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Chapter 9 : Health Information and Administration. Health Information Technicians. History of the Profession 1897: Grace Whiting Myers 1 st medical record administrator 1928: Myers founded Association of Record Librarians of North America

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Chapter 9 : Health Information and Administration


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    1. Chapter 9: 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