Abstract. Introduction. by Jim Condon, MSA, RHIA, CTR, and Amanda Barefield, EdD, RHIA, LNHA

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1 Assessment of Success on the RHIA Certification Examination: A Comparison of Baccalaureate Program Graduates and Postbaccalaureate Certificate Program Graduates Assessment of Success on the RHIA Certification Examination: A Comparison of Baccalaureate Program Graduates and Postbaccalaureate Certificate Program Graduates by Jim Condon, MSA, RHIA, CTR, and Amanda Barefield, EdD, RHIA, LNHA Abstract The demand for registered health information administrators continues to outpace the available supply of credentialed graduates. One solution to address this shortfall has been the availability of postbaccalaureate certificate programs. A health information administration department at an academic health sciences center, which has historically offered a traditional bachelor of science degree in health information administration, has offered a postbaccalaureate certificate program in health information administration since 00. As part of the program s ongoing quality review/performance improvement process, program faculty conducted an analysis to determine whether success on the registered health information administrator (RHIA) certification examination was the same, regardless of the program type or method of course delivery. Results of this analysis demonstrated that the postbaccalaureate certificate program is a viable alternative for producing successful health information administration graduates, increasing program enrollment, and increasing the number of RHIAs in the workforce. Health information administration programs may consider a postbaccalaureate certificate program as a way to increase the number of graduates and in turn increase the health information administration workforce. Introduction As part of a health information administration (HIA) educational program s ongoing evaluation process, a study was conducted to compare the level of success on the registered health information administrator (RHIA) certification examination between graduates of a bachelor of science program in HIA and graduates of a postbaccalaureate certificate program in the same field. The purpose of the study was to assess whether equality of outcomes was being achieved between the two groups of graduates. The measurement of graduate success on the RHIA certification examination was determined by comparing graduates scores from their first attempt at taking the examination. Success on the RHIA certification examination is achieved when the graduate scores at or higher than the threshold set by the American Health Information Management Association (AHIMA), the national association of HIA professionals. The threshold during the time of the study was a score of 0 in and 0 in In

2 Perspectives in Health Information Management, Fall 0 addition, the study examined whether the length of time that elapsed between the date of graduation and date when the RHIA certification examination was taken influenced graduates scores on the examination. Background The demand for credentialed health information administrators continues to outpace the available supply of credentialed graduates. This shortfall could potentially compromise the quality of care received by patients. Acknowledging this challenge, a number of HIA academic programs began offering postbaccalaureate certificates in HIA in an effort to increase the availability of credentialed HIA graduates. In addition, a host of HIA programs are now delivering their programs via online learning, providing access to populations that, in the past, were unable to attend traditional on-campus programs. The model of the postbaccalaureate certificate in HIA enables qualified individuals to attend an accelerated version of a program accredited by the Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM) and acquire eligibility to take the RHIA certification examination upon completion of the program. By recognizing that some graduates already possess many of the skills and much of the experience needed in the HIA profession because of previously earned degrees, the program expands the pool of potential applicants by creating a special curriculum for these individuals. For example, instead of reteaching management and finance principles to business degree graduates, the postbaccalaureate certificate program acknowledges that these graduates instead require the clinical knowledge unique and appropriate to HIA and delivers it to them in a condensed format. The programs under study included both a bachelor of science degree program in HIA and a postbaccalaureate certificate program in HIA. As part of ongoing program evaluation, an analysis was conducted to determine whether postbaccalaureate certificate program graduates were achieving the same degree of success on the RHIA certification examination as the bachelor of science program graduates. Although AHIMA has strongly encouraged employers to exclusively hire credentialed health information professionals, possession of the RHIA credential is not required to work professionally in health information administration. Motivation, therefore, for a graduate in HIA to take the RHIA certification examination may not be as compelling as it would be if credentialing were mandatory. Many graduates who recognize that certification is not a requirement decide to wait before taking the examination, opting first to find work or to take a few months off. Sometimes a significant amount of time elapses before the graduate finally decides to take the examination. Speculation exists as to whether this span of down time impacts the graduate s performance on the examination. Previous studies in other healthcare professions have produced equivocal results. In 00, a study evaluated such down time of graduates of registered nursing programs who took the National Council Licensure Examination (NCLEX). Nursing program graduates are required to pass the NCLEX in order to practice professionally. The study results suggested that the elapsed time between the days of graduation and examination was not significantly correlated with the examination pass rate. However, in another study, more than,000 NCLEX results were inspected, and it was discovered that the number of days between graduation and examination was inversely related to the pass rate. Because of the inconclusiveness of these research results, faculty in the HIA program highlighted in this study conducted research to investigate whether a relationship existed between the number of days from the graduation date to the date that the graduate completed the RHIA certification examination and the score on the RHIA certification examination. Program Descriptions Bachelor of Science Degree Program The HIA program offers a traditional + bachelor of science degree program in HIA. Applicants to the program must first complete 60 semester hours of core curriculum courses as outlined by the

