WESTERN TECHNICAL COLLEGE Health and Public Safety Division ESSENTIAL FUNCTIONS Essential Functions HEALTH INFORMATION TECHNICIAN

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1 Essential Functions HEALTH INFORMATION TECHNICIAN Function # Essential Function* The tasks below are from the American Health Information Management Association s Registered Health Information Technician Domains, Subdomains and Tasks and represent the program s essential functions Domain I: Health Data Management Subdomain A. Health Data Structure, Content and Standards IA1 Collect and maintain data sets and databases IA2 Conduct qualitative analysis to ensure that documentation in the health record supports the diagnosis and reflects the progress, clinical findings and discharge status IA3 Apply clinical vocabularies and terminologies used in the organization s health information systems IA4 Comply with national patient safety goals as related to abbreviation usage IA5 Verify timeliness, completeness, accuracy, and appropriateness of data and data sources (such as patient care; management; billing reports and/or databases) Subdomain B. Healthcare Information Requirements and Standards IB1 Monitor the accuracy and completeness of the health record as defined by organizational policy, external regulations and standards IB2 Perform analysis of health records to evaluate compliance with regulations and standards: a. Quantitative analysis b. Qualitative analysis IB3 Apply policies and procedures to assure organizational compliance with regulations and standards Subdomain C. Clinical Classification Systems IC1 Use and monitor applications and work processes to support clinical classification and coding IC2 Apply diagnosis/procedure codes using ICD-9-CM IC3 Apply procedure codes using CPT/HCPCS IC4 Ensure accuracy of diagnostic/procedural groupings (such as APC; DRG; IPF) IC5 Adhere to current regulations and established guidelines in code assignment IC6 Validate coding accuracy using clinical information found in the health record IC7 Identify discrepancies between coded data and supporting documentation

2 Function # Essential Function* Subdomain D. Reimbursement Methodologies ID1 Apply policies and procedures for the use of clinical data required in reimbursement and prospective payment systems (PPS) in healthcare delivery (such as APC; DRG; RVU; RBRVS) ID2 ID3 Support accurate revenue cycle through: a. Coding Use established guidelines to comply with reimbursement and reporting requirements (such as National Correct Coding Initiative [NCCI]; Local Medical Review Policies [LMRP]) Domain 2: Health Statistics, Biomedical Research and Quality Management Subdomain A. Healthcare Statistics and Research IIA1 Abstract and maintain data for clinical indices/databases/registries IIA2 Collect, organize, and present data for: a. Administrative purposes b. Financial purposes c. Performance improvement programs d. Quality management Subdomain B. Quality Assessment and Performance Improvement IIB1 Participate in facility-wide quality assessment program IIB2 Present data in verbal and written forms Domain 3: Health Services Organization and Delivery Subdomain A. Healthcare Delivery Systems IIIA1 Comply with accreditation, licensure, and certification standards from government (national, state, and local levels) and private organizations (such as Joint Commission onthe Accreditation of Healthcare Organizations) IIIA2 IIIA3 Apply policies and procedures to comply with the changing regulations among various payment systems for healthcare services such as Centers for Medicare and Medicaid Services (CMS), managed care Differentiate the roles of various providers and disciplines throughout the continuum of healthcare and respond to their information needs IIIA4 Understand the role of various providers and disciplines throughout the continuum of healthcare services Subdomain B. Healthcare Compliance, Confidentiality, Ethical, Legal, and Privacy Issues IIIB1 Implement the legal and regulatory requirements related to health information IIIB2 Apply regulatory policies and procedures for access and disclosure of protected health information (PHI) IIIB3 Maintain user access logs/systems to track access to and disclosure of patient-identifiable data IIIB4 Identify and report privacy issues/problems IIIB5 Demonstrate and promote legal and ethical standards of practice IIIB6 Report compliance issues according to organizational policy IIIB7 Collaborate with staff to prepare the organization for accreditation, licensing, and/or certification surveys IIIB8 Implement health record documentation guidelines and provide education to staff

