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It takes highly skilled professionals to keep a health care organization running smoothly. Three key administrative positions are crucial:
Medical Secretary
Medical secretaries provide administrative support for doctors and other health care professionals. Their duties include scheduling appointments, billing patients, and compiling and recording medical charts, reports, and correspondence. The role and responsibilities of the medical secretary have greatly evolved through the years, particularly as the reliance on technology continues to expand. Today's medical secretaries perform highly specialized work that requires knowledge of technical terminology and procedures, along with insurance rules and billing practices. For example, medical secretaries transcribe dictation, prepare correspondence, and assist physicians or medical scientists with reports, speeches, articles, and conference proceedings. They also record medical histories, arrange for patients to be hospitalized, and order supplies.
Medical secretaries held more than 400,000 jobs in 2006.
Medical Records & Health Information Technician
Each time a patient receives health care a medical record is maintained, which includes observations, medical or surgical interventions, and outcomes of treatment. This record also includes information that the patient provides about his or her symptoms and medical history, the results of examinations, reports of x-rays and laboratory tests, diagnoses, and treatment plans.
Medical Records & Health Information Technicians organize and evaluate patients' medical records to ensure they are complete, up to date, and accurate. This entails assembling the patient's health information, making sure that the patient's initial medical charts are complete, that all forms are completed and properly identified and authenticated, and that all necessary information has been entered in the computer's electronic record-keeping database. Technicians regularly use computer programs to tabulate and analyze data in order to improve patient care, better control costs, provide documentation for use in legal actions, or use the data in research studies. Medical Records & Health Information Technicians maintain regular communication with physicians and other health care professionals to clarify diagnoses and/or to obtain additional information.
In large to medium-size facilities, a Medical Records & Health Information Technician might specialize in just one component of record keeping, such as coding patients' medical information for insurance purposes. Using his or her knowledge of disease processes, the technician assigns a code to each diagnosis and procedure, and then uses classification systems software to assign the patient to one of several hundred "diagnosis-related groups" (DRGs). The DRG determines the amount the hospital will be reimbursed if the patient is covered by Medicare or other insurance providers who use the DRG system. There are other coding systems, too, such as those required for ambulatory settings, physicians' offices, or long-term care.
Some Medical Records & Health Information Technicians specialize in cancer registry. A cancer registrar maintains local (the healthcare facility itself), regional, and national databases of cancer patients. He or she reviews patient records and pathology reports, and assigns codes for the diagnosis and treatment of various types of cancer and certain benign tumors. The registrar conducts annual follow-ups on all patients in the registry in order to track their treatment, survival, and recovery. Physicians and public health organizations in turn use this information to 1) calculate survivor and success rates of various types of treatments, 2) locate geographic areas with high incidences of certain cancers, and 3) identify potential participants for clinical drug trials. Public health officials use cancer registry data to determine which areas should be allocated resources to provide intervention and screening programs.
Medical Records and Health Information Technicians Schools
Medical Records & Health Information Technicians entering the field generally have an associate's degree from a community or career college. 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.
Most employers prefer to hire Registered Health Information Technicians (RHIT) who passed a written examination offered by the American Health Information Management Association (AHIMA). Some employers prefer candidates with experience in a health care setting.
Job Outlook
Medical Records & Health Information Technicians held about 170,000 jobs in 2006, nearly half of which were in hospitals. The other half worked in physicians' offices, nursing care facilities, outpatient care centers, and home health care services. Insurance firms that deal in health matters employ a small number of health information technicians to tabulate and analyze health information. Public health departments also employ technicians to supervise data collection from health care institutions and to assist in research.
Medical Transcriptionists
Medical transcriptionists listen to dictated recordings made by physicians and other health care professionals and transcribe (type) the recorded content into a computer. The documents they produce include discharge summaries, medical history and physical examination reports, operative reports, consultation reports, autopsy reports, diagnostic imaging studies, progress notes, and referral letters - all of which eventually become part of patients' permanent files. The transcriptionist's ability to understand and correctly transcribe patient assessments and treatments ensures high-quality patient care and reduces the chance of patients receiving ineffective or even harmful treatments.
In order to understand and accurately transcribe dictated content, medical transcriptionists must have a broad and solid understanding of medical terminology, anatomy and physiology, diagnostic procedures, pharmacology, and treatment assessments. They must be able to translate medical jargon and abbreviations into their expanded forms, using reference materials if necessary. They also must comply with specific standards that apply to the style of medical records and, especially important in today's health care arena, adhere to the legal and ethical requirements for keeping patient information confidential.