3 Assessment of Success on the RHIA Certification Examination: A Comparison of Baccalaureate Program Graduates and Postbaccalaureate Certificate Program Graduates institution (Table ); accepted applicants enter the program as juniors. In 006, an online option was introduced for students unable to attend traditional on-campus classes. Since that time, the program has experienced an increase in enrollment, with the majority of students choosing the online option. The traditional bachelor of science degree program curriculum is composed of 69 semester hours offered over the course of four semesters (two academic years). Table portrays the courses that make up each semester. As in most professional programs, the courses must be taken sequentially in strict accordance with a predetermined curriculum schedule. Postbaccalaureate Certificate Program In 000, the HIA program welcomed its first postbaccalaureate certificate students; the class consisted of students with backgrounds in allied health and in nursing. To be eligible for the postbaccalaureate certificate program, potential applicants were required to possess a bachelor s degree in one of the allied health sciences, a bachelor s degree in nursing, or an associate s degree in nursing with a bachelor s degree in some other discipline. Applicants must also have completed two program prerequisites: an introductory computer course completed within the previous five years and a basic financial accounting course. The duration of the postbaccalaureate certificate program is three semesters or one academic year. The postbaccalaureate certificate program curriculum is composed of semester hours of management and finance courses, 7 semester hours of HIA theory-related courses, semester hours of healthcare systems technology courses, and semester hours of coding and reimbursement courses. In addition, students complete a professional practicum of 0 clock hours ( semester hours) during the summer semester for a program total of 6 semester hours. See Table for the program curriculum. Throughout the recruitment process, it became clear that the majority of the individuals who expressed an interest in earning a postbaccalaureate certificate were neither nurses nor allied health professionals as originally envisioned. Rather, most held one of several degrees: bachelor or master of business administration, bachelor or master of science in healthcare administration, or bachelor or master of science in information systems or computer science. Recognizing this trend, the program faculty reexamined the curriculum and discovered that with an adjustment of program content and the prerequisite requirements, these individuals could become eligible for the postbaccalaureate certificate program as well. Therefore, a separate business and healthcare administration and computer science curriculum track was added alongside the allied health and nursing curriculum track to accommodate this population. See Table for the business and healthcare administration and computer science curriculum track. The business track, designed for the students described in the previous paragraph, includes 7 semester hours of HIA theory-related courses, semester hours of healthcare systems technology courses, semester hours of coding and reimbursement courses, 7 semester hours of clinically focused courses, and a -semester-hour management course in addition to the professional practicum of 0 clock hours, for a program that consists of semester hours. The courses Anatomy & Physiology I and II are prerequisites for the program. Applicants transcripts, regardless of track, are carefully evaluated, and additional prerequisites or corequisites that are required to complete the applicant s entry-level professional knowledge are added to the student s curriculum plan. Programmatic Review As part of the HIA department s ongoing program evaluation process, a study was conducted to ascertain whether a difference existed between the outcomes of the bachelor of science degree graduates and the outcomes of the postbaccalaureate certificate graduates. Program evaluation is a formal process that systematically examines student achievement throughout the entire curriculum; it is an ongoing process designed to monitor and improve student learning. Specifically, the program wanted to

