By Paul Watson
Los Angeles Times
April 19, 2009
Reporting from Manila -- It started out as just another Thanksgiving Day stomachache, a nagging pain that sharpened until it reverberated from California halfway around the world.
When the ache in her lower right abdomen became excruciating, the twentysomething woman was rushed to a surgery center, where the doctor diagnosed a ruptured appendix.
The woman needed an operation -- fast. But before the surgeon could wheel her into the operating theater, he had to find out whether the patient's insurance company would pay. That meant paperwork: An examination report had to be dictated, typed up and submitted to her insurer for approval.
So while the woman waited in agony, her doctor dialed an 800 number. An electronically perky voice invited the surgeon to press 2 if he was ready to start.
The instant he hung up a few minutes later, a digitized recording raced through fiber-optic cables on the Pacific Ocean seabed and into a computer server on the 17th floor of a Manila office tower, where medical school graduate Dinah Barrete was working the graveyard shift.
Ear-bud headphones plugged in, she tapped a pedal to start the doctor's voice file and began typing. Her transcription of his report was on its way to him via the Internet in 15 minutes, as quickly as though the work had been done just down the hall, but much cheaper.
So goes the global traffic in Americans' intimate health information.
In a startling illustration of the life-or-death decisions involving low-paid workers thousands of miles away in today's globalized world, Americans' most personal details move 24 hours a day as U.S. healthcare providers outsource billions of lines of transcription work each year to offices across Asia in a bid to cut the massive cost of medical bureaucracy.
"It's a cyberspace miracle every time it's done," said Fred J. Kumetz, a Beverly Hills lawyer who founded and runs EData Services, one of the biggest companies transcribing U.S. medical records in the Philippines.
From dictated summaries of routine checkups to complete recordings of conversations between surgeons and nurses in operating theaters, the foreign workers are transforming the digital audio files into the documents that tell Americans' medical histories.
Most of the work is done for 10 to 15 cents a line in less than 24 hours. But the cost can be 300 times that for "stat," or immediate, orders, such as when a doctor needs a transcript of an emergency medical team's radio report before its helicopter lands with a patient.
Regardless of the price, the process is largely the same. Audio files dispatched across the Internet are transcribed and the text is fired back to the U.S. to meet government demands for a shift to electronic medical records.
Before broadband connections made it easy to outsource office work in the 1990s, Americans typed out medical records and the cost of healthcare bureaucracy steadily ballooned.
Now thousands of low-paid workers in countries such as India, the Philippines and Pakistan work in offices that never close, churning out massive amounts of U.S. medical records.
Tapping feverishly at keyboards in front of row upon row of computer screens, Asian transcriptionists often strain to understand what American doctors have dictated through phone lines or into digital recorders.
Other typists work under similar pressure to keep up with the demand to transfer decades-old medical documents from paper into computer files to help complete the record-keeping revolution envisaged by President Obama.
A big business
The Philippines hopes to reap big profits from his multibillion-dollar push to computerize health records.
The business of transcribing American medical files employed 34,000 Filipinos and generated $476 million in revenue last year, said Ernesto Herrera, a former senator who heads the Trade Union Congress of the Philippines. He expects the number of transcriptionists to more than triple, and annual billings to jump to more than $1.7 billion, by the end of next year.
"Outsourcing is unavoidable, because the cost in the U.S. is just too high," Herrera said. Filipinos can beat Indians in the race for medical transcription work from the U.S. because, as a former American colony, the Philippines is more familiar with American accents, Herrera said. This country also has a vast pool of jobless medical workers who need little additional training to take dictation from American doctors, he said.
"Right now, we have about 400,000 licensed nurses who are unemployed in the Philippines," Herrera said.
EData's Manila office never closes, and the video camera watching over scores of Filipinos working at computer terminals 24/7 never blinks. It's connected to the Internet so American clients can peep in on the operation whenever they want.
High on one wall, a row of clocks tick off the time in Los Angeles, New York and Denver, as young doctors sit at double-screen computer terminals reviewing Americans' medical insurance claims, performing one of EData's other specialties.
But most of the workers in the long office are typing records from recorded dictation or conversations that constantly stream into the company's computer server. As they listen, transcriptionists pick up hints of how swamped some American doctors are by medical bureaucracy, which follows them everywhere.
"We've had a doctor dictate in a zoo," said Barrete, a transcriptionist and executive vice president with EData. "We could hear the elephant, so where else could she be?"
Transcript editors are usually doctors, who sometimes pick up errors in American physicians' dictation, even what they suspect are misdiagnoses, as they check for typos. Unless clients give permission to correct the mistakes, they stay in the text, usually in italics, to make sure the transcript is verbatim, said Danilo Navarro, executive vice president of Xynet Communication Solutions Inc., which transcribes about 4 million lines of American medical files a month.
The same goes for any cursing, jokes, fishing stories, flirting or the odd "Oops!" that transcriptionists hear in recordings of operating theater chatter, he said.
India takes the largest share of outsourced U.S. medical transcription work. But it faces growing competition from the Philippines, Pakistan and Caribbean countries as American doctors, hospitals and insurers come under increasing pressure to reduce the cost of keeping records.
Jobs for Americans
Outsourcing isn't expected to harm job prospects for American transcriptionists, because there is so much work to be done, said a report by the U.S. Bureau of Labor Statistics. About 101,000 Americans were employed as medical transcriptionists in 2002, according to the bureau. Most were women, many of them working from home. By 2006, the number had dropped to 98,000 as high-speed Internet connections allowed companies to outsource more of the work.
But the bureau estimates that the number of American medical transcriptionists will grow 14% by 2016, faster than the average for other jobs.
The median income for American transcriptionists is $31,250 a year. In the Philippines, a fast one paid by the line can earn about $6,000 annually, or three times a nurse's salary, Herrera said.
The profession's stars earn as much as 300 times the regular rate doing the less frequent, but high-pressure, job of transcribing radio traffic between medevac helicopters and hospitals, Navarro said.
Even if new technology automates more transcription, Navarro said, there is a backlog of about 40 years of American medical files waiting to be typed into computer files, work that could keep legions of foreign workers at keyboards for years.
Paying by ear
His company also trains transcriptionists and turned out 550 graduates last year. Training takes six months to two years, but that's not fast enough for some firms. They are so desperate for staff to handle new American clients that they are poaching their competitors' best workers.
Transcriptionists with the best ear for accents, or different physicians' speaking quirks, are in highest demand, and cause the most disruption when they jump ship. When doctors are difficult to understand, Navarro assigns people to specialize in transcribing them.
For an especially baffling physician's dictation, Navarro has two backup transcriptionists ready in case the lead specialist gets sick.
"Editors normally cannot do miracles," he said. "Whenever the production manager sees a challenging file in the queue, he shouts, 'OK, Rita, clear your desk. Dr. X is coming!'"