How Much Wood Should a Woodchuck, or MT, Chuck?

The Work of the Woodchuck Is Never Done

Pat Forbis, CMT

"How much work should an average medical transcriptionist (MT) produce in a day" is one of the most frequently asked questions by managers, supervisors and others who play numbers games. To answer the question we must agree on the definition of the average MT. In my opinion, defining the average MT is like searching for the Holy Grail. If you are looking for one, good luck. In my 30 years in this industry, I have yet to meet one... one who would admit it, at least.

In 1992 I authored a popular AAMT Track column titled "How Much Wood Should a Woodchuck Chuck...and Why?" It described how variables of the day affected the outcome of work produced by the woodchuck and the MT.

With seven years of changes in the environment, the move toward an electronic patient record, and with health care itself moving forward at an almost dizzying pace, there are some things that haven't changed and aren't likely to. One of those things is a national productivity standard for MTs.

Woodchucks and MTs still have a lot of work to do, although it appears that MTs may be outpacing their furry friends when it comes to current-day demands. Both remain focused and work diligently for long periods of time, continuing to make extraordinary progress in relatively short periods of time. Given just the right amount of uninterrupted time, knowledge and experience, both still deliver an impressive final product.

The answer to the question of how much work an average MT should be able to produce has not changed. Today, as in 1992, there is no such thing as a national average productivity level for medical transcription, and there probably never will be. You can add to that statement that there is no such thing as an average MT.

Consider the variables that MTs encount-er every day:

Dictation

• Dictator characteristics (English as a first or second language, voice inflection, articulation skills, new or experienced dictator)

• Dictation equipment (analog, digital, controls, maintenance, media quality, rerecord or original)

• Dictation software (speech recognition technology)

• Type of report (operative, discharge, progress notes, H&P, radiology, pathology, specialty)

• Completeness of dictation (provision of patient demographics, use of abbreviations, incomplete reports or sentences)

• Difficulty factors of reports (routine or complex; new procedures, drugs, instruments)

• Environmental factors (background noise; sound quality; frequent interruptions)

• MT knowledge (education, experience, English and medical language fluency, editing skills, familiarity with report types, familiarity with dictating staff)

• MT equipment knowledge (experience on facility's equipment)

• Transcription equipment characteristics (quality, features, maintenance)

• Resource availability (adequate, up-to-date, accessible references; access to other MTs, electronic assistants, Internet access)

• Environmental factors (ergonomics, distractions)

• Performance expectations (demands for quantity, demands for quality, personnel policies)

• Other responsibilities (answering telephone, filing, etc.)

If there are significant differences in productivity, the transcription variables will provide valuable information. If transcriptionist A produces 500 lines a day (a line is anything you want it to be) and transcriptionist B produces 2,000 lines a day, one should explore how to stabilize it.

• Does A need to work on skill building?

• Does B produce 2,000 lines of quality transcription?

• Does A have responsibilities other than transcription?

• Does A speak the language of medicine as fluently as B?

• Do A and B have equivalent resource materials?

• Does B willingly assist other MTs who have questions?

The search will likely continue for the average MT. Perhaps s/he will be found lurking behind an average computer screen in an average transcription environment in an average community. Language skills, medical knowledge, and keyboarding coordination will be average, and s/he will receive average dictation from average dictators who perform average procedures on average patients. The difficulty level of the report will be average, and the report will be dictated on average equipment at an average rate and volume in an average dialect. This individual will have access to average resources, and his/her ergonomic surroundings will be average. Management expectations will be average, as will be format design and quality/quantity demands.

One thing is certain: There are still more trees in the forest than the woodchuck population can handle in a day, and seven years after our first look at MTs' average production, there is more dictation than all MTs put together can transcribe in a day.

Pat Forbis is associate executive director for professional affairs, the American Association for Medical Transcription (AAMT), Modesto, CA.

Can Industry Production Standards Work for Medical Transcription?

