31 Oct 2013

When Smartphones Do Dumb Things

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Mobile health apps are slowly revolutionizing patient care, but occasionally the revolution takes a left turn into lunacy and feeds a hypochondriac’s worst fears.

Article by Paul Cerrato, InformationWeek October 28, 2013

What are we to make of the Owlet Baby Monitor, which attaches to a baby’s sock and measures heart rate, skin temperature, blood oxygen levels, sleep quality and more, and sends the data to your smartphone?

“This is an invitation to craziness,” says Kenneth, Bromberg, MD, chairman of pediatrics at Brooklyn Hospital Center.

Bromberg goes on to say in a recent Wall Street Journal article that there’s no medical or safety reason for the device: “It will make [parents] neurotic and anxious. I don’t see how any new parent with that gadget won’t be driven insane.”

It’s only natural for new parents to fret about the well-being of a newborn, especially if it’s the first child, but as Bromberg points out, it’s unlikely they’ll find peace of mind monitoring a long list of vital signs on their smartphone. You might make a case for this kind of monitoring for a newborn suffering from some sort of chronic disease, but not for a normal child.

Devices like the Owlet are symptoms of a more global social disease: The medicalization of everyday life, a growing obsession among the worried well in an affluent nation. Men over a certain age no longer have a normal, age-related decline in libido, they have erectile dysfunction. Restless or poorly disciplined children no longer need firmer parent supervision; now they have attention deficit disorder. And, of course, stressed-out office workers with insomnia are suffering from a sleep “disorder” requiring prescription medicine.

Several social critics have put the blame for such medicalization of life’s everyday ups and downs on the pharmaceutical industry, which seems to always have a new medication to solve the problem. Now some mobile health developers are following this same path, seeing opportunities to cash in on the nation’s hypochondriacal tendencies.

Fortunately, most mobile health apps and devices take the high ground, concentrating on monitoring parameters that matter to people who really need them. Countless diabetics have benefited from blood glucose meters that link to their smartphones. Home-bound patients with congestive heart failure are now feeding body weight readings into mobile devices to send to their physicians. A new app being tested at the Mayo Clinic even allows you to reach a doctor, find a diagnosis, and track one’s medical records. The app, which is simply called “Better,” also includes Mayo’s online symptom checker.

Of course, a digital symptom checker is a two-edged sword. For a well-adjusted person without unrealistic fears of doom and destruction, it can help detect a serious health problem before it requires emergency care. For others, it’s one more excuse to worry about imaginary disease.

It’s so easy to fall into this trap when using a symptom finder because most diseases have no pathognomonic sign. In other words, there is no one signpost that definitively announces the presence of a specific disease. In their earlier stages, many life-threatening disorders announce themselves with vague signs and symptoms that can be caused by a hundred other minor disorders that usually disappear on their own. So it’s easy for a worrywart to jump to the conclusion that their persistent headache is proof that they have a brain tumor, when in fact it’s because they tried giving up caffeine cold turkey.

Mobile health, like telemedicine services, will eventually take us places we never dreamed possible a few short years ago. Let’s not waste time along the way measuring bodily functions that are better left unknown.

24 Oct 2013

Is your doctor spying on your tweets? Social media raises medical privacy questions

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Article by Art Caplan, Ph.D. NBC News, Oct. 21, 2013

A friend recently brought to my attention a disturbing question from a psychiatrist working with a transplant team: Should she be checking the sobriety claims of liver transplant candidates by looking on their Twitter and other social media sites? That question merits discussion because it’s clear both doctors and patients are entering a new world of uncertain medical privacy due to Twitter, Facebook, Google+ and other outlets.

In this case, the doctor was asked to offer an opinion about a young man’s eligibility for a liver transplant. The medical team would not take him if he was still drinking. The doctor knew the young man had a history of at least one binge-drinking episode more than a year ago that resulted in a car crash. Since then, both the would-be transplant candidate and his mother said he had been sober.

The psychiatrist was ready to recommend admission to the liver transplant program when she received a photo by email of the young man in a bar. Someone on the transplant team had thought to check the guy’s Twitter account. There he was for all the world to see, surrounded by booze, hoisting a cold one in a picture he himself had posted.

If you are still drinking you are not going to get into any liver transplant program. The picture was probably enough reason to turn away the young man —meaning in all likelihood a death sentence.

