RUNNING HEAD-EFFECTS OF ONLINE COLLABORATION IN MEDA 271 1

Online Collaboration to Facilitate Instruction of Diagnostic Medical Coding (ICD-10-CM): The effects of collaboration on asynchronous learners in

MEDA 271

Mae Dorado, CMA (AAMA), CPC-I, CPC University of Hawai’i at Mānoa

Learning, Design and Technology maesanto@hawaii.edu

Abstract: The Medical Assistant should be competent in assigning diagnostic codes (ICD-10-CM) from medical documentation to keep up with changing regulation, ensure appropriate reimbursement, and contribute to improved revenue flow for the health care practice. Students in Kapi’olani Community College’s Medical Assistant Program (MEDA) can achieve competence and work toward an Associate’s Degree in Science by completing MEDA 271: Coding for Physician’s Office. In this action research, using Constructivism and Merrill’s First Principles of Instruction, I learned through repetitive emphasis of diagnostic coding concepts, with engagement and collaboration of experiences, that students learn effective coding strategies through practice and feedback regardless of learners attending synchronously or asynchronously. Delivering the course via Zoom, giving students attendance options, and using Google Docs to engage students with collaborative coding practice, encourages confidence and successful coding skill to attempt the American Academy of Professional Coders (AAPC) Professional Medical Coding Certification (PMCC) Exam. Eventually the goal is to increase the number of students in the course which contribute to increasing the number students in the Associate's Degree Track by: 1) targeting students from the Certificate of Achievement Track, 2) recruiting MEDA graduates, who are employed, and 3) recruiting experienced healthcare professionals to take the course thus overall addressing the State’s shortage of Certified Medical Assistants and Certified Professional Coders.

Statement of the Problem The Certified Medical Assistant (CMA-AAMA) and Certified Professional Coder (CPC) are essential employees of the physician’s practice. They are versatile health care employees that can also be employed in hospitals, outpatient clinics, and other healthcare facilities; their duties will vary based on the location, specialty, and size of the practice. The job outlook is expected to “grow much faster than average by 29 percent in 2026,” according to the Bureau of Labor Statistics through the U.S. Department of Labor (2018). As one of the more demanding of health occupations due to their ability to perform administrative and clinical duties, a growth in the aging baby-boom population, increasing demand for preventive medical services, and dramatic changes to the healthcare industry; there is a shortage and physicians are in need of Certified Medical Assistants and Certified Professional Coders to keep up with the demands in the healthcare industry (Russon, 2015). Kapi’olani Community College offers the only accredited Medical Assisting Program on the

RUNNING HEAD-EFFECTS OF ONLINE COLLABORATION IN MEDA 271 2

island of Oahu. Students go through a 3-semester sequence (Fall, Spring and Summer), 1-year program or 5-semester sequence (Fall, Spring, Summer, Fall and Spring), 2-year program of MEDA program curriculum. After successful completion of the 1-year program, students achieve a Certificate of Achievement in Medical Assisting and are eligible to sit for the American Academy of Medical Assistant (AAMA) Certification Exam (MEDA Curriculum, 2018). Students have the opportunity to continue for an additional Fall and Spring Semester (2nd year) to achieve their Associate Degree in Science in Healthcare Practice Management. While in the second year, students take MEDA 271: Coding for the Physician’s Office, which is a course that involves teaching medical coding which is an essential skills of the Certified Medical Assistant and Certified Professional Coder. Coding skills involve: 1) International Classification of Diseases (ICD-10-CM) or diagnostic coding, 2) Current Procedural Coding (CPT) or procedural coding, and 3) Healthcare Common Procedure Coding System (HCPCS) to code products, supplies, and services not included in the CPT book. Upon successful completion of the course, students are eligible to sit for the Certified Professional Coder Certification Exam (CPC) offered through the American Academy of Professional Coders (AAPC). The challenge is retaining current Medical Assisting Students or recruiting Medical Assistants in the community to achieve their Certified Professional Coder Certification. For most students there is the lack of time, lack of ease of access and inability to attend traditional face-to-face courses due to employment. Funding is another factor that prevents students from either continuing their education to the AS Degree or attaining the coding education; due to the need for income supplied by full-time employment and the costs of the Professional Medical Coding Training directly through the AAPC. The purpose of adjusting the course material and the way the course is taught and the reasons for this action research was to assess the effects of collaboration when delivering content via synchronous Zoom sessions with asynchronous students. Asynchronous students will watch recorded synchronous sessions and collaborate with synchronous students using a Google Doc. Students learn, demonstrate, share experiences, and discuss coding scenarios related to the process of diagnostic medical coding. The research was conducted in an online and classroom environment at Kapi’olani Community College. Students were enrolled in MEDA 271 in the Spring Semester and were offered the following three options of: 1) attending classes face-to-face, 2) online synchronously via Zoom, or 3) asynchronously. Literature Review Zoom is a web conferencing and collaboration tool teachers can use as a resource for conducting online classes. Incorporating recordable video conferencing versus being in the classroom can be beneficial to capture a larger audience and increase attrition due to instructors and students can participate as long as there is access to a computer with internet connection. Students have the ability to network with other students from other courses or sections, and students can take control over the screen to give presentations online. Along with these great features, Zoom provides high-quality audio, video, polling tools, whiteboard and annotation tools to gather feedback from students and instructors have the ability to divide students up into breakout rooms to conduct private discussions for facilitated group work. Zoom can be integrated into Learning Management Platforms such as Canvas and provides a means for archiving recorded lectures on the cloud or a

