I though apprencticeship programs were UNIONIZED

I though apprencticeship programs were UNIONIZED [2006-04-07]
I could be wrong here, but all apprentice programs I know of are unionized, such as the Steamfitters, electricians, plumbers, OAW, etc. So, maybe this will open up our field to be unionized and be paid decent wages, such as $23 per hour, etc. Just a thought!

MedQuist Announces Unaudited Financial Results, 6 Million in Operating Loss [2006-05-11]
MT. LAUREL, N.J.--(BUSINESS WIRE)--May 11, 2006--MedQuist Inc. (Pink Sheets: MEDQ.PK) announced today certain preliminary, partial and unaudited financial results, and provided updated information regarding previously-announced litigation and governmental investigations and proceedings. Once the Company completes the financial assessment and review of its billing practices disclosed in the Company's previous filings with the SEC, KPMG LLP, the Company's independent registered public accounting firm, will complete the audit the Company's financial statements. The Company is continuing the process of working toward becoming current in its periodic reports pursuant to the Securities Exchange Act of 1934. The Company's review of its current and prior period unaudited financial statements, as well as KPMG LLP's audits for those periods, may identify adjustments or reclassifications which may be reflected in the periods to which they relate. At this time, the Company cannot estimate the total costs of (i) the billing review, (ii) defense of the class action matters, (iii) the SEC investigation, and (iv) compliance with the Department of Justice investigation, all of which have been previously disclosed in either the Company's filings with the SEC or the Company's press releases. Accordingly, the only costs related to the defense of these matters that have been included in the results below are actual costs incurred through March 31, 2006 by the Company. Because the completion of the billing review and resolution of the litigation and governmental investigatory matters are pending, the Company is not certain whether any changes to the accounting treatment of any component of its consolidated financial statements will be required and, if any changes are necessary, whether any such changes would have a material impact on its current or prior period consolidated financial statements. Accordingly, the financial information set forth below is preliminary, unaudited, and subject to change based on the completion of the financial assessment and review of the Company's billing practices, resolution of the class action matters and governmental investigations and proceedings, and the completion of the review and/or audit of its financial statements, as appropriate. The financial information and related narrative discussion set forth below is derived from the Company's internal books and records. The Company cautions investors not to place undue reliance on the financial information presented below. As a result of the developments described above and in the Company's previous SEC filings, the Company's financial statements have not been audited or reviewed by KPMG LLP, its independent registered public accounting firm. The financial information contained in this press release also has not been audited or reviewed by an independent registered public accounting firm. Such information is not a substitute for the information required to be reported in the Company's Forms 10-K and Forms 10-Q that have not yet been filed. There can be no assurance that the results of the billing review, and resolution of the litigation and governmental investigatory matters will not have a material adverse effect on the Company's revenue, results of operations and financial condition. Legal Proceedings Investigations and Proceedings Commenced by the SEC and the Department of Justice As previously announced, the Securities and Exchange Commission (the SEC) is currently conducting a formal investigation of the Company. The Company will continue to fully cooperate with the SEC. As previously announced, the Company received an administrative HIPAA subpoena for documents from the United States Attorney's Office for the District of Massachusetts on December 17, 2004. The subpoena sought information primarily about the Company's provision of medical transcription services to governmental and non-governmental customers. The information was requested in connection with a government investigation into whether Medquist and others violated federal laws in connection with the provision of medical transcription services. MedQuist continues to cooperate fully with the Department of Justice. Shareholder Securities Litigation As previously announced, a shareholder putative class action lawsuit was filed against the Company in the United States District Court District of New Jersey on November 8, 2004. The action, entitled William Steiner v. MedQuist, Inc., et al., Case No. 1:04-cv-05487-FLW (the Shareholder Putative Action), was filed against the Company and certain former Company officials, purportedly on behalf of an alleged class of all persons who purchased MedQuist common stock during the period from April 23, 2002 through November 2, 2004, inclusive (the Class Period). The complaint specifically alleged that defendants violated federal securities laws by purportedly issuing a series of false and misleading statements to the market throughout the Class Period, which statements allegedly had the effect of artificially inflating the market price of the Company's securities. The complaint asserts claims under Section 10(b) and 20(a) of the Securities Exchange Act of 1934 and Rule 10b-5, thereunder. Named as defendants, in addition to the Company, were its former president and chief executive officer and its former executive vice president and chief financial officer. On August 16, 2005, a First Amended Complaint in the Shareholder Putative Class Action was filed against the Company in the United States District Court District of New Jersey. The First Amended Complaint named additional defendants, including certain current and former directors, certain former Company officers, the Company's former and current external auditors and Koninklijke Philips Electronics N.V. (Philips). Like the original complaint, the First Amended Complaint asserted claims under Sections 10b and 20(a) of the Securities and Exchange Act of 1934 (the Act) and Rule 10b5 of the Act. The Class Period of the original complaint was expanded 20 months and now includes the period from March 29, 2000 through June 14, 2004. Pursuant to an October 17, 2005 consent order approved by the Court, Lead Plaintiff Greater Pennsylvania Pension Fund filed a Second Amended Complaint on November 15, 2005. The Second Amended Complaint dropped Philips as a defendant, but alleges the same claims and the same purported class period as the First Amended Complaint. Plaintiffs seek unspecified damages. Pursuant to the provisions of the Private Securities Litigation Reform Act, discovery in the action is stayed pending the filing and resolution of the defendants' motions to dismiss, which were filed on January 17, 2006, and will be fully briefed by May 26, 2006. The Court has not set a hearing date on the motions. The Company believes that the claims asserted in the Second Amended Complaint are without merit, and is vigorously