The situation raises vital questions about privacy and doctor-patient relationships that simply did not exist before the social media explosion.

Should this doctor or any health care professional have checked the transplant candidate out on social media? I can’t find any ethical guidelines that say no. But even if ethical restrictions existed, it is probably fair to assume that a lot of doctors and those who work with them, many who grew up with Facebook and Twitter and the like, will be tempted to do so.

How is that going to happen, you ask, when most doctors barely have time to see a patient much less spend hours hunting on the Internet? You have to remember now that anyone in the doctor’s office or out in the community can look at your social media profile and rat you out. And a lot of doctors make their living checking out the reliability of what patients say.

Take for example, you say your back really hurts and you are disabled — let’s take a peek at your Facebook page to see if you manage to hit the tennis court, the jogging path or the golf links. Promise to be abstinent due to your venereal disease—what are you doing on dating sites on Craigslist? Swear to stay away from fatty foods and high calorie treats—why did your doctor just read a review by you of barbecue joints on Yelp or Zagat?

Presuming doctors, their helpers or your neighbors are going to look, ethical standards or not, shouldn’t patients be told if someone does? I think so. I think the transplant candidate had the right to know that he tweeted himself right out of a shot at a liver transplant. And you need to realize that information you put up on social media sites may wind up being used by your doctor, hospital, psychologist, school nurse or drug counselor.

Right now there are no rules or even suggestions to guide doctor-patient relationships over the Internet. Both now have new ways to look at one another outside the office or exam room. If they are going to continue to trust one another then we need to recalculate existing notions of medical privacy and confidentiality to fit an Internet world where there is not much of either.

17 Oct 2013

States encounter ObamaCare impostors

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Article By Elise Viebeck, TheHill Blog, October 14, 2013

State insurance regulators are encountering sites designed to mimic ObamaCare’s enrollment portal, the online hub where millions of people are meant to purchase healthcare coverage. Attempts at imitating healthcare.gov have met with cease-and-desist letters; the sites could confuse consumers seeking to enter ObamaCare’s marketplaces.

In New Hampshire, the insurance commissioner reportedly cracked down on one webpage last week that could have been mistaken for the state’s insurance exchange.

And regulators from Washington, Pennsylvania and Connecticut are warning the health insurance industry against creating sites that might mislead the public.

The healthcare law is expected to prompt fraud attempts similar to those seen in Medicare and other government programs. It’s unclear whether the technical problems plaguing the ObamaCare enrollment portal are increasing the instance of consumer scams.

One classic trick is perpetrated when Medicare beneficiaries receive a call from someone who says they work from the government. The caller then asks for sensitive personal details — such as bank account and Social Security numbers — in the name of presenting the individual with a new Medicare card. Regulators fear that ObamaCare will give rise to similar scams and warn consumers not to release their personal information to unverified callers.

Top administration officials met in September to discuss the potential for abuse, though the government shutdown is inhibiting some anti-fraud actions. “We will be vigilant as always in cracking down on this type of opportunistic fraud,” Federal Trade Commission Chairwoman Edith Ramirez told CBS News.

10 Oct 2013

What everyone is getting wrong about Healthcare.gov

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October 7, 2013 Washington Post Article by Tom Lee

This Reuters article about Healthcare.gov has been getting some attention. Alas, it’s not very good, focusing on client-side optimizations that are probably unrelated to the federal health care Web site’s early woes. Healthcare.gov’s problems are almost certainly occurring at a deeper level in the system, making it very difficult, if not impossible, for an outsider to gauge how serious those problems are.

To explain, let’s do one of those analogy things. Say that Kathleen is planning a birthday party for herself.

There are a bunch of tasks associated with the party that need to be done. For instance, guests have to be told where and when the party is and whether to bring gifts. This is a pretty easy task to manage: Kathleen prints up a bunch of flyers with the relevant information and asks some friends to hand them out.

This task can be done well or poorly, of course. Maybe she foolishly printed bits of information on different pieces of paper instead of on a single flyer. Maybe she only asked one friend to hand them out and he’s a flake. These could become real issues if more people than Kathleen anticipated want to attend the party.

These are easy problems to solve, though. Printing more flyers is simple. You can hire people to hand out the flyers if your friends aren’t reliable. There’s no real need for these distributors to coordinate.

