Bragging Rights

Okay, I'm going to take a minute to brag here. My team has caught up all the back loose-filing. It is now done on a daily basis.

We have updated our transcription process so that most transcribed reports are in the practitioner's hands to be signed and then filed in the charts the NEXT DAY! I have recieved several compliments from impressed providers.

Also, I singlehandedly caught up nearly six months worth of coding of offender appointments that no one previously had time for. My boss, the clinic's healthcare manager, had been worried because the statistics showed that our clinic was only seeing two patients per day, which is of course, ridiculous. But once I caught up the coding, that number jumped to nearly 200 per day. We are one of the busiest health-care clinics in the state prison system.

Finally, we just caught up the processing of records of offenders that have been released. One entire shelving unit in the back of our stacks was full of these records, and my team and I knocked them out in a matter of weeks, in addition to our other daily duties. Props to us! I brought brownies for everyone. ;0)

Not bad for a brand-new college grad with nine months on the job. Next project to tackle: all the Release of Information requests that has been assigned to me by head-quarters. No sweat.

I never took Criminal Justice Classes... So why am I a detective?

As an RHIT, I am the protector and keeper of the health records. With an EHR and bar-code scanning, as most large hospitals and even some small doctor's offices have, keeping track of records is relatively easy. If one provider has the record and it needs to go somewhere else, say for coding or documentation, you just look it up in computer, it tells you where that record has been scanned in, you go to that place, grab the record, scan it out and do your thing with it. Then if someone else needs it, they come to your area, scan it out, take it, and it becomes an easy efficient process for tracking records.

However, at the DOC, all health records are entirely paper. While each record does have a bar code along the spine, I think it's only used at headquarters. We have no bar codes, no scanners, no EHR. When we get the call-out in the afternoon, which is, all the provider's appointments for the next day, we go to the stacks, pull out the correct record, pull out the record's out-guide, sign the name of the provider it's going to on the out-guide, the outguide stays on the shelf in the stacks, and the records are delivered to that provider the next morning. The problem with this is, we have two doctors, and ARNP, six nurses, five psych associates and a psychiatrist, a dentist a dental hygienist, and two pharmacists. Oh, and an x-ray tech. If, say, the doctor has just seen an offender, then the nurse takes the record to do documentation and it's supposed to go in a bin or on a rack to go back to the medical records room. But, if the guy got in a fight and broke a tooth, then the dentist snags it and does his thing with it. Then, maybe the guy is issued pain medication and the pharmacist snags it from dentist. Finally, perhaps the psych associate had an appointment with the same guy in the afternoon, they have him sitting in the office, but no chart. They call me and ask me to pull the chart and get it to them, I check the stacks, find the out-card that says it was checked out to the doctor, I check with the doctor, he doesn't have it, I check the nurse's station and they don't have it, and IT'S ON! A facility-wide search for the record that wastes tons of time. Because we're short-staffed because a bunch of our people are in CORE, a mandatory six-week training class, I have no time for this! And apearantly this is a common theme throughout the DOC. A few weeks ago an e-mail was sent from one prison's RHIT on the coast to all the Washington RHIT's asking if and how we solved this problem at our facilities. Everyone responded saying they had the same problem and no one had any ideas. What to do? There has got to be a solution... I'm working on it.

Also, most people think that if an offender goes to prison, he's assigned to a prison, he stays there until his term is up, then he's released and that's that. Not so. Offenders are moving from prison to prison within the state all the time for many reasons, and sometimes they go to other states. If an employee of the prison and one of the inmates know each other, the inmate will be moved. If the inmate has a disease or injury that the facility he is at doesn't have the resources to effectively treat, the inmate will be moved to a facility that does. Sometimes, even if an inmate just wants to be closer to home so his family and friends can visit, he'll be moved. In the prison system, if an inmate moves, his health record goes with him. So we're always sending out charts for guys that are leaving, and recieving charts from guys that are coming in. Oftentimes we get loose filing from other facilities, for instance; they had a guy that had a blood test, and the guy left to come to my facility the day after he took the blood test, but the facility he was at didn't get the results for a week, so they sent it to us because we have him and his chart. And vice-versa. So, we have huge pile of loose-filing right now, before I came they were still short-handed and no one had time to do it, so now I'm here and it's my problem, and oh, it's becoming a problem. Especially with things like lab results that are sitting in loose-filing instead of in the charts to be used. So my staff and I have been whittling the pile down, actually making good progress, but we're running into the fact that many ( almost half) of those sheets in loose-filing belong to inmates that have already left, we don't have their charts anymore. So we look for it, we don't have it, then we have to go into the computer, find out where they are, or where their chart is and send it on. Again, rather cumbersome. And a few times a week, a chart is lost. Just completely gone. Then we have to really do our detective thing. We have to find out where the inmate was before, okay, did they send his chart with him, yes, it says they did. Did we recieve it? Well no, there's no documentation that we did. But that could be because they thought they sent it but didn't, or it fell off the bus while they were unloading at another facility before they came here, or because we really did get it but someone forgot to log it, or maybe he's a guy from the minimum security unit down the road and his chart is there... it goes on and on. So if anyone has any ideas for solutions, I would love to hear them. In the mean-time, this is a good example of what someone in my job does.

