UBC Theses and Dissertations

UBC Theses Logo

UBC Theses and Dissertations

The future role of the health record administrator : a Delphi-survey Szabo, Irma 1980

Your browser doesn't seem to have a PDF viewer, please download the PDF to view this item.

Item Metadata

Download

Media
831-UBC_1980_A6_7 S94.pdf [ 8.46MB ]
Metadata
JSON: 831-1.0095023.json
JSON-LD: 831-1.0095023-ld.json
RDF/XML (Pretty): 831-1.0095023-rdf.xml
RDF/JSON: 831-1.0095023-rdf.json
Turtle: 831-1.0095023-turtle.txt
N-Triples: 831-1.0095023-rdf-ntriples.txt
Original Record: 831-1.0095023-source.json
Full Text
831-1.0095023-fulltext.txt
Citation
831-1.0095023.ris

Full Text

THE FUTURE ROLE OF THE HEALTH RECORD ADMINISTRATOR A DELPHI-SURVEY by IRMA SZABO B.A., York U n i v e r s i t y , 1973 A THESIS SUBMITTED IN PARTIAL FULFILLMENTOF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE i n THE FACULTY OF GRADUATE STUDIES •I (Department of He a l t h Care and Epidemiology) We accept t h i s t h e s i s as conforming to the r e q u i r e d standard THE UNIVERSITY OF BRITISH COLUMBIA i September 1980 © . Irma Szabo, 1980 In presenting th i s thes is in pa r t i a l fu l f i lment of the requirements for an advanced degree at the Univers i ty of B r i t i s h Columbia, I agree that the L ibrary shal l make it f ree ly ava i lab le for reference and study. I further agree that permission for extensive copying of th is thesis for scho lar ly purposes may be granted by the Head of my Department or by his representat ives. It is understood that copying or pub l i ca t ion of th is thesis for f inanc ia l gain sha l l not be allowed without my written permission. Depa rtment The Univers i ty of B r i t i s h Columbia 2075 Wesbrook Place Vancouver, Canada V6T 1W5 Date £ ~ ^ y T t ^ J j t ^ l 4 & ° . ABSTRACT The v o l u n t a r y North American a c c r e d i t a t i o n movement, born at the beginning of t h i s century with the i n t e n t to improve the standards of medical care and t e a c h i n g , decreed that the c l i n i c a l records should r e f l e c t the care given to the p a t i e n t s . As a consequence, the occupation of Medical Record L i b r a r i a n , r e c e n t l y renamed Health Record A d m i n i s t r a t o r , has grown r a p i d l y over the past few decades. In Canada, t h i s growth was more numerical than s u b s t a n t i v e , and the types and q u a l i t y of h e a l t h r e c o r d a d m i n i s t r a t i o n s e r v i c e s — d i s c u s s e d l a t e r , d i d not meet the needs of the h e a l t h care system. Within the occupation, there i s s e r i o u s concern about i t s continued v i a b i l i t y . For these v a r i o u s reasons, the a d a p t a b i l i t y of the h e a l t h r e c o r d a d m i n i s t r a t o r to the s c i e n t i f i c , t e c h n o l o g i c a l and s o c i a l changes ta k i n g p l a c e i n the h e a l t h f i e l d i s i n v e s t i g a t e d here. To study the q u e s t i o n , the h e a l t h r e c o r d a d m i n i s t r a t o r occupation was exam-ined i n the context of the changing s t a t u s of h e a l t h i n f o r m a t i o n w i t h i n the Canadian h e a l t h care d e l i v e r y system and the j o s t l i n g p r o f e s s i o n a l i z a t i o n of the h e a l t h occupations. These two major f o r c e s are b e l i e v e d to have great impact upon the h e a l t h r e c o r d a d m i n i s t r a t o r occupation i n i t s quest f o r s u r v i v a l . The D e l p h i -method developed by the Rand Co r p o r a t i o n was used to e l i c i t the p r e d i c t i o n s of some members of the h e a l t h occupations as to the p o t e n t i a l development or r e g r e s s i o n of the r o l e of the Health Record A d m i n i s t r a t o r i n the f u t u r e . The f i n d i n g s of t h i s study show that the h e a l t h occupations, and p a r t i c u l a r l y the medical p r o f e s s i o n have acknowledged needs f o r h e a l t h i n f o r m a t i o n and h e a l t h i n f o r m a t i o n management s e r v i c e s . They have f o r e c a s t a strong a d m i n i s t r a t i v e r o l e f o r the f u t u r e Health Record Admini-s t r a t o r , w h i l e g i v i n g e q u a l i m p o r t a n c e t o a p a r t i c i p a t i v e r o l e as c o l l a b o r a t o r p r o v i d i n g t h e h e a l t h o c c u p a t i o n s w i t h t h e i n f o r m a t i o n s e r v i c e s t h a t t h e y r e q u i r e f o r t h e p e r f o r m a n c e o f t h e i r own d u t i e s . They a l s o v i s u a l i z e t h e i n t e g r a t i o n o f t h e v a r i o u s s e c t o r s o f t h e h e a l t h f i e l d w i t h t h e H e a l t h R e c o r d A d m i n i s t r a t o r b e i n g a p o t e n t i a l a g e n t o f t h i s i n t e g r a t i o n p r o c e s s . I V THE FUTURE ROLE OF THE HEALTH RECORD ADMINISTRATOR A DELPHI-SURVEY TABLE OF CONTENTS Page ABSTRACT TABLE OF CONTENTS LIS T OF TABLES LIST OF FIGURES LIS T OF ABBREVIATIONS APPENDICES ACKNOWLEDGEMENT CHAPTER I INTRODUCTION STUDY QUESTIONS OUTLINE OF STUDY CHAPTER I I PROFESSIONS, PROFESSIONALIZATION PROFESSIONALIZATION OF THE HEALTH OCCUPATIONS CHAPTER I I I MEDICAL, CLINICAL AND HEALTH RECORDS AND INFORMATION, THEIR EVOLUTION AND STATUS WITHIN THE CANADIAN HEALTH SYSTEM CHAPTER IV ASSOCIATION DEVELOPMENT AND PROFESSIONALIZATION OF THE HEALTH RECORD ADMINISTRATORS EVOLUTION OF THE PRESENT ROLE OF THE HEALTH RECORD ADMINISTRATOR WITHIN THE HEALTH FIELD CHAPTER V THE DELPHI TECHNIQUE LITERATURE REVIEW AND CRITIQUE CHAPTER VI DELPHI SURVEY OF THE FUTURE ROLE OF THE HEALTH RECORD ADMINISTRATOR -PHILOSPHY AND ASSUMPTIONS -METHODOLOGY -DISCUSSION -FUTURE ROLE OF THE HEALTH RECORD ADMINISTRATOR 11 . i v v v i v i i v i i i i x 1 - 4 - . 