Pat Forbis CMT

Associate Executive Director American Association for Medical Transcription

I am Pat Forbis, associate executive director of the American Association for Medical Transcription (AAMT). On behalf of our association, thank you for the opportunity to speak here today.

AAMT is the only professional association representing medical transcriptionists, the medical language specialists whose responsibility it is to assure that dictated healthcare information is complete, consistent, clear, correct, concurrent, and credible.

AAMT supports the patient's right to confidential, private, and secure healthcare documentation. We believe that safeguarding the patient's privacy by maintaining confidentiality and security is essential for quality care.

In 1995 our association published Guidelines on Confidentiality, Privacy, and Security of Patient Care Documentation Through the Process of Medical Dictation and Transcription, and we are currently active participants in ASTM's E.31.22 Subcommittee on Healthcare Information and Documentation. I serve as chair of the confidentiality, security, and privacy subgroup which just submitted the ASTM standard on Management of the Security and Confidentiality of Dictation, Transcription, and Transcribed Health Records for second ballot.

Little about a patient is more revealing than the dictated and transcribed or text portion of the health record. Yet as the debates rage on about confidentiality of health information and systems security or protecting patient privacy, there is little understanding about the complex process of dictation and transcription. Millions of dollars are being spent to change or even to eliminate this process, but the industry continues to grow.

Two factors appear to be at least partially responsible for this growth:

1. As technology moves healthcare information into an electronic format, healthcare providers have two choices: learn how to enter information or have someone do it for them. Most choose the latter; therefore, a greater diversity of healthcare providers is using the dictation and transcription process to assure the documentation of their healthcare delivery.
2. Third party payers, researchers, and an increase in litigation are requiring more, not less, information.

The result of the industry's growth is an increased demand for qualified medical language specialists known as medical transcriptionists. Additionally, as these demands increase, health care continues to experience downsizing, re-engineering, and outsourcing.

These dynamics have resulted in one of America's hottest new industries, healthcare information and the unregulated industry known simply as medical transcription?an unregulated industry that is estimated to annually generate $15 billion. It is an industry that has moved to Wall Street and that has captured the attention and the money of impressive investors, including pharmaceutical and insurance companies. And it is an industry that if allowed to continue to flourish without restraint has tremendous potential to compromise the confidentiality and security of healthcare information and the privacy of patients.

Approximately a decade ago, medical dictation and transcription were considered to be such delicate processes that it was unthinkable to allow them to leave the confines in which they were created. Environments were structured to assure quality, control, responsibility, security, and accountability.

When the outsourcing trend first began, that same control was demonstrated by medical transcription service owners who required transcriptionists to work in their offices under the control of the manager or supervisor. Client organizations continued to carefully monitor the quality, confidentiality, and security of the outsourced work.

I want to assure the Committee that many continue that practice today. Medical transcription lends itself well to being a legitimate home-based occupation. There are hundreds, if not thousands, of highly qualified and reputable home-based medical transcriptionists and services who are dedicated to providing the greatest possible quality healthcare information. They are committed to safeguarding that information, and they support the need for laws that will protect it.

However, it is not uncommon for dictated healthcare information to be outsourced to medical transcription services or individuals about whom little, if anything, is known; nor is it uncommon for dictated healthcare information to be transmitted across state lines and to English-speaking foreign countries, transcribed and transported back to employers and/or client organizations in a variety of ways, including by courier, through express mail services, the United States Postal Service, modems, remote printers, fax machines, and the Internet.

It is also not uncommon for the quality of health information to be compromised because of the demand on medical transcriptionists for high production. In what has been called an "electronic sweatshop environment," transcriptionists are often reimbursed only for the quantity of work they produce, with little regard to its quality.

In addition, some medical transcription services are selling storage space in order to become data repositories. And unless their contract with the healthcare provider specifically prohibits it, some service owners are considering how to market the healthcare information they now control. While they may remove what they believe to be all demographic information, it is important to understand that individually identifiable information is often contained within the text portion of a patient's documentation.

By now you undoubtedly understand that the process of dictation and transcription is rapidly evolving into another autonomous healthcare provider industry about which the public is primarily uninformed and unprotected.

Our concerns and recommendations include the following:

1. Patients are not adequately informed. Release of information forms should include information about their documentation: where it is stored and who controls it, and their right to review it. Reasonable efforts should be made to explain how the information will be used. Do not promise that the confidentiality and security of healthcare information can be guaranteed; we all know that it cannot be. Honesty will surely provide the first step to rebuilding a measure of trust.
2. Because organizations and individuals depend on the accuracy of the data for bill payment, managing the care process, and health policy analysis and assessments, we urge the adoption of quality assurance standards for dictation and transcription processes, and we look forward to participating in their development.
3. Medical transcription companies as data repositories raise privacy concerns. Standards must be adopted that will assure the protection of stored healthcare information and restrict such data repositories from marketing it.
4. Dictation and transcription are sensitive processes. We therefore encourage the adoption of the ASTM standard on Management of the Security and Confidentiality of Dictation, Transcription, and Transcribed Health Records.
5. AAMT urges strong criminal and civil penalties be adopted and enforced for those who knowingly and willfully disclose healthcare information.

In summary, medical dictation and transcription are not magical processes. The expertise of qualified medical transcriptionists is unmatched when it comes to the dictation and transcription processes of healthcare information, including their confidentiality and security. Events of the past decade have introduced outside influences that have created a dangerous gap between the public and the confidentiality and security of healthcare information that they deserve. This gap must be closed.

Again, on behalf of AAMT, we thank the Committee for the opportunity to be here today.