defending the action. Customer Litigation As previously announced, a putative class action was filed in the United States District Court Central District of California. The action, entitled South Broward Hospital District, dba Memorial Regional Hospital, et al. v. MedQuist, Inc. et al., Case No. CV-04-7520-TJH-VBKx, was filed on September 9, 2004 against the Company and certain present and former Company officials, purportedly on behalf of an alleged class of non-Federal governmental hospitals and medical centers that the complaint claims were wrongfully and fraudulently overcharged for transcription services by defendants based primarily on the Company's use of the AAMT line billing unit of measure discussed below. The complaint charges fraud, violation of the California Business and Professions Code, unjust enrichment, conversion, negligent supervision and violation of the Racketeer Influenced and Corrupt Organizations Act. Plaintiffs seek damages in an unspecified amount, plus costs and interest, an injunction against alleged continuing illegal activities, an accounting, punitive damages and attorneys' fees. Named as defendants, in addition to the Company, were a senior vice president, its former executive vice president of marketing and new business development, its former executive vice president and chief legal officer, and its former executive vice president and chief financial officer. On December 20, 2004, the Company and individual defendants filed motions to dismiss for lack of personal jurisdiction and improper venue, or in the alternative, to transfer the putative action to the United States District Court District of New Jersey. On February 2, 2005, plaintiffs filed a Second Amended Complaint both adding and deleting named plaintiffs in an attempt to keep the putative action in the United States District Court Central District of California. On March 30, 2005, the United States District Court Central District of California issued an order transferring the putative action to the United States District Court District of New Jersey. On August 1, 2005, the Company and the individual defendants filed their respective Answers denying the material allegations contained in the Second Amended Complaint. On August 31, 2005, the Company and individual defendants filed motions to dismiss the Second Amended Complaint for failure to state a claim and a motion to dismiss in favor of arbitration, or in the alternative, to stay pending arbitration. On December 12, 2005, the plaintiffs filed an Amendment to the Second Amended Complaint. On December 13, 2005, the Court issued an order requiring plaintiffs to file a Third Amended Complaint. Plaintiffs filed the Third Amended Complaint on January 4, 2006. The Third Amended Complaint expands the claims made beyond issues arising from contracts based on AAMT line billing and beyond customers billed based on an AAMT line, alleging that the Company engaged in a scheme to inflate customers' invoices without regard to the terms of individual contracts and even in the absence of any written contract. The Third Amended Complaint also limits plaintiffs' claim for fraud in the inducement of the agreement to arbitrate to the three named plaintiffs whose contracts contain an arbitration provision and a subclass of similarly situated customers. On January 20, 2006 the Company and individual defendants filed motions to dismiss the Third Amended Complaint for failure to state a claim and a motion to compel arbitration of all claims by the arbitration subclass and to stay the case in its entirety pending arbitration. On March 8, 2006 the Court held a hearing on these motions, and took the matter under submission. The Court has not yet ruled on the motions. The Company believes that the claims asserted have no merit and intends to vigorously defend the putative action. Medical Transcriptionist Litigation Hoffmann Putative Class Action As previously announced, a putative class action lawsuit was filed against the Company in the United States District Court Northern District of Georgia. The action, entitled Brigitte Hoffmann, et al. v. MedQuist, Inc., et al., Case No. 1:04-CV-3452, was filed with the Court on November 29, 2004 against the Company and certain current and former Company officials, purportedly on behalf of an alleged class of current and former employees and statutory workers of MedQuist, who are or were compensated on a per line basis for medical transcription services (the Class Members) from January 1, 1998 to the time of the filing of the complaint (the Class Period). The complaint specifically alleged that defendants systematically and wrongfully underpaid the Class Members during the Class Period. The complaint asserted the following causes of action: fraud, breach of contract, demand for accounting, quantum meruit, unjust enrichment, conversion, negligence, negligent supervision, and Racketeer Influenced and Corrupt Organizations Act violations. Plaintiffs sought unspecified compensatory damages, punitive damages, disgorgement and restitution. On December 1, 2005, the Hoffmann matter was transferred to the United States District Court District of New Jersey. As discussed immediately below under the heading Myers Putative Class Action, the Company believes that the claims presently asserted have no merit and intends to vigorously defend the putative action. Myers Putative Class Action As previously announced, a putative class action entitled, Myers, et al. v. MedQuist Inc. and MedQuist Transcriptions, Ltd., Case No. 05CV 4608 (JBS), was filed against the Company on September 22, 2005 in the United States District Court District of New Jersey. The action was brought on behalf of a putative class of MedQuist's employee and independent contractor transcriptionists who claim that they contracted with the Company to be paid per AAMT line, but were allegedly underpaid due to intentional miscounting of the number of characters and lines transcribed. The named plaintiffs asserted claims for breach of contract, unjust enrichment, and request an accounting. The allegations contained in the Myers case are substantially similar to those contained in the Hoffmann putative class action and the two actions have now been consolidated. A consolidated amended complaint was filed on January 31, 2006. The named plaintiffs assert claims for breach of contract, breach of the covenant of good faith and fair dealing, unjust enrichment and demand an accounting. On March 7, 2006 the Company filed a motion to dismiss all claims in the consolidated amended complaint. The motion has now been fully briefed. The Court has not set a hearing date on the motion. The Company believes that the claims asserted in the consolidated actions have no merit and intends to vigorously defend the suit. Derivative Litigation On October 4, 2005, the Company announced the dismissal with prejudice of a shareholder derivative action filed in United States District Court District of New Jersey. The suit, Rhoda Kanter (Plaintiff) v. Hans M. Barella et al. (Defendants), was filed on November 12, 2004 against Philips and ten current and former members of MedQuist's Board of Directors. MedQuist was named as a nominal defendant. In a ruling dated September 21, 2005, the Court found Plaintiff's allegations that MedQuist's Board members breached their fiduciary duties to the