Chapter 9: Health Information
and Administration
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Health Information Technicians
• History of the Profession
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1897: Grace Whiting Myers 1st medical record administrator
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1928: Myers founded Association of Record Librarians of North
America
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1991: organization renamed American Health Information
Management Association (AHIMA)
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1934: first standards for training programs set
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1942: AMA began approving programs
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1953: standards set for training of medical record technician
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Health Information Technicians (cont’d)
• Education
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Associate’s degree is standard
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225 accredited programs
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Includes:
• General education courses
• Professional education courses
• Practicum experiences
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Health Information Technicians (cont’d)
• Course Work: Professional
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Biomedical sciences
–
Health data structure,
content, & standards
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Health care information
requirements & standards
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Clinical classification
systems
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Reimbursement
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Health care statistics &
research
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Organizational resources
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Quality management &
performance improvement
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Health care delivery
systems
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Privacy, confidentiality,
legal issues, & ethical
issues
–
Information &
communication
technologies
–
Data storage & retrieval
–
Data security & health care
information systems
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Health Information Technicians (cont’d)
• Registration
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Registered Health Information Technician (RHIT) credential
offered by AHIMA
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Gives advantage in job market, higher salary
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Requires 2-year associate’s degree & written exam
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Renewal requires 20 continuing education units every 2 years
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Health Information Technicians (cont’d)
• Work Responsibilities
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Create paper or electronic chart
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Add documents to a patient’s chart
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Make written entries in a chart
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File & retrieve charts according to facility rules
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Release authorized data from a chart
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Compute health care statistics
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Health Information Technicians (cont’d)
• Personal Characteristics
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Good organizational skills
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Attention to detail
–
Good communication skills
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Health Information Technicians (cont’d)
• Employment Opportunities and Trends
–
20% growth fro 2008 to 2018
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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
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>53,000 members
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Provides accreditation
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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
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17th century: bills of mortality published (plague)
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19th century: Farr advanced recording of mortality data
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1855: 2nd International Statistical Conference adopted system
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1893: adoption of International List of Causes of Death
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System expanded to meet needs of many organizations
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Morbidity measured, in addition to mortality
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1948: World Health Organization (WHO) assumed list
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2013: switch from ICD-9-CM to ICD-10 standards
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Health Information Coders (cont’d)
• Education
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Most learn on the job
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A few associate’s degree programs in coding (non-accredited)
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Also included as part of health information technician programs
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36 coding certificate programs approved by AHIMA
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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
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Information technology
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Health information management
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Clinical classification systems
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Anatomy & physiology
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Medical terminology
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Computer software applications in health care
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Coding
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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
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Health Information Coders (cont’d)
• Work Responsibilities
–
Assigns diagnostic codes using ICD-9-CM or ICD-10 (after 2013)
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Assigns procedure codes using CPT or HCPCS
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Monitors patient records for changes & updates codes
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Investigates health plan payment details
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Assists in using coded data for reporting
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Coordinates coding information with other health care
professionals
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Health Information Coders (cont’d)
• Personal Characteristics
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Attention to detail
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Accuracy
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Persistence
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Diligence
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Ability to work alone & independently
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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
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AAPC
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PAHCS
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Medical Transcriptionists
• History of the Profession
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Dates almost to beginning of medicine
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Early physicians recorded information about their patients
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Early 20th century: dictation to stenographers
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Later: dictation to tape recorder, then transcription
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1960s: hospitals staffed with medical transcriptionists
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1978: Association for Healthcare Documentation Integrity
formed
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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
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22 programs approved
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Many programs are online or self-study
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Programs include course work + 2,400 minutes of transcribing
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Medical Transcriptionists (cont’d)
• Course Work
–
Medical style & grammar
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Medical knowledge
• Anatomy & physiology
• Concepts of disease
• Pharmacology
• Laboratory medicine
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Medical transcription technology
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Medicolegal aspects of the health care record
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Medical transcription practice
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Medical Transcriptionists (cont’d)
• Credentials Available
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Registered Medical Transcriptionist (RMT)
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Certified Medical Transcriptionist (CMT)
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AHDI Fellow (AHDI-F)
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Medical Transcriptionists (cont’d)
• Work Responsibilities
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Download & send files
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Transcribe medical reports
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Use references to check medical terms
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Edit, proofread, & format transcriptions
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Query the professional who dictated a document
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Make corrections marked by the professional who dictated a
document
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Medical Transcriptionists (cont’d)
• Personal Characteristics
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Good listening skills
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Ability to focus
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Commitment to accuracy
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Written communication skills
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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
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Sets standards for education & practice
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Represents profession before legislative & regulatory agencies
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Seeks to educate agencies & public about role of profession
–
Awards professional certifications & fellowship designation
–
Offers many membership benefits
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins