Transcription in the Tropics
Palm Trees and Turnaround Times
By Scott Faulkner
For The Record
Vol. 17 No. 21 P. 32
Go inside the Caribbean Community and Common Market, where the medical transcription industry has taken a foothold in recent years.
Business Process Outsourcing (BPO) is the act of choosing a third party to run what is traditionally an internal system or service. In the HIM world, BPO for transcription and/or coding is often viewed as headache management, brought about by chronic labor shortages, avoidance of capital investments for technology, or simply a cost-efficient approach to managing seasonal census shifts. Regardless of the motivation, acceptance of BPO as a viable tool for HIM directors and other healthcare administrators to manage the workload is unequivocally clear.
Most hospitals or clinics looking toward BPO expect to achieve some level of cost savings by managing work through a third party that leverages their economies of scale by doing the same work for many clients. Significant cost savings can also be achieved through lower labor rates in different countries, even though such offshore BPO partnering introduces additional variables that cause buyers to think twice - often for good reason.
When offshoring was in its infancy, failures seemed to outnumber successes. Now, however, many international medical transcription BPO firms are enjoying a new phase of professionalism and respectability. Those who are successful have proven that, if you build and manage the operations and production centers correctly, the market has a place for you.
One of the more comprehensive new transcription BPO efforts to follow this model is presently underway just off the Southern coast of the United States. The Caribbean Community and Common Market (CARICOM) is a group of like-minded, highly industrious countries that include at least two highly effective, well-funded, and expertly engineered transcription industries.
"We are an English-speaking country that inherently comprehends the subtleties of the language. Our primary goal is to create meaningful, long-term employment for hundreds of young, bright, energetic citizens who have shown the acumen and dedication required for medical transcription," says Wendy Fitzwilliam, vice president of business development for e-TecK, a Trinidad and Tobago government-funded incubator for creating new industries. "Through insisting on extremely high quality standards, and in training our MTs [medical transcriptionists] for specific accounts and dictators, Medical Data Caribbean Ltd. [MDCL] is on target to deliver a very significant volume of cost-effective medical documents to the U.S. market, and to scale as required to serve the U.S. client."
For those who may initially envision MTs huddled in grass huts, sharing PCs and creating HIPAA nightmares, think again. The MDCL facility was built from the ground up to rival any facility serving a U.S. hospital information technology (IT) department or transcription firm. A multimillion-dollar facility equipped with diesel back-up generation, redundant Internet carriers, and secure blade-based PC workstations has been empowered by a U.S.-supplied expert training staff and ongoing mentoring program, creating a powerful full production environment under a single roof.
The early offshore efforts in other parts of the globe have proven that on-site training by experienced American industry experts makes the difference. Bob Harvey, president and CEO of Transcription Relief Services, a firm that specializes in providing international training resources-and winner of the coveted 2004 AAMT Employer of the Year Award-explains: "Our company is all about developing gifts in people, wherever they may live, whether that is Spokane, Wash., or Port of Spain. We all know that the United States desperately needs more qualified, quality-conscious MTs, and we see great promise in the people of the CARICOM nations and in other parts of the world for partially filling this void."
From a logistical perspective, a neighbor to the south makes sense. Take world-class infrastructure, a quality-centric training program, all coupled with a location in the Eastern time zone with direct dialing access from the United States, and you have a powerful CARICOM entrance into the transcription market. A three-hour flight from the United States and you can actually visit the people doing the work on your behalf, a key distinction from the far reaches of India or the Philippines.
Another CARICOM member country, Guyana, located on the northern coast of South America, has also found considerable success in the medical transcription industry. "We have seen spectacular improvements in quality from the CARICOM transcription companies over the past two years," says a high-level manager of international transcription operations for a U.S.-based outsource company. "We depend on Guyanese and Trinidadian MTs on a daily basis to produce quality documents for our customers."
Why would a country choose a complex industry like medical transcription? Many of the same market forces affecting other industries are perhaps even more germane to the current globalization of medical transcription: We have a growing demand for medical information, a declining supply of qualified MTs, and a provider market that demands lower costs and faster turnarounds. A better recipe for change could hardly be found. With that said, the resource base of many small nations closely mirrors the requirements for a robust medical transcription enterprise, including a unique combination of medical knowledge, computer skills, and a passion for quality and precision.
Yet it has been anything but easy or simple for smaller nations to enter the medical transcription marketplace. Nearly all transcription initiatives-whether domestic or international-initially underestimate the requirements, interdependencies, and eccentricities of transcription. It is, after all, one of those businesses that has a "zero tolerance" for error: You have to get in all the way or not at all. For developing nations, several barriers to entry exist:
- Infrastructure: Since many developing nations depend largely on manual labor, basic infrastructure requirements such as electricity, water and sewer, and broadband Internet may not be readily available without direct government and regulatory involvement. This, of course, takes time, planning, significant resources, and the ability to manage and execute.
- Capital Expense: Many international pilot projects simply never get off the ground because up-front costs are grossly underestimated. For some, the price of computer systems, an appropriate teaching and management staff, and student recruitment and screening makes it next to impossible to get off the ground.