5 - 1 5 1 6 - 3 4 3 5 - 5 3 5 4 - 6 2 6 3 - 1 1 3 CONCLUSIONS AND RECOMMENDATIONS 113-116 REFERENCES AND BIBLIOGRAPHY V . LIST OF TABLES TABLE 1 I I I I I IV V VI V I I V I I I IX F r e q u e n c i e s o f r e s p o n s e s and o f r e s p o n d e n t s by a r e a o f f u n c t i o n and c a t e g o r y o f a c t i v i t y Round 1 F r e q u e n c i e s o f r e s p o n s e s and o f r e s p o n d e n t s by a r e a o f f u n c t i o n and c a t e g o r y o f a c t i v i t y , Round 2 Group KNOWLEDGEABLE 3: P e r c e n t a g e s o f w e i g h t e d r e s p o n s e s by a r e a o f f u n c t i o n and c a t e g o r y o f a c t i v i t y Group KNOWLEDGEABLE 4: P e r c e n t a g e s o f w e i g h t e d r e s p o n s e s by a r e a o f f u n c t i o n and c a t e g o r y o f a c t i v i t y Group EXPERT 5: P e r c e n t a g e s o f w e i g h t e d r e s p o n s e s by a r e a o f f u n c t i o n and . c a t e g o r y o f a c t i v i t y TOP EXPERT: S e l e c t i o n s o f E x p e r t 5 i n c o m b i n a t i o n w i t h s e l f - r a t i n g E x p e r t i n t h e a r e a s o f f u n c t i o n ALL THREE GROUPS: Number o f r e s p o n s e s / W e i g h t e d R e s p o n s e s / P e r c e n t a g e o f w e i g h t e d r e s p o n s e s ALL THREE "GROUPS: Ra n k i n g o f t h e a r e a s o f f u n c t i o n by w e i g h t e d r e s p o n s e s C o m p a r i s o n between t h e c h o i c e s made by t h e TOP EXPERT Group and t h o s e made by ALL THREE GROUPS Page 73 74 81 84 87 91 93 94 96. LIST OF FIGURES Figu r e 1 . Percentage of frequency of respondents and t h e i r changes between Rounds 1 and 2 , by area of f u n c t i o n and category of a c t i v i t y 2 . Percentages of frequency of responses and t h e i r changes between Rounds 1 and 2 , by area of f u n c t i o n and category of a c t i v i t y 3. Group KNOWLEDGEABLE 3 : Percentages of weighted responses by area of f u n c t i o n and category of a c t i v i t y 4 . Groups KNOWLEDGEABLE 4 : Percentages of weighted responses by area of f u n c t i o n and category of a c t i v i t y 5. Group EXPERT 5 : Percentages of weighted responses by area of f u n c t i o n and category of a c t i v i t y 6 . Percentage": of weighted responses i n the hig h e s t s c o r i n g category f o r the groups Knowledgeable 3, Knowledgeable 4 and Expert 5 L i s t of A b b r e v i a t i o n s Canadian C o u n c i l on H o s p i t a l A c c r e d i t a t i o n Canadian A s s o c i a t i o n of Medical Record L i b r a r i a n s R e g i s t e r e d Record L i b r a r i a n Medical Record L i b r a r i a n A c c r e d i t e d Record T e c h n i c i a n Health Record T e c h n i c i a n Canadian Health Record A s s o c i a t i o n Canadian C o l l e g e of Health Record A d m i n i s t r a t o r s Health Record A d m i n i s t r a t o r v i i i . APPENDICES I. Delphi Round 1: S t r u c t u r e of study, I n s t r u c t i o n s and Form of Inquiry with L e t t e r of I n v i t a t i o n to p a r t i -c i p a t e as member of the panel II Sample of completed Round 1 Form of Inquiry I I I Feedback of Round 1 IV Round 2 Tasks" V Respondents c a t e g o r i z e d according to the t h r e e - p o i n t s e l f - r a t i n g s c a l e attached to each area of f u n c t i o n and to the f i v e - p o i n t s c a l e measuring e x p e r t i s e i n Health Record A d m i n i s t r a t i o n 2 VI X goodness of f i t t e s t c a l c u l a t i o n s VII Wilcoxon-paired-sample-test c a l c u l a t i o n s Page 129 - 139 140 - 146 147 - 155 156 - 159 160 161 - 162 163 - 164 A C K N O W L E D G E M E N T I should l i k e to take t h i s o p p o r t u n i t y to express my g r a t i t u d e to the members of t h i s t h e s i s committee: Dr. Anne C r i c h t o n , (Chairman), F a c u l t y of Medicine, Department of Health Care and Epidemiology, Dr. John H. Milsum, P r o f e s s o r and D i r e c t o r D i v i s i o n of Health Systems, Health Sciences Centre, and Dr. Ronald T a y l o r , P r o f e s s o r and D i r e c t o r of the Ph.D. Program, F a c u l t y of Commerce and Business A d m i n i s t r a t i o n at the U n i v e r s i t y of B r i t i s h Columbia. 1. CHAPTER I . INTRODUCTION STUDY QUESTION OUTLINE OF STUDY M e d i c a l c a r e and h o s p i t a l s have a t r a d i t i o n g o i n g back t o a n t i -q u i t y , b u t t h e C a n a d i a n h e a l t h c a r e s y s t e m i s o n l y a few d e c a d e s o l d . F o r c e s such as t h e p u b l i c ' s c o n c e r n w i t h h e a l t h t h a t f o l l o w e d t h e two w o r l d wars, t h e economic boom a f t e r W o r l d War I I as w e l l as t h e i n c r e a s e i n p o p u l a t i o n were i n g r e a t p a r t r e s p o n -s i b l e f o r t h e s p e c t a c u l a r g r o w t h o f t h e h e a l t h c a r e s y s t e m . These s t i l l q u i t e p o t e n t f o r c e s , added t o t h e a c c e l e r a t i n g s c i e n t i f i c and t e c h n o l o g i c a l c h a n g e s , keep t h e h e a l t h c a r e f i e l d i n t h e t h r o e s o f d e v e l o p m e n t , and make i t t h e b a t t l e g r o u n d o f a m b i t i o u s and v i g o r o u s h e a l t h o c c u p a t i o n s w h i c h r e n d e r s p e c i a l i z e d s e r v i c e s t o t h e s i c k ( 3 4 ) . These h e a l t h o c c u p a t i o n s a r e more i n t e r d e p e n -d e n t on one a n o t h e r t h a n t h e y would r e c o g n i z e . The v i t a l l i f e -l i n e common t o b o t h , t h e h e a l t h c a r e s y s t e m and t h e h e a l t h o c c u p a t i o n s , i s h e a l t h i n f o r m a t i o n , i n t h e management o f w h i c h the H e a l t h R e c o r d A d m i n i s t r a t o r i s a s p e c i a l i s t . In g e n e r a l , i n f o r m a t i o n has two major c h a r a c t e r i s t i c s : a) i t i s i n e x h a u s t i b l e b e c a u s e i t compounds and r e g e n e r a t e s i t s e l f : b) i t does n o t have a p h y s i c a l embodiment o f i t s own ( 1 2 4 ) . The f i r s t c h a r a c t e r i s t i c makes i n f o r m a t i o n an i n v a l u a b l e r e s o u r c e , namely the key t o knowledge and power. The s e c o n d c h a r a c t e r i s t i c r e q u i r e s t h a t i n f o r m a t i o n be r e c o r d e d i n some p h y s i c a l form; an i n h e r e n t d a n g e r i s t h a t t h e s u b s t a n c e , and t h e form s e l e c t e d f o r 2 . i t s capture are o f t e n u n d i f f e r e n t i a t e d . These two major charac-t e r i s t i c s d i c t a t e the need f o r competent management of i n f o r m a t i o n . This g e n e r a l i z a t i o n a p p l i e s to h e a l t h i n f o r m a t i o n ; the v a r i o u s h e a l t h occupations o f t e n confuse form and substance, and have not yet recognized i t as a resource. A group of h e a l t h care workers c a l l i n g themselves Medical Record L i b r a r i a n s emerged i n response to the v o l u n t a r y s t a n d a r d - s e t t i n g a c c r e d i t a t i o n movement which i s now -firmly e s t a b l i s h e d i n North America. This group of workers undertook the custody and the management of the documentation of medical care i n h o s p i t a l s , grew r a p i d l y i n number and changed t h e i r name to Health Record Admini-s t r a t o r s i n Canada. Automation i n the h e a l t h f i e l d c r e a t e d an e x p l o s i o n of i n f o r m a t i o n , i n the handling of which the Health Record A d m i n i s t r a t o r d i d not prove competent due to l a c k of adequate education and t r a i n i n g . Since none of the other h e a l t h occupations had been t r a i n e d to cope with automation, the weakness of