Every time a patient receives health care, a record is maintained of the observations, medical or surgical interventions, and treatment outcomes. This record includes information that the patient provides concerning his or her symptoms and medical history, the results of examinations, reports of x rays and laboratory tests, diagnoses, and treatment plans. Medical records and health information technicians organize and evaluate these records for completeness and accuracy.
Technicians assemble patients' health information. They make sure that patients' initial medical charts are complete, that all forms are completed and properly identified and signed, and that all necessary information is in the computer. They regularly communicate with physicians and other health care professionals to clarify diagnoses or to obtain additional information. Increasingly, this information is maintained electronically in healthcare information systems. Health information management professionals capture, analyze and protect digital and traditional medical information vital to providing quality patient care.
Some medical records and health information technicians specialize in coding patients' medical information for insurance purposes. Technicians who specialize in coding are called health information coders , medical record coders , coder/abstractors , or coding specialists . These technicians assign a code to each diagnosis and procedure. They consult classification manuals and also rely on their knowledge of disease processes. Technicians then use computer software to assign the patient to one of several hundred 'diagnosis-related groups,' or DRGs. The DRG determines the amount for which the hospital will be reimbursed if the patient is covered by
Medicare or other insurance programs using the DRG system. In addition to the DRG system, coders use other coding systems, such as those geared toward ambulatory settings or long-term care.
Some technicians also use computer programs to tabulate and analyze data to improve patient care, control costs, provide documentation for use in legal actions, respond to surveys, or use in research studies. For example, cancer (or tumor) registrars maintain facility, regional, and national databases of cancer patients. Registrars review patient records and pathology reports, assign codes for the diagnosis and treatment of different cancers and selected benign tumors.
Registrars conduct annual follow-ups on all patients in the registry to track their treatment, survival, and recovery. Physicians and public health organizations then use this information to calculate survivor rates and success rates of various types of treatment, locate geographic areas with high incidences of certain cancers, and identify potential participants for clinical drug trials.
Cancer registry data also is used by public health officials to target areas for the allocation of resources to provide intervention and screening.
Medical records and health information technicians' duties vary with the size of the facility where they work. In large to medium-sized facilities, technicians might specialize in one aspect of health information or might supervise health information clerks and transcriptionists while a medical records and health information administrator manages the department. In small facilities,

a credentialed medical records and health information technician sometimes manages the department.
Health information management requires technical skills so that data manipulation provides useful reports. This means that a working knowledge of the integration of the data with database storage software and statistical analysis of the data is needed. The reports generated must serve as a communication link between many different individuals. Providers use information to make health care decisions, and health care facilities and organizations use it to make business decisions. Health information includes tracking data with the intent to make improvements in the system in some way, or to provide solutions to problems such as those related to research, planning, provision of care, and the evaluation of health care services. Thus the process of collecting and disseminating information must have a positive end goal, such as improving patient care. Outcomes that support quality patient care, medical research, health planning, health care evaluation, and financial reimbursement are a required component of the job. In the modern world of health care, an individual who develops and uses innovative approaches to solve problems, save money, or redesign work habits is highly sought.
The individual who is hired to manage health care information is required to have a working knowledge of medical ethics and the legal ramifications of inappropriate use of personal data.
For example, the federal government is very clear about the rights of an individual patient, especially in medical research. It is imperative to store data in a way that protects the anonymity of the individual and his or her privacy rights when the data is accessed for research purposes. In addition, data must be stored to insure that confidentiality is maintained, and that access is denied to those individuals who have no need for the specific information about the individual patient. Data must be stored so that it can be used to compare a patient's care with standards of care and quality indicators, which are needed for evidence-based practice.
Those working with health information may be asked to produce a needs analysis, complete a systems analysis, or redesign the existing system, addressing quality of care, costs, care delivery processes, and financial questions. Tying reports to the volume of services, charges, costs, and reimbursements are current and future expectations. Managers of health information work in a wide variety of settings, such as with private physicians; in hospitals or nursing homes ; with insurance companies, law firms, and government agencies; and for companies who specialize in information technology. In summary, the entire process of health information management is focused on securing, analyzing, and integrating the information so that it can used for a specific purpose.