Company to be insufficient. The Plaintiff had alleged that for a period from 2001 through 2004, the Defendants violated their fiduciary duties by permitting artificial inflation of billing figures; failing to adequately ensure accurate and lawful billing practices; and failing to accurately report the Company's true financial condition in its published financial statements. To the contrary, the Court concluded: Far from alleging facts supporting a substantial likelihood of liability, Plaintiff here has painted a picture of a board of directors that acted responsively given the circumstances . . . . On October 3, 2005, plaintiffs filed a motion for reconsideration of the Court's order dismissing the action with prejudice. On November 16, 2005, the Court denied Plaintiffs' motion for reconsideration. On December 13, 2005, Plaintiffs filed a Notice of Appeal with the United States Court of Appeals for the Third Circuit. On March 21, 2006, Plaintiff filed her opening brief on appeal. On April 20, 2006, MedQuist and the other defendants filed their opposition briefs. The appeal will be fully briefed by May 4, 2006. The Court of Appeals has not set a hearing date for the appeal. Customer Accommodations As previously disclosed, the primary allegations in a number of the litigation matters relate to how the Company interpreted the AAMT line billing unit of measure. The AAMT line billing unit of measure was developed in 1993 through a collaboration among several industry organizations with the intent of providing standardization in industry billing practices. However, due to inherent ambiguities in the definition of this unit of measure not fully anticipated at the time of its introduction, AAMT line-based billing was applied inconsistently throughout the medical transcription industry and eventually renounced by the groups initially responsible for its development. Despite these issues, a number of companies in the industry have continued to use AAMT line-based billing, and some customers still request proposals and contracts based on the AAMT line. Like many medical transcription service providers, MedQuist once used the AAMT line unit of measure to calculate invoices for many of its medical transcription clients. It has been widely recognized and well documented throughout the industry, however, that the AAMT definition of a line is inherently ambiguous and subject to a wide variety of interpretations. In fact, no single set of AAMT characters was ever defined for this unit of measure. Accordingly, MedQuist began the process in 2004 of transitioning its AAMT line-based customers off the AAMT line unit of measure and, in April 2005, the Company completely eliminated the use of the AAMT line for billing and called on other industry transcription providers to follow its lead. Due to these AAMT line unit of measure ambiguities, and the disparity in its interpretation, health care providers have raised concerns regarding charges for transcription services by their respective transcription providers, including the Company. In response to those concerns, and to foster ongoing business relationships with its customers, the Company has approached certain customers and offered to resolve any issues related to their prior AAMT line and other billing related issues. As previously disclosed, the Company's Board of Directors has authorized Company management to make accommodation offers, up to an aggregate amount of $65.0 million, to certain customers to resolve any concerns over AAMT and other billing related issues. As of March 31, 2006, (i) the Company has entered into agreements with certain customers who have accepted accommodation offers to resolve concerns over AAMT and other billing related issues, and paid or credited an aggregate amount of $31.3 million as an accommodation to those customers and (ii) additional accommodation offers have been made by the Company to certain other customers in the aggregate amount of $11.9 million. From April 1, 2006 through the date of this release, the Company has entered into agreements with additional customers and paid or credited an aggregate amount of $2.9 million and has extended accommodation offers to additional customers in the aggregate amount of $1.1 million. Company management currently intends to make additional accommodation offers in the future, consistent with the Board's authorization described above, although the timing and amount of such offers have not yet been determined and the Company's plans may change in the future. The accommodation offers do not represent an estimate of potential liability, if any, in any of the previously disclosed litigation or investigatory matters pending against the Company. The Company is unable to predict how many customers, if any, will accept the outstanding accommodation offers on the terms proposed by the Company, nor is the Company able to predict the timing of the acceptance (or rejection) of any of these outstanding accommodation offers. Until such offers are accepted, the Company may withdraw or modify the terms of the accommodation offers at any time. In addition, the Company is unable to predict how many of the future offers, if made, will be accepted on the terms proposed by the Company. The Company believes that its existing cash resources and cash flows from operations are sufficient to fund all of the customer accommodation offers it may make. By accepting the Company's accommodation offers, the customer must agree, among other things, to release the Company from any and all claims and liability regarding prior AAMT and other billing related issues. The accommodation offers made to date, and those offers which may be made in the future, are not an admission of liability by the Company of any wrongdoing or an admission or acknowledgement that its billing practices with respect to such customers were or are incorrect. MedQuist Inc. -- Preliminary and Unaudited Financial Information (in millions) ---------------------------------------------------------------------- Three months ended ---------------------------------------- March 31, 2006 March 31, 2005 ------------------ ------------------ Revenues $ 97 $ 108 Operating loss $ (8) $ (2) ---------------------------------------------------------------------- As of As of March 31, 2006 December 31, 2005 ------------------ ------------------ Cash $ 164 $ 178 Debt $ - $ - Three Months Ended March 31, 2006 Revenues: Preliminary, unaudited results indicate that the Company's revenues decreased $11 million to $97 million for the three months ended March 31, 2006 from approximately $108 million for the comparable 2005 period. This decline in revenues is largely due to decreases in transcription outsourcing services and product sales of $9 million or 10%, and $2 million or 27%, respectively. The decline in transcription outsourcing revenues is largely due to a decrease in the volume of lines transcribed primarily related to clients for whom we no longer provide transcription services. Additionally, pricing pressures continued on the base transcription business during the first quarter 2006, but revenues were impacted far less by pricing pressures than in the comparable 2005 period. Management expects that pricing pressures will continue for the foreseeable future but that the introduction of several new sales initiatives and improved customer