- Domain Expertise: Developing nations often lack the healthcare expertise required for dealing with the workflow demands and IT environment of U.S. healthcare. Understanding the workflow of ADT, voice conversion, document rendering, and transmission can be tricky business, particularly for countries that do not use such technologies internally.
- Fragmented Growth: Many international medical transcription initiatives make the same mistakes that their American counterparts often make: working on a multitude of platforms for various customers, creating a back-office nightmare, and fragmenting the MT workforce. This makes scaling, and economies of scale, impossible.
- Marketing: Several countries have created respectable programs and expect the phone to ring, pursued by eager customers. Anyone familiar with delivering messages to any segment of the U.S. marketplace knows this will never happen. They lack even the most basic sales and marketing skills for finding customers.
- Platform Deficiencies: Most, if not all, currently marketed platforms for medical transcription have design specifications and requirements that cater to the American customer and reflect a widely available, inexpensive infrastructure. More often than not, developing nations lack the general requirements (such as cheap, widely available broadband connectivity) upon which these platforms were built. The platforms perform poorly or at significantly higher costs than anticipated.
For example, Application Service Provider platform models with thin clients, or those requiring routine server validations, do not work well overseas due to unreliable or inordinately expensive broadband at each workstation.
Some of the most intriguing, pervasive, and, at times, significant challenges are the "people issues" that reflect the cultural differences between the American consumer of medical transcription and the international provider country of those services. Some of these problems, such as the contracted writing of software code in India, are well known in other BPO industries. The lesson? While narrow domain expertise can painstakingly be transferred with careful planning and execution, cultural and religious traits and their associated practices, and the day-to-day pace of life are far more resistant in accommodating the rigors of new industries in many developing nations.
A case in point can be found in several of the CARICOM nations. While the United States is quick to point to its status as a diverse culture, it is in many cases far less so than Suriname, Guyana, Trinidad and Tobago, and many others. Each of these countries has several distinct ethnic and/or religious cultures living and working alongside expatriates and indigenous cultures-and, of course, some lovely mixtures as well. Several of these nations have found a delightful, if not sometimes frustrating, solution for accommodating so many groups: They simply establish scores of national holidays that apply uniformly to all citizens. It is in that way that Muslims "celebrate" Christmas and Christians enjoy time off for Ramadan. Of course, everyone has their own way of participating in Carnival.
Consider the juxtaposition between a "holiday culture" and the 24/7 precision required by a medical transcription customer in the United States and you start to understand the balancing act required by the medical transcription service organization. How can it work? First, by understanding the customer, and then establishing effective feedback mechanisms between the provider client and the international MTs in the trenches. Is it possible to balance the MTs from within the myriad cultures and their incoming workload? With patience and planning, absolutely.
"The market demands consistency in quality and turnaround, and cares nothing for intricacies of the local culture. That is as it should be," says John Melville, general manager of Decipher International, based in Georgetown, Guyana. "While we work to accommodate the needs of the individual MT, [his or her] family, and spiritual responsibilities insofar as we can, we bear in mind at all times that the U.S. market is our customer and, without their happiness, our jobs and indeed our industry could disappear."
As accommodating to the U.S. market as their cultural and religious practices allow, many international firms offer a refreshingly businesslike approach to the industry in general. "We have demonstrated our ability as a nation to meet the demands of other 24/7 industries, such as professional call centers and liquefied natural gas industries," says Fitzwilliam. "Like medical transcription, each of these sectors requires expert logistics, manpower coordination, and a complete understanding of each stakeholders' current and future requirements. Our culture has had to evolve to accommodate the customer."
As e-health initiatives and the digital information explosion continue across the U.S. healthcare landscape, and as each country seeks its place in the medical transcription market, it is important to note that many firms carry no baggage when it comes to pursuing excellence.
"We will follow the market and its needs," Fitzwilliam notes. "We are in a position to adjust our curriculum and production staff quickly to accommodate speech-recognition draft documents, partial dictation fragments from within the EHR [electronic health record] space, whatever we must do to keep ahead of the market need."
Many international transcription firms are actively partnering with American healthcare technology firms to provide needed domain expertise. "We also believe in playing only to our strengths, and have recently established a joint venture in the United States that will allow us to better serve our customers," says Fitzwilliam. "Our partner clearly understands healthcare IT, the market in general, as well as the HIPAA privacy and security rules."
This "outsourcing through outsourcing" approach has a broad appeal across the globe for countries wishing to gain access to what is projected to be a growing $25 billion market. Local stakes could not be higher; as smaller, developing countries observe both the failures and the growth of initiatives in India and the Philippines, they can scarcely avoid the consideration of scale. In a small country, a successful medical transcription industry employing 1,000 or more people can actually change the official government unemployment numbers a full percentage point or more.
It is just in time that these "neighbors" are coming on the scene as the increasing need in healthcare for cost control, rapid turnaround, and a domestic labor shortage continues unabated. Perhaps very soon, some of your documents will be done under the tropical sun. Perhaps some of them already are. - Scott Faulkner is the CEO of InterFix, LLC.