What does an RHIT do?

When you're a new RHIT, recently graduated with little more experience than your six-week clinicals, you expect to take the first entry-level job available, as many new graduates in any field do. Many of my friends in my graduating class have gotten jobs as medical records file clerks. File clerks work in hospitals, doctor's offices, health plans... anywhere medical records are stored. Basically, it's their job to maintain order in the area where the files are stored, make sure they get to where they need to go, for instance if a doctor needs them, then keep track of where they are so they can be accessed at a moment's notice, and finally correctly re-file them when they are done. File clerks are also sometimes responsible for "purging." That is knowing the state laws and your organizations requirements for how long charts are kept past the patients last visit. Usually it's a bout ten years, but it varies from state to state and organization. If a record is older than that date, the record can legally be destroyed and a record is made that it was disposed of. File clerks usually earn between ten to twelve dollars an hour. There aren't usually benefits, but in today's economy, a full-time job is a full-time job.

Some RHIT's start out as receptionists. The important thing is to break into the field with your first job. RHIT's who accept entry-level positions usually don't stay there long because upward movement is easy to be had once you get a little experience. The benefit of getting in at the bottom is that when positions you're more interested in within the organization open up, employees usually have the first opportunity to apply. And even if you work for one organization, and your dream job opens up at another organization, you have a better chance of being hired for it because now you have not only your degree and credential, which carry a lot of weight on their own, but in addition you have experience in the field.

So what are the "bigger" jobs within the Health Information Management field? There are many different jobs in a hospital HIM department. During my clinical experience at Sacred Heart, I learned that each person in the HIM department does one job, that is one small piece of the HIM pie. We'll start with the quantitative analysts. Quantitative Analysis is the process of receiving the chart of a patient that has recently been released from the hospital and making sure that each document, such as discharge summaries and progress notes are signed correctly, with the provider's name, credentials (M.D. or A.R.N.P) the date, and the time of the entry. If something is missing, the analyst notes it, (usually in a computer program) marks it with a sticky note and sends it back to the provider for completion. There are laws and requirements for accreditation that apply to documentation, and it is the responsibility of everyone in the HIM field to ensure that documentation is complete and compliant with those laws and requirements.

The next process the chart goes through is called assembly. The chart has to be in the correct order so that providers and other authorized users can find all the information they need quickly. The assembly person puts each document in the record in it's proper place. There is a somewhat universal order that hospital charts go in, but each facility tweaks it a little bit.

Coding is what many RHIT's aspire to, because it is highly technical, RHIT's are specifically certified to do it, and it's one of the higher paid jobs in the HIM field. Coders use ICD-9-CM codes which are based on the patient's diagnosis and treatments in an inpatient setting. Doctor's visits, or any out-patient care are assigned CPT codes. If a doctor has documented in the chart that a patient has bronchitis, the coder uses the ICD-9 codebook to look up bronchitis. Then the coder chooses the correct code in the bronchitis section, which could be influenced by many factors and documents the code selection. To put it very simply, the coder assigns the codes, then based on those codes, insurance companies reimburse the hospital and/or doctors clinic, etc. There are many different areas of coding an RHIT can go into.

Emergency coding could be considered the most simple. A patient comes into the emergency room with one major problem, an acute condition, and that's usually all that is coded: what the condition was, how it was treated and weather the patient was admitted to the hospital or released.

Inpatient coding can sometimes be the most complicated. When I was at Sacred Heart, I saw a chart for one patient that was the entire length of the shelf. Inpatient charts often have multiple diagnoses and many, many treatments. An inpatient coder really has to know their stuff, including the rules for combination codes (When there are related conditions such as hypertension and chronic kidney disease) and, for instance, that when a patient undergoes surgery, even though each step is meticulously documented in the operative report, you don't code (therefore charging for) the closure of the incision. Or when there is a diagnosis of bronchitis, you only code the bronchitis, not the cough.