Some tasks require Kathleen herself, though. Receiving happy birthday wishes, for instance: There could be a huge number of guests, but there’s only one Kathleen. If she doesn’t plan for this properly, she could wind up being too busy receiving congratulations nonstop to enjoy the party. Perhaps her guests will have to waste their time queued up waiting for her, too.

Many Web application optimization problems can be categorized in a similar way. Some processes can be run in parallel, without central coordination. These processes might be implemented wastefully or unprofessionally, but you can usually fix them by throwing more resources at the problem. Cloud-hosting architectures often make this trivially easy.

Other problems require coordination or centralization. That can cause bottlenecks, and they can be quite severe. You can respond by rewriting, redesigning, tuning or, yes, throwing more resources at the affected systems. Sometimes this works and sometimes it doesn’t; it requires time and expertise, though, not just a credit card and an Amazon account. Sometimes your only real option is to design around these problems: Queue the expensive tasks for later execution, or accept a loss of synchronization across your system.

The Reuters article spends a lot of time on how many static resources are loaded into the browser by Healthcare.gov. Sometimes there are good reasons for loading a bunch of that stuff and sometimes there aren’t. The fact that there’s usually room for improvement — as any Web optimization tool will tell you — means that it’s pretty simple to make a critique of virtually any site. That doesn’t make the bugs and glitches critical problems, however.

Besides, the symptoms that usually show up with this class of problems are different than the ones afflicting Healthcare.gov. And many of the Healthcare.gov assets in question are served through the Akamai Content Delivery Network, which is probably the best-known brand name when it comes to making sure your servers can handle gigantic amounts of static asset requests.

It is much more likely that Healthcare.gov’s problems are related to the more expensive operations involving the insurance application process itself. Checking users’ eligibility and filing their applications requires integration with a separate and more complex set of systems — ones that have little to do with your Web browser. Fixing those sorts of jams can be easy or difficult; the boring truth is that it’s hard to say definitively from outside the system. Much harder than carping about uncompressed Javascript, at any rate.

Parts of Healthcare.gov are down right now, presumably under technical maintenance. Hopefully they improve the system throughput. Traffic is likely to even out after the initial crush of applicants, which should also help. Before long, I suspect that the site will work just fine.

It’s unfortunate that Healthcare.gov hasn’t made a great first impression. But it still has time to get things right. Once it does, there’ll be lessons to be drawn. But they’re probably not going to be ones you can generate automatically from a browser plugin.

03 Oct 2013

Struck by Turtle: Anticipating a New Healthcare-Billing System

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From article on Atlantic.com by Richard Gunderman dated Sep 30 2013

T minus 12 months and counting until physicians and hospitals must comply with the federal government’s October 1, 2014 deadline to implement the ICD-10 system for classifying diseases.

Developed by the World Health Organization, its predecessor ICD-9 has been in place since the late 1970s. It lists no fewer than 13,000 billable codes, which include such exotic diagnoses as “injury from fall while occupying spacecraft” and “exposure to fireball effects of nuclear weapon.” The U.S. clinical modification of ICD-10 will include no fewer than 68,000 codes. These changes are emblematic of a plague of complexification sweeping across healthcare.
The deadline for implementing ICD-10 has been pushed back multiple times, mainly due to the time required to design and install software and hire and train coding specialists to cope with the new system. Most physicians I know are baffled by it. For example, ICD-10 distinguishes between “spacecraft collision injuring occupant,” “spacecraft fire injuring occupant,” “spacecraft explosion injuring occupant,” “forced landing of spacecraft injuring occupant” “unspecified spacecraft accident injuring occupant,” and “other spacecraft accident injuring occupant.”

But this isn’t all. It also distinguishes between such turtle-related injuries as “bitten by turtle” and “struck by turtle,” and between “bitten by turtle – initial encounter” and “bitten by turtle – subsequent encounter,” as well as “struck by turtle – initial encounter” and “struck by turtle – subsequent encounter.” Under just what circumstances someone would be struck by a turtle in a subsequent encounter is left to the imagination of the coder. Similar byzantine coding subcategories apply to assaults by alligators, dogs, and even ducks.

Imagine typical community physicians, who might be a solo or small-group practice. How could they hope to cope with such complexity? Would they be able to master it on their own? Or would they need to retain the services of a small battalion of coders, billers, and information technology support staff to have any hope of putting such a system into practice? And what is the effect of such complexity on the efficiency, ease of use, level of integration, quality of communication, and overall cost of our healthcare system?