the Health Record A d m i n i s t r a t o r r e s u l t e d i n v a r i o u s o p i n i o n s w i t h i n the h e a l t h f i e l d as to which occupation should i n f u t u r e secure the t e r r i t o r y of h e a l t h i n f o r m a t i o n management, the options being a c o n s i d e r a b l y b e t t e r t r a i n e d Health Record A d m i n i s t r a t o r or mostly a computer-based occupation. The eventual outcome of t h i s i s s u e w i l l be o c c u r r i n g i n r e l a t i o n to the needs of the h e a l t h occupations f o r h e a l t h i n f o r m a t i o n and h e a l t h i n f o r m a t i o n management s e r v i c e s . These needs are at times expressed or f e l t , a n t i c i p a t e d or u n s a t i s f i e d , recognized or ignored, but they are changing as a f u n c t i o n of the changes t a k i n g p l a c e w i t h i n the occupations themselves, changes which, of course, occur i n response to pressures both i n t e r n a l and e x t e r n a l to the 3 . h e a l t h f i e l d . Consequently, the study question was examined i n r e l a t i o n to the p r o f e s s i o n a l i z a t i o n of the h e a l t h occupations and these occupations 1 concepts of h e a l t h i n f o r m a t i o n and the needs of the o r g a n i z a t i o n s i n which they work f o r the b e t t e r management of c o s t l y s e r v i c e s . The study question i s : "What i s the f u t u r e r o l e of the Health Record A d m i n i s t r a t o r ? " , and the o u t l i n e of the study i s as f o l l o w s : Chapter II w i l l present some general t h e o r i e s of p r o f e s s i o n a l i z a t i o n and review t h i s process i n r e l a t i o n to the h e a l t h o c c u p a t i o n s . The purpose i s to cre a t e a framework ag a i n s t which to compare the de-velopmental stages of the Health Record A d m i n i s t r a t o r occupation and to int r o d u c e the forum of the v a r i o u s h e a l t h occupations which w i l l be represented on the panel of the Delphi survey. Another reason f o r p l a c i n g the study w i t h i n the context of p r o f e s s i o n a l -i z a t i o n i s to show that an occupation's r i g h t to e x i s t i s contested by other occupations, and i s g r e a t l y dependent on the s o c i a l recog-n i t i o n given to the s e r v i c e s provided by that o c c u p a t i o n . Chapter I I I w i l l p o r t r a y the e v o l u t i o n of the medical records i n t o h e a l t h i n f o r m a t i o n , and assess i t s present s t a t u s w i t h i n the h e a l t h care system i n Canada. The i n t e n t i o n i s to show the degree of r e c o g n i t i o n and of importance that i s granted to the resource h e a l t h i n f o r m a t i o n by the v a r i o u s h e a l t h occupations, as t h i s w i l l r e f l e c t the needs of the h e a l t h occupations f o r h e a l t h i n f o r m a t i o n manage-ment s e r v i c e s . Chapter IV w i l l i n t roduce the Health Record A d m i n i s t r a t o r o c c u p a t i o n , review i t s stages of development and i t s present r o l e w i t h i n the h e a l t h f i e l d . 4 . Chapter V w i l l present the Delphi-method used i n t h i s study. Chapter VI w i l l r e p o r t on the methodology of the Delphi-survey and on i t s f i n d i n g s . Chapter VII w i l l conclude the study and in t r o d u c e some recommen-dations . 5 . CHAPTER I I . PROFESSIONS, PROFESSIONALIZATION The three t r a d i t i o n a l p r o f e s s i o n s were considered to be medicine, law and m i n i s t r y . These p r o f e s s i o n s had s e v e r a l c h a r a c t e r i s t i c s i n common, and these e v e n t u a l l y became accepted as the c h a r a c t e r -i s t i c s of p r o f e s s i o n s : a) s p e c i a l i z e d body of knowledge; b) p r a c t i c i n g of the c a l l i n g not for f i n a n c i a l gain alone; c) rend e r i n g of s e r v i c e s to s o c i e t y ; d) code of e t h i c s r e g u l a t i n g the p r a c t i c e of the c a l l i n g or pro-f e s s i o n s (19, 29, 52, 58). The modern l i t e r a t u r e about p r o f e s s i o n s i s ample. Since C a r r -Saunders and Wilson (29) h a l f a century ago expressed the view that new p r o f e s s i o n s were emerging, many s o c i a l s c i e n t i s t s have presented t h e i r t h e o r i e s on p r o f e s s i o n s and d e f i n e d t h e i r charac-t e r i s t i c s . Wilensky, quoted by Fr e i d s o n (58), d e f i n e d f i v e charac-t e r i s t i c s , so has Greenwood (134); Strauss and Barber (58) recog n i z e d f o u r , while Abramhamson and Goods (134) l i m i t e d themselves to two, namely the a b s t r a c t body of knowledge and the s e r v i c e - c l i e n t o r i e n t a t i o n . The most s u c c i n c t i s Fr e i d s o n (43) who d e f i n e d p r o f e s s i o n as being; "...a dominant p o s i t i o n i n a d i v i s i o n of la b o r so that i t gains c o n t r o l over the determination of the substance of i t s own work". This d e f i n i t i o n promotes i n t r a - p r o f e s s i o n a l o r i e n t a t i o n and bestows s o c i a l and o r g a n i z a t i o n a l power on p r o f e s s i o n s . On that b a s i s , F r e i d s o n ' s theory negates the s e r v i c e -c l i e n t o r i e n t a t i o n which i s t r a d i t i o n a l l y claimed to be the p r o f e s -s i o n s ' main c h a r a c t e r i s t i c because he emphasizes the asymmetry of in f o r m a t i o n that e x i s t s between p r o f e s s i o n a l and c l i e n t , thus denying the c l i e n t the r i g h t to informed c h o i c e s . A consequence of 6 . t h i s t h i n k i n g i s the acceptance by s o c i e t y of p r o f e s s i o n a l mono-p o l i e s , a most undemocratic form of s o c i a l and economic o r g a n i z a -t i o n . Few s o c i a l s c i e n t i s t s are as entrenched i n t h e i r o p i n i o n as E t z i o n i (52), who sees p r o f e s s i o n s , semi-professions and would-be p r o f e s s i o n s , but d i s t i n g u i s h e s between these only i n the vaguest form: " . . . t r a i n i n g s h o r t e r , s t a t u s l e s s l e g i t i m a t e d , r i g h t to p r i v i l e g e d communications l e s s e s t a b l i s h e d , l e s s of a s p e c i a l i z e d body of knowledge, l e s s autonomy f o r s u p e r v i s i o n or s o c i e t a l c o n t r o l " . He e v e n t u a l l y c a t e -g o r i z e s Nursing and Pharmacy as s e m i - p r o f e s s i o n s , and s t a t e s that h o s p i t a l managers are only a would-be p r o f e s s i o n , as they " . . r e q u i r e n e i t h e r t h e o r e t i c a l study nor the a c q u i s i t i o n of exact techniques, but r