4 Perspectives in Health Information Management, Fall 0 determine whether both sets of graduates were exhibiting equal degrees of success on the individual s first RHIA examination attempt. This information is important because the program has a responsibility to provide appropriately qualified graduates who, regardless of the duration of the curriculum or the type of program, possess the knowledge required to successfully pass the RHIA examination. Credentialing examination scores serve as a tool to measure an individual s level of competence in a particular area of professional practice. In turn, these scores are also used as a measure of program quality and are provided as part of the annual reaccreditation process to CAHIIM. In educational research, one seeks to find relationships among educational variables. Evaluation, however, is generally focused on a particular educational program; the intent of program evaluation is not to generalize the results to other situations but to focus on the particular program and what future decisions to make about it. 5 Program faculty members were interested in assessing the effectiveness of the postbaccalaureate certificate program and, depending upon evaluation results, making changes to the program for the future. Methods A convenience sample was utilized that included data on graduates who had taken the RHIA certification examination between January, 00, and December, 00, and for whom examination results had been reported (N = 9). Graduation date, examination date, and examination raw scores were acquired from RHIA examination results provided by AHIMA. Age of the graduates was obtained from HIA program applications. During this time frame, the only change to the RHIA certification examination was a slight adjustment in the passing score. 6 Descriptive statistics identified the characteristics of the two groups under study. Mean scores and standard deviations were calculated. Student s t-test for independent samples was used to determine whether any statistically significant difference existed between the RHIA certification examination scores of the bachelor of science program graduates and the scores of the postbaccalaureate certificate program graduates. To survey whether the number of days between graduation and examination was associated with the RHIA certification examination score, the Pearson product-moment correlation was calculated for graduates of both the bachelor of science program and the postbaccalaureate certificate program. Results This study included a sample of 9 graduates; 8 were from the bachelor of science program and 6 were from the postbaccalaureate certificate program. The mean starting age for the bachelor of science program was 6. years (SD = 6.679), and the mean starting age for the certificate program was 8.9 years (SD = 8.9). The combined mean age was 9.78 years. The mean score on the RHIA certification examination achieved by the bachelor of science program graduates was 7.9 (SD = 7.806), and the mean score on the RHIA certification examination achieved by the certificate program graduates was 9.75 (SD = 5.7), with a combined mean score of 8.8. The data reveal that 78 percent of the bachelor of science program graduates completed the RHIA certification examination, while 6 percent of the certificate program graduates completed the examination. Overall, the exam completion rate of the combined programs was 7 percent. Of the graduates who completed the examination, 9 percent took it within a year after graduation. An independent-samples t-test was calculated to compare the graduates average age at the start of each program. The difference in age at the start of each program was significant; t(7) = 8.95, p =.000. An independent-samples t-test was calculated to compare RHIA certification examination scores between bachelor of science program graduates and certificate program graduates. There was not a significant difference in the scores for bachelor of science program graduates and certificate program graduates; t(7) = 0.5, p =.0.