Who could blame patients and physicians for thinking that the provision of high-quality medical care is already more than sufficiently complex without adding additional burdensome layers of administration? Just look at any contemporary textbook of internal medicine. The best known runs to over 4,000 printed pages. It is chock full of information about human disease and its treatment. Then along comes a disease classification system that runs to 68,000 entries. It is not difficult to imagine many physicians hanging their heads in despair, overwhelmed by a sense of futility.

Many innovations in healthcare that originally seemed like important steps forward have turned out merely to add complexity without offering any real benefit to either patients or physicians. For example, bolting on new information technology and increasing the complexity of medical information systems has frequently accomplished little more than turning the physician into a data entry specialist. Even worse, the goal of such initiatives is frequently not to enhance care but to facilitate billing.

The attractive red ribbon in which such gifts originally came wrapped has often turned out to be a mummifying ball of red tape that makes it difficult to unwrap the present that is supposed to be safely encased inside. Said one of my colleagues recently, “I went to medical school to care for patients, not to fill out forms.”

Put another way, healthcare is becoming more bureaucratic, and the rate of bureaucratization seems to be increasing exponentially. More and more, bureaucrats, not physicians, are shaping how medicine is practiced by assuming control of how healthcare is classified and paid for. The word bureaucracy after all, comes from the French word bureau, meaning desk, and a bureaucrat is someone who sits behind a desk, devising rules and making sure they are followed.

Bureaucrats both public and private frequently have little or no experience of actually caring for patients. What seems obvious from the standpoint of someone with a background in insurance or healthcare administration frequently does not make sense from the perspective of patients and health professionals.

John Stuart Mill famously wrote that bureaucracy stifles the mind, and this is exactly what is happening in healthcare. The personal dimension of the patient-physician relationship is being taken out of the equation and replaced by a series of bureaucratic guidelines and rules. Every complaint, every diagnosis, and every treatment must have its own code. Rules, not the judgment and discretion of human beings, increasingly predominate.

Patients and physicians who thought they were acquiring a new and better range of healthcare options are discovering that such systems frequently turn out to function like huge boa constrictors, squeezing the life out of the collaboration and trust that characterize a thriving patient-physician relationship. For healthcare to thrive in the future, physicians need to see themselves not as nameless and faceless functionaries, but as personally responsible for the quality of work they do and the relationships they build.

What can ordinary people do about the growing complexity of healthcare? When confronted with such looming changes as ICD-10, we can seek answers to some basic questions and then vote accordingly with our ballots and wallets:

Why do physicians spend as little as eight minutes per day in the company of each hospitalized patient, yet spend more than 40 minutes per day interacting with health plans?

Why does the U.S. spend at least $360 billion annually on healthcare administration, more than three times what we spend each year on treating cancer?

And above all, why is my doctor so distracted, distraught, and discouraged, and what can each of us do to help all doctors devote more of their attention to what really matters most in healthcare – taking good care of patients?

26 Sep 2013

Health law enrollment in US to see slow start next week

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Article on Bloomberg.com By Alex Wayne & Alex Nussbaum – Sep 24, 2013

Enrollment in the Affordable Care Act’s public health exchanges, a key effort to reach people without health insurance, will start slowly, a senior Obama administration official said.

While the U.S. exchanges begin selling insurance plans on Oct. 1, the medical coverage doesn’t take effect until Jan. 1, a gap that may lead some Americans to hold off on purchases until the last minute, said the official, who asked not to be identified because the person wasn’t authorized to speak on the record. The biggest portion of sign-ups will occur closer to January, the officials told Bloomberg News today.

Such a scenario would mimic patterns surrounding the initial enrollment periods for Medicare Part D prescription drug plans in late 2005 and Massachusetts’s health-care law in 2006. The Obama administration has said it’s seeking at least 7 million people to enroll through the Affordable Care Act by April.

“A majority of individuals would say, ‘If I’m not going to get my insurance until Jan. 1, then I’m certainly not going to pay my premium on Oct. 1,’” Dan Schuyler, a director at the consulting firm Leavitt Partners in Salt Lake City, said in a telephone interview. “Realistically, a lot of people will not actually buy the product until the end of November at the earliest.”
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19 Sep 2013

Saving U.S. Health Care With Skype

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Lawmakers and proponents of telemedicine have begun exploring how technology can improve the health care system in the wake of Obamacare

Article by Maya Rhodan published in Time magazine’s Swampland

The University of Virginia Health System is home to a program that may be essential to solving the health-care-access problem in the U.S. The program is centered around telemedicine, or the use of electronic communication to exchange medical information either from patient to physician or between doctors.