3 Function # Essential Function* Domain 4: Information Technology and Systems Subdomain A. Information and Communication Technologies IVA1 Use technology, including hardware and software, to ensure data collection, storage, analysis, retrieval and reporting of information IVA2 IVA3 IVA4 Use common software applications (such as spreadsheets; databases; presentation; ) in the execution of work processe Use specialized software in the completion of HIM processes (such as chart management; coding; release of information) Apply policies and procedures for the use of networks, including intranet and internet applications to facilitate the electronic health record (EHR), personal health record (PHR), public health, and other administrative applications IVA5 Protect data integrity using software or hardware technology (Note: Integrity means that data should be complete, accurate, consistent and up-to-date) Subdomain B. Data, Storage and Retrieval IVB1 Use appropriate electronic or imaging technology for data/record storage IVB2 Maintain integrity of patient numbering and filing systems IVB3 Design forms, computer input screens, and other health record documentation tools IVB4 Maintain integrity of master patient/client index/enterprise Master Patient Index (EMPI) IVB5 Query and generate reports using appropriate software IVB6 IVB7 Design and generate reports using appropriate software Coordinate, use and maintain archival and retrieval systems for patient information (such as in multiple formats) Subdomain C. Data Security IVC1 Apply confidentiality and security measures to protected health information (PHI) IVC2 Apply departmental and organizational data and information system security policies IVC3 Use and summarize data compiled from audit trail Subdomain D. Healthcare Information Systems IVD1 Collect and report data on incomplete records and timeliness of record completion IVD2 Maintain filing and retrieval systems for health records

4 Function # Essential Function* Domain 5: Organizational Resources Subdomain A. Human Resources VA1 Apply the fundamentals of team leadership VA2 Develop and/or contribute to: a. Strategic plans, goals and objectives for area of responsibility/responsibilities b. Job descriptions VA3 Develop and/or conduct Performance Appraisals VA4 Participate in intradepartmental and interdepartmental teams/committees VA5 Develop and implement staff orientation and training programs VA6 Provide consultation, education, and training to users of health information: a. Internal users (such as healthcare providers; administrators) VA7 Assess, monitor, and report: a. Quality standards b. Productivity standards VA8 Perform staffing analysis to determine adequate coverage VA9 Prioritize job functions and activities VA10 Use quality improvement tools and techniques to assess, report and improve processes VA11 Promote positive customer relations VA12 Apply the principles of ergonomics in work process design VA13 Comply with local, state and federal regulations regarding labor relations Subdomain B. Financial and Physical Resources VB1 Determine and monitor resources to meet workload needs including staff, equipment and supplies VB2 Make recommendations for items to include in budgets VB3 Monitor coding and revenue cycle processes VB4 Recommend cost-saving and efficient means of achieving work processes and goals *Essential Functions are taken from the Domains, Tasks and Subtasks for Registered Health Information Technicians for of the American Health Information Management Association.

5 Program Specifications HEALTH INFORMATION TECHNICIAN Physical Factors YES NO s Physical Factors YES NO Standing ALL Twisting Walking ALL Turning Sitting ALL Jumping Lifting Grasping-Firm/Strong ALL 10 lbs. ALL Grasping-Light ALL 20 lbs. Finger Dexterity ALL 50 lbs. Reaching Forward ALL 100 lbs. Reaching Overhead ALL 100 lbs. + Pinching Carrying Simultaneous use of 10 lbs. ALL Hand, wrist, fingers 20 lbs. (e.g. typing, data entry) ALL 50 lbs. Coordination 100 lbs. Eye-hand ALL 100 lbs. + Eye-hand-foot ALL Pushing/Pulling Driving 10 lbs. Vision 20 lbs. Acuity, Near ALL 50 lbs. Acuity, Far ALL 100 lbs. Depth perception ALL 100 lbs. + Accommodation ALL Climbing Color vision ALL Balancing Field of vision ALL Bending ALL Face-to-face conversation ALL Stooping ALL Verbal conversation Crouching with others ALL Kneeling Public speaking ALL Crawling Hear normal conversation ALL Running Hear telephone conversation ALL