Health information management professionals usually work a 40-hour week, although some overtime may be required. Options for home-based work or evening and night-shift schedules may be available in hospitals. Other work environments include pharmaceutical firms, insurance companies, long term care facilities, public health settings, physician group practices, consulting firms, computer systems design firms and many more settings.
Health information management graduates entering the field graduate from associate degree programs accredited by Commission on Accreditation for Health Informatics and Information
Management Education (CAHIIM) in community or junior colleges or CAHIIM-accredited baccalaureate degree programs in a college or university. Some go on to earn a master’s degree.
In addition to a general education, coursework includes biomedical sciences, legal aspects of health information, coding and management of clinical data, statistics, database management, quality improvement methods and computer technology applied to health information systems.
Students interested in professional certifications from the American Health Information
Management Association should check the CAHIIM accreditation status of the program for eligibility. Search for schools that provide training for this career.
After graduating, many health information management professionals choose to earn credentials through a combination of education and experience and performance on national certification exams.
Health information encompasses a wide range of job functions and settings. Among these are medical records management, privacy officer, risk management, medical coding, corporate compliance, and data analysis and reporting.
Industries with an increased demand for health information professionals include academic institutions, consulting agencies, government agencies, and healthcare software companies. As health information technology (HIT) becomes more prevalent, health information practitioners will continue to be critical components of the electronic health record (EHR) workforce.
According to the US Department of Labor, HIT will grow to encompass new support positions, including mobile support adoption positions, public health informatics, implementation support specialists, and information management redesign specialists.
Demand is on the rise at all levels of education and credentialing. There are approximately
12,000 to 50,000 new jobs anticipated by 2017, and the Bureau of Labor Statistics cites medical records and health information technicians as one of the 20 fastest growing occupations in the
US. More than half of new health information graduates with bachelor's degrees start with salaries in the $30,000 to $50,000 range. By five years out, one can earn upwards of $50,000 to
$75,000 annually. Most new health information graduates with associate's degrees jump right in and earn $20,000 to $30,000 annually. These figures are just averages—many professionals report higher salaries.

29-2071 Medical Records and Health Information Technicians
Compile, process, and maintain medical records of hospital and clinic patients in a manner consistent with medical, administrative, ethical, legal, and regulatory requirements of the health care system. Process, maintain, compile, and report patient information for health requirements and standards in a manner consistent with the healthcare industry's numerical coding system. Excludes "File Clerks" (43-4071).
Percentile wage estimates for this occupation:
Percentile 10% 25%
50%
(Median)
75% 90%
Hourly
Wage
$10.70 $12.94 $16.42 $21.33 $27.02
Annual
Wage
$22,250 $26,920 $34,160 $44,360 $56,200
Industry profile for this occupation:
Industry Employment
Percent of industry employment
Hourly mean wage
Annual mean wage
General Medical and Surgical
Hospitals
Offices of Physicians
Nursing Care Facilities (Skilled
Nursing Facilities)
Outpatient Care Centers
Home Health Care Services
68,440
40,230
12,980
7,180
6,240
1.31
1.69
0.78
1.12
0.53
$18.68
$15.04
$16.86
$16.77
$17.04
$38,860
$31,290
$35,060
$34,890
$35,440
Industries with the highest concentration of employment in this occupation:
Industry
Offices of Physicians
Employment
Percent of industry employment
Hourly mean wage
Annual mean wage
40,230 1.69 $15.04 $31,290

General Medical and Surgical
Hospitals
Specialty (except Psychiatric and
Substance Abuse) Hospitals
Outpatient Care Centers
Office Administrative Services
68,440
2,960
7,180
3,430
Top paying industries for this occupation:
1.31
1.28
1.12
0.83
$18.68
$19.33
$16.77
$19.10
$38,860
$40,210
$34,890
$39,730
Industry Employment
Percent of industry employment
Hourly mean wage
Annual mean wage
Pharmaceutical and Medicine
Manufacturing
40
Insurance and Employee Benefit
Funds
Scientific Research and Development
Services
Grantmaking and Giving Services
40
540
160
Federal Executive Branch (OES
Designation)
5,260 http://www.bls.gov/oes/current/oes292071.htm
0.02
0.10
0.09
0.12
0.26
$31.76
$24.92
$23.11
$22.52
$22.25
$66,060
$51,840
$48,060
$46,840
$46,280
Professional Associations/Student Resources
American Health Information Management Association www.ahima.org
Commission on Accreditation for Health Informatics and Information Management Education
http://cahiim.org/
Career Prep Tools
www.hicareers.com
American Hospital Association
www.aha.org