Through the UVA system’s Center for Telehealth, physicians from 40 specialties partner with 108 community hospitals, free clinics, schools and more to provide nearly 33,000 people with care they otherwise wouldn’t be able to acquire.

“It saves lives, it saves functions, and it reduces cost,” David C. Gordon, the director of the office of telemedicine and rural network development at UVA Center for Telehealth, says about the program.

According to Gordon, the University of Virginia Health System has reduced preterm deliveries during high-risk pregnancies by 25% via telemedical services that maintain communication between patients and physicians through technology as simple as Skype and as complicated as robotics, even when those in need are hundreds of miles away from care.

Since its inception, Gordon says, they have saved Virginians over 7.9 million miles in travel for health care.

The UVA system, however, is not alone in providing a once unavailable service to patients; every state has a telemedicine program, ranging from stroke diagnosis to psychiatric evaluations to prenatal care. And now, with the expanding insurance coverage provided by the Affordable Care Act — and the doctor shortage predicted to come with it — proponents of telehealth believe its widespread implementation can have a positive impact on the future of the health care system.

“There is this perfect storm of increased demand with the newly insured, a shortage of primary-care physicians and specialists, and a need to keep costs in control,” Mario Gutierrez, the executive director of the Center for Connected Health Policy, a leading telehealth policy center, tells TIME. “I think telehealth provides a real vehicle for doing that.”

If members of health care communities with and without specialists and highly skilled practitioners are able to work together using technology, Gutierrez says, the issue of access to care can be met head-on. “What the system will encourage is for the greatest efficiency and improvements in quality that are going to be measured by the outcomes of the patient population,” he says.

Some outcomes have already begun to prove there is some benefit in adopting telemedicine: the Partners HealthCare system in Boston was able to reduce readmission of 1,200 heart-failure patients by 50% through a home telemonitoring program. Under the Affordable Care Act, Medicare is required to reduce payments to hospitals that have excessive readmissions rates by as much as 2% in 2014. New advancements in telemedicine such as in-home care products, proponents say, allow doctors to follow up with patients from outside the hospital via a computer or mobile device, which can help hospitals reduce readmission rates and avoid penalties.

Other technologies, like WellPoint’s LiveHealth Online, cut out the initial visit altogether, letting patients visit the doctor from home or work via live video and instant-messaging services with doctors. That is something that could be of great use in the coming years, with the Association of American Medical Colleges estimating that the U.S. will be doctor-deficient by as many as 91,500 by 2020.

The benefits of telemedicine were also the topic of discussion at a briefing on Capitol Hill on Friday, where panelists from both the private and public sectors declared everyone is a winner when telemedicine is implemented. “It’s a win-win,” said Neal Neuberger, the executive director of the Institute for e-Health Policy, on Friday. “I’ve never met a member of Congress on either side of the aisle, in either house, that didn’t think this was a good idea.”

Though Congressman Gregg Harper, a Republican from Mississippi, is presenting a bipartisan bill to Congress this week that tackles the cost of telemedicine and expands the role of Medicare and Medicaid, telehealth still faces huge barriers to widespread implementation, largely because of the fact that there is no comprehensive standard policy surrounding it. “The march of technology for health care far exceeds our ability to adopt, diffuse, incorporate and govern … in a public- and private-sector setting, any of these technologies,” says Neuberger.

Because of licensing rules, physicians are generally unable to practice outside their states. If a patient they’re seeking to provide virtual care for is out of state, they will need a license in both places, restricting access for those in need. Medical boards have also placed higher regulatory standards on telehealth practices, like a requirement that a patient mush have an in-person, established relationship with the provider before receiving care.

Doctors are also limited in the services they are reimbursed for under Medicare, which only encompasses telehealth services that are provided in narrow scope of rural areas, by physicians and nurse practitioners in specific offices. According to the American Telemedicine Association, 80% of Medicare beneficiaries are not covered because they live in counties federally designated as metropolitan areas. Despite that, 42 states cover telehealth through the Medicaid program, and 15 states have laws that mandate coverage for telehealth services.

