confidentiality. In transcribing directly for a doctor or a group of physicians, there are specific formats and report types used, dependent on that doctor's speciality of practice, although history and physical exams or consults are mainly utilized. In most of the off-hospital sites, independent medical practices perform consultations as a second opinion, pre-surgical exams, and as IMEs (Independent Medical Examinations) for liability insurance or disability claims. Some private practice family doctors choose not to utilize a medical transcriptionist, preferring to keep their patient's records in a handwritten format, although this is not true of all family practitioners. Currently, a growing number of medical providers send their dictation by digital voice files, utilizing a method of transcription called speech or voice recognition. Speech recognition is still a nascent technology that loses much in translation. For dictators to utilize the software, they must first train the program to recognize their spoken words. Dictation is read into the database and the program continuously "learns" the spoken words and phrases. Poor speech habits and other problems such as heavy accents and mumbling complicate the process for both the MT and the recognition software. An MT can "flag" such a report as unintelligible, but the recognition software will transcribe the unintelligible word(s) from the existing database of "learned" language. The result is often a "word salad" or missing text. Thresholds can be set to reject a bad report and return it for standard dictation, but these settings are arbitrary. Below a set percentage rate, the word salad passes for actual dictation. The MT simultaneously listens, reads, and "edits" the correct version. Every word must be confirmed in this process. The downside of the technology is when the time spent in this process cancels out the benefits. The quality of recognition can range from excellent to poor, with whole words and sentences missing from the report. Not infrequently, negative contractions and the word "not" is dropped altogether. These flaws trigger concerns that the present technology could have adverse effects on patient care. Control over quality can also be reduced when providers choose a server-based program from a vendor Application Service Provider (ASP). Downward adjustments in MT pay rates for voice recognition are controversial. Understandably, a client will seek optimum savings to offset any net costs. Yet vendors that overstate the gains in productivity do harm to MTs paid by the line. Despite the new editing skills