RUNNING HEAD-EFFECTS OF ONLINE COLLABORATION IN MEDA 271 3

computer device (Gonin, 2017). Using Zoom provided ease of access for both synchronous and asynchronous learners by giving students the ability to view recorded sessions at a later time; it helped students successfully access (when missed) and re-access information necessary to complete the diagnostic coding activities. Based on an article by Funderstanding, an Education, Learning and Curriculum Resource, Constructivism is a theory of learning which is reflected by a learner’s understanding of experiences (Constructivism, 2011). A student will experience various activities and incidences, then grasp and build an understanding of why things are the way they are or things happen the way they happen. The author of the article on Constructivism discussed several guiding principles: the learner should be motivated to understand the meaning of an issue, seeing the overall picture and its individual parts helps with understanding, in order for a lesson to be understood (Constructivism, 2011). Being able to understand the way a student perceives information, the learner should understand what is being learned in his or her own way versus memorizing the correct answer. The theory of constructivism impacts learning through engagement by promoting hands-on experiences, educators should focus on connecting facts and customizing their teaching strategies to student responses which should encourage students to analyze, interpret, and predict results of what is observed. In terms of assessment, it should be incorporated within the learning process to assist students in learning and making judgements to contribute to their understanding of concepts (Constructivism, 2011). Students enrolled in MEDA 271 come with a variety of medical experiences and life/educational backgrounds, which have been used in collaboration during group coding exercises. Students learn from each other’s experiences as they work in groups to understand why diagnostic medical codes are selected for documented medical diagnosis. Merrill’s First Principles of Instruction identifies concepts that promote learning in phases. Such phases occur when learners are engaged in solving real-world problems, when existing knowledge is incorporated as a foundation for new knowledge, when information learned is demonstrated, when the newly learned information is applied, and when the information learned is incorporated into a real-life setting. (Merrill, 2002). The students in MEDA 271 have collaborated, demonstrated, and practiced with assignments created in Google Docs which provided an opportunity to perform diagnostic medical coding with patient scenarios from a real-life setting, and students provided engaging discussion while sharing their individual clinical experiences to determine the best diagnostic medical codes for each patient scenario. Intensive training of medical coding is not simple to teach or understand due primarily to a complex medical system of diagnosis, procedures, and insurance regulation. In Victoria Weinert’s article, Creative ways to teach your coders, she discusses various methods to learn medical coding. A student is encouraged to have a clinical background in medical terminology, anatomy and physiology, and typically a student is working full-time in the field. Based on these challenges, an instructor must determine the learning style of the students and adapt the instruction to each learning type plus determine what is the most effective teaching methods. She provides an example of how the student experience and awareness of different learning styles can be determined by providing a Learning Style Quiz and understanding the differences in learning styles as well as how teaching can be adapted to suit those needs. Teaching based on learning styles has been shown to impact the effectiveness of the course (PHEAA, 2011). Victoria