12 Sep 2013

Blood pressure cuff may misdiagnose thousands

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24-hour device offers better blood pressure test, Twin Cities doctors say

By: Jeremy Olson , Twin Cities Star Tribune September 8, 2013

Twin Cities doctors say the cuffs at the clinic may misdiagnose thousands. They are touting a 24-hour monitor.

A blood pressure check may be one of the most tried and true routines of a visit to the doctor’s office. But a group of Allina Health doctors in Edina is challenging the reliability of the conventional test and is trying a new method they believe could provide a more accurate diagnosis for thousands of patients who suffer from hypertension.

While few doubt that routine checks help millions of Americans control their high blood pressure, there is growing evidence that these point-in-time readings overdiagnose some patients — people whose numbers go up at the doctors’ office simply because of nerves — while underdiagnosing others whose hidden hypertension puts them at greater risk for stroke and heart disease.

“The reality is [that] your blood pressure fluctuates day to day, hour to hour, minute to minute,” said Dr. David Ingham, who practices at Allina’s Center for Outpatient Care in Edina. “And those fluctuations are important.”

Over the past year, Ingham and his colleagues have been testing a new device on more than 1,000 Twin Cities patients to see whether 24-hour blood pressure monitoring can provide a more accurate diagnosis.

One of those patients is 37-year-old Jeff Zoss of Minnetonka, who agreed to wear the wireless monitor. It was strapped to his left arm and took his blood pressure every 20 minutes, then tracked his scores so they could be uploaded to the doctors.

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05 Sep 2013

We need a Moore’s Law for medicine

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Technology is the primary cause of our skyrocketing health-care costs. It could also be the cure.

Article on TechnologyReview.com by Antonio Regalado, September 3, 2013

Moore’s Law predicts that every two years the cost of computing will fall by half. That is why we can be sure that tomorrow’s gadgets will be better, and cheaper, too. But in American hospitals and doctors’ offices, a very different law seems to hold sway: every 13 years, spending on U.S. health care doubles.

Health care accounts for one in five dollars spent in the United States. It’s 17.9 percent of the gross domestic product, up from 4 percent in 1950. And technology has been the main driver of this spending: new drugs that cost more, new tests that find more diseases to treat, new surgical implants and techniques. “Computers make things better and cheaper. In health care, new technology makes things better, but more expensive,” says Jonathan Gruber, an economist at MIT who leads a heath-care group at the National Bureau of Economic Research.

Much of the spending has been worth it. While the U.S. spends the most of any country by far, health care is becoming a larger part of nearly every economy. That makes sense. Better medicine is buying longer lives. Yet medical spending is so high in the U.S. that the White House now projects that if it keeps growing, it could, in 25 years, reach a third of the economy and devour 30 percent of the federal budget. That will mean higher taxes. If we can’t accept that, says Gruber, we’re going to need different technology. “Essentially, it’s how do we move from cost-increasing to cost-reducing technology? That is the challenge of the 21st century,” he says.
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29 Aug 2013

Top 10 Reasons Why You Should Make The Switch To Digital From Cassettes

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Still using audio tapes to dictate? 

Thinking about switching to a digital recorder or call-in system?

Top 10 reasons why you should make the switch:

  1. Tapes easily become lost or misplaced, resulting in wasted time and productivity. When a digital audio file is sent for transcription, a copy can be sent and a copy kept for a period of time (for redundancy purposes).
  2. Tapes wear out and recording quality degrades over time, resulting in wasted time and additional costs. Digital audio files do not contain any actual moving parts and cannot be “eaten” by a recorder.
  3. Tapes are normally recorded with multiple reports on them, which means the transcriptionist receives these jobs all at once. The moment a digital audio file has been dictated, it can be sent–thus the MT receives the dictation more quickly and turnaround time improves.  Stat dictation can be transcribed immediately.
  4. It is only possible to record onto tapes using “overwrite” mode. This means that if you need to add additional audio to a file, you have to append the additional audio. With most digital systems, it is possible to insert audio mid-file, which means if you need to add an extra paragraph, you can.
  5. Tapes are physical, meaning that a tape recorded in Timbuktu cannot be transcribed in Topeka within the same hour. Digital audio files are not geographically constrained. A digital file recorded in Timbuktu can therefore be transcribed in Topeka or any other location within the hour, thus improving turnaround and providing the opportunity to reduce office space and cut expenses via out-sourcing. Read more