Evelyn J. Graham

Industry standards have been widely used for years by word processing business owners. If applied to the medical transcription industry, these standards would be a measuring stick against which employers could evaluate medical transcription performance and MTs could track their career growth.

(Editor's note: This article originally ran in the August 1998 issue of MT Monthly.)

Fast forward to the year 2000. You're sitting in your office and the phone rings. It's the health information management (HIM) director of Big-Volume Hospital asking if you can transcribe about 1,000 minutes of dictation a day and, if so, what you charge. You tell the HIM director that yes, you can handle that volume for $0.xx per line of transcription or $x.xx per minute of dictation. Big-Volume Hospital's HIM director agrees and asks if you can start in two weeks. You say yes and suggest a time to get together and sign the contract.

Wow! Wouldn't that be great?

Why can't it be that easy today?

It is! But you have to think "outside of the box."

Industry standards have been widely used for years by word processing business owners. In fact, The National Association of Secretarial Services and Executive Suite Network is getting ready to publish the fourth edition of Industry Production Standards while we have struggled for years--unsuccessfully--to agree on an industry standard definition of a line. There is no quantitative difference between a line of word processing and a line of medical transcription.

Here's how the Industry Production Standards can work for the medical transcription industry. The production standard for good quality medical dictation is 4.9 minutes of transcription for 1 minute of dictation (1:4.9 ratio). Applying this ratio to Big-Volume Hospital, the job will take 4,900 transcription minutes (81.67 hours). If a company hypothetically charges $25.00 an hour for basic services, then 1,000 minutes of dictation will cost $2.04 per minute (81.67 hours times $25/hour divided by 1,000 minutes).

But wait a minute. Big-Volume Hospital wants a price quote for a line of transcription. Well, that's easy enough. The production standard is 10,840 characters per hour. Using the hypothetical hourly rate, the equivalent price per line is $0.1499 ($25/hour divided by 10,840 characters/hour times 65 characters/line).

OK, but we're back to square one. What constitutes a line? Well, look at this page you're reading. You can see printed characters and you can see spaces between the words, right? Now, count 65 sequential printed characters and spaces, and you will have one standard line. (The issue of format codes, etc., is addressed in Industry Production Standards, but space limitations here preclude a discussion.) But remember, there is no quantitative difference between a line of word processing and a line of medical transcription.

Meanwhile, back at the office your phone is ringing. The HIM director at Big-Volume Hospital wants to know if you can provide 12-hour turnaround time and weekend coverage. You explain that Industry Production Standards defines basic service as 24-hour turnaround time, five days a week. However, you can accommodate Big-Volume's requirements for X-amount premium for 12-hour turnaround time and Y-amount premium for weekend coverage. You might even want to offer an incentive to do business with your company, such as not charging the Z-amount premium for after-hours coverage or offering a volume discount.

I submit it is not coincidental that, in the last 10 years, medical transcription prices have increased about 15 percent and the size of the line has increased about 35 percent, whereas word processing prices increased about 50 percent and the size of the line remained constant. I also submit it is foolish to compete on the basis of who-has-the-largest-line-for-the-lowest price. It's hard enough recruiting qualified medical transcriptionists (MTs) when we are competing for the lowest price without the largest line component.

Finally, I submit that we are vendors of medical transcription services. We assume the costs and the risks of producing the end result--the medical record. Why, then, have our customers reaped the economic rewards of our production efficiencies and technological advances? Think about it.

What's in it for the MTs? The Industry Production Standards are a measuring stick against which employers can evaluate medical transcription performance and MTs can track their career growth. Employers can set more realistic production expectations for MTs. As the MT's speed and skills increase and his or her salary level increases, so should revenue to the employer.

I say it's time for medical transcription service owners to adopt, industry-wide, the proven and well-established Industry Production Standards. What do you think?

Submit your arguments for or against the adoption of standards, and specifically industry-wide adoption of Industry Production Standards, to ADVANCE, 2900 Horizon Dr., Box 61556, King of Prussia, PA 19406-0956; HIMedit@merion.com.