a t h e r a f a m i l i a r i t y with modern p r a c t i c e s i n bu s i n e s s , admini-s t r a t i v e p r a c t i c e s and cu r r e n t conventions". To d i s c u s s E t z i o n i ' s o p i n i o n i s q u i t e o u t s i d e the boundaries of t h i s study, yet i t must be remarked that although h o s p i t a l a d m i n i s t r a t o r s are not l i c e n s e d , they represent on the premises of the h o s p i t a l the Board of Tr u s t e e s , that i s the body l e g a l l y r e s p o n s i b l e f o r the e n t i r e o p e r a t i o n of the h o s p i t a l , i n c l u d i n g the performance of the medical s t a f f , not-withstanding the l e g i t i m a t i o n of t h i s l a t t e r group. Commenting on the changing concept of " p r o f e s s i o n " , Barnes (16) wri t e s that the o l d e s t p r o f e s s i o n s "...seemed such permanent and r e a d i l y i d e n t i f i a b l e p a r t of s o c i e t y . . . " , but that with the pro-l i f e r a t i o n of s p e c i a l i z e d and h i g h l y s k i l l e d occupations with w e l l s p e c i f i e d r e s p o n s i b i l i t i e s , the term p r o f e s s i o n and i t s s o c i a l s t a t u s w i l l have to be r e d e f i n e d . Barnes's view i s supported by a host of s o c i a l s c i e n t i s t s . They recognize one important d i s -t i n c t i o n between the o l d and the new p r o f e s s i o n s , namely that many new t e c h n o l o g i c a l and s c i e n t i f i c occupations are performing w i t h i n an o r g a n i z a t i o n a l s t r u c t u r e , l i k e l y a bureaucracy as opposed to independent p r a c t i c e . Such occupations then r e c e i v e s a l a r i e s and not p r i v a t e remuneration, yet they have r i c h bodies of knowledge, they may even be l e g i t i m a t e d , and have o r g a n i z a t i o n a l r e s p o n s i b i -l i t i e s which could be equated with power and c o n t r o l over t h e i r work (16,58, 87, 134). Rene Dussault (118) r e l a t e s that p r o f e s s i o n s and p r o f e s s i o n a l i z a t i o n i n Quebec are now under the government's c o n t r o l , and that the c h a r a c t e r i s t i c s developed by the " O f f i c e des P r o f e s s i o n s du Quebec" i n 1973 granted p r o f e s s i o n a l s t a t u s to some 29 occup a t i o n s . Green (142) r e p o r t s t h a t , i n the Quebec s i t u a t i o n , there i s a dramatic departure from the t r a d i t i o n a l p r o f e s s i o n a l autonomy, s i n c e the r e s p e c t i v e c o r p o r a t i o n s formed by each p r o f e s s i o n must r e p o r t to and be re - e v a l u a t e d by the " O f f i c e des P r o f e s s i o n s du Quebec". V o l l n e r and M i l l s (134) set p r o f e s s i o n as an i d e a l model of occu-p a t i o n a l o r g a n i z a t i o n ; they view p r o f e s s i o n a l i z a t i o n as a process through which an occupation p r o g r e s s i v e l y m o d i f i e s i t s body of knowledge, i t s standards, o b j e c t i v e s and behaviors i n order to reach toward the p r o f e s s i o n a l s t a t u s , that i s as a continuum of p r o g r e s s i o n . In t h i s context, p r o f e s s i o n a l i z a t i o n becomes a dynamic and p e r f e c t i n g a c t i v i t y whereby the occupations can measure t h e i r progress and evaluate t h e i r performance. A l a s , t h i s model does not s e t t l e the is s u e of i n t e r d i s c i p l i n a r y i n t e r a c t i o n s and competition. The o c c u p a t i o n a l ( p r o f e s s i o n a l ) a s s o c i a t i o n s mediating between the groups of i n d i v i d u a l s performing some s k i l l e d tasks and s o c i e t y impart a sense of f u n c t i o n a l importance and o c c u p a t i o n a l consciousness, and create a s o c i a l arena f o r strong i n t e r d i s c i p -8 . l i n a r y c o m p e t i t i o n ( 6 4 ) . The e v o l u t i o n a r y t h e o r y o f p r o f e s s i o n a l -i z a t i o n r e c o g n i z e s t h a t t h e s t a t u s and t h e r o l e s o f e x i s t i n g o c c u p a t i o n s w i l l change, s t a t u s r e f e r r i n g t o t h e a g g r e g a t e o f r i g h t s and d u t i e s , and r o l e s t o t h e dynamic p r o c e s s o f u s i n g t h e s e r i g h t s and p e r f o r m i n g t h e s e d u t i e s ( 2 1 ) . N e i t h e r s t a t u s n o r i t s c o n c u r r e n t r o l e s may be e q u a t e d e n t i r e l y w i t h s o c i a l p o s i t i o n , as t h i s would a s s i g n a t e c h n i c a l c h a r a c t e r t o t h e c o n c e p t o f s t a t u s , l e a d i n g t o t h e a s s u m p t i o n t h a t e v e r y o n e w i t h t h e same s t a t u s w i l l p e r f o r m t h e same r o l e s i n t h e same f a s h i o n w i t h t h e same r e s u l t s , an a s s u m p t i o n w h i c h i s c o n t r a r y t o human n a t u r e i n g e n e r a l and t o t h e c o n c e p t o f p r o f e s s i o n i n p a r t i c u l a r , where i n d e t e r m i n a c y i s p e r c e i v e d t o endow c e r t a i n i n d i v i d u a l s and c e r t a i n p r o f e s s i o n s w i t h s t a t u s t h a t a p p ear g r e a t e r t h a n t h e y r e a l l y a r e , s i m p l y b e c a u s e o f t h e way t h e y p l a y t h e i r r o l e s (13). I t i s t h i s e l u s i v e i n d e t e r m i n a c y t h a t i s so g r e a t l y s o u g h t by t h e a s p i r i n g o c c u p a t i o n s , n o t f o r e s e e i n g t h a t t h e t e c h n o l o g i c a l and s c i e n t i f i c w o r l d o f tomorrow w i l l c l e a r t h e s h r o u d s o f m y s t e r y s u r r o u n d i n g o c c u p a t i o n a l p e r f o r m a n c e s . I n t e r -a c t i o n s between t h e o c c u p a t i o n a l g r o u p s a r e and w i l l be h i g h l y d e p e n d e n t on t h e s t a t u s o f e a c h one, b u t t h e g r e a t l y p r a i s e d o c c u -p a t i o n a l and f u n c t i o n a l autonomy w i l l become an o b s o l e t e c o n c e p t , as o c c u p a t i o n s w i l l be s u b m i t t e d t o s p e c i f i c s o c i a l e x p e c t a n c i e s and w i l l have t o a c c e p t t h e p r i n c i p l e s o f r e c i p r o c i t y and a d a p t a t i o n (83). 