1. Chapter 14: Health Information and Administration

2. Health Information Technicians
History of the Profession
1897: Grace Whiting Myers 1st 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

3. Health Information Technicians (cont’d)
Education
Associate’s degree is standard
225 accredited programs
Includes:
General education courses
Professional education courses
Practicum experiences

4. 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

5. 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

6. 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

7. Health Information Technicians (cont’d)
Personal Characteristics
Good organizational skills
Attention to detail
Good communication skills

8. 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

9. 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

10. Health Information Coders
History of the Profession
17th century: bills of mortality published (plague)
19th century: Farr advanced recording of mortality data
1855: 2nd 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

11. 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

12. 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

13. 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

14. 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

15. Health Information Coders (cont’d)
Personal Characteristics
Attention to detail
Accuracy
Persistence
Diligence
Ability to work alone & independently
Ability & willingness to learn

16. 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

17. Health Information Coders (cont’d)
Professional Organizations
AHIMA
AAPC
PAHCS

18. Medical Transcriptionists
History of the Profession
Dates almost to beginning of medicine
Early physicians recorded information about their patients
Early 20th 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

19. 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

20. 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

21. Medical Transcriptionists (cont’d)
Credentials Available
Registered Medical Transcriptionist (RMT)
Certified Medical Transcriptionist (CMT)
AHDI Fellow (AHDI-F)

22. 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

23. 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

24. 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

25. 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