Use electronic health records (EHR) systems technology to access, input, store, update, and retrieve patient health information. Organize and manage healthcare information data ensuring its accuracy, quality, accessibility, privacy, and security in both electronic and paper formats.
Specialization focus may occur in different information areas such as medical coding, health information technology systems, data analytics, reimbursement and insurance claims, and cancer and other disease registries. Tasks and duties vary with the size and type of employment setting.
Medical records and health information technicians (commonly called health information technicians) assist hospitals, doctors' offices, nursing care facilities, and other medical services providers in compiling, organizing, and managing patient health information. They regularly communicate with physicians and other health care professionals to clarify diagnoses and procedures for accurate clinical classification and appropriate documentation. They increasingly use more technologically advanced, computer-based electronic health records (EHRs) systems on a daily basis for most work activities.
Health Information technicians may process patient admission and discharge documents, reviewing these records for completeness, accuracy, and compliance with rules and regulations, including privacy. They may assist in preparing or receiving patient insurance claims data and payments. They may develop, maintain and operate a variety of health record indices, and storage and retrieval systems to collect, classify, store and analyze information.
Health information technicians also may compile medical care and census data for statistical reports on diagnoses, procedures, occupancy rates, and other data analytics as requested from the clinical staff. They may prepare statistical reports, narrative reports and graphic presentations of information such as cancer registry data for use by hospital staff, researchers, or other users. They may support data-based research by physicians, nurses, and other medical staff. They may assist in the development of in-service educational materials.
Some health information technicians specialize in coding patient medical information for clinical indices, statistics, and health insurance reimbursement purposes, and are known as medical coders or clinical coding specialists. Others may specialize in the registry and tracking of a particular disease such as cancer. Cancer registrars help maintain facility, regional, and national databases of cancer patients. These databases are used to support cancer research and share treatment results.
In carrying out all of their various tasks and duties, health information technicians work to fully protect the privacy and security of all patients' medical records to ensure that confidentiality is maintained. In this area of security, they work to keep and apply strict privacy andsecurity rules and procedures for the protection of health information, especially as required under the federal law known as the Health Insurance Portability and Accountability Act, or HIPAA.
An entry-level health information technician with experience, additional education and training, and/or industry-based certification can become a supervisor, and with a bachelor's or master's degree, advance to become a healthcare information manager or director. Health information technicians can also chose to use specialty education and certification to attain promotion in areas such as cancer registry or public health and clinical data research.
Credentials Needed: Health information technicians are not required to be state licensed or registered. Most employers prefer to hire those medical records and health information technicians who have completed a postsecondary health information management training program, and who also may have further benchmarked their knowledge and skills by earning a voluntary industry-based skill certification for this occupation.
For example, the American Health Information Management Association (AHIMA) offers certification as a Registered Health Information Technicians (RHIT). To obtain the RHIT credential, an individual must graduate from a two-year associate degree program accredited by the Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM) and pass an AHIMA administered certification examination. Additional specialty certifications are available through AHIMA, such as the Clinical Coding Specialist (CCS) and Clinical Coding Specialist - Physician Practice (CCS-P).
The American Academy of Professional Coders (AAPC) offers a range of certifications in medical coding, auditing, and compliance. In addition, the Board of Medical Specialty Coding & Compliance (BMSCC), National Healthcareer Association (NHA), and Professional Association of Health Care Coding Specialists (PAHCS) also sponsor certifications in specialty coding. The National Cancer Registrars Association (NCRA) offers a specialty certification as a Certified Tumor Registrar (CTR).
When there are multiple industry-based certifications sponsored by different organizations it may helpful to find out which ones are more widely-used and accepted in your geographic area, medical setting in which you are planning to work, or specialty that you are working to acquire.
You can begin to acquire this kind of information by talking with the education instructors or counselors at the school you are attending and with persons already in the occupation, and by contacting the human resources personnel at potential employers for their suggestions regarding which certifications they more highly value when hiring for an entry-level position.
Some Key Things to Remember: Medical records and health information technicians increasingly are using computer-based electronic health records (EHR) systems technology to access, input, store, update, and retrieve information. Employers prefer to hire health information technicians who have completed a short-term postsecondary certificate program or have earned a two-year associate's degree in healthcare information technology.
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