5 Assessment of Success on the RHIA Certification Examination: A Comparison of Baccalaureate Program Graduates and Postbaccalaureate Certificate Program Graduates A Pearson product-moment correlation coefficient was computed to assess the relationship between the RHIA certification examination score and the number of days between graduation and examination. There was a weak negative correlation between the two variables, r = 0.75, n = 9, p =.056. The records of two graduates whose times between graduation and examination were considered outliers (more than,000 days) were removed from the data. The Pearson product-moment correlation coefficient was recalculated, this time revealing an insignificant positive correlation, r = 0.0, n = 7, p =.797. Discussion Because the postbaccalaureate certificate program is condensed into three semesters and offers fewer credit hours, it was necessary to determine whether the certificate program graduates were as successful on the RHIA certification examination as the bachelor of science program graduates. One program objective for ongoing accreditation is to provide both cohorts of program graduates with the same, highquality education experience despite the different approaches and models of each program. The study results suggested that graduates of both programs fared equally well on the RHIA certification examination and that this program objective has been attained. One explanation for the success of the certificate program was the approach of the students that completed the program. The average age of the certificate program cohort was years older than that of the bachelor of science program cohort. Many certificate program graduates may have envisioned the program as an efficient and effective method of making a career transformation in a short period of time, with 00 percent of the curriculum online, earned from a highly regarded institution at a reasonable cost. These graduates also recognized the importance and potential consequences of this career decision and may have approached the entire experience with a sense of urgency, commitment, and focus that may have offset any negative aspects of the condensed curriculum and the decreased number of credit hours. The study results suggested that the amount of time between graduation and completion of the RHIA certification examination did not significantly impact graduates scores on the examination, even with outliers removed. The scatterplot in Figure summarizes the results. The insignificant association of the number of days between graduation and the examination date with the RHIA certification examination score was somewhat surprising given the amount of anecdotal data to the contrary. Conventional wisdom assumes that as the length of time between graduation and the RHIA certification examination increases, the resulting likelihood of a lower score should also increase. With that conventional wisdom in mind, graduates of both programs are encouraged by faculty to continue studying and reviewing previous coursework until they take the examination. They are also provided with a list of RHIA certification examination preparation materials and must complete the department s comprehensive mock examination shortly before graduation. These processes and other unidentified influences might have colluded to mitigate the time factor regarding the RHIA certification examination. It is also possible that some graduates, after having waited a certain amount of time without taking the examination, decided ultimately not to take the examination, decreasing the number of attempts and the number of lower scores. Finally, evidence from this study suggests that a properly designed postbaccalaureate certificate program in HIA can increase the number of credentialed HIA professionals that are available in the workforce. The availability of more RHIAs enhances the prospect that supply will equal demand in the workforce and, consequently, increases the likelihood that patients quality of care will not be compromised. It should be noted that the curricula of several other postbaccalaureate certificate programs in HIA were examined during the literature review process; the programs differ in length, content, and structure. Currently, there is little research available that reports outcomes of other such programs; however, as other postbaccalaureate programs gather enough data to conduct outcome studies, it is expected that a pattern of HIA best practices specific to postbaccalaureate education and subsequent professional credentialing will emerge.