service programs should cause transcription volume to stabilize or improve throughout the duration of 2006. Operating Loss: Preliminary, unaudited results indicate that our operating loss increased $6 million to a loss of approximately $8 million for the three months ended March 31, 2006 from an operating loss of $2 million for the comparable 2005 period. The operating loss of $8 million was primarily attributable to $9 million of costs associated with the following: (1) costs related to the ongoing billing review including (i) legal fees incurred in connection with governmental investigations and proceedings and defense of the class action matters and (ii) non-legal professional fees; and (2) increased expenses related to prior years' accounting reviews and audit. Operating loss was also impacted by the $11 million decline in revenues over the same period. Balance Sheet Highlights: As of March 31, 2006, the Company had $164 million in cash and cash equivalents and no debt. The $14 million decrease in cash as of March 31, 2006 compared with December 31, 2005 was primarily attributable to accommodation payments ($10 million) and capital expenditures ($4 million). There were no issuances of capital stock or other securities for the three months ended March 31, 2006. The Company expects to incur significant costs and expenses in the future relating to the ongoing billing review, defense of the class action matters and governmental investigations and proceedings, and accommodation agreements. These costs and expenses include (i) legal fees relating to the SEC and Department of Justice investigations and proceedings, (ii) legal fees relating to defense and resolution of the litigation matters described above, (iii) customer accommodation payments and credits, and (iv) non-legal professional fees. The timing and level of these costs and expenses is, in many cases, not within the Company's control. While the Company is unable to predict the timing and level of these costs and expenses, the Company currently believes that it has sufficient resources, including cash on hand and cash flow from operations to fund these costs and expenses. However, there cannot be any assurance that unanticipated changes in the level of these costs will not exceed the Company's available cash resources, nor can there be any assurance that sufficient financing from external sources will be available to the Company on acceptable terms, if at all. In the event that the Company's cash requirements exceed its available cash resources, or if the timing of such costs and expenses requires the Company to divert cash resources away from operations, the Company may not be able to execute its operating plan, which could have a material adverse effect on the Company's business and results of operations. Other Developments Restructuring: As previously disclosed, in conjunction with the Company's movement to a single national service and support organization, a restructuring plan was developed in 2005 to consolidate approximately forty-eight (48) operating facilities and centralize certain components of the business in order to improve operating efficiencies. The Company is expecting to incur total restructuring costs of up to $8.5 million associated with this plan through the end of the fourth quarter of 2006. The Company incurred $1 million of restructuring costs for the three months ended March 31, 2006. This restructuring is expected to generate annualized savings of approximately $18.5 million. The Company realized approximately $1.9 million in savings during the three months ended March 31, 2006. Specifically, the Company has shifted resources to a single national service delivery and support organization for all of the Company's services and products and is in the process of eliminating local service centers. The plan does not contemplate reductions of, and the Company has no current intentions to reduce, its medical transcription workforce. Rather, the Company will continue in its efforts to hire additional qualified transcriptionists. Further, although the Company is consolidating its local service centers as described above, customer-facing teams, led by account managers, will continue to coordinate customer support on the local level. The customer-facing teams will continue to work with and be supported by the Company's centrally managed customer service organization.

I though apprencticeship programs were UNIONIZED [2006-04-07]
I could be wrong here, but all apprentice programs I know of are unionized, such as the Steamfitters, electricians, plumbers, OAW, etc. So, maybe this will open up our field to be unionized and be paid decent wages, such as $23 per hour, etc. Just a thought!

I'll quit paying taxes if they use it to train overseas MTs [2006-03-21]
G et AL can take a bite out of that one if they think that is the direction they will take this program! After all, the approved programs are online and AAMT provides certification overseas, so what is to stop the big MT corporations who are devoloping facilities to house 5000 MTs in India and other locations from using MY tax money to train overseas MTs???

Medical Transcription Recognized as an Apprenticeable Occupation [2006-03-14]
CHICAGO--(BUSINESS WIRE)--March 10, 2006--Graduates of selected medical transcription training programs will now have access to registered apprenticeship programs, as the U.S. Department of Labor (DOL) has now declared medical transcription to be an apprenticeable profession - the first step in establishing a national apprenticeship program. The Office of Apprenticeship Training, Employer and Labor Services approved the application for apprenticeability determination submitted by the Medical Transcription Industry Association (MTIA) along with the American Association for Medical Transcription (AAMT). Having a recognized apprenticeable occupation will provide a pipeline of medical transcription professionals entering into a workforce facing a serious labor and skills shortage. stated Keith Flannery, Vice President, MTIA. Workforce development under the standards established by this apprenticeship program will aid in facilitating the transition between student and an employable, productive, and qualified medical transcriptionist. Given the challenge the industry faces in recruiting qualified candidates to meet the ever-increasing demand for real-time, quality healthcare data, a registered apprenticeship program couldn't be developed and launched at a more critical time, stated Peter Preziosi, PhD, CAE, AAMT Executive Director. Workforce development is essential to ensuring that documentation experts are in place to assist the industry in transitioning to an electronic health record and to preserving the quality and integrity of the health record in that future. The Registered Apprenticeship Program, sponsored by the Medical Transcription Industry Association (MTIA), will offer structured on-the-job learning and related technical instruction for qualified medical transcriptionists entering the profession. The two associations, along with the Office of Apprenticeship Training, Employer and Labor Services, are finalizing program details. Medical Transcription is a crucial process in the provision of quality healthcare in our country. This is a hallmark program for the industry, said Sean Carroll, President, MTIA.

