Staying abreast of technological advancements in manufacturing is a daunting task. Over the past years while machine tool capacity has become an issue, management’s first response has likely been to reduce cycle times and/or purchase new machines. For years, the misconception that automation is only for production has persisted. However, for one Indianola, Pennsylvania shop, challenging this notion and taking a look “outside the box” has enabled the company to standardize its fixturing procedures while reducing errors.

Founded in 1964, Medrad Inc. operates according to the slogan “Performance for Life.” The company says its mission is to become a worldwide leader of medical devices and services, to either enable or enhance diagnostic and therapeutic imaging procedures. Daniel Kazousky, Manager of the Rapid Prototyping Center for Medrad, recently faced a serious manufacturing problem–his department needed to increase throughput and improve the overall turnaround time for mold production.

Even though the company employs hundreds of individuals around the world, the Rapid Prototyping Department is no bigger than the average job shop, with a staff of approximately seven to ten individuals. During a typical year, the department produces about 50 injection molds. On the machining side every year, nearly 3,000 new parts are completed for product development. To support the steel inserts and mold plates necessary for manufacturing these parts, the company uses just two machining centers.
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“Although we were producing quality molds in-house faster than could be done if outsourced, we felt internal pressure to operate more effectively by increasing our overall flow of output,” explains Mr. Kazousky. “The urgency we faced involved a bottleneck at the primary point of burning (EDMing) the steel. This was partially the result of our not being able to produce electrodes quickly enough.”

After discussing its options, the company contacted its current EDM supplier to discuss the problem. At first, Medrad contemplated adding another sinker EDM to improve the volume of mold throughput. To the company’s surprise, however, the supplier proposed taking a different route. Suggesting that automation could resolve many of the issues, the supplier referred Medrad to a local representative for Erowa Technology (Arlington Heights, Illinois).

Mr. Kazousky says he was shocked to learn that purchasing an additional sinker EDM and/or milling center was, albeit an obvious solution, not the best option in terms of the overall production problem “My first thought was that automation would be far too costly for an organization our size,” he says. “We were just a small job shop tackling one and two jobs at a time.”

Putting his skepticism aside, Mr. Kazousky called Erowa Technology to investigate the process. By his own admission, Mr. Kazousky had previously been “in the dark” about what automation actually entailed. His rationale was that there was no harm in exploring the viability of the automation packages available. It wasn’t until he spoke with Bob Meyers, Senior Applications Engineer for Erowa Technology that Mr. Kazousky says he realized that automation was attainable for his company and that the entire process could be implemented on the machining centers operating within the prototyping department.

“Some are afraid that automation will eliminate jobs in the plant,” states Mr. Meyers. “By adding automation to your machining centers, however, you can use your machines, work space and employees more efficiently. In addition, companies can improve production output and quality.

“It should never be the reason employees lose their jobs,” he adds.

In addition to working with Mr. Meyers, the company consulted Tom Watkins, Erowa’s Vice President of Engineering. Together, the two examined the applications being performed by Medrad, and then they collaborated to pinpoint the appropriate package.

Mr. Meyers had to take into account the characteristics of the part being produced; more specifically, size, weight and average cycle time to make the part before selecting a package. The team also needed to understand exactly how much time the machine would run unattended. Thereafter, Erowa made some specific calculations regarding the storage capacity in various robots to decide which would be the best fit for Medrad.

“We didn’t want to short-change the customer by suggesting only the purchase of electrode tooling to reduce setup time,” says Mr. Watkins. “At the same time, we only wanted to present an automation solution that was absolutely essential for improved efficiency and output.”

What followed was the purchase of Erowa’s Robot Multi and the EasyChange Robot and ITS palletizing system. The ITS Zero Point palletizing system uses a chuck operating on a principle that allows the company to standardize its fixturing procedures. It holds both electrodes and workpieces with equal precision and with a high degree of repeatability, says the manufacturer. Appropriate for numerous applications, it is the basis for a modular tooling system. Able to be integrated on milling, grinding and drilling machines, on EDM sinking and WEDM centers or on measuring and presetting stations, ITS assists the company in achieving a more profitable use of production time.

This study used a sample of 209 repeat-respondent medical technologists over a 4-year period to investigate correlates of intent to leave one’s job. Correlates measured included two job search behaviors (i.e., preparatory and active) and three job search motives (i.e., gain leverage, leave employer, and family related). Results showed that active job search and the leave employer job search motives were each positively related to final intent to leave one’s job. The gain leverage job search motive was negatively related to final intent to leave one’s job. In addition, job satisfaction was negatively related, while only initial job loss insecurity was positively related, to final intent to leave one’s job. J Allied Health 2006; 35:94-100.

JOB SEARCH remains an important applied topic and research area for study across different samples, for example, graduating students entering the job market,1,2 the unemployed,3-5 and the employed.6-8 Job search is also a topic of international interest.4,9-11 Recent research on further understanding job search has focused on personality-motivation and cognitive ability variables,7 including a meta-analysis by Kanfer et al.12 The dominant research samples captured in the meta-analysis by Kanfer et al. were individuals entering the job market following a period of full-time education or those who were unemployed. Boudreau et al.7 argued for focusing more job search research on those currently employed because they compose a larger domain. There is a current general shortage of health care employees in the United States, including nursing, radiologic technology, and medical technology employees.13-15 Any type of labor shortage in a particular occupation can make it easier for those currently employed to change jobs across organizations.16 The purpose of this study was to further investigate the impact of correlates on medical technologists’ intent to leave their jobs.
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Why Do the Employed Job Search? Different Motives

Using a sample of higher-level managers, Boswell et al.6 distinguished between specific leverage-seeking versus separation-seeking job search motives or objectives. They found that leverage-seeking but not separation-seeking search was positively associated with actual use of leverage one year later, while separation-seeking but not leverage-seeking search was positively associated with voluntary turnover one year later.