RUNNING HEAD-EFFECTS OF ONLINE COLLABORATION IN MEDA 271 4

elaborates that learners typically have more than one learning style, and working with various learners, veering from traditional lecture is recommended. Additionally, developing group and gamification-style activities were memorable and encouraged motivation to learn. Strategies such as varying teaching methods kept students engaged and prevent distraction from the topics of conversation. Lastly, preventing monotony by incorporating web conferencing tools such as Zoom and Kahoot removed the learner from the regular environment and helped the student to be engaged, focused, prevented distraction, thus the potential for capturing a larger audience who may be discouraged to take the course if employed full-time (Weinert, 2012). In the years I have taught the course and over the span of the project, I have discovered that students need the clinical background to be familiar with complex topics in diagnostic medical coding which also involve a knowledge of medical terminology, anatomy and physiology, and the knowledge of clinical procedures. With these experiences, student have confidence in performing coding skills which involve selecting the diagnostic medical code to the highest level or detail of specificity. Without the clinical background, as discovered by one of the students in the project, students struggle to understand coding concepts and affect retention in the course. Methodology Participants Recruitment of the participants of the study would come from Kapiolani Community College’s Medical Assisting Program. There are two cohorts, a beginner or 1st year and advanced or 2nd year, participants would only come from the 2nd year since the course is offered each Spring in the AS Degree. The number of students in each cohort can range between 7 to 24 students. Student ages can range between 18 to 50 years of age and sex tends to be female dominant, but still represented by both male and female populations within each cohort. Since we are the only AAMA accredited Medical Assistant program on Oahu, students come from various distances, primarily from urban areas of Oahu. Acceptance in the program is every Fall based on a best-qualified, first-accepted rating system and potential applicants are qualified based on their English and Math Accuplacer results, GPA for any program support courses completed, their typing test scores (administered during the application period), and any volunteer or work experience in the health field. Originally, the cohort started with 9 students in the Fall of 2017, with 6 students who successfully completed the first year after the Spring Semester. However, there were 7 participants in the study, 5 of the 7 students were currently in the Medical Assisting Program pursuing their Associate Degree after successfully completing the first year. Another student started with the five last Fall but exited after the 1st year due to an offer of full-time employment, this student shared an interest in taking the course prior to exiting the program and due to the availability of asynchronous options she was able to take the course. The last student had no clinical experience but took a medical terminology and anatomy and physiology course to justify enrolling in the course, she ended up withdrawing from the course after completing the 4th week because she struggled to understand coding concepts throughout the weekly lessons and assignments. The student’s assignment and assessment scores consistently averaged lower than the required 70% passing, the student decided it was in her best interest to withdraw from the course. The enrollment numbers were lower than expected due to a recent trend of low enrollment which affected not just the Medical Assisting Program but the college and system statewide.

RUNNING HEAD-EFFECTS OF ONLINE COLLABORATION IN MEDA 271 5

The students in the course ranged in age from 19 to 50 years of age. This cohort was strictly all female and they came from various areas of Oahu from Mililani, Pearl City, Hawaii Kai, and Honolulu. Because of the traffic situations on Oahu, employment schedules, and the long commute time for those students who lived more than one hour driving distance away from the campus, many of the students commented to me, during the course, their appreciation of having various attendance options, face-to-face, the option of Zooming synchronously or watching recorded Zoom sessions asynchronously to access lectures and complete assignments based on their various learning styles and convenience of completing the course requirements. All but one student was employed on a full-time or part-time basis and all but one student had a clinical background, it was the student who withdrew from the course that lacked the background in clinical experience and interestingly, the one that is not currently employed but had little clinical experience, she struggled a bit more to pass the assignments and assessments than the students with current employment in the field. The various clinical experiences were through required externship in the first year program and current employment in the field, representing multiple areas of healthcare, students had the following clinical backgrounds to share during collaborative coding practice: Dermatology, Aesthetics, Oncology, Internal Medicine, Family Practice, Obstetrics, Gynecology, and Fertility. My coding course and most of the coding courses that I researched are taught traditionally in a face-to-face environment with students receiving content in the form of face-to-face lectures then given assignments and an assessment in the form of a multiple choice quiz to determine their understanding of the diagnostic coding process. In previous years, student retention from first to second year was about 84%. Students who did not move on to the second year of the program were mainly due to obtaining full-time employment and that caused a lack of time, lack of access, or inability to attend traditional face-to-face courses. I have discovered the incorporation of instruction with Zoom, offering attendance options: 1) face-to-face, 2) online synchronously, or 3) asynchronously can increase enrollment and accessibility, and do not differ when determining effectiveness of knowledge or retention of the content, because as Dr. Ruiz explains in his article, The Impact of E-Learning in Medical Education, “learners using computer-based instruction learned more efficiently and demonstrated better retention” (Ruiz, 2006). However, with effective coding instruction and learning strategies through practice and feedback my results showed students were successful in passing requirements regardless of learners attending synchronously or asynchronously.