6 Program Specifications HEALTH INFORMATION TECHNICIAN Environmental Factors YES NO Environmental Factors YES NO Works indoors ALL Works around others ALL** Works outdoors Works alone ALL** Exposure to extreme hot or Works with others ALL** cold temp Safety Equipment Working at unprotected heights (Required to wear ) Being around moving Safety glasses machinery Face mask/face shield Exposure to marked changes Ear plugs in temperature/humidity Hard Hat Exposure to dust, fumes, Protective Clothing smoke, gases, odors, mists or other irritating particles (specify) (Ethylene oxid gas) Exposure to toxic or caustic chemicals Exposure to excessive noises Exposure to radiation or electrical energy Exposure to solvents, grease, or oils Exposure to slippery or uneven walking surfaces Working in confined spaces ALL Using computer monitor ALL Working with explosives Exposure to vibration Exposure to flames or burning items ** Most tasks require independent work but usually in an open office setting when the work of one is dependent upon the completion of the work of another. Teamwork is essential.

7 Program Specifications HEALTH INFORMATION TECHNICIAN Cognitive/Mental Factors YES NO Cognitive/Mental Factors YES NO Simple skills - Reasoning Comprehend simple Deal with abstract and concrete instructions or notations from a variables, define problems, log book ALL collect data, establish facts, Writing and draw valid conclusions ALL Complex skills Prepare Interpret instructions furnished business letters, report sumin oral, written, diagrammatic, maries using prescribed form or schedule form ALL at and conforming to all rules Deal with problems from of punctuation, spelling, standard situations ALL grammar, diction and style VA1-13, VB1-4 Carry out detailed but Simple skills English uninvolved written or sentences containing subject, oral instructions ALL verb and object; names and Carry out one or two step addresses, complete job appliinstructions ALL cation or notations in log book ALL Mathematics Perception Complex skills Business math, Spatial ability to comprehend algebra, geometry or statistics IIA2, VA7, VB1-4 forms in space and understand Simple skills add, subtract, relationships of plane and solid multiply and divide whole objects; frequently described as numbers and fractions, the ability to visualize calculate time and simple objects of two or three dimenmeasurements IIA2, VA7, VB1-4 sions, or to think visually of Reading geometric forms Complex skills - Comprehend Form ability to perceive newspapers, manuals, journals, pertinent detail in objects or instructions in use and main- in pictorial or graphic material; tenance of equipment, safety to make visual comparisons and rules and procedures discriminations and see slight and drawings ALL differences in shapes and shadings of figures and widths and lengths of line

8 Program Specifications HEALTH INFORMATION TECHNICIAN Cognitive/Mental Factors YES NO Cognitive/Mental Factors YES NO Clerical ability to perceive Ability to make generalizations, pertinent detail in verbal or evaluations or decisions tabular material; to observe without immediate supervision ALL differences in copy, to proof- Ability to accept and carry out read words and numbers, and responsibility for direction, to avoid perceptual errors in control and planning VA1-13, VB1--4 arithmetic computation ALL Data Synthesizing ALL Coordinating ALL Analyzing ALL Compiling ALL Computing ALL Copying ALL A change in your ability to perform any of the Essential Functions must be reported to Laurie Raddatz, Associate Dean, (608) , or to your instructor immediately. Comparing ALL Personal traits Ability to comprehend and follow instructions ALL Ability to perform simple and repetitive tasks IVD2 Ability to maintain a work pace appropriate to a given work load ALL Ability to relate to other people beyond giving and receiving instructions ALL Ability to influence people ALL Ability to perform complex or varied tasks ALL

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