M-Tec and The Andrews School Approved by AAMT/AHIMA [2005-11-02]
According to the AAMT web site, Upon the recommendation of the AAMT Review Committee, the following medical transcription programs have been approved by the Approval Committee for Certificate Programs (ACCP), a joint committee established by AAMT and AHIMA for certifying and approving medical transcription education programs. http://www.aamt.org/ScriptContent/mtapproved.cfm M-TEC offers quality distance education training for the novice, the healthcare professional wanting to make a career change, and continuing education programs for the practicing MT. Special discounts are available on continuing education and refresher products for AAMT members. The M-Tec Skillbuilding Wizard is available through the AAMT Store and offers 54 CECs to certified medical transcriptionists. This is also a great resource for companies offering continuing education classes for their employees. The Andrews School has been providing quality medical transcription education and training since 1989. With what we believe to be the best program, instructors, and advisory staff in the MT community, the Andrews School has a proven track record, graduating thousands of students who have gone on to successful MT careers. The Andrews School offers distance learning opportunities via the Internet anywhere in the country. Graduates are able to work from home after completion of the program. Related Links Medical Transcription Program Approval Manual

Registration Open for Nation's First University Course [2005-10-25]
Registration Open for Nation's First University Course on Medical Transcription Voice Recognition Editing; Pair of Richmond, VA Community Colleges Partner With OAK Horizons Cymed For Online Class 10/24/2005 5:18:00 PM EST The Community College Workforce Alliance (CCWA) in Richmond VA, opened enrollment today for a medical transcription training course aimed at graduating students who are prepared to edit preliminary medical reports generated through voice recognition. CCWA is a partnership between J. Sargeant Reynolds and John Tyler Community Colleges and serves the workforce needs of the Greater Richmond area. This first of its kind university-based course was developed with the support of OAK Horizons, an online content developer of Transcriptionist training courses and CyMed, the nation's third largest employer of domestic transcriptionists. We're excited about launching the Medical Transcription/Voice Recognition Editing program, stated Matt Meyer, Dean of CCWA Workforce Training. Our mission is to serve the workforce and economic development needs of the region through educational programs that prepare students for positions that offer solid long term employment prospects. Since CyMed has already agreed to hire each graduating student for the first three years of the program, we are able to offer tremendous security for any student who is anxious about choosing an educational track that leads towards a long term employable career path. This partnership makes a lot of sense for CyMed, CCWA and the MT community on a number of levels, commented Robert Lynch, CyMed's President and CEO. Although we certainly expect the current method of transcription to be around for a long time, this course will help extend the range of employment opportunities available to program graduates. CCWA and OAK Horizons have developed an excellent program and we are looking forward to hiring graduates with the expanded voice recognition editing skill set.

Medical Transcription Industry Association (MTIA), new strategic goals [2005-08-12]
Aug. 11, 2005--At its recent meeting of the Board of Directors for the Medical Transcription Industry Association (MTIA), new strategic goals were crafted for 2005-2006. According to Sean Carroll, President of MTIA, the association will be dedicated to activities that will direct member companies to be valuable and relevant in the rapidly evolving healthcare documentation environment. The following strategies were approved: -- In order to be valuable and relevant, MTIA will lead by asserting itself in the standards development arena, and by serving as a valuable resource for the medical transcription business community and the vendors that support it. -- In order to be valuable and relevant, MTIA will be coordinated and strong by proactively building productive alliances with related associations and becoming an active participant in government relations. -- In order to be valuable and relevant, MTIA will engage with technology by educating its members in the effective use of emerging technologies for continuous quality improvement and greater efficiencies. -- In order to be valuable and relevant, MTIA will focus on programs and deliverables that will help their members preserve and increase profitability and succeed within the dynamic evolution of this industry. Carroll proudly proclaims that the Board is fully committed to achieving these objectives, making this the most important year ever for the association. MTIA is definitely on the move! MTIA is a nonprofit membership association founded in 1993 to represent medical transcription companies of all sizes. For more information about MTIA, contact Elaine Olson, Executive Director, at 800-543-MTIA or eolson@mtia.com.

