Chapter 24: Health Information and Administration

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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