The Do-It-Yourself ASP

The Do-It-Yourself ASP

A few years ago application service providers (ASPs) were the latest and greatest thing to hit medical transcription. They promised to buy all the technology, do all the programming and setup, train service owners, MTs, doctors, and office staff. They also promised to make you, their client, continually HIPAA-compliant, or at least HIPAA-ready. Using their technology you could run your business from the Bahamas, or any other location where you have Internet access. Your clients can use this technology to retrieve and search for their reports online, again, from anywhere there is an Internet connection. In exchange for this great technological support the ASP would ask back a portion of your transcription revenue. Usually this ranges anywhere from 1 cent a line to 4 cents a line.

Now that many people are worried about a possible recession most transcription services can no longer afford the costs associated with outsourcing their technology to an ASP. The question becomes, what technology can your business deliver to your clients in the current economy?

Features of most ASPs

Most ASPs share some common features that make renting their technology beneficial to MT services.

Digital dictation capture, either through the use of a handheld unit or a call-in dictation system that answers on a 1-800 phone line.
Some form of encryption technology to safeguard the confidential information as it is transferred through the Internet.
A method of audio playback so the MT can actually transcribe the work.
An online delivery system. So that MTs can get audio from the doctors and send their completed reports back to the service. The doctor can also use this method to get his completed reports from the MT or service.

Digital Dictation Capture

In order for you to put speech on the Internet in any form you must first digitize it so it can be stored as files on a computer. There are many different ways to digitize audio. You can use an expensive call-in system which will allow the doctor to dictate by calling into a special dictation computer located at your home or office. The following companies make such systems: ByteScribe, Dictaphone, DVI, Lanier, and VDI. If you need to go this route, be warned, these systems are very expensive. You will also need to get a system that allows for a digital export of the audio files, usually into WAV format. Digital export usually costs extra and WAV files are quite large and difficult to move across the Internet. The cost of adding phone lines will need to be taken into account as well.

A better and cheaper route to capture dictation is through the use of a digital handheld recorder like those made by Sony and Olympus. These are small easy-to-operate devices that the dictating physician can carry around with him like a portable tape recorder. When he is finished dictating, he connects the handheld unit to his PC where the files are saved. More expensive/newer models allow the physician to store the dictation on removable media which can be swapped out of the unit like a floppy disk. These handhelds have excellent compression usually somewhere between 50k - 100k per minute of voice. (WAV files usually take up 1 megabyte per minute of voice.) They will usually hold at least two hours of dictation between downloads.

Available units from Olympus are the DS-3000, DS-2000, DS-320, and the DS-150 (which may already be discontinued). Olympus models can be found at: http://www.olympusamerica.com/cpg_section/cpg_vr_digitalrecorders.asp

Available units from Sony are the ICD-MS1 and the ICD-R100PC. Sony models are on the web at: http://www.sel.sony.com/SEL/consumer/icrecorder/models.html

Encryption Technology

The next thing you need when moving to digital dictation is some form of encryption technology. Without this in place third parties have access to your data as it moves through the Internet or is stored on a server. ASPs use Secure Socket Layer (SSL) encryption to secure the connection. This is a very expensive option and setting it up is more in the domain of an experienced system administrator than an MT.

An easier and more straightforward approach is to encrypt the files while they reside on a computer before they are exposed to the Internet. You can do this with file encryption software. Encryption software can be found and downloaded from http://www.tucows.com, http://download.cnet.com, or any number of other shareware repositories on the Internet. PGP is a very popular program which can be downloaded from http://www.pgpi.org, http://www.pgp.org, or http://web.mit.edu/network/pgp.html. I have written one as well, called MEP which you can download from my website at http://www.deturi.com.

You will need to have doctors encrypt their audio and your MTs will need to encrypt their completed reports. Once the files are securely encrypted they can safely be moved about the Internet at will. You can move them through e-mail, FTP (File Transfer Protocol), or through the World Wide Web. (While many digital transcription products offer e-mail capability for audio files I have yet to see one that actually encrypts the files before e-mailing.)

Audio Playback for MTs and QAs

The method you choose for audio playback will depend on the method you choose for dictation capture. For instance, you can't play Olympus DSS files on some WAV players and you can never play them on a C-phone. Makers of digital handhelds (Sony and Olympus models) have hardware available so the MT can play the files back from her computer with a footpedal control. This additional hardware runs about $150 -$250 per MT.

The digital handheld units mentioned above come with software that will allow you to convert their proprietary compressed audio formats to a standard WAV file. Depending on the licensing restrictions of the software, you may be able to distribute it to your MTs. This will allow them to use any of the numerous WAV players available on the market for transcription from their computers.