6 6 Perspectives in Health Information Management, Fall 0 Limitations The results of this study are from bachelor of science and postbaccalaureate certificate program graduates at one academic health sciences center and are specific to the curricula and program formats offered at the institution. Therefore, the results may not be entirely generalizable to another institution. In addition, the paucity of data provided with the RHIA certification examination results limited the scope of the research. Recommendations for Further Study As a result of this study, the researchers recommend that the following questions be considered during future research:. Are there differences in RHIA certification examination domain scores achieved between postbaccalaureate certificate and bachelor of science program graduates?. Are there differences among RHIA certification examination scores based on various curriculum models and course delivery methods for both postbaccalaureate certificate and bachelor of science program graduates?. Is there a relationship between program comprehensive examination (mock RHIA examination) scores and success on the RHIA certification examination for both postbaccalaureate certificate and bachelor of science program graduates?. Do any other individual graduate variables, such as demographic and academic variables, have an impact on RHIA certification examination scores? Conclusion Results of this study may be used as a foundation for developing best practices for HIA programs that are considering implementing a postbaccalaureate certificate program. Specifically, other programs considering such an approach could use the curriculum template established by the program in this study as a starting point for their own curriculum design. The results of this study suggest that it is possible to deliver a postbaccalaureate certificate program that, combined with a student s previous bachelor s or even master s degree experience, provides the knowledge necessary for program graduates to be successful on the RHIA certification examination. Leveraging potential students previously completed degree courses, the postbaccalaureate certificate program examined in this study was especially attractive to such students because it is offered entirely online and can be completed in less than a year. The particular model that this HIA program employs will continue to be evaluated and adjusted based on both qualitative and quantitative feedback. Graduates of both programs will still be strongly encouraged to take the RHIA certification examination as soon as possible after graduation and, in some cases in accordance with recent AHIMA guidelines, prior to graduation. The objective is for every graduate to take and pass the examination; however, as long as not all potential employers insist upon newly graduated professionals obtaining their professional credentials, it is not realistic to expect every program graduate to earn RHIA certification. Educational program faculty should remind students and graduates that earning the RHIA credential serves as confirmation that a graduate possesses the entry-level knowledge required of the health information profession as prescribed by AHIMA. As the healthcare industry continues to implement electronic health records and works toward compliance with federal initiatives such as the Health Information Portability and Accountability Act (HIPAA), the Health Information Technology for Economic and Clinical Health (HITECH) Act, and the American Recovery and Reinvestment Act of 009 (ARRA), acquisition of the RHIA credential will likely become even more necessary. This study demonstrates that a postbaccalaureate certificate program in HIA is a viable means of increasing the number of credentialed HIA professionals and reducing the

7 Assessment of Success on the RHIA Certification Examination: A Comparison of Baccalaureate Program Graduates and Postbaccalaureate Certificate Program Graduates workforce shortage of health information administrators. Additionally, a potential model of best practices for the postbaccalaureate certificate approach to HIA education has been identified. Jim Condon, MSA, RHIA, CTR, is an associate professor and program director in the Department of Health Informatics at Georgia Health Sciences University in Augusta, GA. Amanda Barefield, EdD, RHIA, LNHA, is an associate professor in the Department of Health Informatics at Georgia Health Sciences University in Augusta, GA.

8 8 Perspectives in Health Information Management, Fall 0 Notes. Spath, Patrice. Role of HIM in Quality Management. Perspectives in Health Information Management (Summer 009).. Beeman, Pamela, and Julie Waterhouse. Post-graduation Factors Predicting NCLEX-RN Success. Nurse Educator 8, no. 6 (00): Woo, Ada, Anne Wendt, and Weiwei Liu. NCLEX Pass Rates: An Investigation into the Effect of Lag Time and Retake Attempts. JONA s Healthcare Law, Ethics, and Regulation, no. (009): 6.. Allen, Mary J. Assessing Academic Programs in Higher Education. San Francisco: Anker, Popham, W. James. Educational Evaluation. Boston: Allyn and Bacon, Russell, Barbara Landis. A Comparison in Academic Performance between Distance Learning and Traditional On-Campus Students in Allied Healthcare Education at the Medical College of Georgia. Doctoral dissertation, Georgia Southern University, 006. Available at _00608_edd.pdf.

9 Assessment of Success on the RHIA Certification Examination: A Comparison of Baccalaureate Program Graduates and Postbaccalaureate Certificate Program Graduates Table Core Curriculum for Entry into the Bachelor of Science HIA Program Course Semester Hours Area A: Essential Skills English Composition I English Composition II College Algebra or similar Area Total 9 Area B: Institutional Options Select from: Computers, Critical Thinking, Creative Writing, Ethics, Health & Wellness, Statistics, Economics, Speech, Medical Terminology Area C: Humanities/Fine Arts Ethics, Foreign Language, Literature, Communications/Speech, Religion, Philosophy, Drama/Art/Music Appreciation 6 Area D: Science, Mathematics, and Technology A two-course sequence (8 hours) in laboratory science, such as Biology I and II, Chemistry I and II, Physics I and II, and an additional hours in math, science, or technology Area E: Social Sciences US History, American Government (strongly encouraged); Economics, Psychology, Sociology, Anthropology, other History or Social Science courses Area F: Courses Appropriate to the Major Anatomy & Physiology I with lab Anatomy & Physiology II with lab Financial Accounting Fundamental of Computers (including proficiency in word processing, spreadsheet, and presentation software) Guided Electives: Choose from Technology, Computer Science, Accounting, Management, Biological Sciences, Social Sciences Area Total 8 Total Core Curriculum Hours 60