Research Questions My action research focused on the following research questions: • Are collaborative online tools an effective way of teaching diagnostic medical

coding skills to Medical Assisting Program students? • Could collaborative online tools be used to increase diagnostic medical coding

skills and improve assessment scores for asynchronous learners? As shown in the results, students attended lectures using the variety of options and with the use of the various online tools, such as Zoom and a collaborative Google Doc, my project has proven that collaborative online tools are an effective way of teaching diagnostic medical coding skills. When analyzing the data, it showed knowledge of

RUNNING HEAD-EFFECTS OF ONLINE COLLABORATION IN MEDA 271 6

diagnostic medical coding skills were attained regardless of synchronous or asynchronous attendance and assessment scores for asynchronous learners were higher than the synchronous learner. Content Analysis I have found that offering course instructional options, such as attending classes synchronously face-to-face or online via Zoom, and asynchronously, I was able to increase the number of students taking the MEDA 271 course by 2 students more than would have enrolled for the course and student attendance and submission of assignments have been satisfactory due to the increase in options for viewing the course lectures and accessing the assignments. In my data collection in Appendix 9, I kept track of each student’s attendance method and compared their results. Adding collaboration of coding scenarios, medical expertise and experience, were beneficial for students to gain confidence and knowledge in the diagnostic coding process. In student feedback on the Discussion Board Assignment, see Appendix 10 and in my results section, students successfully achieved a score of 70% or higher in the assignments and assessments which could potentially reflect their performance in the Certified Professional Coder (CPC) Certification Exam to be offered later in the semester. Additionally, increased student success, equates to increasing numbers of graduates and Certified Medical Assistants and Professional Coders in the workforce; despite the limited equipment, resources and classroom space which posed a challenge for increasing the numbers of accepted students in each cohort. Delivery of the material according to Cummings’ Comparative Analysis of Distance Education and Classroom-based Formats for a Clinical Social Work Practice Course, specifies that, “online courses are as effective as face-to-face courses in delivering knowledge-based content.” (Cumming, 2013, p. 68). Delivery of online content via E-learning is an alternative to expansion despite limited equipment, resources and classroom space. Project Design The project was conducted over a period of one year. Planning started in the Fall of 2018 with implementation and presentation the following Spring. Major tasks and goals are listed in Table 1. Table 1 - Action Research Project Goals and Timeline

Date Task

October Began writing detailed project plan. Began the IRB approval process. Created data collection tools such as evaluation tools, assignments,

quizzes, journal/discussion board assignments. November Continued drafting and revising project plan

Began populating content in Laulima.

December Finalized project plans for approval Continued populating content in Laulima.

RUNNING HEAD-EFFECTS OF ONLINE COLLABORATION IN MEDA 271 7

January Received IRB approval Begin project implementation. Collected assignment assessment data. Completed Evaluating Student Performance of Diagnostic Coding Tool for

Week 3 February Continued implementing project

Continued collecting assignment and quiz assessment data Completed Evaluating Student Performance of Diagnostic Coding Tool for