9 . PROFESSIONALIZATION OF THE HEALTH OCCUPATIONS Some s p e c i f i c c h a r a c t e r i s t i c s of the h e a l t h care d e l i v e r y system i n Canada have great i n f l u e n c e upon t h i s p r o f e s s i o n a l i z a t i o n movement. F i r s t , the s o c i o - p o l i t i c a l c l i m a t e exerts strong pressure upon the h e a l t h care system. The a c c e l e r a t e d growth of the h e a l t h i n d u s t r y f o l l o w i n g the 1949 f e d e r a l h e a l t h grants program (34) i n c r e a s e d the need f o r d i v i s i o n of labor and s p e c i a l i z a t i o n . The ground became very f e r t i l e f o r the p r o f e s s i o n a l i z a t i o n process to take h o l d . H a l l r e p o r t e d that during the time of study on the Paramedical P r o f e s s i o n s , "the number of occupations i n that year was s m a l l , fewer than a dozen", but as the study progressed, he saw "that these occupations had subdivided and were s u b d i v i d i n g r a p i d l y . . . New ones were emerging ... New t e c h n o l o g i c a l p o s s i b i l i t i e s arose" ( 1 4 3 , p . v i i ) . Health, which emerged as a s o c i a l value and a s u i t a b l e p o l i t i c a l p l a t f o r m a f t e r World War I I , has been promoted by the Canadian government as the r i g h t of every Canadian c i t i z e n . T h i s ideology was eagerly absorbed by the p r o v i d e r s and the users of h e a l t h s e r -v i c e s , and the demands made on the h e a l t h care system i n c r e a s e d the costs v e r t i g i n o u s l y . From the e a r l y s i x t i e s , the government attempted to modify t h i s ideology from h e a l t h being a r i g h t to h e a l t h being a p r i v i l e g e (26,34). Lalonde(87) p u b l i c l y uncovered the concept of s e l f - i n f l i c t e d d i s e a s e s through l i f e s t y l e , and whereas he does not s t a t e that s o c i e t y w i l l r e f u s e care to those cases, he i m p l i e s , that i n the f u t u r e , d i s c r i m i n a t i o n i n the d e l i v e r y of h e a l t h s e r v i c e s may occur. He presents h e a l t h as an i n d i v i d u a l , yet c o l l e c t i v e wealth, and intends to make i t the duty of each Canadian to promote h i s / h e r h e a l t h s t a t u s by the adoption of h e a l t h h a b i t s r a t h e r than unnecessary use of h e a l t h s e r v i c e s 10 . (34 , 87 , 124) . So f a r , the h e a l t h occupations had been mostly care- and Cure-o r i e n t e d , and the usual s e t t i n g f o r the d e l i v e r y of care had been the h o s p i t a l s and the d o c t o r s ' o f f i c e s . This new emphasis on p r e v e n t i o n of disease and maintenance of h e a l t h , as w e l l as ambulatory and home care w i l l f o r c e the occupations to set new standards and re-catalogue the s e r v i c e s they can and want to o f f e r . Consequently, these new trends w i l l d i c t a t e changes i n the occu-p a t i o n a l t e r r i t o r i e s , and perhaps encourage the development of new ones as the need f o r s p e c i a l i z e d s e r v i c e s becomes p e r c e i v e d . Second, the s c i e n t i f i c and t e c h n o l o g i c a l advances s t r o n g l y i n f l u e n c e the h e a l t h care system. I t i s >.: commonplace to remark that many m o d a l i t i e s of disease i n v e s t i g a t i o n and treatment were unknown a decade or so ago, while others have been d i s c a r d e d i n the l i g h t of new r e s e a r c h . Such changes g r e a t l y a f f e c t the r e s p e c t i v e bodies of knowledge of the v a r i o u s h e a l t h occupations, consequently t h e i r r e l a t i v e t e r r i t o r i e s . For example, with the p h y s i c i a n ' s r o l e i n c r e a s i n g so r a p i d l y i n content and complexity, n u r s i n g had been q u i t e eager to s e i z e some of the tasks formerly performed by p h y s i c i a n s only, such as a u s c u l t a t i o n , a d m i n i s t r a t i o n of i n t r a -venous f l u i d s , i n j e c t i o n s , e t c . The a d d i t i o n of these new r e s -p o n s i b i l i t i e s caused the t r a n s f e r of other tasks considered more menial from n u r s i n g to an occupation judged lower i n s t a t u s . Thus c e r t a i n aspects of bedside nursing were shed and p i c k e d up by the l i c e n s e d p r a c t i c a l nurses or n u r s i n g a s s i s t a n t s . An i n t e r e s t i n g outcome of t h i s t r a n s f e r of tasks r e s u l t e d however i n the l i c e n s e d p r a c t i c a l nurses c l a i m i n g that they had more p a t i e n t c o n t a c t s , were more c l i e n t - o r i e n t e d , possessed more c o n f i d e n t i a l knowledge of the p a t i e n t s than the r e g i s t e r e d nurses, and thus had g r e a t e r c l a i m to being recognized as a p r o f e s s i o n . A s t r o n g l y organized n u r s i n g promptly responded by a "back to bedside" movement ( 1 2 4 ) . Yet i n t e r e s t i n g l y , B i l l 2 5 0 of the Province of Quebec which c r e a t e d a c o n t r o l l i n g mechanism to r e g u l a t e a l l p r o f e s s i o n a l s e r v i c e s , i n c l u d e s the P r o f e s s i o n a l C o r p o r a t i o n of Nursing A s s i s t a n t s of Quebec among the 3 8 p r o f e s s i o n s named ( 1 4 2 ) . Another aspect of the s c i e n t i f i c and t e c h n o l o g i c a l advances i s that the new types of s e r v i c e s w i l l n e c e s s i t a t e the t r a i n i n g of new occupations. I t i s estimated that there are approximately 3 0 h e a l t h occupations ( 1 1 8 , 3 4 ) at v a r i o u s stages of development and of p r o f e s s i o n a l i z a t i o n . In t h i s r e v o l u t i o n a r y process, many t e r r i t o r i e s are claimed, c l i p p e d and others c r e a t e d , and the r e s u l t a n t u n c e r t a i n t y about the f u t u r e has s t i r r e d the p r o f e s s i o n -a l i z a t i o n process i n t o an i n t e r d i s c i p l i n a r y s t r u g g l e . T h i r d l y , the medical p r o f e s s i o n as a whole i s o r g a n i z a t i o n a l l y independent of the h o s p i t a l and of the i n s t i t u t i o n a l h e a l t h care s t r u c t u r e . Notwithstanding that the medical s t a f f has a tremendous impact on the h o s p i t a l f i n a n c i a l and o p e r a t i o n a l a c t i v i t i e s , and that i n f a c t h o s p i t a l management i s d i r e c t l y dependent upon the medical s t a f f f o r the o p e r a t i o n of the f a c i l i t y , the medical s t a f f i s c l e a r l y e n t r e p r e n e u r i a l , and s t r o n g l y organized to maintain and i n c r e a s e the s t a t u s and the p r i v i l e g e s of t h e i r p r o f e s s i o n . The power of p h y s i c i a n s i s l e g i t i m a t e d through l i c e n s i n g laws. P h y s i c i a n s , t h e r e f o r e , speak of having r e c e i v e d a s o c i a l mandate which confers upon them r a t i o n a l - l e g a l power. This r a t i o n a l -l e g a l power added to the t r a d i t i o n a l power over l i f e and death and the charisma developed by p h y s i c i a n s f o r t h e i r p r o f e s s