10 0 Perspectives in Health Information Management, Fall 0 Table Bachelor of Science Degree Program and Postbaccalaureate Certificate Program Professional Curricula BACHELOR OF SCIENCE IN HIA CERTIFICATE IN HIA (BUSINESS ADMIN/COMPUTER SCIENCE MAJORS) CERTIFICATE IN HIA (ALLIED HEALTH/NURSING MAJORS) Fall HINF 0 HINF 06 HINF 07 HINF 08 HINF HINF 56 Spring HINF 0 HINF 0 HINF HINF 5 HINF 57 Fall HINF 0 HINF 09 SAHS 60 HINF 6 HINF 58 STAT 00 Spring HINF 05 HINF HINF HINF 59 HINF 7 st Semester Management Introduction to HIM HC Statistics & Data Management Record Processing Practicum Medical Terminology Computer Fundamentals for HC nd Semester Human Resource Management Managerial Practicum Pathophysiology and Essentials of Pharmacology Health Data Classifications and Coding Systems (ICD 9) Introduction to Database Design and Health Information Systems rd Semester Budget and Finance Legal Aspects & Ethics Ethics for Health Professionals Procedural Coding & Principles of Reimbursement Advanced Database Design & HIS Analysis Statistics & Research Methodology th Semester Management Capstone HC Delivery Systems Quality Management Systems Design Implementation Administrative Practicum PROGRAM Fall HINF 000 HINF 00 HINF 00 HINF 06 HINF 07 HINF Spring HINF 00 HINF 006 HINF 007 HINF HINF 5 Summer HINF 005 st Semester Legal Aspects & Ethics Module Introduction to Health Information Systems Module Systems Analysis & Design Module Introduction to HIM HC Statistics & Data Management Medical Terminology nd Semester Quality in Healthcare Module Office Administration in HIM Module CPT/HCPCS Coding and Reimbursement Essentials Module Pathophysiology and Essentials of Pharmacology Health Data Classifications and Coding Systems rd Semester HIA Practicum PROGRAM 0 5 Fall HINF 000 HINF 00 HINF 00 HINF 0 HINF 06 HINF 07 HINF 0 Spring HINF 00 HINF 007 HINF 0 HINF 5 Summer HINF 005 st Semester Legal Aspects & Ethics Module Introduction to Health Information Systems Module Systems Analysis & Design Module Management Principles Introduction to HIM HC Statistics & Data Management Budget & Finance nd Semester Quality in Healthcare Module CPT/HCPCS Coding & Reimbursement Essentials Module Human Resource Management Health Data Classifications & Coding Systems rd Semester HIA Practicum PROGRAM 6 5 9

11 Factors Influencing Students to Enroll in Health Information Management Programs Table Descriptive Statistics Postbaccalaureate Certificate Program Graduates Bachelor of Science Program Graduates Number of graduates (00 00) 6 8 Age at start of program (mean) Standard deviation RHIA examination score (mean) Standard deviation Number of days between graduation and examination: With outliers (N = 9) Mean Median Outliers removed (N = 7) Mean Median 8.9 (range, 57) (SD = 8.00) (SD = 8.00) (range, 9 8) (SD =.68) (SD =.65) Percentage of graduates who took the RHIA certification examination (00 00) 6% 78%

12 Perspectives in Health Information Management, Fall 0 Figure Scatterplot Portraying the Relationship between RHIA Examination Score and Number of Days between Graduation and Completion of the RHIA Examination