American College of Physicians: Internal Medicine — Doctors for Adults ®


Transcription costly and slow? Try online dictation

New Web-based services give physicians quick turnaround time-and easy access to patient notes

From the December ACP-ASIM Observer, copyright 2001 by the American College of Physicians-American Society of Internal Medicine.

By Bryan Walpert

Internist and gastroenterologist Anil R. Garde, MD, used to get his transcriptions the traditional way. After he dictated notes into a tape recorder, a transcriptionist would pick up the tape and return the typed notes to his practice, Riverside Medical Clinic, the following day.

Late last year, however, the Riverside, Calif.-based multispecialty clinic began to experiment with Internet transcription. Dr. Garde now dictates his notes into a digital tape recorder and transmits the contents to a transcriptionist via the Web. Once the notes have been transcribed, he gets them back electronically.

That makes a big difference in a clinic like Riverside, where two or three of its 90-plus physicians might see the same patient during a single day, and tracking down a patient's paper chart can be impossible. Now, Dr. Garde said, if another physician has his patient's chart, he simply goes online and views the transcribed electronic notes from the patient's last visit. While he can't access notes from that day's exams, he said, he still gets detailed information on the patient.

Many physicians still receive paper transcriptions after sending cassettes to local transcription firms or dictating notes over a toll-free phone line. But medical transcription vendors are trying to promote Internet dictation services to physicians like Dr. Garde. While these companies claim they can transcribe patient notes faster and for less money, that is only part of the story. Several boast that by getting physicians to view patient charts electronically, they're helping physicians take a first step toward electronic medical records.

How it works

Most Internet transcription service vendors serve as middlemen between physicians and transcriptionists. The companies accept dictated notes over the phone from physicians via the Web and electronically deliver the material to transcriptionists.

Some vendors allow physicians to dictate their notes via telephone using a toll-free number. In other cases, physicians must dictate into a digital recorder or handheld computer. They can then transfer these voice files to their computer and send them to the vendor's Web site. (Physicians say the process of uploading dictations to the Web takes a few minutes.)

No matter how they get their notes to vendors, physicians who use digital dictation services receive their completed transcriptions electronically, either via e-mails that are encrypted for security, or from a password-protected Web site. Edward Dolci, MD, a solo family physician in Weaverville, Calif., for example, dictates notes into a digital recorder and stores the dictations on his computer. Twice a day, he uploads the files to a Web site run by Global MedData Inc. in Redwood City, Calif., an electronic dictation service vendor. A few days later, he goes back to the Web site to download and print the transcriptions, which he puts into the chart.

Dr. Dolci can also send files from his home computer. He simply connects to his office computer over the phone, transfers the notes he has already dictated to his home computer and sends them to the transcription company's Web site.


Vendors like to boast about the speed of electronic transcription services. Physicians no longer have to wait for transcriptionists to pick up tapes and deliver finished transcripts.

To speed up their turnaround time, many digital transcription vendors use transcriptionists in other time zones, sometimes on the other side of the globe. A number of firms send physician notes to transcriptionists in India, who start work when most American physicians are eating dinner or going to bed. Vendors say that because many Indians are fluent in English, the quality of their transcribing is excellent.

Even without offshore transcription, however, vendors like Scribes Online, a Pittsburgh-based online transcription company, say they can turn patient notes around in about 48 hours. For users willing to pay a little extra, many services say they can process dictations in 12 hours.

Family physician Larry Couture, MD, who practices at Riverside with Dr. Garde, said that with traditional transcription services, he often waited two or three days for documents. Now that the clinic uses an Internet-based service, he said, "all transcriptions are available when I come to work the next morning."

Each transcription service has its own method for handling corrections, depending on the type of error and the physician's preference. In some cases, physicians fix errors themselves by simply changing the electronic notes. (Many vendors send the notes to physicians in standard word-processing files.) Physicians can also mark up a printout of the notes and either fax or e-mail them back to the vendor for corrections.