Evelyn J. Graham owns CMT Corp., in San Francisco.

Industry Production Standards is published by The National Association of Secretarial Services and Executive Suite Network. The current publication, Third Edition, June 1995, can be purchased from the Association of Business Support Services International, Inc., 22875 Savi Ranch Parkway, Suite H, Yorba Linda, CA 92887-4619.

Measuring Productivity HAS MTs Divided

By Anne Miller

(Editor's note: ADVANCE originally published Evelyn J. Graham's article, "Can Industry Produc-tion Standards Work for Medical Transcription?" in its Feb. 1, 1999 issue. After this article appeared in print, ADVANCE created a bulletin board on its Web site to solicit our readers' opinions on this topic. The original article and the bulletin board [titled, "MT Production Standards"] can still be accessed at www.health-information.advanceweb.com.)

Mention the subject of production standards around any medical transcriptionist (MT), and you are sure to get a reaction. Some folks in the industry believe it is high time for some type of enforceable, nationwide standard to be implemented, if only to get everyone involved in medical transcription--MTs, medical transcription service owners, physicians who dictate, customers in need of MT services--"on the same page," so to speak, with how the prices for such services should be determined. Others believe that national productivity standards could actually have a detrimental effect on MTs and MT service owners in the long run.

So who's right? Should there be a national productivity standard for MTs, and if so, what should it be?

Isn't There One Already?
There is one standard that exists in the medical transcription industry, relating to the definition of a line. In 1993, after two years of work groups, discussions and meetings, three of the industry's largest professional associations--the American Association for Medical Transcription (AAMT), the Medical Transcription Industry Alliance (MTIA) and the American Health Information Management Association (AHIMA)--reached an agreement about a standard unit of measure for medical transcription work.

However, this standard was established only as a voluntary (and not an enforceable) unit of measure for MT work. "Leaders from the three professional organizations agreed that it was not the goal or intent to develop enforceable standards or to establish any kind of pricing structure," said Molly Malone, executive director of MTIA.

According to the voluntary standard, the smallest unit of measure was proposed to be the character, which is defined as all letters, numbers, symbols and function keys necessary for the final appearance and content of a document, including the space bar, carriage return, underscore, bold, and all characters contained within a macro, headers and footers.

A line was said to equal 65 characters. Consistency in work measurement, it was agreed, could be achieved by counting characters the same way and converting the character count to a 65-character line.

MTIA and AHIMA still support this definition of a line. AAMT, however, withdrew its support of this 65-character line in 1998.

In an April 20, 1998 ADVANCE article ("AAMT No Longer Supports Quantity Definitions"), author Pat Forbis, CMT, AAMT's associate executive director for professional affairs, wrote, "Unfortunately, one of the common challenges that MTs have been burdened with has been the manner in which some employers have misused, or even abused, the quantity definitions... some employers [have even] used [the 65-character line] as an excuse to change their method of measuring production, resulting in lower pay."

Industry Production Standards & MTs
If MTIA and AHIMA support the voluntary use of a 65-character line to calculate the price of transcription services, then what are the Industry Production Standards that Evelyn J. Graham recommended for MT service owners in the Feb. 1, 1999 issue of ADVANCE?

The National Association of Secretarial Services and Execu-tive Suite Network publishes the Industry Production Stan-dards (now in its fourth edition). These have been widely used for years by word processing business owners.

According to the Industry Production Standards, the following rules apply:

• One line equals 65 characters;

• The production standard for good quality medical dictation is 4.9 minutes of transcription for 1 minute of dictation (1:4.9 ratio);

• The production standard per hour is 10,840 characters per hour; and

• Basic service is defined as a 24-hour turnaround time, five days a week.

Issue Has MTs Divided
The issue of production standards for MTs is not one that will be easily re-solved, it seems. Many of our readers' comments, which were culled from the ADVANCE bulletin board, have been reprinted here with some minor editing for clarity (see related article below.).

