medical language specialists”; however, the vast majority of the industry still refers to these practitioners as medical transcriptionists. In the past couple of years some medical transcriptionists have again begun looking at a new name. Medical transcriptionists’ animosity towards EMR and speech recognition technologies and vendors stems primarily from early claims by vendors that these technologies would “replace the medical transcriptionist”. Seeing threats to their jobs and livelihoods, medical transcriptionists have taken firm stands against companies offering these products. US transcriptionists also feel the threat to their livelihood from offshore transcription companies. Strong discussions attempting to curb the sending of work oversees are common in the industry. The majority of offshore companies wholesale their production to US-based transcription companies. Industry and Technology Just as new technologies are slow to penetrate healthcare providers’ operations and processes, technologies haven’t made much headway into the transcription industry either. For the most part, only the transcription companies larger than the “mom and pop” organizations have really integrated technology into their suite of services. Provider organizations with in-house transcription are also slow to adopt new transcription technologies, and many are using dated versions of their medical records systems. WordPerfect 5.1 is still one of the most widely used word processors in the industry. Whether using WP51, Microsoft Word, WordPerfect Office, or even occasionally WordStar, the majority of the industry has no standardization in production, format, indexing, or storage. The majority of the industry produces the transcription in the word processor alone, with no interfacing to practice management systems and no formal indexing or storage in databases. The files are typically stored in a flat word processor file and without a structured naming convention. It is also true that the majority of the industry still prints the transcribed documents for storage in paper form, comparatively few use or own more recent technologies that provide electronic storage, distribution, and signature. With this lack of specifically designed transcription software, concerns abound around the industry’s ability to protect patient privacy and provide audit trails of access to the patient information. Transcription is not the only function that is performed just as it has been for years. Vast amounts of dictation today continue to be recorded on microcassette tapes rather than new digital media, by microphone and recorder rather than telephone, etc. Even when digital recorders are offered to physicians and organizations free of charge, many of them still prefer to use “old faithful”: the tape and recorder. This slow migration to technology is due to two primary reasons — physician resistance to change, and more significantly, a transcription providers’ inability to provide new technologies. In some ways this slow migration may be a blessing in disguise. There are numerous documented and anecdotal accounts of transcriptionists providing services using new technologies without taking precautions to protect patient confidentiality. The average medical transcriptionist has minimal to no experience or understanding of important data security and privacy concepts, such as encryption, firewalls, authentication, and access controls. Even outside of these new technologies, there have been accounts of medical transcriptionists sending patient files via email to unintended recipients. Concerns about the Present Industry Industry experts, provider organizations, and many physicians have numerous concerns about the current condition of the medical transcription industry. These concerns are based on valid issues and are increasing in intensity. Diminishing Labor Force and Quality Today, forty-nine is the average age of the medical transcriptionist. Many medical transcriptionists are retiring due to age and health problems like carpal tunnel syndrome. As these transcriptionists retire, the new entrants are typically far from qualified to fill the void. Large numbers of transcriptionists have fallen prey to the “quick way” advertisements and transcription curriculum. Many (of course not all) online schools and at-home courses fail miserably to adequately teach the student even close to what is needed to get a job, and few do a good job. Some courses are as short as nine weeks. One physician recently commented, “Nine weeks turns someone into a risk to my practice; they think they know enough, but aren’t even 5% prepared for the quality of work I need from them. I spend more time answering questions and fixing errors than I would if I typed all of my own reports.” Online and at-home courses are not the only problem with the educational process for medical transcription. Even the many of vocational technical schools aren’t preparing their students properly for a career in medical transcription. Many medical transcription curriculums last no more than nine months and have as few as one class in transcription and no classes in English. Even the most basic understanding of the career is often left out of vocational, online, and at-home courses. A medical transcription certification (CMT) is available from the Medical Transcriptionist Certification Commission (MTCC). There are just a few thousand transcriptionists who have been able to successfully obtain their CMT. Many say that the CMT test is harder than the registered nurse (RN) nursing licensure examinations. It concerns many in the industry, that “graduates” of vocational, online, and at-home courses often are of the belief that they have their CMT. The unwary employer or physician may not realize that they have only obtained a certificate of completion of the course. Trusting that a graduation certificate is a CMT could lead to dire circumstances for patients and physicians. It is also of great concern that many of these “graduates” enter into the industry without ever hearing about HIPAA. As schools fail to present such an important regulation in health care, physicians are the unfortunate recipients of medical transcriptionists who are not prepared to adequately protect a patient’s privacy. This becomes a significantly larger concern as many new “graduates” enter their transcription career as a “transcription business owner”. Running their business without an inkling of how to meet HIPAA requirements puts everyone at risk. Although a new labor force is emerging in offshore companies, major concerns exist over the quality of work coming from these companies and how this may increase the risk to patients and physicians and how it is likely to increase susceptibility to malpractice. There are numerous accounts of transcription that is filled with errors, many of which are clinically significant. Although a few offshore companies are producing quality work, the remaining can’t deliver on their promises of quality. Independent tests have found that claims of 98.5% accuracy are regularly contradicted and, in some cases, accuracy rates of 60% were found. HIPAA It wasn’t long ago that self-proclaimed transcription industry experts stated that HIPAA would not have any effect on the medical transcription industry. Either in a state of denial or ignorance of the law, many transcriptionists and mom and pop companies have continued on their existing course of providing medical transcription. It is only now that many in the industry are realizing the fact that they must comply. Many providers are concerned that the majority of the transcription industry will not be able to meet several specific requirements: namely, access controls, policies and procedures, and audit trails of access to the patient information. Without the knowledge or resources to comply, many in the industry are claiming to comply and signing their business associates agreements without taking the measures required. Many will argue that they only have to sign the documents and that most of the regulations don’t apply to them; however, many attorneys are expecting that civil litigation will result from their lack of action. Some may claim that if the transcriptionist or transcription company didn’t offer compliance while signing agreements that they have compliance, this action would constitute fraud and the signer would have sole responsibility. However, trial lawyers are already predicting that physicians’ ignorance will not be a defense and that the patient/physician contract obliges physicians to verify that their business associates have complied with the regulations. Trial lawyers also state that a physician’s failure to select and use a compliant transcription company is likely to constitute negligence and expose the physician to litigation under the Racketeer Influenced and Corrupt Organizations Act (RICO). These lawyers make it a point to comment that their position is strengthened by the fact that physicians “have no excuse” not to choose a company that more than adequately meets all the HIPAA requirements. They cite the fact that choosing a compliant company is as simple as picking up the phone book or getting on the Internet. Mom and pop companies and individual transcriptionists are not the only ones who face major compliance issues. Many providers overlook their own transcription departments and employee transcriptionists. Providers are now rushing to bring these systems and individuals into compliance. Providers who use offshore companies are facing an unusual twist on the HIPAA issue. Offshore companies are not subject to US regulations, but the physicians who use them are. Of the hundreds of new offshore transcription companies popping up each year, it is expected that only a few of the established companies have met the necessary requirements regardless of their claims. Many providers are concerned that if a patient requests access to their records and the entities who produce or maintain their records, as provided by HIPAA, the patient’s or agent’s inability to access the facilities offshore or the physician’s inability to unequivocally verify that the offshore company is in compliance will lead to charges of noncompliance and litigation. Professionalism While transcription departments and reasonably sized transcription companies operate within the expectations of normal business operations, it has been found that a huge number of independent transcriptionists who claim to be a transcription company and a large number of mom and pop transcription companies operate their businesses in a manner that may put themselves and their physician clients at risk. More often than not, these “companies” lack most or all of the typical elements of running a business. They were found to be operating their “business”: Without Using A business license A computer that is used to surf the web Liability insurance A computer that is used by others in the household including children Property insurance Family members to assist in various duties including sorting, delivery, etc. Errors & omissions insurance A taxpayer ID Adequate home security Adequate computer security Regard for confidential information Technological Immaturity Plain and simple — the bulk of the industry doesn’t produce transcription using advanced technologies or structured data. HL7 and XML are unknown to the large majority of the industry. Digital equipment and electronic signature have little penetration. INDUSTRY FUTURE AND EVOLUTION The longevity of the transcription industry is likely to depend on its ability to evolve to meet the dynamically changing healthcare environment. Evolution, Recognition, Acceptance, and Industry Longevity The medical transcription industry has shown poor success in adapting to change over the past ten to fifteen years. Regardless of the position or beliefs of the industry, there will come a time within the next three to seven years where technologies like the EMR and SR will begin to make significant penetration into the healthcare market. It is not likely that that they will fully penetrate the market within seven years, and medical transcription may never fully disappear, as there will always be some need for freedom of expression. If the transcription industry does not recognize the opportunities and accept transition to new technologies, its demise will be more rapid. Medical transcription, its companies, and its labor will have opportunities to become involved in these new technologies. Transcription companies can become service bureaus for speech recognition or may evolve into EMR companies. Transcriptionists can move into similar positions as editors, template designers, etc. Transcription itself could become the catalyst to advance