Chapter 9 Health Information and Administration Copyright 2013

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 1 st 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 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 – 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 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 – 17 th century: bills of mortality published (plague) – 19 th century: Farr advanced recording of mortality data – 1855: 2 nd 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 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) – 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) – 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 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 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Medical Transcriptionists • History of the Profession – Dates almost to beginning of medicine – Early physicians recorded information about their patients – Early 20 th century: dictation to stenographers – Later: dictation to tape recorder, then transcription – 1960 s: 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) Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 – 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