Week 4 March Administered Reflection Discussion Board Assignment

Analyzed data Completed final paper draft

April Created TCC Presentation Slides Conducted TCC Presentation

May Completed final paper

The starting point for the project was to research other diagnostic coding programs; especially those that delivered courses via distance education. There were very limited findings, only strictly online or face-to-face options and the instructor must be a Certified Professional Coding Instructor (CPC-I) credentialed through the American Academy of Professional Coders (AAPC) to teach the course. The implementation of the course is a combination of both options focusing on accessibility and collaboration of student experiences. Design and implementation within effective distance educational tools, platforms, or learning management systems (LMS) for course instruction was an essential next step in the planning process. As D.A. Beck explains in an article pertaining to Learning Management System and e-learning tools, contents of a learning management system support an efficient learning environment, using interactive tools and their conceptual integration into face-to-face teaching are important for student success (Beck, 2016). I used Sakai’s Laulima to deliver course content which linked directly to the University of Hawaii Star Registration System to capture current registration information. Zoom was the most effective tool to broadcast and record lectures and Google Docs was most effective for collaborative group work. Along with registration in the 5-credit course each student was required to sign a consent form, see Appendix 7, have a computer with internet access, know how to access and have some knowledge of Google Docs and Laulima, and had to purchase current editions of the AAPC coding curriculum textbook with workbook and the current year professional ICD-10-CM coding book. Instruction consisted of weekly textbook reading assignments, supplemental workbook practice, scenario-based coding practice which utilized the ICD-10-CM book, and tools or resources accessible in Laulima’s resources, such as PowerPoint presentations, recorded Zoom lectures, and handouts. Synchronous sessions were conducted every Thursday for 5 hours during the Semester. Assignments were assigned weekly, due every Wednesday by midnight, and consisted of a

RUNNING HEAD-EFFECTS OF ONLINE COLLABORATION IN MEDA 271 8

collaborative and an individual assignment submission. The collaborative assignment was created with one Google Doc for working on group coding practice, sharing and receiving feedback. There were 2-3 groups of 2-3 students in each group. Students were assigned different group members weekly and each group was assigned 2-5 out of the 10 coding scenarios found in the workbook. Within each group, students were able to decide which coding scenarios they wanted to work on for the week and were given time to work on the scenarios with their group members at the end of the class or on their own outside of class time. Upon returning to class the following week, students presented their scenarios and how they found the assigned medical codes followed by discussion and feedback. Along with the collaborative assignment, students submitted an individual assignment using Assignments in Laulima based on the same 10 coding scenarios and this was due Wednesday by midnight prior to the presentation. Students did not have to agree with the collaborative answers shared in the Google Doc, they had the ability to submit answers based on their own experiences and knowledge of the coding material. Lastly, an assessment using a multiple-choice quiz tool in Laulima was utilized to determine each student’s level of understanding of the material learned. I used test and quizzes; however, assessments could be delivered using alternative online tools such as Socrative or Kahoot to further engage and provide a variety of assessment techniques to students. As Charles Docherty emphasizes in his article on eLearning techniques, “eLearning techniques can help students acquire clinical skills in the safety of a simulated environment within the context of a problem based learning curriculum” (Docherty, 2005). Students were guided through the material on a week-by-week basis regardless of synchronous or asynchronous attendance to acquire clinical skills of diagnostic coding. Students needed to score a 70% or higher on the assessment to simulate the required score necessary to pass the AAMA Certified Professional Coder (CPC) Certification Exam. The instructional process is elaborated in detail and displayed in Figure 1 below.

Figure 1 - Overall Timeline of Diagnostic Coding Instructional Process

Implementation as broken down in Figures 2 through 5, demonstrated the Diagnostic Coding

RUNNING HEAD-EFFECTS OF ONLINE COLLABORATION IN MEDA 271 9

Process for each week over a 4-week period. It started the 2nd week of the Spring semester with the analysis and reflection conducted after the 4th week. The instructional time frame, including report write up, was 5 weeks during the Spring Semester. MEDA 271 is only offered during the Spring once a year and the Diagnostic Coding (ICD-10-CM) process is a small portion of the MEDA 271 Course using the AAPC Professional Medical Coding Curriculum, it is typically taught first and thus was the reason for selecting diagnostic (ICD-10-CM) coding versus procedural (CPT) Coding.

Figure 2 – Week 1’s Timeline of Diagnostic Figure 3 – Week 2’s Timeline of Diagnostic Coding Process Coding Process