Online transcription costs vary by company. At a minimum, physicians need a computer equipped with a Web browser to retrieve their notes. If you don't want to dictate over the phone, you'll need a digital recorder or handheld computer to produce dictated versions of your patient notes. Companies like Global MedData charge $399 for a digital recorder, training and other necessary equipment.

The primary cost for most physicians, however, is the per-line transcription fee. While the industry standard for traditional transcription ranges from 12 cents to 17 cents per line, the definition of what exactly constitutes a "line" varies from vendor to vendor, making direct price comparisons difficult.

Some vendors say that the use of offshore transcription helps lower their per-line fees. Global MedData's general manager Anand Patel, for example, said that offshore transcription produces a 30% to 40% savings over traditional services because labor is less expensive. He said his company tends to charge physicians 8 cents to 10 cents per line, depending on volume and turnaround requirements.

Raul Kivatinetz, president and CEO of AssistMed, said that physicians using his service can expect to pay 11 cents to 11.5 cents per line for India-based transcription. (He said his company uses quality controls to guarantee the quality of transcriptions.) Riverside, which uses AssistMed and its transcriptionists in India, has saved more than 20% over traditional transcription fees, said Ravi Berry, MD, a pediatric gastroenterologist who is spearheading the clinic's online transcription effort.

Other potential savings exist. Etoila Schuplin, president of Physician's Management Services, a transcription company in Fredericksburg, Va., said providing online transcription service has significantly cut courier use, so she hasn't had to pass on rising gasoline and paper costs to clients. Since last spring, Ms. Schuplin's company has moved much of its business from a traditional to an electronic transcription model.

Electronic edge

Some vendors suggest that the major benefit to physicians will come not from per-line cost savings, but from their increasing use of electronic documents.

Marco Zarlengo, MD, an internist and nephrologist with Heritage Medical Group in Croton-on-Hudson, N.Y., used to write brief notes by hand because he thought it wasn't worth the 12 cents to 15 cents a line for transcription. But coding requirements have forced him to provide longer, more detailed notes to substantiate what he bills. Dictation allows him to do that.

Dr. Zarlengo said he now has the confidence to code higher when appropriate, in part because he can provide the documentation that an HMO might request during a spot check. "I'm not downcoded anymore. It just doesn't happen," said Dr. Zarlengo, who uses xpressMD Technologies Inc. in Tarrytown, N.Y., for online dictation. "It's a seamless way to develop an electronic medical record (EMR), something that is going to happen in everybody's office."

Riverside is also using online dictation as a first step toward computerizing records. The practice is building its own electronic medical records system and hopes to have lab, radiology, ultrasound and pathology results available electronically this year.

Some companies have already integrated online transcription with existing electronic records. Medinex Systems Inc. in Post Falls, Idaho, for example, offers online transcription as an add-on to Medinex Office, a system that electronically tracks patient encounters and scheduling (though the company does not call it an EMR). The transcribed record is attached to the rest of a patient's information.

Even physicians who don't have a full-blown electronic medical records system have access to electronic copies of transcribed documents because their vendors store files electronically. As a result, physicians can access an electronic copy of their progress notes from almost anywhere.

That feature came in handy for Riverside's Dr. Berry this summer when a late-night call brought him to the emergency room to see a patient with a flare-up of inflammatory bowel disease. Using a hospital computer, he went to his vendor's Web site, entered his access code and pulled up the patient's files. "I just wanted to see what medications he was taking and what the lab results were last time," said Dr. Berry.

Such easy access also affects patient care in the clinic, where physicians can pull up electronic records. Dr. Garde recently saw two patients with similar cancers. At one point, he wanted to call both back to discuss biopsy results and treatments, but enough time had passed that he couldn't recall certain test details that differentiated the two patients. Waiting for the paper chart would have meant delaying those calls another day—and prolonging the stress levels of both patients. "Mentally, that's agonizing for them," Dr. Garde said.

Thanks to the electronic notes from online dictation, however, he was able to contact them as soon as he received the biopsy results. "I called the patients within 15 minutes instead of the next day."

Bryan Walpert is a freelance writer in Denver.


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