i o n c r e a t e the dichotomous s i t u a t i o n well-known i n almost a l l h o s p i t a l s and 12 . h e a l t h i n s t i t u t i o n s (85), and which co n f r o n t s the medical s t a f f and the a d m i n i s t r a t i o n . No other h e a l t h occupation possesses t h i s o r g a n i z a t i o n a l and l e g a l l y s a n c t i f i e d independence, but a l l h e a l t h occupations look upon the medical p r o f e s s i o n as the embodiment of t h e i r a s p i r a t i o n s and t h e i r model i n terms of behaviors and a t t i t u d e s . Upward m o b i l i t y i n the h e a l t h occupations i s s t r i c t l y c o n t r o l l e d by education, and w i t h i n the h e a l t h h i e r a r c h y , the dominance of the medical p r o f e s s i o n i s obvious and e s p e c i a l l y notable through i t s being a m i n o r i t y group. Thus the medical p r o f e s s i o n i s considered the i d e a l s t a t u s on the continuum to p r o f e s s i o n a l i z a t i o n . O f f i c i a l r e c o g n i t i o n of st a t u s i s very important to the h e a l t h occupations as i t c o n s t i t u t e s some form of reward to i t s i n d i v i d u a l members and to the group, thus i m p l i c i t l y c o n f e r r i n g upon them some form of power. In accordance with the presented t h e o r i e s of p r o f e s s i o n a l i z a t i o n , the h e a l t h occupations have a l l formed p r o f e s s i o n a l a s s o c i a t i o n s . These a s s o c i a t i o n s purport to serve and p r o t e c t s o c i e t y ; i n f a c t , they i n t e r p r e t t h e i r occupation to the p u b l i c with the i n t e n t of c r e a t i n g an i d e a l i z e d image f o r themselves and a respected s o c i a l r o l e . The f a b l e d b e l i e f that anyone i n a white coat w i l l o b t a i n i n s t a n t t r u s t e x i s t s perhaps to a gr e a t e r extent than an apparently r e l a t i v e l y educated s o c i e t y w i l l care to admit. By v i r t u e of the one-sided intimacy that c h a r a c t e r i z e s the d e a l i n g s between p a t i e n t s and h e a l t h p r o f e s s i o n a l s , and by v i r t u e of the near t o t a l depen-dence of these same p a t i e n t s on the h e a l t h p r o f e s s i o n a l s i n moments of p e r s o n a l c r i s i s or tragedy, t r u s t , on the p a r t of the p a t i e n t s , has to be unquestionably bestowed upon the h e a l t h p r o f e s s i o n a l s . 13 . A l l h e a l t h occupations share the f e e l i n g that they deserve the p u b l i c ' s t r u s t because they are p r a c t i c i n g more i n the l i n e of c a l l i n g than of duty, and see themselves as s e l f - s a c r i f i c i n g and devoted. This t r u s t i s i n f a c t based upon the asymetry of i n f o r m a t i o n that e x i s t s between p a t i e n t s and h e a l t h p r o f e s s i o n a l s , an asymetry which i s c a r e f u l l y c u l t i v a t e d by the h e a l t h p r o f e s -s i o n a l s i n order to make t h e i r p r o f e s s i o n s appear more mysterious, important and a w e - i n s p i r i n g . Thus, a b a r r i e r i s c a r e f u l l y maintained between the p u b l i c and the h e a l t h occupations, u l t i m a t e l y s e r v i n g to i n s u l a t e the occupations from p u b l i c s c r u t i n y . In t h e i r r e s p e c t i v e codes of e t h i c s , the h e a l t h occupations always emphasize t h e i r s e r v i c e o r i e n t a t i o n and express a strong Commit-ment to the p a t i e n t . Yet the same codes hold the p r o f e s s i o n a l answerable p r i m a r i l y to the p r o f e s s i o n . Concepts such as account-a b i l i t y to the p a t i e n t s and to s o c i e t y , as w e l l as m u l t i d i s c i p -l i n a r y a u d i t s are t a l k e d about a great d e a l , but have been n e i t h e r s e r i o u s l y pursued nor implemented. As these concepts would a l s o imply a c c o u n t a b i l i t y to the o r g a n i z a t i o n s i n which the h e a l t h occupations work, the l a t t e r e x e r c i s e a great deal of o c c u l t r e s i s t a n c e a g a i n s t the p o s s i b l e t h r e a t that the h e a l t h o r g a n i -z a t i o n s would attempt to exert too s t r i c t c o n t r o l over the h e a l t h occupations, or even worse, that the government may e s t a b l i s h n a t i o n a l p o l i c i e s s i m i l a r to the P r o f e s s i o n a l Standards Review O r g a n i z a t i o n of the United S t a t e s . With r e s p e c t to the s p e c i a l i z e d body of knowledge the h e a l t h occupations g r e a t l y emphasize t h e i r own and the s p e c i a l s k i l l s t h a t t h i s knowledge confers upon the i n i t i a t e d members. That t h i s body of knowledge i s never pure, but r a t h e r contains a great deal 14 . of knowledge taken from the s c i e n c e s , the t e c h n o l o g i e s and other d i s c i p l i n e s , i s a f a c t seldom acknowledged. The occupations p r e f e r to i n g e s t t h e i r a c quired i n f o r m a t i o n to make i t more t h e i r own, thus d i f f e r e n t from o t h e r s . An obvious example of t h i s process can be found i n a nursing c u r r i c u l u m , where a l l the s u b j e c t s are mostly amalgamated under " n u r s i n g " courses, and s p e c i f i c s u b j e c t s such as pharmacology, psychology or management sci e n c e are o f t e n u n detectable. An obvious r e s u l t i s that student nurses w i l l absorb t h i s knowledge as i s , and b e l i e v e that i t i s s p e c i f i c to n u r s i n g . The other occupations mostly act i n a s i m i l a r manner and s e r i o u s communication b a r r i e r s are thus e r e c t e d between the h e a l t h occu-p a t i o n s themselves. In summary one sees that the combination of s o c i o - p o l i t i c a l and t e c h n o l o g i c a l f a c t o r s added tremendous complexity to the r a p i d l y expanding h e a l t h s e c t o r and promoted the p r o l i f e r a t i o n of s k i l l e d occupations c l a i m i n g s p e c i a l i z e d bodies of knowledge, assuming the r i g h t to c h a l l e n g e e x i s t i n g boundaries, to stake t h e i r own t e r r i t o r i e s , and to form o c c u p a t i o n a l groups and p r o f e s s i o n a l a s s o c i a t i o n s . T h e i r main i d e o l o g i c a l stance i s claimed to be centered on the c l i e n t and on s o c i e t y . Although bound to bureau-c r a t i z e d o r g a n i z a t i o n s by a master-servant r e l a t i o n s h i p , t h e i r a l l e g i a n c e to these o r g a n i z a t i o n s i s very weak. Based on t h e i r concept of p a t i e n t - t h e r a p i s t r e l a t i o n s h i p , t h e i r p r o f e s s i o n a l o b j e c t i v e s have higher p r i o r i t i e s than those of the o r g a n i z a t i o n w i t h i n which they perform, thus c r e a t i n g p o l i t i c a l f o r c e s commen-surate with the s o c i a l r e c o g n i t i o n accorded them, with the numerical s i g n i f i c a n c e of t h e i r membership and with the d i s t r i b u t i o n of t h e i r members w i t h i n the o r g a n i z a t i o n a l s t r u c t u r e . 