Medical Records and Health Information Technicians

Summary

What Medical Records and Health Information Technicians Do About this section

Health information technicians assemble patients' health information including medical history, symptoms, examination results, tests, and treatments.

Medical records and health information technicians, commonly referred to as health information technicians, organize and manage health information data by ensuring that it maintains its quality, accuracy, accessibility, and security in both paper files and electronic systems. They use various classification systems to code and categorize patient information for insurance reimbursement purposes, for databases and registries, and to maintain patients’ medical and treatment histories.

Duties

Health information technicians typically do the following:

• Review patients’ records for timeliness, completeness, accuracy, and appropriateness of data
• Organize and maintain data for clinical databases and registries
• Track patient outcomes for quality assessment
• Use classification software to assign clinical codes for insurance reimbursement and data analysis
• Electronically record data for collection, storage, analysis, retrieval, and reporting
• Maintain confidentiality of patients’ records

Health information technicians document patients’ health information, including their medical history, symptoms, examination and test results, treatments, and other information about healthcare services that are provided to patients. Their duties vary by employer and by the size of the facility in which they work.

Although health information technicians do not provide direct patient care, they work regularly with registered nurses and other healthcare professionals. They meet with these workers to clarify diagnoses or to get additional information to make sure that records are complete and accurate.

The increasing adaptation and use of electronic health records (EHRs) will continue to change the job responsibilities of health information technicians. Technicians will need to be familiar with, or be able to learn, EHR computer software, follow EHR security and privacy practices, and analyze electronic data to improve healthcare information.

Health information technicians can specialize in many aspects of health information. Some work as medical coders, sometimes called coding specialists, or as cancer registrars.

Medical coders typically do the following:

• Review patient information for preexisting conditions, such as diabetes, so patient data can be coded properly
• Assign appropriate diagnoses and procedure codes for patient care, population health statistics, and billing purposes
• Work as a liaison between the healthcare providers and billing offices

Cancer registrars typically do the following:

• Review patients’ records and pathology reports to verify completeness and accuracy
• Assign classification codes to represent the diagnosis and treatment of cancers and benign tumors
• Conduct annual followups to track treatment, survival, and recovery
• Compile and analyze cancer patient information for research purposes
• Maintain facility, regional, and national databases of cancer patients

Work Environment About this section

This is one of the few health-related occupations in which there is no direct hands-on patient care.

Medical records and health information technicians typically work in offices and may spend many hours in front of computer monitors. Some technicians may work from home.

Work Schedules

Most health information technicians work full time. In healthcare facilities that are always open, such as hospitals, technicians may work evening or overnight shifts.

How to Become a Medical Records or Health Information Technician About this section

Health information technicians organize and maintain data for clinical databases and registries.

Health information technicians typically need a postsecondary certificate to enter the occupation, although some may need an associate’s degree. Certification is often required.

Education

Postsecondary certificate and associate’s degree programs in health information technology typically include courses in medical terminology, anatomy and physiology, communication, health data requirements and standards, classification and coding systems, healthcare reimbursement methods, healthcare statistics, and computer systems. Applicants to health information technology programs may increase their chances of admission by taking high school courses in health, computer science, math, and biology.

A high school diploma or equivalent and previous experience in a healthcare setting are enough to qualify for some positions, but most jobs for health information technicians require postsecondary education.

Important Qualities

Analytical skills. Health information technicians must understand and follow medical records and diagnoses, and then decide how best to code them in a patient’s medical records.

Detail oriented. Health information technicians must be accurate when recording and coding patient information.

Integrity. Health information technicians work with patient data that are required, by law, to be kept confidential. They must exercise discretion and a strong sense of ethics when working with this information in order to protect patient confidentiality.

Interpersonal skills. Health information technicians need to be able to discuss patient information, discrepancies, and data requirements with other professionals such as physicians and finance personnel.

Technical skills. Health information technicians must use coding and classification software and the electronic health record (EHR) system that their healthcare organization or physician practice has adopted.

Licenses, Certifications, and Registrations

Most employers prefer to hire health information technicians who have certification, or they may expect applicants to earn certification shortly after being hired. A health information technician can earn certification from several organizations. Certifications include the Registered Health Information Technician (RHIT) and the Certified Tumor Registrar (CTR), among others.

Some organizations base certification on passing an exam. Others require graduation from an accredited program. Many coding certifications also require coding experience in a work setting. Once certified, technicians typically must renew their certification regularly and take continuing education courses.

A few states and facilities require cancer registrars to be certified. Certification as a Certified Tumor Registrar (CTR) requires completion of a formal education program and experience, along with passing an exam.

Advancement

Technicians may advance to a position as a medical or health services manager after completing a bachelor’s or master’s degree program and taking the required certification courses. Requirements vary by facility.

Pay About this section

Most health information technicians work full time. In healthcare facilities that are always open, such as hospitals, technicians may work evening or overnight shifts.

Job Outlook About this section

Overall employment of medical records and health information technicians is projected to grow $pc.toString().replaceAll("^\-","") percent from 2020 to 2030, $gra.

About $tools.number.format('#,###',$op) openings for medical records and health information technicians are projected each year, on average, over the decade. Many of those openings are expected to result from the need to replace workers who transfer to different occupations or exit the labor force, such as to retire.

Employment

Employment of medical records and health information technicians is projected to grow 11 percent from 2018 to 2028, much faster than the average for all occupations.

An aging population will require more medical services, and health information technicians will be needed to organize and manage the older generations’ health information data. This will mean more claims for reimbursement from insurance companies.

Additional records, coupled with widespread use of electronic health records (EHRs) by all types of healthcare providers, will lead to an increased need for technicians to organize and manage the associated information in all areas of the healthcare industry.

Cancer registrars are expected to continue to be in high demand. As the population ages, there will likely be more types of special purpose registries because many illnesses are detected and treated later in life.

Job Prospects

Prospects will be best for those with a certification in health information, such as the Registered Health Information Technician (RHIT) or the Certified Tumor Registrar (CTR). As EHR systems continue to become more common, health information technicians with computer skills will be needed to use them.

State & Area Data About this section

Occupational Employment and Wage Statistics (OEWS)

The Occupational Employment and Wage Statistics (OEWS) program produces employment and wage estimates annually for over 800 occupations. These estimates are available for the nation as a whole, for individual states, and for metropolitan and nonmetropolitan areas.

Projections Central

Occupational employment projections are developed for all states by Labor Market Information (LMI) or individual state Employment Projections offices. All state projections data are available at www.projectionscentral.com. Information on this site allows projected employment growth for an occupation to be compared among states or to be compared within one state. In addition, states may produce projections for areas; there are links to each state’s websites where these data may be retrieved.

CareerOneStop

CareerOneStop includes hundreds of occupational profiles with data available by state and metro area. There are links in the left-hand side menu to compare occupational employment by state and occupational wages by local area or metro area. There is also a salary info tool to search for wages by zip code.

Contacts for More Information About this section

For more information about health information technicians, including details about certification, visit

American Health Information Management Association

American Academy of Professional Coders

Professional Association of Healthcare Coding Specialists

National Healthcareer Association

For more information about medical coding and billing, visit

MB&CC (formerly known as Medical Billing & Coding)

For more information about cancer registrars, visit

National Cancer Registrars Association

For a list of accredited training programs, visit

Commission on Accreditation for Health Informatics and Information Management Education