Figure 4 – Week 3’s Timeline of Diagnostic Figure 5 – Week 4’s Timeline of Diagnostic Coding Process Coding Process In addressing domains of learning, to capture cognitive learning function, students were given reading assignments prior to the lecture, refer to Figure 1. There were a total of 5 chapters assigned, 2 chapters the first week and 1 chapter each week for the remaining 3 weeks. Synchronously, students were given the option to attend lectures face-to-face or online via Zoom. The lectures or discussion of each week’s chapters were recorded using Zoom and made available for viewing by all students in Laulima Lessons. For data analysis purposes, students were categorized by asynchronous (full or partial non-synchronous attendance during lecture) and synchronous (face-to-face or online via Zoom). To capture the psychomotor function, after each chapter, students practiced diagnostic coding exercises and activities by presenting their findings, discussed the process for finding each diagnostic code to the level of highest specificity. They received feedback to check their understanding. I used an observation tool (see Appendix 4) to evaluate student’s performance of diagnostic coding, if the correct codes were selected (using an answer key per scenario), the student received a satisfactory or passing grade if they answered

RUNNING HEAD-EFFECTS OF ONLINE COLLABORATION IN MEDA 271 10

with the correct codes. For the evaluation or affective function and to determine retention and assess understanding from all 5 chapters, a cumulative, multiple-choice quiz was administered where students were given questions which required selection of the correct diagnostic medical codes. Lastly, students completed a discussion board assignment (Appendix 5) to reflect on the process and evaluate their own level of understanding.

Evaluation Instruments The following items as listed in Table 2 were used as data sources for comparative data analysis for the project. Table 2 - List of Data Sources

Data Sources Assessment Tool Frequency

Data Source 1 (Appendix 1) Collaborative Google Doc Assignments

Students in groups of 2-3 collaborated on 2-5 of the 10 patient scenarios to share expertise in their clinical knowledge of diagnostic coding.

Data Source 2 (Appendix 2) Individual Assignments Students submitted diagnosis codes for each of the 10 patient scenarios based on their clinical knowledge of diagnostic coding.

Data Source 3 (Appendix 4) Evaluating Student Performance of Diagnostic Coding Tool

Students in their assigned groups of 2-3 presented their collaborative findings for the assigned 10 patient scenarios. The instructor graded each student based on their ability to properly explain and select the diagnostic code to the level of highest specificity.

Data Source 4 (Appendix 3) Quiz Students were evaluated on their diagnostic coding knowledge with a 50-question, multiple-choice assessment that simulated the AAMA Certified Professional Coder (CPC) Certification Exam. Questions consisted of selecting the proper diagnostic medical code from a given

RUNNING HEAD-EFFECTS OF ONLINE COLLABORATION IN MEDA 271 11

diagnosis. Students needed to score a 70% or higher on the assessment to simulate the required score necessary to pass the AAMA Certified Professional Coder (CPC) Certification Exam.

Data Source 5 (Appendix 5) Reflection Discussion Board Assignments

Students were given feedback after each assignment and the quiz. Students reflected on their ability to learn and evaluate their own level of understanding the diagnostic medical coding process.

Effectiveness of methods of instruction were assessed by using the results of the asynchronous learner, then comparing the results of the asynchronous learner to the synchronous learner’s assignments, the Diagnostic Coding Tool results, and the quiz results. Not only did the students need to score a 70% or higher on the assessment to simulate the required score necessary to pass the AAMA Certified Professional Coder (CPC) Certification Exam, but because the Medical Assistant Program is an accredited program, it’s students are required to maintain a grade of 70% or higher for each assessment per accreditation standards.

Results

To determine successful competency coding knowledge, the results of the individual assignment (Data Source 2 and Appendix 2), collaborative coding assignment Google Doc (Data Source 1 and Appendix 1), diagnostic coding observation tool (Data Source 3, Appendix 4), and quiz (Data Source 4, Appendix 3) were analyzed. In Figure 6, the average percentage of the assignment results were analyzed and compared asynchronous students to synchronous face-to-face (F2F) and online students. The blue bar in Figure 6 show that in all four assignments the asynchronous students performed better than the synchronous students thus demonstrating the asynchronous learner is capable of performing successful diagnostic medical coding without requiring the traditional face-to-face environment.

RUNNING HEAD-EFFECTS OF ONLINE COLLABORATION IN MEDA 271 12

Figure 6 – Average Assignment Results for Asynchronous versus Synchronous Students In Figure 7, I used the results of the observation tool and compared the results of the asynchronous students to synchronous face-to-face (F2F) and online students. The observation tool demonstrates competence in the psychomotor procedural skill of diagnostic medical coding. Again, the asynchronous students (shown with the blue bars) outperformed the synchronous students (shown with the purple and pink bars) resulting in instruction being just as effective for asynchronous students.