15 . The i n t e r e s t i n g aspect of the p r e v i o u s l y quoted t h e o r i e s of pro-f e s s i o n a l i z a t i o n i s that none o f f e r s a l t e r n a t i v e s f o r the occupa-t i o n s between p r o f e s s i o n a l i z i n g and not p r o f e s s i o n a l i z i n g . B a s i c a l l y there are perhaps none, since r e f u s a l to p a r t i c i p a t e v i g o r o u s l y i n the p r o f e s s i o n a l i z a t i o n movement w i l l unquestionably mean r e g r e s s i o n of the occupation and i t s being overtaken by some other more aggressive group. Th e r e f o r e , the true dimension of p r o f e s s i o n a l -i z a t i o n i s one of s u r v i v a l , which i s an o c c u p a t i o n - o r i e n t e d a c t i v i t y . P r o f e s s i o n a l i z a t i o n then r e a l l y i m p l i e s s u s t a i n e d competition with s e l f and o t h e r s , as- w e l l as the value-judgment by s o c i e t y to allow the occupation the r i g h t to e x i s t because deemed to be u s e f u l . 16 . CHAPTER I I I MEDICAL, CLINICAL AND HEALTH RECORDS AND INFORMATION THEIR EVOLUTION AND STATUS WITHIN THE CANADIAN HEALTH SYSTEM MEDICAL RECORDS The h i s t o r y of medical records goes back to a n t i q u i t y , yet l e s s than two decades ago, an o p e r a t i v e r e p o r t t h r e e - l i n e s long was not an unusual occurrence, even i n a teaching h o s p i t a l (124) . Cen t u r i e s a f t e r H i p pocrates' d e t a i l e d records (80), s i x decades a f t e r the Flexner Report (28) and the i n s t i t u t i o n of standard-i z a t i o n by the American C o l l e g e of Surgeons (93), the medical records are s t i l l too o f t e n completed days or weeks a f t e r the p a t i e n t s ' d ischarges from the h o s p i t a l s (124) i n open v i o l a t i o n of the l e g a l and e t h i c a l codes. A medical r e c o r d i s the aggregate of a l l the r e p o r t s completed by the p h y s i c i a n s during a p a t i e n t ' s episode of i l l n e s s , and covers the p a t i e n t ' s c o n d i t i o n , the d i a g n o s t i c procedures and t h e i r r e s u l t s , the t h e r a p e u t i c treatment and t h e i r e f f e c t s . The term "medical r e c o r d s " as w e l l as the concepts r e l a t e d to them are not s p e c i f i c to h o s p i t a l use; they apply e q u a l l y to the p r i v a t e p h y s i -c i a n ' s records of t h e i r p a t i e n t s . The importance of medical records was promoted by the h o s p i t a l s , because of the n e c e s s i t y of e s t a b l i s h i n g standards; but i t should not be assumed that those standards need be l e s s f o r the p r i v a t e p r a c t i t i o n e r s . Although one could argue that the complexity of the l a r g e i n s t i t u t i o n s may d i c t a t e a higher l e v e l of complexity i n r e c o r d i n g , i t must be remarked that the general c h a r a c t e r i s t i c s of medical r e c o r d s , such as t i m e l i n e s s , accuracy, completeness and p e r t i n e n c e , are not 17 . a l t e r e d . Furthermore, the r e c o r d s , whether o r i g i n a t i n g i n h o s p i t a l s or i n the p r i v a t e p r a c t i t i o n e r s ' o f f i c e s , are s u b j e c t to the same e t h i c a l and l e g a l r e s t r i c t i o n s with r e s p e c t to t h e i r management and t h e i r use, and have to be kept i n v i o l a t e f o r the l e n g t h of time d e f i n e d by the s t a t u t e s of l i m i t a t i o n s (80). In the 1920's, Dr. Malcolm T. MacEachern, D i r e c t o r of H o s p i t a l A c t i v i t i e s at the American C o l l e g e of Surgeons (93) d e f i n e d the purpose of a medical r e c o r d f o r the program of s t a n d a r d i z a t i o n of h o s p i t a l s , and subsequently f o r the program of a c c r e d i t a t i o n . He s t a t e d that the medical r e c o r d i s the b a s i s of the assessment of the q u a l i t y of the care rendered by the h o s p i t a l s seeking approval, and that i t "...must c o n t a i n s u f f i c i e n t data w r i t t e n i n sequence of events to j u s t i f y the d i a g n o s i s and warrant the treatment and end r e s u l t s " (80, p.31). T h i s d e f i n i t i o n i n t r o d u c e s the medical record as a requirement set f o r t h by the medical p r o f e s s i o n to render i t s own members accountable. The Canadian C o u n c i l on H o s p i t a l A c c r e d i t a t i o n that succeeded the American a c c r e d i t i n g body i n the l a t e 1950's played a key r o l e i n the development of the medical records by promoting the d e s i r -a b i l i t y f o r uniform standards. These standards were s p e c i f i c to format as w e l l as to substance. Medical s t a f f by-laws had to s p e c i f y t h e i r r u l e s with regard to the medical r e c o r d s , t h e i r accuracy, completion and p e r t i n e n c e . H o s p i t a l s ' governing bodies r e a l i z e d that the medical r e c o r d department was Considered an e s s e n t i a l s e r v i c e under the CCHA r e g u l a t i o n s and that the depart-ment had to be under the d i r e c t i o n of a q u a l i f i e d department head. Over the years, the CCHA r e v i s e d i t s program and made i t s standards r e l a t i n g to medical records more s t r i n g e n t . I t i s now no longer 18 . enough to have medical, c l i n i c a l or p a t i e n t s ' records (terms used interchangeably by the CCHA) i n good order and with good content; these records should be used to produce s t a t i s t i c a l i n f o r m a t i o n as input i n t o medical and a d m i n i s t r a t i v e decision-making as w e l l as e d u c a t i o n a l programs. This emphasis on the value of the medical records i n t r o d u c e s l e g a l , e t h i c a l , payment and q u a l i t y of care i s s u e s , which are b a s i c to f u r t h e r d i s c u s s i o n s , and w i l l be expanded l a t e r on under the s t a t u s of h e a l t h i n f o r m a t i o n and the f u t u r e r o l e of the HRA. The value of the medical r e c o r d was b r i e f l y expressed by MacEachern (93) and by Huffman (80). T h e i r views are summarized