Bretz et al.17 observed that because job search activity may not always be associated with separation, there can be greater observed variance in search behavior than turnover. Using a sample of 1,388 employed managers, Bretz et al.17 found that a considerable amount of managers’ job search activity did not lead to subsequent voluntary turnover. Whether it leads to voluntary turnover or not, job search by itself can be a costly behavior because it can distract an employee from his or her current job duties18 or reduce the employee’s commitment to his or her current employer.19

Beyond its relevance to voluntary turnover, research has suggested that job search can serve several other distinct purposes for the employed.17 A second “motive” suggested for job search is to increase one’s leverage or advantage in a current job,20 such as gaining higher pay or other improved employment conditions. Clearly this motive is related to at least some degree of employee unhappiness with the current job situation. However, this motive suggests that employees do not necessarily want to leave their employer but to improve their situation (e.g., pay, promotion) while remaining with their current employer.21 Deshpande and Schoderbek22 found that getting a job offer elsewhere was used by subordinates to get a pay raise from their current boss. There can be “other” motives for job search, such as family related. For example, if one’s working spouse is transferred, the affected individual must now find a new job in the working spouse’s new location. Another family-related reason for job search is if an employee moves to be closer to an elderly parent to help care for that parent.16

Job Search Activity

For an individual who voluntarily changes jobs, most prior turnover research suggests that the closest proximal determinant to such change is the intent to leave that job.”16,23 Prior theory on job search activity suggests distinct preparatory and active search phases (Rees24 and Soelberg,25 as noted by Power and Aldag26). During the preparatory phase, individuals gather their resources (e.g., prepare/revise their resume, research getting/changing jobs) and collect potential job leads through various sources (e.g., Internet, newspaper, friends, previous employers); in the active phase, individuals apply to specific job positions/employers they have identified (e.g., sending a resume to or interviewing with an employer, filling out a job application). Generally, it is assumed that preparatory job search precedes active job search, because often individuals will want to first determine the perceived availability of “greener pastures” (preparatory job search) before determining their accessibility,27 which involves active job search.

This study used a sample of 209 repeat-respondent medical technologists over a 4-year period to investigate correlates of intent to leave one’s job. Correlates measured included two job search behaviors (i.e., preparatory and active) and three job search motives (i.e., gain leverage, leave employer, and family related). Results showed that active job search and the leave employer job search motives were each positively related to final intent to leave one’s job. The gain leverage job search motive was negatively related to final intent to leave one’s job. In addition, job satisfaction was negatively related, while only initial job loss insecurity was positively related, to final intent to leave one’s job. J Allied Health 2006; 35:94-100.

JOB SEARCH remains an important applied topic and research area for study across different samples, for example, graduating students entering the job market,1,2 the unemployed,3-5 and the employed.6-8 Job search is also a topic of international interest.4,9-11 Recent research on further understanding job search has focused on personality-motivation and cognitive ability variables,7 including a meta-analysis by Kanfer et al.12 The dominant research samples captured in the meta-analysis by Kanfer et al. were individuals entering the job market following a period of full-time education or those who were unemployed. Boudreau et al.7 argued for focusing more job search research on those currently employed because they compose a larger domain. There is a current general shortage of health care employees in the United States, including nursing, radiologic technology, and medical technology employees.13-15 Any type of labor shortage in a particular occupation can make it easier for those currently employed to change jobs across organizations.16 The purpose of this study was to further investigate the impact of correlates on medical technologists’ intent to leave their jobs.
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Why Do the Employed Job Search? Different Motives

Using a sample of higher-level managers, Boswell et al.6 distinguished between specific leverage-seeking versus separation-seeking job search motives or objectives. They found that leverage-seeking but not separation-seeking search was positively associated with actual use of leverage one year later, while separation-seeking but not leverage-seeking search was positively associated with voluntary turnover one year later.

Bretz et al.17 observed that because job search activity may not always be associated with separation, there can be greater observed variance in search behavior than turnover. Using a sample of 1,388 employed managers, Bretz et al.17 found that a considerable amount of managers’ job search activity did not lead to subsequent voluntary turnover. Whether it leads to voluntary turnover or not, job search by itself can be a costly behavior because it can distract an employee from his or her current job duties18 or reduce the employee’s commitment to his or her current employer.19

Beyond its relevance to voluntary turnover, research has suggested that job search can serve several other distinct purposes for the employed.17 A second “motive” suggested for job search is to increase one’s leverage or advantage in a current job,20 such as gaining higher pay or other improved employment conditions. Clearly this motive is related to at least some degree of employee unhappiness with the current job situation. However, this motive suggests that employees do not necessarily want to leave their employer but to improve their situation (e.g., pay, promotion) while remaining with their current employer.21 Deshpande and Schoderbek22 found that getting a job offer elsewhere was used by subordinates to get a pay raise from their current boss. There can be “other” motives for job search, such as family related. For example, if one’s working spouse is transferred, the affected individual must now find a new job in the working spouse’s new location. Another family-related reason for job search is if an employee moves to be closer to an elderly parent to help care for that parent.16

Job Search Activity

For an individual who voluntarily changes jobs, most prior turnover research suggests that the closest proximal determinant to such change is the intent to leave that job.”16,23 Prior theory on job search activity suggests distinct preparatory and active search phases (Rees24 and Soelberg,25 as noted by Power and Aldag26). During the preparatory phase, individuals gather their resources (e.g., prepare/revise their resume, research getting/changing jobs) and collect potential job leads through various sources (e.g., Internet, newspaper, friends, previous employers); in the active phase, individuals apply to specific job positions/employers they have identified (e.g., sending a resume to or interviewing with an employer, filling out a job application). Generally, it is assumed that preparatory job search precedes active job search, because often individuals will want to first determine the perceived availability of “greener pastures” (preparatory job search) before determining their accessibility,27 which involves active job search.