the movement of the EMR. Industry Size It is unlikely in the short term that the industry will see a reduction it its size. In fact, the industry could see substantial growth over the next three to five years. Even as EMRs and SR begin to take hold, there is likely to be an increased demand for transcription due to increases in documentation to support reimbursement and risk management. Furthermore, it is likely that the relationship between handwriting of charts and medical errors will be studied just as handwritten prescriptions were studied by the Institute of Medicine. The study would likely reveal risks associated with illegibility of the handwriting, loss of charts, and lack of usable data. Evidence continues to mount that the values of square footage and infrastructure are much higher when they are generating revenue than when they are used in a cost center such as transcription. As this evidence continues to mount, more providers will outsource their transcription and the ratio of dollars, number of transcriptionists, and distribution between in-house and outsourced will change. The industry as a whole is likely to see its growth to as much as $35B in the next five years. Need for Data Industry associations, researchers, federal and state governments, and patients are all recognizing the need for more “useable” health data. Data really aren’t usable unless they can be electronically processed to assist in monitoring, decision support, diagnosis, research, and so on. Transcription is already an excellent source of data. This source will become more useful as new technologies like XML and natural language understanding (NLU) evolve. It is important for the industry to adapt to the needs for this data. It is not likely that mom and pop companies and independent transcriptionists will be able to implement technologies that support the data acquisition. This lack, combined with other issues, will likely result in independent transcriptionists and mom and pop companies joining the employee ranks of larger transcription companies. Rather than rebel against this trend, transcriptionists should recognize that the many entities driving this need for data will are not likely to be patient and to accommodate them for the sake of their job independence, especially when the quality of care is likely to be increased by the increase in data. One alternative does seem to appear however, and that is application service provider (ASP) transcription. ASP transcription products have, for the most part, been miserable failures. Their business model sought to get revenues from all sides: the transcriptionists, the physicians, and the data (via data mining). With new business models, ASP transcription businesses could provide methods and technologies that would allow independent transcriptionists and mom and pop companies to remain independent while providing standardized and structured data to the resources that desire it. Industry Standardization Ultimately the industry must begin standardizing, including file structures, document formats, and interfaces. This standardization will provide benefits to patients, research, physicians, and others. The industry should adopt the principles outlined in the Report from the Consensus Workgroup on Information Capture and Report Generation, which can be accessed on the Medical Records Institute’s website (www.medrecinst.com). For optimal information capture and report generation, it is important to establish a set of documentation principles to be implemented on a national/international basis. The Report recommends that all healthcare documentation must meet the following “Essential Principles of Healthcare Documentation.” Unique identification of patient Systems, policies, and practices should: Provide unique identification of the patient at the time of recording or accessing the information Provide within and across organizations: Simple and easy methods to identify individuals and correct duplicate identities of the same individual. Methods to distinguish among individuals, including those with similar names, birth dates, and other demographic information Linkages between different identifications of the same individual Accuracy Systems, policies, and practices should: Promote accuracy of information throughout the information capture and report generation processes as well as during its transfer among systems Require review to assure accuracy prior to integration in the patient’s record Include a means to append a correction to an authenticated document, without altering the original Require the use of standard terminology so as to diminish misinterpretations Completeness Systems, policies, and practices should: Identify the minimum set of information required to completely describe an incident, observation, or intent Provide means to ensure that the information recorded meets the legal, regulatory, institutional policy, or other requirements required for specific types of reports, e.g., history and physical, operative note Link amendments to the original document, i.e., one should not be able to retrieve an original document without related amendments (or vice versa) or notification that such amendments exist and how to access them Discourage duplication of information Discourage non-relevant and excessive documentation Timeliness Systems, policies, and practices should: Require and facilitate that healthcare documentation is done during or immediately following the event so that: Memory is not diminished or distorted. The information is immediately available for subsequent care and decision-making. Promote rapid system response time for entry as well as retrievability through: Availability and accessibility of workstations User-friendly systems and policies that allow for rapid user access Provide for automatic, unalterable time-, date-, and place-stamp of each: Documentation entry, such as dictation, uploading, and scanning (original, edits, amendments) Access to the documentation Transmittal of the documentation Interoperability Systems, policies, and practices should: Provide the highest level of interoperability that is realistically achievable Enable authorized practitioners to capture, share, and report healthcare information from any system, whether paper- or electronic-based Support ways to document healthcare information so that it can be correctly