Electronic Health Records: Just around the Corner? Or over the Cliff? [2005-08-02]
We recently implemented a full-featured electronic health record in our independent, 4-internist, community-based practice of general internal medicine. We encountered various challenges, some unexpected, in moving from paper to computer. This article describes the effects that use of electronic health records has had on our finances, work flow, and office environment. Its financial impact is not clearly positive; work flows were substantially disrupted; and the quality of the office environment initially deteriorated greatly for staff, physicians, and patients. That said, none of us would go back to paper health records, and all of us find that the technology helps us to better meet patient expectations, expedites many tedious work processes (such as prescription writing and creation of chart notes), and creates new ways in which we can improve the health of our patients. Five broad issues must be addressed to promote successful implementation of electronic health records in a small office: financing; interoperability, standardization, and connectivity of clinical information systems; help with redesign of work flow; technical support and training; and help with change management. We hope that sharing our experience can better prepare others who plan to implement electronic health records and inform policymakers on the strategies needed for success in the small practice environment. Policymakers and physician leaders are counting on electronic health records to improve quality of health care and revitalize practice , and a recent report forecasts that widespread use of electronic health records will save the health care system $77.8 billion annually�5% of total health care expenditures in the United States. It is difficult to get an accurate figure for use of electronic health records by primary care physicians, but estimates range from 5% to 13%. Seventy-eight percent of physicians in the United States practice in groups of 8 or fewer; therefore, understanding and overcoming the obstacles faced by small practices will be essential to successful use of electronic health records. Although the experience of small physician practices that implemented electronic health records has been usefully described, more work is needed. Our independent, community-based, 4-internist primary care medical practice went live with an electronic health record system on 14 July 2004. We report on our experience. Our medical practice, Greenhouse Internists, has operated in Philadelphia since 1989. We serve an economically and ethnically diverse urban and suburban population. We derive approximately 60% of our revenue from capitated managed care and participate in Medicaid (through 2 Medicaid health maintenance organizations) and Medicare (fee-for-service and capitated managed care). We handle more than 16 000 patients encounters yearly, and our focus is comprehensive ambulatory care. We have 1 registered nurse who handles clinical and administrative contact with insurers, forms, telephone triage, and routine prescription refills; a front desk staff that handles reception, referrals, and telephone calls; and medical assistants who handle chief symptoms, vital signs, phlebotomy, and electrocardiography. We have no mid-level practitioners. Before we instituted electronic health records, we used computers for scheduling and billing only. When our malpractice carrier stopped offering occurrence coverage and we had to accept claims made coverage, we used the 2-year savings window to invest in an electronic health records system. Our motivation was complex: We hoped it would automate frustrating repetitive processes (such as prescription refills) and minimize some of the ways in which we routinely failed to meet patient expectations (such as one of us not knowing what another had said the previous day to a patient on the telephone). We hoped that the system might pay for itself, but we were not at all confident that it would. We made a leap of faith that pay for performance was coming and that this investment would eventually position us for greater success. Like many of our colleagues, we believed that we would have to implement an electronic health record system sooner or later, and the one-time cash surplus made it possible for us to do so sooner. One of us had experience in managed care and population health and was hoping to use those insights at the practice level. We chose our system on the basis of recommendations of colleagues and because it was offered by a large national company. We hoped that the latter attribute would make it more likely that we could count on long-term support. We did not interview multiple vendors because we believed that all full-featured products would have unanticipated advantages and disadvantages. To support our electronic health records system, we needed to change the practice management system that was in place for scheduling and billing. To minimize the impact on physician�patient interaction, we opted for an encrypted wireless network with Tablet personal computers (Hewlett Packard, Palo Alto, California), which we purchased from a different vendor. None of the physicians was especially computer-literate. The total quoted cost of our system, including hardware, software, training, and 1 year of support, was approximately $140 000, which is within the range that other investigators have reported on a cost-per-physician basis. Staff and Physician Training Training meant different things to different team members. None of the physicians had previously used a Tablet PC with a Windows XP operating system (Microsoft Corp., Redmond, Washington), and we needed training on the device as well as on the new system. Some staff members had never used a mouse (our previous practice management system was not Windows-based). The medical assistants, who had previously made notes by hand, were now asked to use wireless-equipped laptops with mouse pads or track-ball pointers. For the system itself, 2 types of training were given. Super users were taught how to set up and administer the record (and therefore were enabled to make some structural changes to the system). Regular users were trained in basic system operation but were not given administrative training and privileges to make changes to the system. Super users were charged with customizing the system for our particular practice environment and developing work flows, which were clearly defined and documented steps to guide everyone on how to use the new system to accomplish the work of the office. After 2 rounds of planning meetings and 2 days of on-site training, we went live, meaning that we committed to using our electronic health record to document clinical care from that time forward. Training requires organizational redundancy or reserve; in a busy physician practice, neither is present. Our business manager incurred an injury that kept her out of work for 1 month before we went live; during that month, much of our focus became covering her core functions (payroll, billing, scheduling, and staff management) rather than training. For the first 3 days of live operation, we reduced our appointment schedule by 50%; thereafter, we attempted to maintain our schedule at two thirds for 2 weeks, but ongoing demand for appointments made this impossible. Hardware and Performance We had put in place a complex computer network that none of us knew how to support, maintain, or operate. Shortly after we implemented the practice management system, we experienced a virus attack that crashed our system. After the virus was removed, we experienced several lengthy losses of both telephone and data service. Identifying the cause of each of these system failures was a diagnostic problem well beyond our skills, with several possible corporate culprits. Before we went live, we had had a limited, inexpensive relationship with a small local computer support company; because we were paying annual support fees to both hardware and software vendors, we thought we would not need these local services after implementation. We were wrong. In fact, our relationship with the local company expanded rapidly in time, importance, and cost after implementation. Because we now rely on our system for core clinical functions (prescriptions, telephone calls, and accessing records), small technical malfunctions