A health information specialist, also known as a health information technician or a medical records technician, is a nonclinical healthcare worker who is trained in the organization, maintenance, filing, cross-filing, preservation and coding of patient medical records. Entry into this position now generally requires a community college certification or an associate's degree, although many established medical records technicians began their jobs with high school diplomas and on-the-job training. Now, most employers require specialists to be certified as a registered health information technician (RHIT), an accreditation that requires a two-year degree in the field and successful completion of a written examination. A health information specialist is increasingly a computer-related position as more medical records are maintained electronically rather than on paper.
Most health information specialist positions are held in hospitals and medical centers. These specialists' responsibilities begin with a patient's admission to the facility and the collection of personal information, current and past medical history and insurance coverage data. In Western hospitals — or those based upon Western-medicine practices — diagnoses, secondary diagnoses, treatments and surgeries are all codified according to the International Statistical Classification of Diseases and Related Health Problems (ICD-9) and either Current Procedural Terminology (CPT) codes or Healthcare Common Procedure Coding System (HCPCS) codes for Medicare or Medicaid patients. These disease codes automatically allow a given number of inpatient days and specify types of allowed treatment for hospital patients. Both outpatient and inpatient insurance reimbursements are also determined by the disease and treatment codes.
The duties of a health information specialist continue during a patient's hospital stay. Disease codes must be updated according to the discovery of new diagnoses and procedure codes must be added as different treatments are administered. Many health information specialists work closely with discharge planners or insurance reimbursement specialists to ensure that coding will result in appropriate reimbursement by the insurance company. If the patient has exhausted the original number of days approved for his hospital stay, a health information specialist may review his chart for additional information allowing for more treatment days. In some highly technical health information specialist positions such as cancer registry coders, the patient's personal information, treatment history and response to treatment is collected to evaluate the efficacy of different treatment options.
Following a patient's discharge, a health information specialist reviews the medical chart to ensure that all information required legally is present. A discharge summary must be dictated, printed and signed by the attending physician. All laboratory and radiology reports ordered and charged for must be available. Diagnostic and treatment codes are double-checked for accuracy. Having reviewed the chart to guarantee the medical and legal document is correct and complete, the health information specialist then turns the patient's chart over to the hospital insurance and billing office.