Occupation Profile for 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.

Signficant Points

• Employment is expected to grow faster than average.
• Job prospects should be very good; technicians with a strong background in medical coding will be in particularly high demand.
• Entrants usually have an associate degree.
• This is one of the few health occupations in which there is little or no direct contact with patients.

Overview

Sample Job Titles

Training

• These occupations often involve using your knowledge and skills to help others. Examples include sheet metal workers, forest fire fighters, customer service representatives, pharmacy technicians, salespersons (retail), and tellers.
• These occupations usually require a high school diploma and may require some vocational training or job-related course work. In some cases, an associate's or bachelor's degree could be needed.
• Some previous work-related skill, knowledge, or experience may be helpful in these occupations, but usually is not needed. For example, a teller might benefit from experience working directly with the public, but an inexperienced person could still learn to be a teller with little difficulty.
• Employees in these occupations need anywhere from a few months to one year of working with experienced employees.

Medical records and health information technicians entering the field usually have an associate degree from a community or junior college. Many employers favor technicians who have become Registered Health Information Technicians (RHIT). Advancement opportunities for medical record and health information technicians are typically achieved by specialization or promotion to a management position.

Education and training. Medical records and health information technicians generally obtain an associate degree from a community or junior college. Typically, community and junior colleges offer flexible course scheduling or online distance learning courses. (See the Sources of Education, Training, and Financial Aid section of the Handbook for more information regarding community and junior colleges.) In addition to general education, coursework includes medical terminology, anatomy and physiology, legal aspects of health information, health data standards, coding and abstraction of data, statistics, database management, quality improvement methods, and computer science. Applicants can improve their chances of admission into a program by taking biology, math, chemistry, health, and computer science courses in high school.

Certification and other qualifications. Most employers prefer to hire Registered Health Information Technicians (RHIT), who must pass a written examination offered by the American Health Information Management Association (AHIMA). To take the examination, a person must graduate from a 2-year associate degree program accredited by the Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM). Technicians trained in non-CAHIIM-accredited programs or trained on the job are not eligible to take the examination. In 2007, there were about 245 CAHIIM accredited programs in Health Informantics and Information Management Education.

Some employers prefer candidates with experience in a health care setting. Experience is valuable in demonstrating certain skills or desirable qualities. It is beneficial for health information technicians to possess good communication skills, as they often serve as a liaison between health care facilities, insurance companies, and other establishments. Accuracy is also essential to technicians because they must pay close attention to detail. A candidate who exhibits proficiency with computers will become more valuable as health care facilities continue to adopt electronic medical records.

Certification and advancement. Experienced medical records and health information technicians usually advance in one of two ways—by specializing or by moving into a management position. Many senior technicians specialize in coding, in cancer registry, or in privacy and security. Most coding and registry skills are learned on the job. A number of schools offer certificate programs in coding or include coding as part of the associate degree program for health information technicians, although there are no formal degree programs in coding. For cancer registry, there are a few formal 2-year certificate programs approved by the National Cancer Registrars Association (NCRA). Some schools and employers offer intensive 1- to 2-week training programs in either coding or cancer registry.

Certification in coding is available from several organizations. Coding certification within specific medical specialty areas is available from the Board of Medical Specialty Coding and the Professional Association of Healthcare Coding Specialist (PAHCS). The American Academy of Professional Coders (AAPC) offers three distinct certification programs in coding. The AHIMA also offers certification for Certified Healthcare Privacy and Security because of growing concerns for the security of electronic medical records. Certification in cancer registry is available from the NCRA. Continuing education units are typically required to renew credentials.

In large medical records and health information departments, experienced technicians may advance to section supervisor, overseeing the work of the coding, correspondence, or discharge sections, for example. Senior technicians with RHIT credentials may become director or assistant director of a medical records and health information department in a small facility. However, in larger institutions, the director usually is an administrator with a bachelor’s degree in medical records and health information administration.

Hospitals sometimes advance promising health information clerks to jobs as medical records and health information technicians, although this practice may be less common in the future. Advancement usually requires 2 to 4 years of job experience and completion of a hospital’s in-house training program.

Nature of Work

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, making sure that patients’ initial medical charts are complete, that all forms are completed and properly identified and authenticated, 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. Technicians regularly use computer programs to tabulate and analyze data to improve patient care, better control cost, provide documentation for use in legal actions, or use in research studies.

Medical records and health information technicians’ duties vary with the size of the facility where they work. In large to medium-size 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 may have the opportunity to manage the department.

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, relying on their knowledge of disease processes. Technicians then use classification systems 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 required for ambulatory settings, physician offices, or long-term care.

Medical records and health information technicians also may specialize in cancer registry. Cancer (or tumor) registrars maintain facility, regional, and national databases of cancer patients. Registrars review patient records and pathology reports, and assign codes for the diagnosis and treatment of different cancers and selected benign tumors. Registrars conduct annual followups 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. Public health officials also use cancer registry data to target areas for the allocation of resources to provide intervention and screening.

Work environment. Medical records and health information technicians work in pleasant and comfortable offices. This is one of the few health-related occupations in which there is little or no direct contact with patients. Because accuracy is essential in their jobs, technicians must pay close attention to detail. Technicians who work at computer monitors for prolonged periods must guard against eyestrain and muscle pain.

Medical records and health information technicians usually work a 40-hour week. Some overtime may be required. In hospitals—where health information departments often are open 24 hours a day, 7 days a week—technicians may work day, evening, and night shifts.

Related Occupations

• Pharmacy Technicians
• Payroll and Timekeeping Clerks
• Procurement Clerks
• Correspondence Clerks
• Insurance Claims Clerks
• Insurance Policy Processing Clerks
• Office Clerks

Related Academic Programs

• Health Information/Medical Records Technology/Technician.
• Medical Insurance Coding Specialist/Coder.