Finally, outpatient coding is also done in a hospital, as well as in doctor's offices, ambulatory surgery centers, etc. using CPT codes. The coding supervisor over all the coders in the HIM department is often an RHIT. Coding can also be done from home, which is my eventual dream-job. Remote coding is becoming more prevalent as organizations seek to cut things like overhead costs. However, if you're coding at home there is no one to stand over your shoulder to answer questions and check your work, so you have to be a fairly experienced coder.

One big thing affecting coding is the adoption of ICD-10-CM. The rest of the world is already using ICD-10. America has been behind the 8-ball for a long time. But we are adopting it on Oct. 1st, 2013. ICD-10 is more complicated in a lot of ways, but will also be more accurate. It will be super-important for the coder to have a thorough knowledge and understanding of anatomy and physiology in order to properly use ICD-10.

Release of Information is a very important area in which an RHIT can work. Again, there are many laws and requirements an organization must follow in regard to who can access health records and under what circumstances. Patients often request to see or have copies of their medical records, outside providers often need that information for continuity of care, sometimes law enforcement wants health information on a particular person, lawyers involved in law-suits often want records and they want EVERYTHING. It is one of the most important jobs an RHIT does, protecting health information. If you work in that area you need to know exactly what the laws and requirements are. There can be major consequences if you do something wrong, knowingly or not, including law suits against you or your employer, fines and loss of the facilities accreditation.

No matter where you work, RHIT's are the experts on requirements for documentation, legal issues surrounding it, and we are in a perfect position to write policies and procedures for our organizations and be advisers concerning new laws, such as ARRA, which is causing quite a stir right now, and the adoption of EHR's, (Electronic Health Records.)

In my job at the prison, I run the medical records department, so my job includes everything. I make sure the records get where they need to go, that they have all the required documentation, I do a lot of release of information, and the coding... I work with the providers to make the documentation part of their job easier, and because I'm an RHIT, I have the knowledge and skills to be able to do all that, and I'm part of a huge, nationwide family of professionals just like me. So that is in a nutshell what an RHIT does.

How It All Began

I had never been a good student in Jr. and High school, so for most of my life I felt that college was just not for me. But, I was 26 and newly divorced with a five-year old to support. I was working two minimum-wage jobs and just barely making ends meet. I though, is this all there is? Is my whole life going to be just this? Working all the time at a job I don't like, always too tired and too broke to have any fun, never having enough money to buy any of the things I want for myself and my son? I refused to accept that. I realized that the only way my life was going to change, was if I changed it. No one else could or would do it for me. So I decided to give college a try.

With a slightly hopeful but gaurded attitude, I filled out a FAFSA online. (Free Application For Federal Student Aid.) Then I drove my boat, my '86 Ford Crown Victoria, down to the local Community College and filled out an application there. I had a nagging feeling in the back of my mind that this was all an exercize in futility, that something was going to go wrong and I wouldn't be accepted, but, at least I would have done something. And if college didn't work out, I was sure I would be presented with another avenue to change. But, three weeks later I got a letter from the college saying, "Congratulations, you have been accepted, and this is your financial aid amount... etc." So, I was going to college.

Now I had to choose a program. Another reason I had never gone to college was that I had no idea what I wanted to do with my life, and was not in posession of any great talent in any area. But, at that time, my main motivation was providing for myself and son and I knew that nurses made quite a bit of money and the healthcare field was fairly recession-proof, so I decided nursing was the way to go.

Now that I had been accepted, I was terrified. I hadn't been in any kind of educational arena for almost ten years. What if I failed? Then there would be loans and grants to re-pay, not to mention the devastating hit to my already small self-esteem from which it would never recover, and (shudder) crawling back to my manager at McDonald's in defeat, begging for my job back. But I knew all I could do was try my best and deal with the consequences, good or bad.

I met with an academic counsuelor. I had to take almost a year of pre-requisites for the nursing program and then wait on a waiting list for a spot in the program to open up. I knew I would be in school for three or even four years for an AA degree, but I was determined.

On the first day of school, I was nearly sick with nerves when I got to my math class. I have always had a high reading and writing level and can spell and define almost any word in the dictionary, but I was really bad at math. Since fourth grade it had always been my worst subject, and in the past, teachers didn't have the time or the inclination to help me "get it" and had just passed me over, confirming in my mind that I was hopeless. But over the course of the quarter, I was pleasantly surprised. I had lucked in to one of the best math instructors at the college. He had a passion for math, great knowlege and understanding of his subject and a no-nonsense but kind and patient teaching style. If you really wanted to understand something, he would go over it again and again, using different techniques until you got it. For the first time in my life, I was understanding and- dare I say, enjoying,- math. That first quarter I took spanish, english and math. At the end of the quarter I had a cumulative GPA of 3.9 and was on the President's Honor Roll. I was shocked to discover that I was smart. I could do this!