Summary points

Several websites provide information for geneticists on genetic disease, genetic services, and professional training

Two UK sites act as gateways to information on specific diseases and support groups, suitable for patients and their carers

Public health professionals and policymakers are well served by sites maintained by the Department of Health and the NHS

Good web based information on genetics for general practitioners and non-geneticist clinicians is lacking

Ethical, legal, and social issues in genetics are covered in sites maintained by national and international regulatory bodies in bioethics

Health professionals, patients, and the general public need authoritative, up to date information on genetics to enable them to understand and apply advances in this discipline. The immediacy and accessibility of the world wide web make it the perfect vehicle for this information. Identifying high quality, resources tailored to the requirements of particular users among the vast number of sites is not easy. We have compiled a list of useful web resources from the perspective of users based in the United Kingdom.

Methods

We selected sites on the basis of those used most often by our colleagues in different specialist areas of genetics. This article represents a consensus of their views. Sites are grouped by their major user communities; there is overlap, but the contents of the site give a good indication of those with wider relevance. We have also included both national and international online resources for bioethics.

Sites for genetics professionals

OMIM–Online Mendelian Inheritance in Man (www.ncbi.nlm.nih.gov/Omim/) is the “Bible” for all geneticists. The site contains constantly updated information on over 12 000 genetic diseases, their symptoms, inheritance patterns, and associated genetic loci (where known). It is easy to search and is now linked to the National Center for Biotechnology Information’s “Entrez” system, so that it can be queried in the same way as other resources such as PubMed and GenBank.

The British Society for Human Genetics (www.bshg. org.uk) is a federation of professional associations representing genetics professionals. Its site includes information about training and accreditation in genetics, regional genetic centres, and the society’s policy statements. It also hosts the minutes of the joint committee on medical genetics, the profession’s main advisory body to the government and other organisations.

The Clinical Molecular Genetics Society (www. leeds.ac.uk/cmgs) provides a useful compendium of practical information. The site includes a searchable list of DNA tests offered by NHS based laboratories (and a link to the European directory of DNA laboratories), best practice guidelines for DNA tests for several different genetic diseases, and information on jobs and accreditation.

The European Society of Human Genetics (www.eshg. org) is an international professional association. Its well organised and frequently updated site includes information about courses and conferences, a page of links, and the policy documents formulated by the society’s professional and public policy committee.

The human gene mutation database (archive. uwcm.ac.uk/uwcm/mg/hgmd0.html) is a comprehensive international database of genetic lesions that cause disease. It is regularly updated and may be searched by disease, gene name, or identifiers used by OMIM.

The familial cancer database (facd.uicc.org/) offers free software for downloading, which is designed to aid in the differential diagnosis of familial cancer. Registration is required.

Sites for other doctors and other primary care professionals

We could find no single site with comprehensive coverage of genetics topics of interest to professionals in primary care. A promising development is the planned addition of a “virtual genetics group” to the Royal College of General Practitioners clinical and special projects network. Its web page should be operational later this year (www.rcgp.org.uk/rcgp/ clinspec/index.asp).

The South West Thames Regional Genetics Service (www.genetics-swt.org/main.htm) operates from St George’s Hospital Medical School in London. The site contains information on local services. The “GP forum” pages contain brief notes about topics such as taking a family history, inheritance patterns for single gene disorders, and familial cancers.

Two sites based in the United States offer courses on genetics for doctors that can be downloaded. Although they are tailored for American users, they are a useful resource for organisers of training courses for general practitioners and for doctors with a special interest in genetics.

Genetics and your practice (mchneighborhood. ichp.edu/wagenetics/906317226.html) is produced by the Washington State Department of Health. The course was last updated in August 2000.

Clinical genetics: a self-study guide for health care providers (med.usd.edu/som/genetics/curriculum/ Handspic.html) is produced by the University of South Dakota Medical School. The course is not dated.

Sites for patients, families, and carers

Those affected by genetic diseases need information about their disease and its inheritance, advice on management, and how to find both knowledgeable clinicians and other affected families for support. For many affected families in the United Kingdom there are good local resources, but those with extremely rare diseases may need a larger resource such as the American based Genetic Alliance website (www. geneticalliance.org).

The Genetic Interest Group (www.gig.org.uk/) represents over 120 different support groups for families affected by genetic diseases. Its site contains basic information about inherited diseases and a list of member groups, many of which have their own websites (of these, the Tuberous Sclerosis Association (www.tuberous-sclerosis.org) has recently set up an online chat room for siblings of children with any genetic disorder (www.sibspace.org/)). The Genetic Interest Group is also active in policy development, and its papers can be downloaded as pdf files.

Contact a family (www.cafamily.org.uk/) provides support and advice to families caring for children with severe disabilities, many of which are genetic in origin. The site contains a searchable directory of conditions. Basic clinical information on each condition is provided by a named medical specialist, and this is dated. The site also includes contact details for support organisations and information about their activities.

The Cancer Research Campaign (www.crc.org.uk) provides a good summary of familial cancer (www.crc.org.uk/cancer/Aboutcan_fam1.html/). This page outlines the types of family history that indicate a high risk of breast, ovarian, or bowel cancer and explains genetic testing in families at high risk.

Sites for public health professionals and policymakers

The Department of Health has a genetics page (www.doh.gov.uk/genetics.htm) that links to all the major genetics advisory groups (Human Genetics Commission, Genetics and Insurance Committee, Gene Therapy Advisory Committee) and to the online text of policy and consultation documents.

The Human Genetics Commission (www.hgc.gov.uk/) is the major advisory body on genetics to the government. Its views and recommendations are not yet represented on the site in a systematic, subject based way, but those with sufficient interest can glean a great deal from the published minutes of its plenary and subcommittee meetings. Information about the commission’s public meetings and consultations are also posted on the site.

The Public Health Genetics Unit (www.medinfo. cam.ac.uk/phgu/) provides regularly updated information on the regulatory framework and policy development for genetics and the policy implications of ethical, legal, and social issues in genetics. A set of “disease profiles” outlines the genetic basis of nine diseases of importance to public health. The monthly newsletter highlights news, events, and papers of interest in the literature.

The Office of Genetics and Disease Prevention, US Centers for Disease Control and Prevention (www.cdc.gov/ genetics/) is the pioneer in the field of public health genetics. Its site features papers and policy documents on public health aspects of genetics, links to the human genome epidemiology net, and a listing of news stories, new papers, and events that is updated weekly.