While many ADVANCE readers support the need for productivity standards for MTs, there is no agreement about what type of standard would be best. Many indicated that they were disinclined to adopt the Industry Production Standards for medical transcription, as the knowledge required to become an MT is so much more complex than that of a mere word processor.

And what do the leaders in the field seem to think? One thing is certain. "Read the online bulletin board comments from MTs--many harbor very strong feelings about this issue," said MTIA's Malone. "They blame MT professional associations for not championing this cause; and some feel the MT services are not paying them what they are worth."

Indeed, the MT profession currently finds itself in a catch-22 situation--there is a great (and increasing) demand for MTs; but not enough people are being recruited into the profession to meet this demand. Some believe this may be because the average pay for MTs is not high--especially for the new MT, as it takes a lot of time and experience to become truly proficient.

But Stephanie Golden, who was an MT for 15 years and is currently vice president, director of national recruiting for MedQuist, a national MT service company with approximately 100 offices and 9,000 MT employees nationwide, disagrees. "Our MTs, on average, earn between $12 and $25 per hour. Some are making as much as $34 to $40 per hour," she stated. "They receive approximately 50 percent of what we charge our clients--and remember, after the transcriptionists' salaries are deducted, MedQuist still has to pay for its employees' benefits, office space, telecom charges, management costs, etc."

MedQuist offers its MT employees a benefits package that includes a 50 per- cent co-payment on health insurance costs, paid time off, participation in both a 401(k) plan and a stock-purchase op- tion, and worker's compensation and unemployment insurance. In addition, MedQuist has recently implemented a new, nationwide bonus incentive program for MTs, and sponsors an MT of the month contest (with a $50 cash prize) in every office.

But, "It's obvious that some of the smaller services are using our pricing structure to charge their clients without offering the same types of benefits to their MT employees," Golden conceded. "It seems that the smaller a service is, the less likely it is to offer employees a benefits package."

AAMT's Forbis believes that a national industry standard would actually be detrimental to MTs everywhere. "Don't get me wrong--I do believe MTs should receive a good day's pay for a good day's work; and I do believe it's important and beneficial to track productivity," she said. "However, I also believe production expectations must be limited to the environment in which the MT is working."

Both Golden and Forbis agree: there are so many factors and variables that affect MTs that it would be impossible to take them all into account when designing a national standard. "There are equipment differences; equipment failures; word expanding software; different levels of work; different types of dictators; and so on," Forbis noted. "If Company A is using much older, slower computers than Company B, would it be fair to hold both sets of MT employees accountable to the same expectation?"

"You'd have to create a multitude of different industry standards to come anywhere close to a true 'apples to apples' comparison of MT productivity," added Golden. "A national standard just isn't practical or realistic."

So then, what should be done? "I think the only fair way to ad-dress this issue is to have every employer track productivity, but recognize and account for the fact that it is susceptible to change," Forbis commented.

To illustrate her point, Forbis recounted the following story. "I had been an MT for years and was considered ex-tremely proficient in my field," she related. One day, however, a physician handed her a tape containing a dictated bone marrow transplant--a brand-new procedure at the time.

"This dictation was full of unknown medical terminology, new references, new procedures, etc.," Forbis recalled. "Normally, I would have breezed through a tape of that length in one hour or less--but this one took me all day to transcribe!"

It was the same type of situation when AIDS first hit the scene, Forbis added. "If the profession adopts industry-wide production standards, then the next time there's a big change or breakthrough in medicine, I'm afraid every MT would suffer," she remarked. "Productivity standards could, in effect, actually punish the MTs who strive to increase their knowledge and keep abreast of new developments."

Again, ADVANCE wants to know: what do you think? The "MT Productivity Standards" bulletin board is still available on our Web site at www.health-information.advanceweb.com. We invite you to check it out and submit your opinion on this topic.

Anne Miller is an associate editor at ADVANCE.