create major operational problems. Our expanded relationship with the local computer company now costs an unbudgeted $2000 per month, and the response time of our technical support is often inadequate. Redesign of Office Work Flow A well-run primary care office is a complex interdependent operation with well-defined work flows. General principles that guide the design of work flows in our office include simplicity and accessibility for patients, safety, comprehensive documentation, and delegation. We operate under the assumption that the physician is the most skilled, and most expensive, person in the office and should only do what no one other than a physician could do. Our entire office meets monthly for 1 hour, and weekly meetings of staff teams are held to adjust work flows as conditions or demands change. Responding to a request for a prescription refill, for example, requires 3 or 4 people performing interrelated but distinct tasks to deliver it safely, reliably, and promptly; we average 30 to 40 such requests daily. The collective integrated operation of our office thus represents 15 years of weekly and monthly staff meetings that constructed our functional systems piece by piece over time. On 14 July 2004, we had to redesign every office system we had in place. Our commitment that going live would mean that documentation of clinical care on or after that date would be created and found in the electronic health record seemed simple, but clinical care included not only office visits but telephone calls, prescription refills, handling of laboratory results, and other functions. Each of these tasks had a work flow, and all work flows had to be redesigned more or less simultaneously. A clear go-live date was desirable because, as a matter of patient safety, we needed to know where to look for information, and the longer we ran parallel paper and electronic systems, the harder that would be. The process of radically redesigning 15 years of accumulated work flow in a short interval was extremely stressful. The system we chose is designed for flexible application in a variety of settings, ranging from large integrated delivery systems to smaller practices. Although the vendor urged us to think through and document the new work flows in advance, we found ourselves making innumerable decisions about how we would use the system before we really understood how it worked, and our vendor did not know enough about how our office worked to help us. We were forced rapidly to adjust our work flows during implementation, which seemed akin to redesigning an airplane in flight. Decreased Competence and Increased Effort Going live rendered everyone in the office incompetent to do their core jobs. The front desk had to use new on-screen forms to record telephone messages; pairing electronic messages with paper charts required the file clerks to follow a new work flow; physicians had to find telephone messages on their computer desktop rather than neatly piled in a physical telephone message bin. The medical assistants had to record vital signs and chief symptoms in the computer and had to learn how to record results of a tuberculosis skin test, visual acuity test, or urinalysis. Everyone in the office simultaneously experienced pervasive anxiety and unhappiness. Waiting time for patients dramatically increased. In short, people were miserable at work. We began to have weekly full staff meetings and weekly physician meetings, all of which were more acrimonious than they had ever been. Variations in clinical style and work flow among the physicians�which had seemed acceptable if unnoticed before�now became a subject of group scrutiny. What did we have to change, and what could we hang on to? What did the physicians have to do the same way, and where could we tolerate difference? All these issues had to be renegotiated at a time of enormous stress on the practice. We observed that a culture of blame set in: Things were not going well, and it had to be someone's fault. Several staff members complained that the work environment was less collegial, and they often felt criticized, as one put it, by everyone. They did not associate these feelings with the electronic health record and, at least initially, neither did we. Coincident with our shared frustration came a dramatic increase in workload, especially for the physicians. Even when we had reached the point where we could competently use the new system, every patient represented a new patient to the electronic health record, and the old paper chart had to be abstracted and data moved into the electronic chart. Some aspects of chart abstraction could perhaps have been delegated (for example, entering medication lists or immunization histories), but we worried that our staff�who have only limited clinical training�might make mistakes, and decisions about what data to abstract require the clinical judgment of a physician. At first, the system shut down daily at midnight for backup and maintenance; backup was later moved to 2:00 a.m. to accommodate 2 of the doctors who were trying to work from home in the evening. The stress level in our office remained high for about 3 months, by which time we had seen most of our complex patients and entered their long medication and problem lists into the system. We had now begun to realize some of the benefits of computerization, including computer-generated prescriptions, faster access to specialist correspondence, real-time access to charts anywhere in the office, the ability to message or route information and tasks electronically in the office, and the ability for the same chart to appear on multiple desktops. Within 4 to 6 months, waiting time had improved and staff were more excited and confident. Patient Acceptance Patients have been impressed and pleased to see their prescriptions appearing on wireless-enabled printers sitting unconnected to our Tablets. They have also enthusiastically benefited from occasional use of the Internet or such tools as the National Cholesterol Education Program Risk Calculator during their visit. Some patients, however, found the increased waiting time during the early phase of implementation unacceptable, and many left our practice because of it. At a time when everyone in the office was stressed, our customer service skills were not at their best. Several patients have asked a version of a question posed by a supportive, long-established patient: Doctor, do you find you are spending more time interacting with the computer than with your patients? For a while, the answer was clearly yes. Financial Impact Our total annual budget for technology support before implementation was approximately $10 000, which comprised maintenance and support of our previous practice management system and limited network. Our postimplementation annual budget will be $40 000, which includes annual support payments to hardware and software vendors and our local computer support vendor. We will have $24 000 in annual carrying costs for the financing of our system purchase over the next 5 years. The clearest savings we have seen was from the elimination of $45 000 in annual transcription costs. Although the file clerks no longer do filing, they now scan and name correspondence (see the following description), and we have been able to eliminate only 1 staff position for an additional annual savings of $20 000. We expect savings on chart supplies to be offset by increased costs of toner and printer maintenance, technical support, and replacement of equipment. At best, we see the expense side as a wash. On the revenue side, we accrue no additional revenue from any current payer for having an electronic health record. We had already maxed out on most quality incentives for which we were eligible when we were using well-organized paper charts and office systems. The electronic health record may enable us to see more patients in the same time or offload physician work more reliably and safely because the system provides clear, timely, legible documentation to support expanded clinical team activities, but this reallocation will require substantial staff retraining. Within 1 year of implementation, we expect to free up our current file room space and perhaps make it clinically productive and revenue-generating. As an offset to these potential gains, it is possible (although unlikely) that physicians will be less productive because