HumGen (www.humgen.umontreal.ca/en/) was developed at the Centre de Recherche en Droit Public at the University of Montreal. Its three modules offer a searchable international database of policy documents in genetics, a monthly news update, and a searchable listing of organisations involved in developing genetics policy.

With keen listening skills and fast typing ability, these transcriptionists use their training to document medical histories.

“The patient had discomfort anterior to the lateral malleolus. Talar tilt negative. Drawer sign negative.”

What does that mean? Medical transcriptionists know. And because of transcriptionists’ work, the fact that the patient’s sore ankle passed two tests for stability becomes part of his or her recorded medical history.

Medical transcriptionists are experts in the language of medicine. They turn healthcare providers’ spoken notes into well-edited, typed reports. They can recognize–and spell–the names of bones, muscles, procedures, and prescriptions. Their efforts ensure that doctors and other healthcare workers have accurate information about patients.

The chance to learn about medicine is one reason some people are attracted to this occupation. Ample job openings, flexible schedules, relatively short education requirements, and opportunities for home-based work are other draws. On the following pages, you’ll learn what medical transcriptionists do and what their working conditions, earnings, employment prospects, and training requirements are.

Dictation into document

Medical transcriptionists type voice recordings made by physicians or other healthcare professionals into medical reports and correspondence. The documents that transcriptionists produce include discharge summaries, physical examination reports, patients’ history reports, operating room reports, consultation notes, diagnostic imaging studies, autopsy reports, and referral letters.

Transcriptionists usually listen to recordings on a special headset, using a foot pedal to pause the recording when desired. As they listen, they type the text using word processing software. Then, they organize the material into a set format and return transcribed documents to the dictator for review and signature or correction. Finished documents become part of patients’ permanent medical files.

It takes more than careful listening and fast typing to transcribe medical records, though. Medical transcriptionists use their understanding of medical terminology, anatomy and physiology, diagnostic procedures, and treatment to create accurate reports. For example, the medical terms “ilium” and “ileum” sound the same on a recording, but a transcriptionist knows which is correct in a given context: “ilium” refers to a bone in the hip, and “ileum” is part of the small intestine.

Some people confuse the work of medical transcriptionists with that of another transcribing occupation, court reporter. Both occupations listen to speech and type it on a word processor. But while court reporters use a special typewriter to record verbatim reports of legal proceedings, medical transcriptionists are more concerned with the speaker’s meaning than with his or her exact words.

As they work, transcriptionists translate medical abbreviations and jargon into their expanded forms so that records are easy to understand. They check the spelling and meaning of these terms by consulting standard medical reference materials, both printed and electronic.

Experienced medical transcriptionists spot inconsistencies or mistakes, such as misspoken prescriptions, in a medical report and verify the correct information with the dictator. Transcriptionists’ ability to understand and correctly transcribe patient assessments and treatments reduces the chance that patients will receive ineffective or harmful care.

The emergence of speech recognition technology, which translates sound into text automatically and creates draft reports, has allowed some medical transcriptionists to spend less time typing and more time editing for accuracy and clarity. Transcriptionists format draft reports; edit them for mistakes in translation, punctuation, and grammar; and check for possible errors by the speaker. In specialized areas with more common terminology, such as radiology or pathology, transcriptionists are more likely to encounter speech recognition systems. However, use of these systems will become increasingly widespread as the technology becomes more sophisticated.

Medical transcriptionists are careful when transmitting storing the medical records they create. They keep records confidential by following strict legal and ethical guidelines. As more transcriptionists use the Internet and intranets to transmit records, new security procedures are being implemented. Using the Internet to send records will become widespread only when the technology becomes more secure.

Medical transcriptionists who work in physicians’ offices and clinics may have nonrecordmaking duties, such as scheduling appointments, answering the telephone, and handling mail.

Worklife at the keyboard

Most medical transcriptionists work in comfortable office settings. About 40 percent worked in hospitals in 1999 and another 40 percent in physicians’ offices and clinics. Others worked in laboratories, colleges and universities, transcription service offices, and personnel supply services agencies. An increasing number of medical transcriptionists work from home, either as subcontractors for hospitals and transcription services or as independent contractors.

Many medical transcriptionists work a conventional 40-hour week. But many others work irregular schedules, including part-time, weekend, evening, or on-call hours. Self-employed and home-based workers are most likely to have irregular hours and flexible schedules. However, self-employed transcriptionists usually receive no benefits and face a higher risk of job loss than other transcriptionists do.

Working in this occupation presents few hazards. But sitting in the same position for long periods can be tiring, and workers can suffer strains resulting in wrist, back, neck, or eye problems. Transcriptionists also risk repetitive motion injuries, such as carpal tunnel syndrome.

Transcriptionists must meet tight deadlines. And sometimes, their earnings depend on how fast they transcribe. This pressure to work accurately and quickly can be stressful and wearing. But for some, working fast is a job benefit: transcriptionists often say they enjoy the quick, steady pace of their work.

Medical transcriptionists also like seeing tangible results of their efforts. And inquisitive transcriptionists enjoy satisfying their curiosity as they track down the meanings and spellings of the latest treatments.

Earnings for recordmakers

Medical transcriptionists had median hourly wages of $11.67 in 1999. The middle 50 percent earned between $9.70 and $13.54, the lowest paid 10 percent earned less than $8.38, and the highest paid 10 percent earned more than $16.17.

Compensation for medical transcriptionists varies. Some are paid by the hour for their work. Others are paid based on the number of standardized, 65-character lines they transcribe. Large hospitals and healthcare organizations usually prefer to pay transcriptionists by the hour. Most independent contractors and employees of transcription services receive line-based pay. Employers sometimes combine the two methods, paying a base hourly fee and giving bonuses for extra production.