read, integrated, and supplemented within any other system in the same or another organization Retrievability Systems, policies, and practices should: Support achievement of a worldwide consensus on the structure of information so that the practitioner can efficiently locate relevant information. This requires the use of standardized titles, formats, templates, and macros, as well as standardized terminology, abbreviations, and coding. Enable authorized data searches, indexing, and mining Enable searches with incomplete information, e.g., wild card searches, fuzzy logic searches Authentication and Accountability Systems, policies, and practices should: Uniquely identify persons, devices, or systems that create or generate the information and that take responsibility for its accuracy, timeliness, etc. Require that all information be attributable to its source (i.e., a person or device). Require that unsigned documents be readily recognizable as such Require review of documents prior to authentication. “Signed without review” and similar statements should be discouraged Auditability Systems, policies, and practices should: Allow users to examine basic information elements, such as data fields Audit access and disclosure of protected health information Alert users of errors, inappropriate changes, and potential security breaches Promote use of performance metrics as part of the audit capacity Confidentiality and Security Systems, policies, and practices should: Demonstrate adherence to related legislation, regulations, guidelines, and policies throughout the healthcare documentation process Alert the user to potential confidentially and security breaches[2] Technological Advancement Over time the transcription industry must embrace advancement of technologies. These technologies will evolve to increase efficiency, decrease turnaround time, increase accuracy, and support data capture. While many of these technologies exist today (such as digital dictation and electronic signature), several technologies are still on the horizon. Although natural language understanding is showing promise, it still has issues that will take time to resolve. Natural language understanding will enable physicians to use their transcription in ways never before possible. Today’s methods of producing transcription are a clutter of systems, applications, and processes that cannot be represented with ease. To remain a viable industry, it must adapt to the changes, fine-tune the methods, and simplify the overarching processes. Figure 1 shows a simplified high-level process of producing transcription while capitalizing on new echnologies. Figure 1: A simplified high-level process of producing transcription Legislative Acceptance and Compliance HIPAA is not likely to be the only legislation to affect medical transcription. Patient privacy, with compliance required by April 14, 2003 , has already begun to show movement in the transcription industry. The final security regulation is likely to affect transcription even more as it will require that the chain of trust and its security requirements are far more robust than currently exist in the majority of the transcription industry today. Independent transcriptionists and small companies should consider complying fully today with patient privacy to prepare them for security. If they are not able to comply, they should consider taking employment with a company that is compliant. Medical transcription is a fairly unique industry as transcriptionists go into the career with the intent of being an independent business. Physicians should be watchful for other responsibilities and liabilities that can arise as a result of HIPAA noncompliance or using a company that is not compliant. Physicians should weigh the risks and consider avoiding civil litigation by: Bringing their transcription department or employee transcriptionist into compliance Verifying a transcription company’s or independent transcriptionist’s compliance Don’t take their word for it. If they don’t meet and preferably exceed requirements, the physician’s choice is simple — provide resources and financial assistance to bring them to compliance, bring transcription back in-house, or switch to a company that is already compliant. It would be better to exceed compliance requirements than put themselves at significant risk of litigation and large civil damages. Verifying that transcription is produced in the US If it is produced offshore, verify compliance rather than taking their word for it. If it cannot be verified, weigh the risks of facing verification of compliance, bringing transcription back in-house, or switching to a compliant service. Centralization The industry must be prepared to centralize its resources as more providers outsource transcription to free up space and migrate from individuals and mom and pop companies to larger companies. The industry will need to support changing demographics and distribution of transcriptionists as more companies of substantial size are formed and transcriptionists become employees rather than their own boss. CONCLUSION The transcription industry survived and actually grew when it had been projected to dwindle to almost nothing. We are again challenged to predict the future of this very large and established industry. We should recognize that technologies such as EMRs and SR will continue to advance. This advancement will likely yield systems that are more user friendly and address previous problems with adoption. However, our prediction is not as aggressive as those of the past. The transcription industry is likely to increase in size over the next few years. It will see centralization of labor and resources in response to technology, production, and legal issues. As technologies move forward, proactive and visionary companies will adapt their services and business models to take advantage of the changes and insure the companies’ longevity. As provider needs and demands for data and services change and increase and as legislative issues continue to surface, those players who don’t adapt to the system or accept changes in their career are likely to be put out in the cold. The transcription industry will never fully disappear; however, it will take a very different form in the next three to five years, begin to diminish in size in five to seven years, and be much smaller in seven to ten years.