the electronic health record generates more work for them. For example, whereas the physicians used to dictate notes, they must now type them. Physicians must also participate more in filing. Our electronic system offers us 24 document types (for example, consultation or laboratory report), and each document must be assigned a type and given a name. Because accurate labeling and data entry are essential both to take advantage of the information retrieval capability of the system and to find anything once it is filed, the physicians must oversee and modify the categorization and manual input of key data elements. As a result, we often feel like data input drones. No wonder one of us described the new work flow as a physician speed-up. Computerization in a world without established standards that link medical data systems is inefficient. When we have a working interface, as we do with our main outside clinical laboratory (which handles about 80% of our laboratory testing volume), the reports come named, and the individual laboratory results automatically populate flow sheets and letters to patients. Results can be efficiently retrieved and graphed, and trends can be analyzed. Unfortunately, most of the information we receive (such as radiology reports, consultations, and procedure reports) does not come to us in a format that the system can recognize electronically. Our colleagues in integrated delivery systems and the Veterans Administration do not face this problem because most of their clinical data are generated within their system and the interfaces already exist. National standards on the interoperability of medical data systems would be a big step forward for small practices. For now, we may switch referral patterns to hospitals and specialists who will give us information in a form that flows most easily into our system. Lessons Learned It is naive to assume that small practices will move to electronic health records without a variety of supports, one of which is certainly financing. None of the many beneficiaries of our investment�patients, insurance companies, our specialist colleagues, health plans, our liability carrier�have directly shared in the cost of implementing an electronic health record system. Enhanced reimbursement models will be needed for wider adoption. This could be achieved through performance incentives tied to implementation of such systems in capitated contracts or through a common procedural terminology code for data transfer to reflect the one-time increased effort and cost of moving data from paper to electronic format. A recent report estimates incentives of $12 000 to $24 000 per full-time physician per year would be needed to make the business case for immediate adoption of electronic health records, with those incentives transferring to performance-based incentives over time. Any of these incentive models would work for us and make adoption easier in other small practices. Although some predict that vendors will shift their focus to the small practice market, it is difficult to see how vendors will support implementation of an electronic health record in the small practice setting while keeping prices affordable. Small practices need much more training and support from vendors than do large groups. The support provided by our large national vendor presupposed the existence of dedicated information technology staff and an administrative layer that could plan work flow and train staff. Neither of these infrastructures are present in a small office, and both are critical to success. In addition, small practices need structured assistance to develop their capacity to manage organizational change. Models of shared local training and support must be developed if small offices are to be successful in implementation. Perhaps the most important asset we could have used to ease the pain of implementation was more clinical capacity. A decline in productivity after implementation of an electronic health record seems inevitable, and if a practice is already straining to meet patient demand, an absence of reserve magnifies the stress of implementation. For us, the financial stress of acquiring the electronic health record precluded simultaneous addition of a new mid-level practitioner or physician, which argues even more strongly for the need for financial support. Patients want and expect their physician, especially their primary care physician, to have a comprehensive grasp of what is going on with them medically and to be able to respond to such questions as, How much weight have I lost? or What was my cholesterol level last time? Clearly, aggregating comprehensive clinical information at the point of care is a basic function of excellent primary care. Why is it that every academic health center and hospital acquires state-of-the-art cardiac imaging tools promptly, but primary care offices and residency training programs are still using paper records? Given their experience with other customer service operations, such as retail, banking, or travel, patients assume a level of information technology infrastructure that most of us in health care simply do not have. Unsupported by technologies now taken for granted almost everywhere else, we in health care regularly fail to meet basic patient expectations. A major factor that prompted us to adopt an electronic health record was the hope, now at least partially fulfilled, that it would improve our ability to meet patient expectations and improve our job satisfaction. Despite the difficulties and expense of implementing the electronic health record, none of us would go back to paper. We find ourselves able to be better physicians: We communicate more quickly and clearly with patients on the telephone and by letter, transmit important clinical information (albeit on paper produced automatically by our system) more efficiently to specialists, and spend less time paging through charts to find out what the previous cholesterol values (for example) had been. Practicing with a computer in hand allows us to access current health information for ourselves and our patients without having to leave the room or interrupt the flow of a patient encounter. We have already caught a glimpse of population health possibilities when, on the same day as the withdrawal of valdecoxib from the market, we were able to identify and send letters about the withdrawal to the 16 patients in our practice who were taking the drug. We expect soon to produce a list of patients with diabetes so that we can audit their care and see how well we meet our care standards. We also plan to use our electronic health record to provide each of these patients with an individualized report on services for which they appear to be overdue. If the United States is to realize the benefits of information technology in health care, substantial investments will be needed to shepherd small offices through what is an arduous process. We believe that many practices will examine the current environment and defer a decision to adopt an electronic health record, and given our experience, it would be hard to disagree with them. All the hoped-for benefits to the overall delivery system and to patients will only accrue if small offices, which are the access points to health care for most patients in the United States, successfully adopt information technology. We believe that new models are urgently needed to deliver both financial and administrative support to those who would accept the challenge. Author and Article Information From Greenhouse Internists, P.C., Philadelphia, Pennsylvania. Acknowledgments: The authors thank their office staff for their courage, flexibility, and support throughout this project. Without their willingness to try something new, implementation of the electronic health record would not have been successful. They also thank business manager Debbie Preite for her leadership and willingness to learn more about computers than she ever thought she could, or wanted. Finally, they thank Cheryl Norvell for manuscript assistance and Steve Downs, Holly Humphrey, and David Reuben for their encouragement and review of an earlier draft of the manuscript. Potential Financial Conflicts of Interest: None disclosed. Requests for Single Reprints: Richard J. Baron, MD, Greenhouse Internists, P.C., 345 East Mt. Airy Avenue, Philadelphia, PA 19119; e-mail, rbaron@greenhouseinternists.com .