According to a 1999 study conducted by Hay Management Consultants for the American Association for Medical Transcription, entry-level medical transcriptionists had median hourly earnings of $10.32. The most experienced transcriptionists had median hourly earnings of $13. Earnings were highest in organizations employing 1,000 or more workers. Transcriptionists receiving production-based pay earned about 7 to 9 cents per standardized line. Independent contractors, who have higher expenses than their corporate counterparts, typically charge about 12 to 13 cents per standardized line.

Transcription prediction: Job growth

Medical transcriptionists held about 97,260 wage and salary jobs in 1999. Many others were self employed. And employment of medical transcriptionists is projected to grow rapidly through 2008, with demand spurred by a growing and aging population. Older age groups receive proportionately greater numbers of medical tests, treatments, and procedures that require documentation.

A high demand for transcription services also will be sustained by the continued need for the electronic documentation that transcriptionists provide. This documentation is shared easily among providers, third-party payors, regulators, and patients.

Because medical transcriptionists will still be needed to review and edit drafts for accuracy, advancements in speech recognition technology are not expected to significantly reduce the need for these workers. Despite advances in this technology, the software is not yet sophisticated enough to grasp and analyze the complexities of voice and the English language. Skilled medical transcriptionists still will be needed to identify and fix errors created by speech recognition systems and to create final documents.

Speech recognition has been a positive force in improving the efficiency of clinical documentation in limited practice areas like radiology. Giga Information Group projects the speech recognition software market is expected to grow from $100 million in 2000 to $2.5 billion by 2005, with healthcare representing a significant piece of the pie.

As speech systems begin to spread slowly across the healthcare enterprise, a major opportunity exists to extend the technology for the benefit of the other key stakeholder in this productivity equation: transcriptionists.

Due to the continuing shortage of transcriptionists, cost concerns and the persistent increase in amounts of documentation required, pressure is intensifying to limit or even eliminate the use of transcriptionists. Giga estimates that hospitals spend $1,200 or more per month per physician on transcription, and the American Association for Medical Transcription estimates that $20 billion is spent annually on medical transcription services.

In cases when a physician’s encounter with the patient is especially brief or routine, it may be viable to reduce reliance on transcriptionists. Speech recognition, combined with enhancements like templates, structured notes, menu-driven forms and other tools, will allow physicians to complete reports with just a few utterances and a couple of taps of the stylus on a PDA, thus bypassing transcription altogether. At least, that’s the vision.

As the volume of reports continues to climb, hospitals will strive to keep transcription costs low, typically by deploying productivity-enhancing transcription platforms, employing techniques such as incentive pay for transcriptionists–directly or through outsourcing–and enabling transcriptionists to work from home.

Another approach worth exploring is to leverage speech technology for transcriptionists, thus increasing their productivity. By extending the reach of speech technology into the business process of transcription, hospitals can further streamline transcription workflow–after some change in user behavior–advance patient care through improved report turnaround, and impact the payment cycle by facilitating timely coding and increasing free cash flow.

This perspective of clinical documentation is becoming more common, as budget-conscious hospitals replace aging stand-alone dictation systems with integrated solutions designed to increase efficiency throughout the entire clinical documentation lifecycle.

Speech Recognition Innovations

Speech recognition has come in two approaches: front-end, in which the physician directly sees the recognized text on a PC, and back-end, in which the system completes speech recognition and sends recognized text together with the original voice file to an editor for corrections.

With front-end systems, users need to adjust their normal dictation pattern to optimize for higher recognition accuracy. As users dictate, they can view and edit the document as it appears.

Several factors have enabled front-end systems to gain a foothold in radiology. Since radiologists use a relatively small vocabulary of about 50,000 words, the burden to correct and train front-end speech systems for radiology is less. This, in turn, limits the amount of mistakes generated with each report and minimizes disruption to workflow. Radiologists also generate large amounts of dictation per physician, thus providing an easy return on investment (ROI) justification for the dollars spent in acquiring the technology–typically from $5,000 to $10,000 per license.

This environment has not been without challenges. Most physicians are not inclined to devote the hours necessary to train and customize the system to recognize and interpret voices to the necessary level of accuracy. This is understandable, given the rigorous deadline pressures and powerful financial drivers that radiologists have to contend with to maintain a high throughput of reports. Besides the high licensing fee, the software has to be integrated with a hospital’s ADT feed and a document management system, and customized to include hospital-specific voice-activated templates, physician-specific normals (preset blocks of formatted text for repetitive dictations) and physician training. Many hospitals concerned with near-term ROI and changes in physician behavior have stayed on the sidelines.

Since cost and workflow issues block wider acceptance of front-end speech systems, a different approach has emerged: back-end speech recognition. With back-end systems, users dictate at their normal pace into a phone, PC microphone or handheld device; the text is generated behind the scenes on the “back end.” Once dictation is completed, the voice file is processed by the system’s speech recognition engine to generate a text file that the medical editor or transcriptionist edits.

The key advantage to back-end systems is that they allow users to maintain their customary workflow without changing their dictation pattern to accommodate the technology. Physicians can go back to seeing patients without diverting time to clean up dictations. Meanwhile, the speech engine will compare the original text against the edited version provided by the transcriptionist and “remember” the corrections, thus improving recognition accuracy over time.

Recent Changes in Technology

Just as the first iterations of speech recognition technology were designed to make document generation more cost-efficient, so, too, have recent improvements in the technology:

* the integration of comprehensive vocabulary sets for various healthcare specialties;

* more sophisticated engines that can compensate for dead air or distinguish between ambient sounds and voices;

* the incorporation of structured text and templates for documents; and

* the ability to accommodate more input devices.

While the emphasis of back-end speech recognition technologies has been not to alter physician behavior, transcriptionists have had to adapt. The more than 200,000 transcriptionists in the U.S. have trained themselves, over many years, to listen to dictation through their ears and type using their fingers. The back-end speech recognition paradigm requires them to listen to the dictation through their ears, watch recognized text through their eyes and type corrections using their fingers.

Furthermore. there is no integration of process or technology to aid transcriptionists as they toggle back and forth between text files that are generated by speech recognition systems and recordings produced by traditional phone-based dictation.

