Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 9: Health Information and Administration

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Health Information Technicians History of the Profession –1897: Grace Whiting Myers 1 st medical record administrator –1928: Myers founded Association of Record Librarians of North America –1991: organization renamed American Health Information Management Association (AHIMA) –1934: first standards for training programs set –1942: AMA began approving programs –1953: standards set for training of medical record technician

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Health Information Technicians (cont’d) Education –Associate’s degree is standard –225 accredited programs –Includes: General education courses Professional education courses Practicum experiences

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Health Information Technicians (cont’d) Course Work: Professional –Biomedical sciences –Health data structure, content, & standards –Health care information requirements & standards –Clinical classification systems –Reimbursement –Health care statistics & research –Organizational resources –Quality management & performance improvement –Health care delivery systems –Privacy, confidentiality, legal issues, & ethical issues –Information & communication technologies –Data storage & retrieval –Data security & health care information systems

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Health Information Technicians (cont’d) Registration –Registered Health Information Technician (RHIT) credential offered by AHIMA –Gives advantage in job market, higher salary –Requires 2-year associate’s degree & written exam –Renewal requires 20 continuing education units every 2 years

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Health Information Technicians (cont’d) Work Responsibilities –Create paper or electronic chart –Add documents to a patient’s chart –Make written entries in a chart –File & retrieve charts according to facility rules –Release authorized data from a chart –Compute health care statistics

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Health Information Technicians (cont’d) Personal Characteristics –Good organizational skills –Attention to detail –Good communication skills

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Health Information Technicians (cont’d) Employment Opportunities and Trends –20% growth fro 2008 to 2018 –Growth due to: Increase in older population Shift toward electronic records –Setting distribution About 40% of jobs in hospitals 26% of jobs in physicians’ offices Other: nursing care, government, outpatient care, home health care, administrative support

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Health Information Technicians (cont’d) Professional Organization: AHIMA –>53,000 members –Provides accreditation –Offers certification & continuing education –Advocates before Congress, federal agencies –Offers many member benefits

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Health Information Coders History of the Profession –17 th century: bills of mortality published (plague) –19 th century: Farr advanced recording of mortality data –1855: 2 nd International Statistical Conference adopted system –1893: adoption of International List of Causes of Death –System expanded to meet needs of many organizations –Morbidity measured, in addition to mortality –1948: World Health Organization (WHO) assumed list –2013: switch from ICD-9-CM to ICD-10 standards

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Health Information Coders (cont’d) Education –Most learn on the job –A few associate’s degree programs in coding (non-accredited) –Also included as part of health information technician programs –36 coding certificate programs approved by AHIMA –Approved programs include: Course work 40 hours of practical coding experience

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Health Information Coders (cont’d) Course Work –Biomedical sciences –Information technology –Health information management –Clinical classification systems –Anatomy & physiology –Medical terminology –Computer software applications in health care –Coding

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Health Information Coders (cont’d) Certification –American Academy of Professional Coders (AAPC) Offers 5 general & 19 specialty credentials Some credentials require 2 years of coding experience Apprentice status available Renewal requires continuing education –AHIMA Offers Certified Coding Associate + 2 advanced credentials Suggests ≥6 months coding experience or completion of program

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Health Information Coders (cont’d) Work Responsibilities –Assigns diagnostic codes using ICD-9-CM or ICD-10 (after 2013) –Assigns procedure codes using CPT or HCPCS –Monitors patient records for changes & updates codes –Investigates health plan payment details –Assists in using coded data for reporting –Coordinates coding information with other health care professionals

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Health Information Coders (cont’d) Personal Characteristics –Attention to detail –Accuracy –Persistence –Diligence –Ability to work alone & independently –Ability & willingness to learn

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Health Information Coders (cont’d) Employment Opportunities and Trends –Growth: 20% between 2008 & 2018 –Growth due to: Increase in # of medical tests, treatments, & procedures –Setting distribution 40% in hospitals 26% in physicians’ offices Remainder in nursing care, government, outpatient care, home health care, administrative support

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Health Information Coders (cont’d) Professional Organizations –AHIMA –AAPC –PAHCS

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Medical Transcriptionists History of the Profession –Dates almost to beginning of medicine –Early physicians recorded information about their patients –Early 20 th century: dictation to stenographers –Later: dictation to tape recorder, then transcription –1960s: hospitals staffed with medical transcriptionists –1978: Association for Healthcare Documentation Integrity formed –1999: medical transcriptionists granted their own classification

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Medical Transcriptionists (cont’d) Education –2-year associate’s degree or 1-year certificate program –22 programs approved –Many programs are online or self-study –Programs include course work + 2,400 minutes of transcribing

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Medical Transcriptionists (cont’d) Course Work –Medical style & grammar –Medical knowledge Anatomy & physiology Concepts of disease Pharmacology Laboratory medicine –Medical transcription technology –Medicolegal aspects of the health care record –Medical transcription practice

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Medical Transcriptionists (cont’d) Credentials Available –Registered Medical Transcriptionist (RMT) –Certified Medical Transcriptionist (CMT) –AHDI Fellow (AHDI-F)

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Medical Transcriptionists (cont’d) Work Responsibilities –Download & send files –Transcribe medical reports –Use references to check medical terms –Edit, proofread, & format transcriptions –Query the professional who dictated a document –Make corrections marked by the professional who dictated a document

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Medical Transcriptionists (cont’d) Personal Characteristics –Good listening skills –Ability to focus –Commitment to accuracy –Written communication skills –Attention to detail –Analytical skills –Ability to work alone & independently

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Medical Transcriptionists (cont’d) Employment Opportunities and Trends –Growth of 11% between 2008 & 2018 –Increased opportunities due to: Increasing # of older adults Transition to electronic documentation –Setting distribution 1/3 in hospitals ¼ in physicians’ offices Remainder in business support, medical & diagnostic labs, outpatient care, & offices of health care practitioners

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Medical Transcriptionists (cont’d) Professional Organization: AHDI –Sets standards for education & practice –Represents profession before legislative & regulatory agencies –Seeks to educate agencies & public about role of profession –Awards professional certifications & fellowship designation –Offers many membership benefits