A list of some of the currently available WAV player software and pricing:

StartStop - $199 w/footpedal
(http://www.startstop.com/Transcription.htm)

WAVPedal - $190 w/footpedal
(http://www.theprogrammers.com/wavp.html)

GearPlayer - $129.95 w/o footpedal, $169.95 w/serial footpedal, $189.95 w/USB footpedal
(http://www.transcriptiongear.com/products/gearplayer/)

ByteScribe WAV Player - $149 w/serial footpedal, $169 w/USB footpedal
(http://www.bytescribe.com/wavplay/)

Express Scribe - FREE w/o footpedal
(http://www.nch.com.au/scribe/)

If you need to order footpedals (for use with ExpressScribe or for a backup in case your footpedal from one of the other vendors breaks) you can get them from:

Sound Technologies
1-800-472-0358

Online Access and Storage

Now comes the hard part. At this stage of the game you've probably decided that you want to go digital, and moving encrypted files through e-mail is okay for a while, but it has some problems. For one thing e-mail limits you to a small amount of mail, usually only 2-3 megabytes. That won't be sufficient for moving large files, like uncompressed WAV files, if you have to. Also, e-mail can be unreliable. The recipient has to wait for it to get to her. If it doesn't get there in time there isn't too much that you can do about it.

You could FTP the files, but this requires that you give everyone who is going to be sending and receiving them access to your FTP server. What if you don't have an FTP server with a constant high speed connection to the Internet? What if you don't have the money to purchase a server and configure it?

There is another way to move confidential files besides e-mail and FTP. You can use the World Wide Web or HTTP (Hyper-text Transfer Protocol). Most people get free web space along with their Internet service, most people don't use that web space. Hold that thought while we look at how ASPs use the web to deliver files.

An ASP uses their web servers to query a database of files that your company and clients have uploaded to them. The ASP then uses some form of software (usually programmed in Java, ASP, or ActiveX) running on their server to create a web page from your data. This is why an ASP costs you money. They have to put the software and the server in place so it can manage your data. They have to hire people to do the programming and get people to make sure the system is running correctly. They have to buy or lease an expensive digital dictation server and multiple phone lines so your clients can call into a 1-800 number without ever getting a busy signal.

So far, we've sidestepped the SSL issue by encrypting files with PGP, MEP, or whatever before moving them across the Internet. We've avoided the monolithic outlay for a digital dictation system by having our clients use relatively inexpensive handheld digital recorders. We've kept our MTs from having to purchase $1000 C-phones or $600 C-phone clones by having them use WAV player software and a footpedal that connects to their computer. We can sidestep the need for ASP server software by acquiring our own web host access.

By using free web space you can let someone else deal with the hassles of managing servers maintaining constant uptime. You will have to deal with ads, probably, but that is usually a small price to pay. You always have the option of signing on with an ad-free web hosting company for a set fee per month, usually $10 to $20.

The next question is: How can we upload files to a web server and use it to dynamically create a viewable web page that will allow our MTs and clients to get their work, for little or no money?

Free FTP software from Microsoft

It turns out that Microsoft included a nifty little utility in Windows 95 and 98 called FTP.exe. (This program may also be in Windows ME and XP, I haven't checked.) This is a command line program that allows you to connect to an FTP server, like the one that houses your free web space from your Internet Service Provider (ISP). It will also allow you to upload files to your web page, create and remove directories, and it will do everything any other FTP software will do.

The easiest, and therefore best way, to use FTP.exe is to create a series of batch files that contain the commands you need to run on the FTP server. You can execute the commands individually, but that takes time so just pay attention and I'll walk you through creating some command files that will allow you to get the job done with a few clicks of a mouse.

Creating the directories we need

First, you need to have a server address along with a login and password. You can get this from your ISP, your hosting company, or you can sign up for a free website online at places such as http://www.geocities.com. For demonstration purposes I created an account at GeoCities. It took less than 5 minutes. (If you use GeoCities keep in mind that you will be able to login to your FTP site an hour or so after signing up.)

The server information for my GeoCities account is as follows:

Host or Server: ftp.geocities.com
User ID or Login: deturi
Password: XXXXXXXXXXX (No, I'm not giving out my password.)