Improving Workflow

A number of technology improvements hold the potential to allow transcriptionists to reap the benefits of speech technology, while easing the transition from transcriptionist to editor:

Voice and text bookmarking. Bookmarking speech recognition-generated text to match corresponding sections of dictation adds an extra measure of efficiency to the editor’s workflow. An editor now can edit a particular part of the document and hear the corresponding dictation without searching for it using a foot pedal.

Highlighting low-recognition-confidence sections. By presenting editors with multimedia documents that automatically highlight the sections of documents that have a level of recognition confidence below a certain predetermined percentage, editors can directly transcribe such sections without changing their behavior, while accepting the rest of the recognized document as is.

IP telephony. As hospitals upgrade their voice infrastructure to adopt IP telephones such as the Cisco 7900 series, voice can be captured at a higher quality (16-KHz, 16-bit samples, instead of 8-KHz, 8-bit samples with current telephony technology), resulting in improved accuracy for speech recognition with no change in physician behavior. This would also reduce the editing load for transcriptionists.

Saving the original. Storing the original dictated voice as part of the electronic medical record (indexed by all the same metainformation as the text report) is another way healthcare organizations are gaining more and more comfort with speech-recognized documents. It is going to become mandatory that the electronic chart of the future is a multimedia document, not just a replacement of current paper-based information.

Building in productivity tools like dictionaries, normals and word expanders tied to specialty disciplines, which automatically offer to insert a complete word when the first few letters of it are typed, also enhances efficiency.

Of course, transcriptionists will have to adapt their habits to work with reports generated by speech recognition. Changing a deeply ingrained behavior and then ramping up a new behavior to a productive level will be a critical step for transcriptionists to thrive in the new document-creation paradigm.

While still in the middle of an organizing campaign at Somerset Medical Center in Somerville, New Jersey, the New York State Nurses Association stepped in to defend the rights of RNs laid off through the illegal closing of the hospital’s inpatient psychiatric unit. Somerset administrators suddenly closed the unit on October 24, 2003.

“This unit also happened to employ some of NYSNA’s strongest supporters,” said Marvin Moschel, assistant director for organizing of NYSNA’s Economic & General Welfare Program. “More than a dozen RN jobs were lost, with the administration claiming in a memo to staff that it closed the unit because the census was low and the RNs were providing care that was below par.”

NYSNA contacted the New Jersey Department of Health (DOH). In its initial reply to a DOH inquiry, hospital administrators claimed the unit was still open, but DOH inspectors conducted a surprise visit and found the unit closed. As a result, the New Jersey Health Department charged the medical center with violating state law by closing its psychiatric unit without permission from the state, and without adequate justification, fining the hospital $5,000 a day, retroactive to October.

NYSNA then confirmed through inside sources that the RNs on the psych unit were indeed fired because they were union supporters, and learned that the medical center offered some psych nurses a severance package on the condition that they not speak about the issue. Based on unfair labor practice (ULP) charges by NYSNA, the National Labor Relations Board (NLRB) is investigating the firing of one pro-union nurse leader, as well as the closing of the psychiatric unit. A third charge has been filed over threats by the hospital to fire RNs who vote or campaign to unionize.

NYSNA has also contacted the American Nurses Credentialing Center-the organization that grants magnet status-informing them of these events. In theory, a medical center with magnet status has an ideal work environment for RNs, and an applicant’s history of labor relations is an important factor in granting or withholding magnet status. By filing ULPs with the NLRB, NYSNA has put the magnet designation process on hold.

Meanwhile, the medical center’s physicians have asked for the chief executive officer’s resignation over the closing of the psych unit. “The pressure is really on medical center administration now,” Moschel said. “The RNs are standing up for themselves, letting them know that there must be improvements in working conditions and that this must happen through collective bargaining.”

ENDICOTT - ENSCO, Inc. and Endicott Interconnect will manufacture a baggagescreening machine designed to detect explosives. The venture will add 700 jobs ,over the next four years at Endicott Interconnect. The ENSCO-developed SureScan screening system can check up to 1,000 bags per hour for explosives. Technology-development company ENSCO turned to Endicott Interconnect to manufacture the SureScan machines for a commercial market, says Karen Carpenter, director of marketing and communications for Endicott Interconnect Technologies.

Endicott Interconnect will spend $10 million readying its facility to produce the SureScan, she adds.

Endicott Interconnect is a privately held venture of several partners including the Maines family of Maines Paper and Foods and the Matthews family of electronics maker, the Mateo Group. Local investors purchased the IBM microelectronic division’s assets in 2002 as part of a $100 million venture. The company employs 1,900 and had $200 million in annual revenues for 2003. Endicott Interconnect manufactures electronic components, electromechanical equipment, and other electronics used in the defense, medical, and automotive industries, as well as for other sectors.

The ENSCO manufacturing partnership reflects the change the former IBM operation has undergone since the local owners took control.

“We have gone from a computer-focused [business] to a very diversified company over the past year,” says Carpenter.

The company has customers around the world, she adds. Its facilities cover more than one-million square feet. The SureScan manufacturing venture won’t require the addition of any space, says Carpenter.

ENSCO and Endicott Interconnect will begin testing the SureScan machines at airports in the U.S. and Europe later this year, pending approval of the Transportation Security Administration. After approval and testing, the units will be sold directly to airport-operating authorities around the world.

ENSCO unveiled the latest version of the SureScan this month at the Passenger Terminal Expo trade show in Geneva, Switzerland.

Virginia-based ENSCO, Inc. employs 725 at facilities in Endicott, Melbourne, and Cocoa Beach, Fla. and its field offices in Beijing. The privately held company has annual revenues of $90 million.

The demand for certain health-care workers is growing faster than the supply. There are more people needing more health care, and the numbers will only grow. Nevertheless, the public still expects high-quality care.

Geriatric Care

One of the reasons for the demand for health-care workers is the aging baby boomer generation. As a result, geriatric care (care of the elderly) is one of the areas experiencing rapid growth. High demand in that field is likely to continue over the next 30 years.

