Tag Archives: Transcription

The Consequences of Not Taking HIPAA Seriously | Medical Documentation | iData Medical

The Consequences of Not Taking HIPAA Seriously | Medical Documentation | iData Medical

Privacy. Speech Recognition

In today’s global climate, privacy feels like a thing of the past. Our cell phone numbers, emails, employment and home addresses, credit cards, and so forth are almost daily being compromised by hackers or released due to human error. The effect of this on-going reality is that we’ve become accustomed to the news that the database of yet another Fortune 200 company was infiltrated, and consequently millions of records of American consumers are no longer private. Slowly, this numbing wave of unwelcomed news bleeds (no pun intended) into the medical documentation world.  Organizations unintentionally become victims of tolerating this reality. Few are the intentional violators; but many possess the careless and passive attitudes towards HIPAA compliance. Often, they (we) think “Besides, what are the odds that my business will be compromised?” or “what are the odds that my business will be audited and penalized?”

The odds? They are increasing and not in your favor. AGs across the US are clamping down on violators, regardless of cause, and are issuing heavy fines, both civil penalties, injunctive relief, and in rare cases criminal indictments against individuals and organizations that are not diligent with HIPAA regulations. Just because someone else didn’t comply will never exonerate your lack of vigilance.

Take the case of ATA Consulting and Best Medical Transcription which was fined $200K by the New Jersey Attorney General. While the civil penalties are steep, the material and good will impact to the reputation of the defendant is cataclysmic. ATA Consulting (Best Medical Transcription) shuttered its doors and is no longer permitted to operated in New Jersey. For more on this story, click below to read the news release:

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New Jersey AG slaps medical transcription vendor with $200K fine

ATA Consulting, which conducted business as Best Medical Transcription, agreed to pay $200,000 to settle allegations it violated HIPAA and the New Jersey Consumer Fraud Act after a breach in 2016.

Here are six things to know about the settlement:

1. ATA Consulting and its owner, Tushar Mathur, entered into the settlement with New Jersey Attorney General Gurbir S. Grewal and the New Jersey Division of Consumer Affairs to resolve allegations arising from a 2016 breach, in which the vendor allegedly allowed the public to view online records of patients from Virtua Medical Group, a network of medical and surgical practices in southern New Jersey.

2. Physicians at three VMG practices had contracted Best Medical Transcription to transcribe dictations of medical notes, letters and reports. In 2016, Best Medical Transcription updated its software on a password-protected website that stored the transcribed documents. During the update, the vendor unintentionally misconfigured the web server, allowing the site to be publicly viewable.

3. As a result of the server misconfiguration, the private health information — including names and medical diagnoses — of up to 1,654 patients treated at VMG practices was publicly exposed online. Subsequently, those who conducted web searches for terms included in the dictation information, such as patient names, were able to find portions of the exposed records online.

4. In April 2018, VMG  agreed to pay $417,816 to settle allegations it failed to secure these patients’ medical records when they were made accessible online. At the time, the New Jersey Division of Consumer Affairs alleged VMG had not conducted a thorough analysis of the risk associated with electronically sharing protected health information with Best Medical Transcription.

5. Best Medical Transcription, which was based in Georgia, dissolved as a business in June 2017, an act it said was independent of New Jersey’s investigation. Along with paying the fine, Mr. Mathur also agreed to a permanent ban on managing or owning a New Jersey business. Mr. Mathur said he would no longer serve as an officer or trustee, among other positions, of any corporation in the state.

6. The $200,000 settlement amount comprises $191,492 in civil penalties and an $8,508 fine to reimburse the state for attorney fees and investigative costs.

“Patient privacy laws don’t just apply to doctors, they also apply to vendors like Best Medical Transcription,” said Paul R. Rodríguez, acting director of the New Jersey Division of Consumer Affairs. “Our settlement with Best Medical Transcription sends a message that New Jersey requires compliance from all entities bound by patient privacy standards.”

Attribution: Portions of this are the exclusive work of Becker’s Hospital Review, written by Jessica Kim Cohen 


Pausing for Dollars

Before you earnestly launch into your “To Do” list you created at the end of 2016, do yourself a favor and PAUSE!

 Surely you’ve created a list (at least in your mind) that more-or-less hits the mark on critical near-term goals, but have you considered that we – the human types – are creatures of habit and often govern our actions based on past experience? We are so engrossed in the weeds, the details, the urgent, that we fail to step back and reconsider the view from afar.  You see, the beginning of a New Year should compel all of us to ask, “What can I do better?”, “What should I do more of?”, and “What should I do less of?” In other words: What should change!

 It is with this posture that I ask you to reexamine your core business relationships with transcription or coding partners (and notice I said partners, not “vendors”).

Definition of Partner (according to Meriam-Webster): noun  part·ner \ˈpärt-nər also ˈpärd-\. Archaic. 1. one that shares. 2a. one associated with another especially in an action. b. either of two persons who dance together. c. one of two or more persons who play together in a game against an opposing side. d. person with whom one shares an intimate relationship.

 Simply put, partners are people that share, do things together, dance and play together. 

 At iData Medical, we are not your stereotypical medical documentation company, and we certainly do not view ourselves as “vendors”; rather we are partners.  Truth is, that many medical documentation companies do a good job.  But what sets us apart? What do we do that’s better? What differentiates us from the rest.  It’s simple: Our people. Companies like ours have software, processes, policies, etc.  But our biggest and most valuable assets are our human assets – our work force. Talented people are our differentiator!

 This forms that basis for our iD3 philosophy.  We have reduced our entire business DNA to three distinct concepts:

Client ID – We will get the right people in place to serve you.