Armed with this information, let's hit FTP.exe. We're going to log in to the server manually and create a directory for one client and one MT using the "mkdir" command. Open an MS-Dos prompt by going Start menu | Programs | MS-Dos. Below is what I typed (in bold) and the responses I received from the server:

Microsoft(R) Windows 98(C)Copyright Microsoft Corp 1981-1998.C:\WINDOWS\Desktop>ftpftp> open ftp.geocities.comConnected to ftp.geocities.com.220-Welcome to the Yahoo! GeoCities FTP server.220-Need help? Get all details at:220-http://help.yahoo.com/help/us/geo/gftp/220-220-No anonymous logins accepted.220 Yahoo!User (ftp.geocities.com:(none)): deturi331-Enter your Yahoo! GeoCities member password331Password: not shown when typing230-You are using 0.0% of your subscribed disk space230 You have 14.997 MB of space availableftp> mkdir client1257 "/deturi/client1" new directory created.ftp> mkdir mt1257 "/deturi/mt1" new directory created.ftp> quit221-You have transferred 0 bytes in 0 files221-Total traffic for this session was 498 bytes in 0 transfers.221-Thank you for using the FTP service on ftp.us.geocities.com.221 Goodbye.

As you can see from the above example I started the ftp.exe program by typing "ftp" at the DOS prompt. Then I opened the connection to my server by typing "open ftp.geocities.com." I logged in with my login name and password. I created two directories named "client1" and "mt1" by typing "mkdir client1" and "mkdir mt1," respectively. I then closed the FTP connection by typing the "quit" command.

Now that we've created the directories, we need to upload the files for one of our MTs and one of our clients. Since this is going to be a daily occurrence, lets get some automation in the process.

Automatic uploading to the FTP server

Since I know you don't want to sit in front of your computer for hours at a time uploading files through a command line interface, I'm going to show you how to create a batch file that will start FTP.exe and automate the uploads for us. To do this, right-click on an empty space on your Windows Desktop and choose New > Text Document from the pop-up window. This creates a new file named "New Text Document.txt." Press Enter.

If you don't see the ".txt" in the filename your system isn't set up to show the file extensions for known file types. We'll need to change that. Here's how:

Double-click the My Computer icon.
Open the View menu and choose Folder Options...
Click once on the View tab.
Take the check out of "Hide file extensions for known file types"
Click on the Like Current Folder button to make this change apply to all your folders.
Close the Folder Options window by clicking the OK button.
Close My Computer window by clicking the X in the top right corner.

Now back on your Desktop right-click on the New Text Document.txt that we just created. Choose Rename from the pop-up menu. Rename the file mt1.bat by typing "mt1.bat" (without quotes). Press Enter. Windows will ask you if you are sure you want to change a file extension. Yes, you are sure.

Right-click mt1.bat and choose Edit from the pop-up menu. This opens the empty batch file in Notepad. Type the following text into the file:

ftp -i -n -s:mt1.txt ftp.geocities.com

Save the file and Exit Notepad.

The flag -i suppresses confirmation prompts when uploading multiple files. The -n flag suppresses autologin upon connection. The flag -s:mt1.txt refers to a file in the same directory as mt1.bat that contains the commands we want to execute on the FTP server. (We'll get to that in a minute.) The last command-line parameter is the name of our server.

Let's create mt1.txt by right-clicking an empty area on the Desktop again. Choose New > Text Document from the pop-up menu. A file named New Text Document.txt will appear with the filename highlighted. Type "mt1.txt" (without quotes) to rename the file. Press Enter when you are done. Press Enter again or double-click the file to open it in Notepad. Type the following text into the file:

USER deturi XXXXXXXcd mt1mput c:\mt1\audio\*.*quit

Save the file and Exit Notepad.

The first line contains the "USER" command followed by my login name and my password. The second line uses the "cd" command to tell the FTP server to change the current working directory to mt1, the directory we created previously. The third line uses the "mput" command to upload all the files on my hard drive in the directory named "c:\mt1\audio" to the server. The last line closes the FTP connection and quits the FTP program.

You would want to create a separate batch file named client1.bat and also an associated client1.txt file. Using the statements above as a template for the new files, you'd want to replace occurrences of mt1 with client1 and point the upload directory to an appropriate directory on your hard drive.

When you want to upload files to an MT or a client, just copy the files you want to upload to their directory and double-click their batch file. A DOS window will open and they will upload automatically.

(If you are going to use GeoCities for your web host only certain file types are supported, see http://us.geocities.yahoo.com/v/filetypes.html for a complete list.)

WARNING!! Any audio or report files you upload to the Internet can be downloaded by everyone on the planet with an Internet connection. You must secure patient confidentiality with encryption before uploading the files to the Internet.

Other FTP commands

There will come a time when you will want to delete files from the server. You can do this with the delete and mdelete commands.

delete filename.txt

Deletes the file named "filename.txt" from the current working directory on the FTP server.

mdelete *.*

Deletes every file in the current working directory on the FTP server.