Julie Kemp-Havican is a social worker/special needs unit coordinator at the Marquette County Medical Care Facility in Ishpeming, Michigan. “I oversee a 30-bed special needs unit designed for people in the middle stages of Alzheimer’s disease or related dementia,” Kemp-Havican says. “Our goal is to provide a stimulating, homelike environment to individuals who are too confused to live independently, but who are not yet ready for a traditional nursing home.”

Kemp-Havican screens candidates for the unit. Once they are admitted, she evaluates their needs and develops care plans for them. As their disease progresses, she monitors their ongoing eligibility for the unit. “I also train all staff in dementia care skills and supervise the staff and the operation of the unit,” she says.

Her favorite part of the job is the time she spends with residents. The staff involves residents in activities like cooking, arts and crafts, and music. They also spend time reminiscing with residents. “It is truly rewarding because those who you work with and help are very grateful to you,” Kemp-Havican says.

Nursing

The U.S. Department of Labor’s Bureau of Labor Statistics (BLS) says nursing is the largest health-care profession. It is also one of the 10 fields projected to have the most new jobs.

Pam Webb is a registered nurse (R.N.) and also has a certification in infection control (CIC). She is the infection control coordinator at Benefis Healthcare, hospital in Great Falls, Montana. “It’s an art, being a nurse,” Webb says. “It’s using your scientific knowledge and balancing it with your communication and organizational skills.”

Webb earned her bachelor’s degree in nursing from Montana State University. She is now working on a master’s degree in public health from the University of Washington.

She keeps patients healthier by preventing infections. That means keeping patients, employees, and visitors from getting infections that can then spread among patients.

“I make rounds in the hospital, identify patients who have healthcare-associated infections, and I look for trends or patterns of infection,” Webb says. “Prevention efforts are very critical to my daily role, so that our patients have the best possible outcomes.”

There are a wide range of specialties within nursing. Nurses can work in hospitals, doctors’ offices, or other medical settings. They can work with children, the elderly, or patients of all ages.

Webb has worked in many different settings as a nurse. Those areas include coronary care, coronary intensive care, and surgical intensive care. She has also worked as a traveling nurse in hospitals around the country.

Webb says that her love of science helped her choose to go into nursing. She also enjoys using her communication and people skills in her job. “Nursing as a profession has been the best possible career I ever could have chosen for myself,” says Webb. “I’ve had opportunities presented to me that I never would have had otherwise, in any other profession.”

Dental Care

As people live longer and keep their own teeth longer, the need for dental care workers is rising. Dental hygiene is one of the 30 fastest growing careers, according to the BLS.

“A lot of people think hygiene is just cleaning teeth,” says Angeline Nichols, a dental hygienist in Lima, Ohio. The practice she works in focuses on nonsurgical periodontal (having to do with the tissue and structures that support the teeth) therapy, a fairly new area of treatment.

“We have an instrument called a probe, and we measure the space in between where the gums attach to the teeth,” explains Nichols. “Once that space gets deeper, the bacteria get down [into it] and will start to destroy the bone, so a lot of our adult therapy is getting under the gums and keeping the teeth clean there. It’s trying to keep patients’ oral health without surgery, because it can get bad enough that they need gum surgery or bone grafting.”

Dental hygienists are only required to have an associate’s degree. However, Nichols suggests getting a bachelor’s degree to allow career growth, including the option of teaching.

Nichols enjoys feeling that her work makes a difference. “I think we’re changing the way young adults and middle-aged adults feel about keeping their teeth,” she says. She explains that while older people accept dentures as a normal part of aging, today’s middle-aged population is learning that they can keep their teeth for a lifetime.

Physical Therapy

Physical therapists are also in high demand. They help people recover from injury or illness. The need for their services is higher among older patients, whose numbers are growing as the population ages.

Penny Reid, a registered physical therapist, works at St. Luke’s Rehabilitation Institute in Spokane, Washington. She treats patients with spinal cord injuries or orthopedic problems. Many people get outpatient physical therapy, but Reid’s clients are inpatients at St. Luke’s.

She spends six to seven hours a day in direct patient care. That includes helping patients with exercise programs and other therapy. The rest of her time is spent on tasks like paperwork and staff meetings. She also supervises physical therapy students working as interns at St. Luke’s.

Patient care is her favorite part of the job. “I wanted to work in a medical field, and chose not to go into nursing,” Reid says. “I enjoy the patient interaction. It’s very rewarding to help people in a tangible way to get back into living their lives.” She also says that the career pays well, and offers a wide range of job choices.

Reid has a bachelor’s degree in physical therapy, and a master’s in applied behavioral sciences. Currently, a career in physical therapy requires only a bachelor’s degree. However, Reid says that is changing. “Most educational programs now graduate their students with a master’s in physical therapy, and many are moving toward a doctor of physical therapy (DPT),” says Reid. “In the next several years, all new graduates will likely have a DPT at the time they enter the workforce.”

IS HEALTH CARE THE FIELD FOR YOU?

Are you wondering if a job in the Health Science Career Cluster is right for you? If you can check off most or all of these items, it may be! (Some items apply to health care in general, while others are more career-specific.)

* I am interested in the sciences, such as biology.

* I enjoy working with people.

* I show respect for people of all ages, backgrounds, and conditions.

* I am strong enough to lift and support patients.

* I am nurturing and compassionate. am patient

* I have strong observation and analytical skills.

* I am able to communicate my findings and recommendations.

Hot Jobs in HEALTH CARE

MEDICAL STAFF ROOTS date back to initial quality improvement efforts of physician leaders such as Ernest A. Codman, a surgeon who led in the initiation of review of the quality of surgical care in the early 1900’s.

Paul Starr noted in The Social Transformation of American Medicine (1) that the American College of Surgeons first took a formalized approach to hospital surgical review in 1919, establishing a voluntary standard that ACS-approved hospitals must affiliate physicians into a “definite medical staff.”