Figure 7 – Results of Diagnostic Coding Tool for Asynchronous versus Synchronous Students The analysis of the quiz results in Figure 8, show the students (listed individually) who attended classes mostly asynchronously (reflecting higher blue bars) performed better or just as well as the students that attended mostly synchronously (lower blue bars).

RUNNING HEAD-EFFECTS OF ONLINE COLLABORATION IN MEDA 271 13

Figure 8 – Results of Quiz by Student Based on Percentage of Asynchronous Days of Attendance

Figure 9 – Average Percentage of Quiz Results Based on Percentage of Asynchronous Days of Attendance Comparing Students with and without Clinical Experience Based on the results, my findings indicated that students learned effective coding strategies through practice and feedback regardless of learners attending synchronously or asynchronously.

● Looking at the results of the course requirements, surprisingly, my findings uncovered that the asynchronous students were more successful than the synchronous students. This may have been the case because the synchronous learners absorbed the material in class together and earlier than the asynchronous leaners, who learned at their own pace. Based on readings comparing synchronous to asynchronous learners, it is suggested that asynchronous learners have more time to ponder the material, thus being more successful. As discussed by Elizabeth Murphy in her paper titled, Asynchronous and Synchronous Teaching and Learning in High-School Distance Education, ‘Asynchronous communication may induce increased cognitive effort since students have more time for reflection.” (Murphy, 2011).

RUNNING HEAD-EFFECTS OF ONLINE COLLABORATION IN MEDA 271 14

● A student with little to no clinical experience will struggle and have difficulty with adapting to the course material. The student with limited clinical experience had lots of questions and concerns during class, eventually dropping the course, due to difficulty in passing assignments and assessments satisfactorily. The student that is not currently employed and had little experience struggled as well.

● Attendance was satisfactory and accessibility was increased due to Synchronous (face-to-face and Zoom online) and Asynchronous course options. 100% of first year students registered for the course plus 2 more than expected due to accessibility.

Based on Merrill’s First Principles of Instruction…I observed the following:

● Learning is promoted when learners are engaged in solving real-world problems — Based on feedback, students valued coding exercises to prepare for the quiz.

● Learning is promoted when new knowledge is demonstrated to the learner — Students demonstrated successful and passing coding skills, due to coding demonstrations rather than being told how to code.

● Learning is promoted when new knowledge is applied by the learner — Based on feedback, students understood complex coding rules with collaborative exercises.

● Learning is promoted when new knowledge is integrated into the learner’s world — Based on feedback, students are able to have better understanding of coding rules and relate newly acquired skills for use in their current jobs.

Discussion Coding skills are an important and necessary scope of practice for the Certified Medical Assisting and Certified Medical Coders. Our program produces on average of 24 graduates a year, with an 84% retention and a record of 98% successful certification exam passing rates for the past 3 years. Physicians are in need of more Certified Medical Assistants and Certified Medical Coders to keep up with their growing practices and prevent a shortage in the healthcare workforce. In this action research, using Constructivism and Merrill’s First Principles of Instruction, I learned through repetitive emphasis of diagnostic coding concepts, with engagement and collaboration of experiences, students learn effective coding strategies through practice and feedback regardless of learners attending synchronously or asynchronously. Dr. Jack Ende, elaborates on the importance of feedback during the performance of an activity to guide future performance in the same or related activity being the key step to acquisition of clinical skills (Ende, 1983). Diagnostic coding is not as simple as it seems; however, with the clinical background obtained in the Kapi’olani Community College Medical Assisting Program, combined with collaboration and synchronous or asynchronous options, students gain the confidence to perform diagnostic medical coding which is necessary for justifying the hard work and expertise of the healthcare practitioner. I must reach out to current Certificate of Achievement students, healthcare workers and graduates of our program who are currently working in the field, to continue to offer asynchronous and synchronous instructional options based on individual learning styles. By conquering these barriers, providing asynchronous and synchronous instructional options, seeking resources that

RUNNING HEAD-EFFECTS OF ONLINE COLLABORATION IN MEDA 271 15

prevent or limit equipment and resource usage and classroom space, I hope to increase cohort numbers to eventually fulfil the demand for more Medical Assisting and Medical Coding Graduates necessary to keep up with the growing healthcare community.