You can delete directories from the server by running the rmdir command from the parent directory. Like so:

rmdir directoryname

This will only work when the directory is empty.

Creating and uploading index.html

Theoretically, we could stop there but that would leave you open to another security breach. Go to http://geocities.com/deturi/mt1 and you will see there is a link to my parent directory, which is http://geocities.com/deturi. If my MTs or clients were to go to the main page at http://geocities.com/deturi they would see a listing of all the directories I had created. They could also see how much work I was giving MT2, MT3, etc. My clients could see how many other clients I have and how much volume I am producing for them. (This isn't exactly true, GeoCities puts a fake index file in the root directory, so this doesn't happen. But you'll still want to know how to do this in case you ever want to put directories inside other subdirectories, as in: http://geocities.com/deturi/mts/1234/ or http://geocities.com/deturi/clients/smith/.)

To stop this from happening we'll create a simple file named index.html and put that in the parent directory. Here's how:

Right-click on your Desktop and choose New > Text Document from the pop-up menu.
Press Enter to leave the name New Text Document.txt. Press Enter again to open the file in Notepad.
Add some simple text to the file. In my sample index.html I put, "This is my parent directory. Now get back to where you belong!!"
Save the file and Exit Notepad.
Right-click the file and choose Rename from the pop-up menu. Rename it "index.html" (without quotes).
Upload it to the parent directory using the following FTP.exe commands from a DOS prompt:

ftp
open ftp.geocities.com
deturi
XXXXXXX (for the password)
mputs c:\windows\desktop\index.html
quit

Options and enhancements

There is free FTP software with a graphical user interface (GUI). If you have Internet Explorer 5.x or better you can FTP files to a server using the Windows copy and paste commands. You can also drag and drop files directly from Windows Explorer to your server.

Some really nice and easy-to-use FTP software is called WS-FTP by Ipswitch. There is a free LE version for individual users and a Pro version for business users. As far as I'm concerned, Ipswitch makes the best general purpose FTP software on the net. Get it along with more information about FTP'ing files at: http://www.ftpplanet.com. The Pro version costs less than$40.

I've put together some FTP software of my own specifically for the purpose of uploading files to a web server and creating an HTML page listing the files that reside in the server in the specified directory. It will also send out e-mail notification when you upload files to someone's directory. Check out FTPWizard on my Programs page at www.deturi.com. It costs $50.

When you add a file named index.html to your mt1 or client1 directory you can have graphics and instructions in the pages that your MTs and clients visit along with links to their downloads. Also, if there is an index.html file in the individual directories your MTs and your clients won't see the Parent Directory link.

You can take advantage of domain name registration to get a web address similar to www.mypage.com. Or use domain forwarding so that people accessing their web pages can go to names like, mt1.mywebsite.com or client1.mywebsite.com. Register.com sells domain names for $35 a year and will forward 10+ domains for free with the register.com ad frame showing. If you don't like the ad frame it will cost you $50 a year for frame-free forwarding. Yahoo! GeoCities will also give you domain names and extra web space for $8.95 and $11.95 per month depending on the package you want.

MTs and doctor's offices can get their files to you the same way that you get your files to them. They can use this article to learn how to create their own websites and upload encrypted files for you to download and distribute at your convenience.

Since your files are encrypted no one will be able to access someone else's work, unless you use the same password for everyone. Don't do that! People will still be able to see how much work others are getting if they know someone else's web address. Using hard to guess web addresses will help. Instead of naming the mt1 directory mt1 I could have named it mt1_10g7DbqH4. Then I'd just tell my MT to bookmark the site or add it to their Favorites. Had I done this the address would have been: http://geocities.com/deturi/mt1_10g7DbqH4.

Doing the math

Okay, did you do the math? We're encrypting our files with free encryption software (PGP). We've got free web hosting (Yahoo! GeoCities), using a free FTP program (FTP.exe), free WAV player software (Express Scribe) with a $40 footpedal (VEC Technologies). Assuming your MTs can buy their own footpedals and you can get the doctors to purchase their own handheld units, you've just created a do-it-yourself ASP for next to nothing. Congratulations!!

If you like having the security of being able to e-mail or call tech support when there is a problem, you will probably want to purchase your own software and some of your own hardware. Having an extra handheld unit and footpedal on hand never hurts either. Even if you do that, an FTP program ($40-$50), encryption software ($20-$50), and ad-free web hosting ($10-$20 per month) combined, cost less than the start-up and training costs charged by most ASPs.

The most significant benefit to using the methods I've outlined in this article is that we've managed to stay compliant with HIPAA through our use of encryption and we've maintained total control of our data throughout the entire transcription process.