In addition to dealing with the intense financial and competitive elements then dividing organized medicine, the surgeons recognized a need for an organized quality evaluation of surgical services that required a more formal organization of surgeons at hospitals.

These concepts matured to create the Joint Commission on Accreditation of Hospitals (JCAH) in 1951.

The historical development of hospitals from charities sponsored by wealthy patrons to today’s medical centers was not an easy road. Three centers of authority and power emerged:

2. Physicians

3. Executive management

“Instead of a single governing power, three centers of authority are held together in loose alliance,” Starr states. “Hospitals remained incompletely integrated, both as organizations and as a system of organizations–a case of blocked institutional development, a precapitalist institution radically changed in its functions and moral identity but only partially transformed in its organizational structure.”

Medical staff regulation

The initial Standards by the JCAH (now the Joint Commission on Accreditation of Healthcare Organizations, or JCAHO) required accredited hospitals to have organized medical staffs.

The medical staff was responsible for overseeing the clinical practice and quality of care provided by physicians at the hospital. While recognizing the ultimate responsibility for patient care in a hospital is vested in the governing board, a de facto delegation of most of these functions to the medical staff exists in hospitals.

External regulation of hospital medical staff functions was very limited until the advent of the federal government payment programs in the 1960s. Additional regulation stemmed from judicial decisions establishing the doctrine of corporate liability of hospitals for the professional negligence of independently practicing physicians providing care at the hospital.

The Darling v Charleston Memorial Hospital (2) and Johnson v. Misericordia Hospital (3) cases clearly established that hospitals have liability responsibility for patient injuries caused by acts or omissions of physicians on the medical staff.

This responsibility exists even if the physician is not employed by the hospital, but while acting as an independent contractor. Fulfillment of some of the regulatory responsibilities of hospitals is accomplished through the effective performance of an organized medical staff.

In particular, this includes:

* Credentials review

* Appropriate privilege delineation

* Quality of care and risk management activities

As hospital responsibilities increased, the ability to get physicians to perform required medical staff functions diminished.

Physician involvement has been, in effect, quid pro quo. That is, in exchange for the hospital providing the essential professional and technical staff assistance, equipment and supplies to support patient care, physicians are expected and required to provide voluntary services in medical staff leadership, service on committees and departments.

Recent developments

Until the last decade, the quid pro quo approach functioned fairly effectively. Volunteer physician services generally fulfilled the primary functions of a medical staff. These activities included:

* Reviewing physician credentials

* Making recommendations for staff appointment and clinical privileges to the hospital governing body

* Reviewing quality of care in committee and clinical department activities

* Participating in hospital clinical services planning

* Providing continuing medical education

* Participating in the accreditation process and other regulatory compliance

The scene changed dramatically in recent years.

Medical staff leadership activities matured into real jobs requiring special skills. Collaborative medical staff relationships often transformed into competitive camps of physicians with differing allegiances.

Medical staffs of the past were often composed of independently practicing physicians. Today, many hospital medical staffs are a mixture of hospital-employed physicians, physicians providing services under exclusive specialty service agreements and independent physicians.

Pressure to produce strong financial results requires medical staff physicians to devote more time to patient service and less time to medical staff responsibilities. All this reduces physicians’ willingness and ability to provide the volunteer medical staff leadership services required by hospitals.

With more complex medical staff tasks, hospital support staff is now handling functions formerly performed by physicians. In some places, intense differences exist between a hospital’s governing board and executive administration policy direction and the views of physicians on the medical staff. All of this strains the internal working relationships.

The process of selecting leaders sometimes compounds the problems. Elections are most often used to choose medical staff officers. Department chairs are generally appointed or elected by the medical staff. Leadership is usually rotated, resulting in inconsistent quality. It is seldom based on a thoughtful evaluation of the leaders’ competency.

This “sharing of the burden” method can give way to organizational disasters. Many tasks are now managerial and few physicians possess adequate management training. This greatly narrows the pool of competent physician leaders who can handle the tasks.

Minor medical staff organizational changes

In recent years, hospitals and medical staff physicians tried to address these challenges through minor evolutionary changes.

Examples include:

* Lengthening the term of office for the medical staff president (In years past, the chief of staff or staff president often served a one-year term. In most hospitals today, presidents serve multi-year terms following a term as president-elect.)

* Offering formal training for medical staff leaders

* Paying the medical staff leader a stipend to offset income lost because of medical staff duties

* Recognizing a clinical department chair as a management function, appointed by the governing body

* Providing funding and training of medical staff administrators so people with proper skills handle medical staff activities

Even with a mixture of these changes, however, most hospital medical staffs continue to maintain ingrained dysfunctional components. Many physicians view leadership positions as a burden. Physicians who may have the talent for leadership eschew the positions. The pool of available, talented and willing physician leaders in many hospitals has decreased to a critical level.

Even in hospitals with a director of medical staff affairs, it is common for a physician who lacks credibility with medical staff members or lacks the talents and skills necessary to perform the job to fill the position.

Nothing better dramatizes these challenges than situations where a corrective action, or the denial, reduction or termination of a physician’s appointment or privileges at a hospital is taken.

These actions are always difficult. Peer physicians acting in a voluntary capacity possessing little if any training in such matters are often reluctant to undertake adverse action involving a fellow physician even if corrective action is apparent. Hospital medical staff structures often hamper more than help in these cases.

Revolutionary approach to medical staff leadership

It may be time for a more revolutionary approach to medical staff leadership.

Two primary goals of a new structure should be:

1. Centralization of responsibility and authority for medical staff activities in a recruited core group of selected and trained physicians

2. A significant reduction in the total time required of medical staff members performing committee and department functions

Reduced committee time cannot lessen ongoing improvements in the quality of a medical staffs core elements. To the contrary, patient care should measurably improve from the changes or they are not worth undertaking. Core elements include:

* Assurances of quality care

* Participation by physician leaders in the hospital’s policy formulation and strategic planning

* Credentials review and privilege determination

* Appropriate corrective action and assistance in external and internal compliance programs