Ernest Camponovo, MD, MBA

I'm not a fan of voice recognition transcription, so I read Eric Trefelner's column, "Voice recognition misses a few beats" (May, page 104), with special interest. I'm also not naive enough to believe individual radiologists can, or should, stand in the way of this remarkable technology.

Many of us went into radiology at least in part because we were comfortable with technology and wanted to apply the latest innovations to advance the health of our patients. But voice recognition could become just the latest high-tech method of increasing our cost of doing business.

Trefelner touches on how radiologists should approach issues of cost awareness, a concept of critical importance to all radiologists. What concerns me is the insidious, incremental passing on of costs to radiologists, while the benefits of voice recognition go to hospitals or imaging center owners. We must be vigilant over costs even when they appear in the guise of innovations necessary to maintain competitive advantage.

Increasing consumer and competitive pressure requires radiologists to constantly evaluate where they "add value" to the patient's healthcare experience. The "radiology value chain" represents the entire cascade of decisions and events that constitutes the patient's encounter with imaging services. From the moment the referrer makes a decision to obtain a radiologic exam until we provide a timely, accurate, and clinically useful interpretation, we have the ability to add value to the patient's care. This includes the dictation/transcription process, which is too often downplayed by radiologists as someone else's problem. But we are often judged by our reports, and, therefore, the dictation/transcription problem has to become our problem.

All of us have experienced different systems, each with its strengths and weaknesses. My favorite experience occurred long ago when a group of us military radiologists were moonlighting at a local community hospital. The after-hours transcriptionists were also moonlighters-one in her last semester of a Ph.D. program in English. This was the one time in my life when my reports came back better than I dictated them. Too often, however, we are satisfied just to see reports that reasonably reflect what we meant.

The problem with voice recognition transcription is that the strengths add value and the weaknesses add costs, and the value and costs go to different entities. The two major strengths frequently touted for voice recognition are timeliness of reports and cost savings.

 But accurate and timely report production is not yoked to voice recognition. My experience with several hospitals with a dedicated, stable, in-house transcription crew that knows the radiologists and their idiosyncrasies is that very high quality reports can be turned out and autofaxed to the referrers easily within four hours, and often within one hour. Even in today's highly charged consumerist medical marketplace, this has to be considered more than adequate for most reports.

As for the cost savings, it would serve radiologists well to recall the saying, "There's no such thing as a free lunch." As Trefelner says, the huge savings in labor advertised for voice recognition systems are really just shifted costs, typically from the hospital to the radiologist. The costs saved from eliminating transcription jobs resurface as decreased radiologist productivity. Unfortunately, because the radiologist is the most expensive link in the radiology value chain, even a minor decrease in his or her productivity results in a disproportionately high cost to the whole practice, and the competitive advantage of rapid reports can be quickly negated. When the radiologist is not a hospital employee, however, this cost is invisible to administrators, who are often eager to accept the trade.

Over the past 10 to 20 years, the costs of doing business have been steadily climbing for radiology practices, and reimbursements have failed to keep up. A practice's success is a complex interplay of revenues and costs that the group hopes will result in net profits.

 Keeping close tabs on costs is critical but increasingly difficult, as many costs are insidious, incremental, or otherwise hidden. Voice recognition, separate from any potential benefit, is clearly a cost to radiologists in decreased productivity, and any net benefit must be realized at least in part by the radiologists bearing the real costs.

Radiology is performed more efficiently and more accurately when done in batches. Voice recognition systems using the radiologist as the editor cause interruptions with every case and decrease the radiologist's productivity. Some studies show up to a 36% decrease in productivity with voice recognition.

 Anecdotally, voice recognition adds 30 minutes to three hours to the radiologist's work day.

My group recently took over a reading contract with three MRI centers using voice recognition. Each radiologist had to spend two to three days of training for the system-and these were all U.S. radiologists with English as a primary language and no accents. All of this time represents costs borne by the radiologists, while the savings benefit the center owners. Even proponents of voice recognition agree that costs are shifted to radiologists.

 One challenge to radiologists is to show administrators how the radiology value chain depends on all links working together and that decreased radiologist productivity can lead to decreased imaging volumes for the facility.

Instead of blindly allowing ourselves to be entranced by the seeming magic of voice recognition, we need to carefully and objectively evaluate it on a cost-benefit basis as we would any proposed change to our practice/business structure. Keeping in mind the problem with voice recognition systems-that the costs and benefits do not necessarily accrue to the same entities-what are the radiologist's options?

First, as Trefelner pointed out in an earlier Diagnostic Imaging column, "Don't put a radiologist up against the wall until you mean it" (January 2002, page 56), radiologists should realize that they do not have to cater to administrators' whims. The national shortage of radiologists has given the specialty market power that we can exercise in evaluating activities and opportunities-what we will and won't do and what we will and won't accept. Radiologists should be aware of their rights and obligations under their contracts. They should have rights that at a minimum allow input into decisions regarding report generation: not only if it is done but how it is done. Radiologists should demand that they be allowed to continue batch reading and that there be at least one full-time in-house editor with primary responsibility for editing reports.

My comments are not made to condemn voice recognition, but rather to focus attention on how decisions should be made regarding the anticipated costs and rewards, and who pays and who benefits. Certainly, an increasing number of facilities and practices across the country are incorporating voice recognition technology with at least superficial success. But radiologists should be aware that even if the decision is made after careful analysis, the course can be treacherous. At Children's Hospital of Boston,

 it took two separate attempts in four years to finally implement voice recognition. Success was achieved only after a dedicated multidisciplinary team of radiologists, hospital management, IT specialists, and vendor experts approached the problem in stages. Interestingly, their chronicle of the implementation emphasizes the importance of cost-benefit analysis but does not address the issue of who incurred the costs and where the benefits were credited. Radiologist productivity was not addressed at all.

Ultimately, the challenge for radiologists is to work with administrators to develop true strategic partnerships with aligned interests. With voice recognition, realigning interests may be as simple as Trefelner's suggestion that some of the savings be spent in the radiology department. Radiologists need to convince administrators that when the radiology value chain works to maximum utility, providing excellent customer service, the facility benefits. Conversely, any impediment to a highly performing value chain, such as decreased radiologist productivity and ability to handle workload, can create delays, dissatisfaction, and even lowered quality. This, in turn, has a negative impact on the facility's profitability. With any new technology, program, or procedural change, radiologists should expect a true partner's share of input into the decisions and a fair share of benefits commensurate with the costs they bear.

1. Trefelner E. Voice recognition misses a few beats. Diagnostic Imaging May 2004;26:104.

2. Heilman R. Voice recognition transcription: Surely the future, but is it ready? Radiographics 1999;19:2.

3. Mehta A. Voice recognition technology. www.imagngeconomics.com/supplements/ddept/voice.html. Accessed June 2004.

4. Sperry K. Study looks at the pros and cons of voice recognition. www.eurekalert.org/pub_releases/2003-05/arrs-sla042203.php. Accessed June 2004.

5. Bankhead C. Voice recognition adds time to radiology reports. www.diagnosticimaging.com/webcast99/previous.shtml#1129am. Accessed June 2004.

6. Antiles S, Hornberger C, Weis M, et al. Implementing speech recognition at Children's Hospital Boston. www.imagingeconomics.com/library/200405-19.asp. Accessed June 2004.

7. Camponovo E. The business of radiology: cost accounting. JACR, in press.

Dr. Camponovo is a practicing diagnostic radiologist and nuclear medicine physician in central Pennsylvania. He now serves as chairman of The Heart of Lancaster Regional Medical Center and Carlisle Regional Medical Center.

Ernest Camponovo, MD, MBA

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