Chapter 14 PPT

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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 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)
–
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
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Add documents to a patient’s chart
–
Make written entries in a chart
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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
–
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
–
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)
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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)
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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
–
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
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Medical Transcriptionists
• History of the Profession
–
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
–
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)
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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
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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
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
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