Medical Records and Health Information Technicians

Summary

Medical records and health information technicians need to be able to discuss patient information and discrepancies with other professionals such as physicians and insurance personnel.

Quick Facts: Medical Records and Health Information Technicians
2010 Median Pay	$32,350 per year $15.55 per hour
Entry-Level Education	Postsecondary non-degree award
Work Experience in a Related Occupation	None
On-the-job Training	None
Number of Jobs, 2010	179,500
Job Outlook, 2010-20	21% (Faster than average)
Employment Change, 2010-20	37,700

What Medical Records and Health Information Technicians Do

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

Work Environment

Most medical records and health information technicians work in hospitals or physicians’ offices. Most technicians work full time.

How to Become a Medical Records or Health Information Technician

Medical records and health information technicians typically need a postsecondary certificate to enter the occupation, although they may have an associate’s degree. Many employers also require professional certification.

Pay

The median annual wage of medical records and health information technicians was $32,350 in May 2010.

Job Outlook

Employment of medical records and health information technicians is expected to increase by 21 percent from 2010 to 2020, faster than the average for all occupations. The demand for health services is expected to increase as the population ages. An aging population will need more medical tests, treatments, and procedures. This will also mean more claims for reimbursement from private and public insurance. Additional records, coupled with widespread use of electronic health records by all types of healthcare providers, should lead to an increased need for technicians to organize and manage the associated information in all areas of the healthcare industry.

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Contacts for More Information

Learn more about medical records and health information technicians by contacting these additional resources.

What Medical Records and Health Information Technicians Do About this section

Technicians assemble patients’ health information including medical history, symptoms, examination results, tests, and treatments.

Medical records and health information technicians organize and manage health information data by ensuring its quality, accuracy, accessibility, and security in both paper 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

All technicians document patients' health information, including the medical history, symptoms, examination and test results, treatments, and other information about healthcare provider services. Medical records and health information technicians' duties vary with the size of the facility in which they work.

Medical records and health information technicians typically do the following:

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

Although medical records and health information technicians do not provide direct patient care, they work regularly with physicians 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 use of electronic health records (EHRs) will continue to change the job responsibilities of medical records and 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 as more healthcare providers and hospitals adopt EHR systems.

Medical records and health information technicians can specialize in many aspects of health information. Most 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
• Retrieve patient records for medical personnel
• Work as a liaison between the health clinician and billing offices

Cancer registrars typically do the following:

• Review patient records and pathology reports for 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
• Analyze and compile 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 held about 179,500 jobs in 2010. Most medical records and health information technicians worked in hospitals or physicians’ offices. Some worked for the government. Technicians typically work at desks or in offices and may spend many hours in front of computer monitors.

The industries that employed the most medical records and health information technicians in 2010 were as follows:

Work Schedules

Most medical records and health information technicians work full time. In healthcare facilities that are open 24 hours a day, technicians may work evening or overnight shifts. About 15 percent of technicians worked part time in 2010.

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

Technicians organize and maintain data for clinical databases and registries.

Medical records and health information technicians typically need a postsecondary certificate to enter the occupation, although they may have an associate’s degree. Many employers also require professional certification.

Education

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

Certification

Most employers prefer to hire medical records and health information technicians who have professional certification. A medical records and health information technician can get certification from several organizations. Some organizations base certification on passing an exam. Others require graduation from an accredited program. Once certified, technicians typically must renew their certification regularly and take continuing education courses. Certifications include Registered Health Information Technician (RHIT) and Certified Tumor Registrar (CTR), among others. Many coding certifications require coding experience in a work setting. Some states require cancer registrars to have certification; requirements vary by state.

Important Qualities

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

Detail oriented. Medical records and health information technicians must be pay attention to details to be accurate when recording and coding patient information.

Interpersonal skills. Medical records and 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. Medical records and health information technicians must be able to use coding and classification software and the EHR system that their healthcare organization or physician practice has adopted.

Pay About this section

The median annual wage of medical records and health information technicians was $32,350 in May 2010. The median wage is the wage at which half the workers in an occupation earned more than that amount and half earned less. The lowest 10 percent earned less than $21,240, and the top 10 percent earned more than $53,430.

Most medical records and health information technicians work full time. Some work evenings or weekends to cover shifts in medical facilities that remain open 24 hours a day.

Job Outlook About this section

Employment of medical records and health information technicians is expected to increase by 21 percent from 2010 to 2020, faster than the average for all occupations. The demand for health services is expected to increase as the population ages. An aging population will need more medical tests, treatments, and procedures. This will also mean more claims for reimbursement from private and public insurance. Additional records, coupled with widespread use of electronic health records by all types of healthcare providers, should 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 more types of illnesses are detected and treated later in life.

Job Prospects

Prospects will be best for those with a certification in health information. As EHR systems continue to become more common, technicians with computer skills will be needed to use them.

Contacts for More Information About this section

For more information about medical records and health information technicians, including details about certification, visit

American Health Information Management Association

American Academy of Professional Coders

The Professional Association of Healthcare Coding Specialists

National Cancer Registrars Association

For a list of accredited training programs, visit

Commission on Accreditation for Health Informatics and Information Management