RUNNING HEAD-EFFECTS OF ONLINE COLLABORATION IN MEDA 271 16

References Back, D.A. (2016). Learning management system and e-learning tools: an experience of

medical students’ usage and expectations. International Journal of Medical Education. 7:267-273. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/27544782

Constructivism. (2011). In Funderstanding online. Retrieved from http://www.funderstanding.com/theory/constructivism/

Cummings, Sherry M.; Foels, Leonora; Chaffin, Kate M. (2013). Comparative Analysis of Distance Education and Classroom-based Formats for a Clinical Social Work Practice Course. Social Work Education, 32(1), 68-80.

Docherty, Charles. (2005). eLearning techniques supporting problem based learning in clinical simulation. International Journal of Medical Informatics, 74(7), 527-533. doi: 10.1016/j.ijmedinf.2005.03.009

Ende J. (1983). Feedback in Clinical Medical Education. JAMA, 250(6), 777-781. doi:10.1001/jama.1983.03340060055026.

Gonin, Madeleine. (2017). Engaging Students Online with Zoom Video Conferencing. Retrieved from http://blogs.iu.edu/citl/2017/06/07/zoom-video-

conferencing/#.WmVByzdG1PY

MEDA Curriculum. (2018). In Kapi’olani Community College’s Medical Assisting Program online. Retrieved from https://www.kapiolani.hawaii.edu/academics/programs-of- study/medical-assisting-program/

Merrill, M. David. (2002). First Principles of Instruction. ETR&D, 50(3), pp. 43-59. Retrieved from: https://mdavidmerrill.com/Papers/firstprinciplesbymerrill.pdf

Murphy, E., Rodríguez-Manzanares, M., & Barbour, M. K. (2011). Asynchronous and Synchronous Teaching and Learning in High-School Distance Education. British Journal of Educational Technology, 42(4), 583-591. Retrieved from: https://www.academia.edu/2311599/Murphy_E._Rodr%C3%ADguez-Manzanares_M._and_Barbour_M._K._2011_._Asynchronous_and_synchronous_teaching_and_learning_in_high-school_distance_education._British_Journal_of_Educational_Technology_42_4_583-591

Pennsylvania Higher Education Assistance Agency (PHEAA). (2011). What’s Your Learning

Style? Education Planner.org. Retrieved from http://www.educationplanner.org/students/self-assessments/learning-styles.shtml

Ruiz, Jorge G. MD; Mintzer, Michael J. MD; Leipzig, Rosanne M. MD, PhD. (2006). The Impact of E-Learning in Medical Education. Academic Medicine, 81(3), 207-212.

RUNNING HEAD-EFFECTS OF ONLINE COLLABORATION IN MEDA 271 17

Russon, Jennifer. (2015). Why the Healthcare Field is Struggling to Fill Medical Coding Jobs.Rasmussen College School of Health Sciences. Retrieved from https://www.rasmussen.edu/degrees/health-sciences/blog/healthcare-industry-struggling- to-fill-medical-coding-jobs/

United States Department of Labor. (2018). Medical Assistants. Bureau of Labor Statistics. Retrieved from https://www.bls.gov/ooh/healthcare/medical-assistants.htm

Weinert, Victoria. ICD-10-CM/PCS Education: Creative ways to teach your coders. (2012). Retrieved from http://www.hcpro.com/HIM-275766-8160/ICD10CMPCS-education- Creative-ways-to-teach-your-coders.html

RUNNING HEAD-EFFECTS OF ONLINE COLLABORATION IN MEDA 271 18

APPENDICES Appendix 1 - Collaborative Google Doc Assignment

Appendix 2 - Individual Assignments

a) Assignment for ICD-10-CM Chapters 1-11

b) Assignment for ICD-10-CM Chapters 12-21

Appendix 3 - Quiz

a) Quiz questions for Chapters 1-11

b) Quiz questions for Chapters 12-21

Appendix 4 – Evaluating Student Performance of Diagnostic Coding Tool

Appendix 5 – Diagnostic Coding Procedure Reflection Assignment

Appendix 6 - Snapshot of Laulima Site Home Page

Appendix 7 - Consent Form for Participation in Project

Appendix 8 - Dorado Citi Training Certificates Appendix 9 – Data Results Organized for Analysis Appendix 10 – Student Demographics and Feedback on the Discussion Board Assignment