Keeping Health Records Straight

You can have a satisfying career in healthcare - even if you hate blood and guts. "People who work in health information management (HIM) understand pathophysiology, disease process, treatment options and medications - yet they never go near a patient," says Robyn Socha-Hanson, assistant director of health information management at Fairview Southdale Hospital.

Whenever healthcare providers interact with a patient, they list their observations and the details of any treatment in the patient's medical record. This record includes the patient's medical history, examination results, X-ray and lab reports, diagnoses, orders, medications, procedures and treatment plans. This information is collected, analyzed and interpreted by medical coders, health information technicians and information administrators.

"Right now, we're living in a hybrid world, with both paper and digitized records," says Sandie Helgeson, director of health information management at Fairview Southdale. "But at some point in the future, all information will be scanned or entered directly into the computer."

Coding is the heart of health information management. Coding specialists read the medical record and assign code numbers to each diagnosis and procedure, using an international classification system. The codes are reported to insurance companies or government agencies that reimburse the patient's medical expenses. Researchers also use coded data to monitor patterns of illness and confirm the results of new treatments.

Coding specialists usually complete a one- or two-year postsecondary certificate or degree program that includes courses in anatomy, medical terminology and professional practice. In addition, most employers require one of several coding or HIM credentials, which are earned by passing an exam offered by the American Health Information Management Association (AHIMA).Coding certification can also be obtained in specialized areas such as interventional radiology, cancer data registry and physician practice.

According to Helgeson, home-based coding is a growing trend in the Twin Cities. Coders must work on-site for a time before they can work at home. Home-based coders keep the same schedule as their on-site colleagues. They also attend regular meetings on-site. "Home-based employees save on gas and commuting time," Helgeson says. "The organization benefits because home-based employees free up office space, which is always at a premium. And we've found that when coders work from home, their productivity increases. It's a win-win situation for everyone."

Registered health information technicians (RHITs) analyze data and ensure the completeness and accuracy of records, and some specialize in coding. RHITs need an associate degree and certification from AHIMA. Registered health information administrators (RHIAs) need a bachelor's degree and AHIMA certification.

RHIAs are skilled in the collection, interpretation and analysis of patient data. They also carry out related management functions and interact with other departments that use patient data in decision making and daily operations. Some health information professionals also earn additional certifications in healthcare privacy and security.

According to the U.S. Department of Labor Bureau of Labor Statistics median annual earnings of medical records and health information technicians were $25,590 in 2004. The middle 50 percent earned between $20,650 and $32,990. The lowest 10 percent earned less than $17,720, and the highest 10 percent earned more than $41,760.? The Minnesota Department of Employment and Economic Development indicates the medium wage for Minnesota in 2006 was $14.55 an hour or $30,250 a year and wages in the Twin Cities metro area were $31,804/yr.

Source: Star Tribune, Nancy Giguere, 9/1/06