I continued to do well in my pre-requisite classes. I had a great instructor for biology and really enjoyed it. Even though I had heard it was tough, I was excited to take Anatomy and Physiology. I enjoyed the challenge and the learning in the first half of my first quarter of A and P, but then, we had to start lab dissections. I had been raised a vegetarian, had never even so much as cut in to a piece of meat. So, when I walked into lab that first day, on top of being sickened by the smell of formaldehyde my lab partners and I were presented with a pale, shriveled fetal pig, to be our specimen for the rest of the quarter. I decided to face my fear head-on and offered to open. As I was working, my lab partners asked, "Are you okay?"

"Sure." I said. Even to my own ears my voice sounded weak and breathless.

"You better stop, you're really red." on of my partners said. I was horribly embarrassed as one of them took my arm and led me shakily out the door. After that I never went back into the lab. I kept up with the lectures in classes and book-work because I wanted to learn as much as I could, and ended up failing the class with a 1.8. Thankfully I did well enough in my other classes that my cumulative GPA didn't drop below passing, but my plan to be a nurse was over. I knew that if I couldn't handle a dissection, I probably wouldn't do well as a nurse doing injections, handling bodily fluids, etc. So I started looking for a new direction. I wanted to stay in the health-care field, but couldn't think of anything that didn't involve direct patient-care.

So I headed to the counsuelor's office in the health-sciences building. While I was waiting a paper on a rack next to the door with information about the Health Information Technology program caught my eye. It stated that the average pay for someone in this position was almost as high as a nurse's and that job opportunities were plentiful. I asked the counsuelor about it, and she told me an RHIT does medical coding. I decided to give it a try. Thankfully, there was no waiting list, I started the program the next quarter. The first year of the program, I took medical terminology, anatomy and physiology (These courses had no lab requirement), and Introduction to HIM. (Health Information Management). Unfortunately, that class, which I had been looking forward to, didn't tell me much about what a Health Information Technician really does. It was mostly the history of the profession, which was great, but I wanted to know what my job was actually going to be.

For the entire first year in the program, I was pretty clueless as to why I was learning what I was learning and what it's application would be in the real world after college. And that's why I started this blog. Maybe you're in the same place, thinking about going to college, wondering if it's the right move. Trust me, it is. Maybe you don't have a clue what you want to do. A lot of people are in the same boat. My advice is, just give it a try. Going to college was the most empowering experience of my life. I learned so much about myself, and I had so many new experiences. Just starting school is bound to expose you to something you never even knew existed that could turn out to be your calling.

Maybe you're like me, you have kind of stumbled across and into a Health Information Management Technician program, but you have no clue what your actual job is going to be, and why you need to take these seemingly useless classes. Hang in there, I will cover that in this blog next week. It all began to come together for me in the second year, but during the first year there was a lot of frustration stemming from not knowing what my job was going to be and why I had to wade through all this stuff that seemed pretty general, uninteresting and from that early perspective, fairly useless. Now I know that it was important, it was laying the foundation. You have to have certain core skills on which to build the job-specific skills you learn in your second year. It was all worth it.

Fast forward three years to the present day. I was excited and proud on graduation day which was one month ago. Most of the members of my class have already found jobs as Medical Record Clerks, Emergency room Coders, Quantitative Analysts etc. There are so many different Avenues and job options in the field.

And me? Three weeks after graduation I got a job that far exceeds my expectations. I got hired as a Forms and Records Analyst II with the Department of Corrections. I work at a prison in Medical Records. I just finished my first week of work and I love it. My pay is quite a bit more than I expected right out of school, I supervise the Medical Records Department, albeit a small one, three employees in a records room. But I have my own office. Not a cubicle mind you, but a real office, with a window. I still have the '86 Crow Vic, because it has sentimental value, but I also just bought a brand-new 2010 car and next month, I'm moving to a bigger apartment (we lived in a 1-bedroom all through college). I went from being a minimum-wage McDonald's employee to a proffessional in a respected, growing field. It changed my life. My sister said, "Success looks good on you.", and I have already inspired people in my life. My boyfriend and his sister just registered for college last week. (I think it might have had something to do with me rolling up to their house in my new car.)