Every organization is different. In one hospital or medical practice, the IT department may be really involved in projects, and in others not so much. The CFO may be hands-on in a hospital system, or the Health Information Managers might be left to make the tough choices. We work to understand your organizational DNA, and we set in place a plan for long-term success.  Our list of gratified clients isn’t only long, but most partnered with us for almost a decade.

Workforce ID – Because great results starts with a great talent.

Based on your identified needs in the Client iD process, we select the workforce that can deliver. We are superlatively selective in our hiring practices: We hand-select professionals from our team of fully-vetted high-gear human assets. We have learned that intelligent and satisfied professionals provide exceptional, consistent, and reliable work.  Exceptional technologies and processes abound. It is our human, intelligent assets that are our differentiator.  Front loading the right team skill level to successfully service your account, and we ensure that ongoing training and support aligns with your ongoing goals. In the end, we prefer (and value the wisdom of) paying now, not later. 

Secure ID – Your standards are our first priority.

 A globally-recognized Information Security Standard like ISO 27001 is not a one-size fits all in a privacy-starved market place. Your IT department or other constituents sometimes have security protocols and requirements that are unique. Your organization also quite likely has different ways of using technology and software. We assess those use cases and your unique requirements, and set a security program in place to give you peace of mind, ensure strict and audit-certified HIPPA compliance, and keep everyone happy.

And to top things off, we very often can do all of this at a decisively competitive price. 

So, how about we talk and see how iData can partner with you? In 2017, do things differently and Leverage the Power of iD3!

Importance of Transcription in the EHR

This article is written specifically for iData Medical by Darice Grzybowski, MA, RHIA, FAHIMA, President and Founder, H.I.Mentors, LLC and is a certified AHIMA Approved ICD-10-CM and ICD-10-PCS Trainer and Ambassador.


The electronic health record (EHR) is still in very much of an infancy state when it comes to accurately being used to tell the story of the patient.  There is much fragmentation in the method of recording information into the record vs. how it is displayed and organized for the end-user (reader) of such information.  Often lost in translation is the continuity from one note to the following report, from one order to the results, and between one caregiver and the next.

Much of this was due to the very confusing requirements of the Meaningful Use standards that tried to force practitioners into too heavy use of structured discrete data within template, while EHR vendors simultaneously were limiting physician flexibility due to restrictive designs in format. Adding to this decline of dictation use was the provider organization’s push to eliminate costs associated with the practice of dictation and transcription to justify the expensive purchase of an EHR. The EHR vendors were also supporting this push toward use of templates to build a return on investment case, but with no one considering the impact that the loss of dictation would have on the integrity of the medical record itself.


When clinicians are forced, or choose to use templated documentation, they fall into bad habits.  These habits include such problematic documentation short cuts such as copy and paste, auto-fill-in of existing templates from previously recorded information, over-use of drop down menus which are pre-populated with erroneous or old data, and data pulled from other sources or records that are not appropriate to be re-copied.

Rushing the act of documentation, or performing template fill-ins may allow the doctor to see more patients, but can result in several problematic and risk prone situations that can result in harm to the patient as well as create legal risk for the organization.   For example:

  1. Copy and paste can create fraudulent billing as coders may accidentally code a situation more than once or bill for something that was documented more than once, but truly only completed once
  2. Automatic filling of templates from previous information from another record or practitioner speeds up documentation, but fails to update current information such as the status of medications, conditions, allergies or other items that change frequently. When relying on old data, a safety risk is present for patients.
  3. Incorrectly populated drop down menus that come from limited diagnostic problems lists can omit critical detail necessary for care of the patient, communication to other providers, and denials for medical necessity.

It is no wonder why physicians are demanding the use of dictation and transcription once again, and why the CMS has come out with statements supporting the use of dictation once again within the EHR and many hospitals are returning to fully transcribed core documents such as history and physicals, operative reports, consultation reports, and discharge summaries.

Please refer to the article “Transcription and EHR’s: Benefits of a Blended Approach” by Jay Cannon and Susan Lucci to understand many of the industry issues that support a return to dictation and transcription as a core strategy for the EHR. http://bok.ahima.org/doc?oid=97974#.WIlUUIcryuU  [i]

Although this article was penned in 2010, very little has changed and it is still relevant today to the need in the physician community for the documentation of clear, concise, complete, chronologic and compliant documentation in the medical record.


Caring for patients is a very human business. It consists of the simple actions of

  1. assessing a patient
  2. creating differential diagnoses as to the cause of a symptom/condition
  3. ordering diagnostic testing
  4. creating a treatment plan based on results of testing (which may include procedural-surgical components as well as therapeutic/pharmaceutical modalities)
  5. monitoring the patient over time to validate the diagnoses
  6. and then eventually repeating the evaluation, diagnostic, and therapeutic cycle

To describe these stages effectively, the SOAP process was put into place (Subjective, Objective, Assessment and Plan) as a guideline for clinicians to document their care. These principles are still taught in medical schools today as a proper form of documentation that follows language in a spoken format to describe each of these components.   The problem is that EHR’s tend to require discrete templated documentation that consists of fields of drop down choices that do not appear in very SOAP oriented format and certainly don’t convey that phased process when reading the output of the documentation.

It is ONLY in use of dictation and transcription that one can truly read a formatted note within the EHR to help support SOAP charting, and to create the true infrastructure of the medical record content that supports telling the story of the patient during each episode of care.

Disclaimer: This blog represents the opinion of the author and is not to be considered legal advice. Grzybowski is the author of the award-winning book “Strategies for Electronic Document and Health Record Management” (AHIMA, 2014) You can read more about her at http://www.himentors.com/about-himentors/

[i] Cannon, Jay; Lucci, Susan. “Transcription and EHRs: Benefits of a Blended Approach” Journal of AHIMA 81, no.2 (February 2010): 36-40.