Although many health care providers transmit dictation to medical transcriptionists using digital or analog equipment, it is becoming more common for transcriptionists to receive dictation over the Internet. An advantage of this method is that it allows the transcriptionist to quickly return the transcribed documents for approval.
Speech recognition technology is another increasingly popular method for dictation, especially in medical specialties like radiology or pathology, which have standardized terminology. Specifically, the technology is able to electronically translate sound into text and create drafts of reports. The transcriptionist can then take these reports and format them; edit them for mistakes in translation, punctuation, or grammar; and check for consistency and correct any wording that doesn't make sense medically. Undoubtedly, speech recognition technology will become more widespread across the board as the technology becomes more sophisticated and is better able to recognize and more accurately transcribe diverse modes of speech.
Work environment
Most medical transcriptionists are employed in comfortable settings, such as hospitals, physicians' offices, transcription service offices, clinics, laboratories, medical libraries, or government medical facilities. Many medical transcriptionists telecommute from their own home-based offices.
One risk of this type of work is that the transcriptionist usually sits in the same position for long periods of time. This can lead to wrist, back, neck, or eye problems due to strain and repetitive motion injuries such as carpal tunnel syndrome. The constant pressure to be accurate and productive also can be stressful.
Many medical transcriptionists work a standard 40-hour week. Self-employed medical transcriptionists are more likely to work irregular hours - including part time, evenings, weekends, or on call at any time.
Medical Transcriptionist Training
By and large, employers prefer to hire transcriptionists who have completed postsecondary training in medical transcription offered by vocational schools, community colleges, and distance-learning programs. Completion of a 2-year associate's degree or 1-year certificate program that includes coursework in anatomy, medical terminology, legal issues relating to health care documentation, and English grammar and punctuation is highly recommended, but not always required. One advantage to many of these programs is that they include supervised on-the-job experience.
Because medicine is constantly evolving, medical transcriptionists are encouraged to update their skills regularly and, as in many other fields, certification is recognized as a sign of competence. The Association for Healthcare Documentation Integrity (AHDI) awards two voluntary designations: the Registered Medical Transcriptionist (RMT) and the Certified Medical Transcriptionist (CMT). A medical transcriptionist who is a recent graduate of a medical transcription educational program or who has less than 2 years of experience in acute care may become a registered RMT. The RMT credential is awarded upon successfully passing the AHDI level 1 registered medical transcription exam. The CMT designation requires at least 2 years of acute care experience working in multiple specialty surgery areas using different format, report, and dictation types. Candidates also must earn a passing score on a certification examination. RMTs and CMTs must earn continuing education credits every 3 years in order to be recertified.
RMTs are eligible to participate in the Registered Apprenticeship Program sponsored by the Medical Transcription Industry Association through the U.S. Department of Labor. The Registered Apprenticeship program offers structured on-the-job learning and related technical instruction for qualified medical transcriptionists entering the profession.
Job Outlook
Medical transcriptionists held about 98,000 jobs in 2006. About 40 percent worked in hospitals, 29 percent worked in physicians' offices, and the rest worked for business support services; medical and diagnostic laboratories; outpatient care centers; and offices of physical, occupational, and speech therapists, and audiologists.
Future job opportunities should be plentiful, especially for those who are certified. The demand for medical transcription services will increase as the population continues to grow and age, and will be sustained by the continued need for electronic documentation that can be shared easily among providers, third-party payers, regulators, consumers, and health information systems. Growing numbers of medical transcriptionists will be needed to amend patients' records, edit documents from speech recognition systems, and identify discrepancies in medical reports.
According to the Bureau of Labor Statistics, medical transcriptionists had median hourly earnings of $14.40 in May 2006. Medical transcriptionists are compensated in varying ways. Some are paid based on the number of hours they work or on the number of lines they transcribe. Others receive a base pay per hour with incentives for extra production. Employees of transcription services and independent contractors almost always receive production-based pay. Independent contractors earn more than do transcriptionists who work for others, but independent contractors have higher expenses than their corporate counterparts, receive no benefits, and may face higher risk of termination than permanent-employee transcriptionists.
Resources:
Association for Healthcare Documentation Integrity, www.ahdionline.org.
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