because they r e f l e c t . t h e t h i n k i n g i n t h e i r time. a) Value to the p a t i e n t : the records w i l l t e s t i f y that the p a t i e n t ' s case was t r e a t e d i n a p r o f e s s i o n a l manner. In any subsequent i l l n e s s , the records w i l l allow f o r the c o n t i n u i t y of care, the avoidance of r e p e t i t i o u s i n v e s t i -g a t i o n s , and thus speed up the d e l i v e r y of care and render i t more economical. b) Value to the p h y s i c i a n : the records w i l l preserve a l l the f a c t u a l i n f o r m a t i o n that the doctor could not p o s s i b l y remember; should a change of doctor occur, the new p h y s i c i a n w i l l be able to manage the p a t i e n t on the b a s i s of accurate i n f o r m a t i o n . The records are h e l p f u l i n medical education; the p h y s i c i a n may review h i s own cases and compare h i s r e s u l t s with the i n s t i t u t i o n ' s r e s u l t s , and i n q u i r e i n t o reasons f o r those r e s u l t s . The records are a l s o good evidence i n medico-legal cases. c) Value to the h o s p i t a l : the records document the care given to the p a t i e n t s . The h o s p i t a l can analyze the q u a n t i t y 19 . and the q u a l i t y of the s e r v i c e s and i n q u i r e i n t o the r e s u l t s and t h e i r determinants. These r e s u l t s can be r e l a t e d to the competence of the p h y s i c i a n s and the f a c i l i t i e s of the h o s p i t a l . Again, the records are v a l u a b l e i n m edico-legal cases. d) Value i n medical r e s e a r c h : every r e c o r d that i s s c i e n t i -f i c a l l y accurate adds to the mass of data a v a i l a b l e f o r study, and on the b a s i s of l a r g e numbers, the evidence i s more v a l u a b l e . MacEachern a l s o adds e) Value i n l e g a l defense: the records, compiled at a time when no thoughtof l i t i g a t i o n e x i s t e d , are a d m i s s i b l e as evidence. However, i f "the p a t i e n t has grounds f o r l e g a l a c t i o n . . . the p h y s i c i a n or the h o s p i t a l w i l l u s u a l l y s e t t l e . . . o u t of c o u r t " (93, p.723) ; l o g i c a l l y then, the records w i l l con-s t i t u t e good evidence i n favor of the p h y s i c i a n s or of the h o s p i t a l . f) Value i n P u b l i c H e alth: on the b a s i s of the i n f o r m a t i o n obtained from the r e c o r d s , the h o s p i t a l i s able to cooperate with the p u b l i c h e a l t h s e c t o r f o r e f f e c t i v e disease c o n t r o l and f o r the promotion of h e a l t h i n the community. One sees i n these views the emergence of s e v e r a l concepts which over the years have acquired c o n s i d e r a b l e values of t h e i r own. For example, the concept of the q u a l i t y of care, important from the p o i n t of view of the p a t i e n t s , the p h y s i c i a n s , the h o s p i t a l s and medical r e s e a r c h , has since grown v i g o r o u s l y . S p e c i a l programs are now set up to monitor the q u a l i t y of care rendered by the h e a l t h care i n s t i t u t i o n s a c c ording to predetermined i n d i c a t o r s 20 . and the medical records are r e g u l a r l y used as source of the documentation. Another i s s u e which i s no t o r i o u s today i s cost containment, but not q u i t e i n the same sense as used by MacEachern. In h i s time, h o s p i t a l s were r e s p o n s i b l e f o r t h e i r o p e r a t i o n a l c o s t s , and de-pended not only on the paying p a t i e n t s , but a l s o on donations and c o n t r i b u t i o n s from the community; economy was a powerful i n c e n t i v e . S i m i l a r l y , the p a t i e n t s were r e s p o n s i b l e f o r t h e i r medical and h o s p i t a l c o s t s , unless they had some type of insurance coverage; and the medical and h o s p i t a l costs were u s u a l l y p r o h i b i t i v e . Today, the government pays f o r the h e a l t h care costs and n e i t h e r the h o s p i t a l s , nor the p h y s i c i a n s , nor the p a t i e n t s have much i n c e n t i v e toward economy. Health care costs have i n c r e a s e d e x t e n s i v e l y over the past two decades, and the government has been f o r c e d to impose t i g h t e r budgets. Reporting to the government from the medical records i s one form of c o n t r o l , and the i n f o r m a t i o n i s used to develop standards of care on a p r o v i n c i a l and n a t i o n a l b a s i s , as w e l l as to c a l c u l a t e the per diem r a t e s . Cost containment i s , of course, d i r e c t l y l i n k e d with the u t i l i z a t i o n of re s o u r c e s ; u t i l i z a t i o n s t u d i e s are p a r t l y based on the r e c o r d s , measuring the inputs and processes of p r o v i d i n g care a g a i n s t the p a t i e n t outcomes. There i s , however, no a s s o c i a t i o n made between t h i s u t i l i z a t i o n process and medical competence, as p a t i e n t outcomes cannot be s a i d to be the d i r e c t r e s u l t s of the inputs and processes of care. The concept of the l e g a l value of the records presented by MacEachern appears l o g i c a l to a p o i n t : the re c o r d s , compiled at a time when no l i t i g a t i o n i s contemplated, c o n s t i t u t e good evidence. What 21 . MacEachern d i d not say was t h a t , more o f t e n than not, records are completed days or weeks a f t e r the p a t i e n t s ' d i s c h a r g e s . In view of these d e l a y s , the r e l a t i v e value of the medical records as evidence of the care given and of the p a t i e n t ' s r e a c t i o n s to d i a g -n o s t i c and t h e r a p e u t i c procedures i s debatable; however, the courts have e i t h e r not admonished the p h y s i c i a n s f o r t h e i r record-keeping p r a c t i c e s , or have not achieved much improvement, as records today s t i l l go incomplete f o r days and weeks. A shocking aspect of MacEachern's expr e s s i o n as to the l e g a l value of records i s h i s statement of the records s e r v i n g p r i m a r i l y as evidence i n favor of the p h y s i c i a n and of the h o s p i t a l , because he adds, i f the p a t i e n t has a l e g a l case, then the p h y s i c i a n or the h o s p i t a l would s e t t l e out of c o u r t . MacEachern's p o s i t i o n negates the value of the p h y s i c i a n s and the h o s p i t a l s ' codes of e t h i c s , which maintains that the i n t e r e s t of the p a t i e n t i s primary. Furthermore, r e c o r d s , although p h y s i c a l l y owned by the h o s p i t a l , c o n t a i n i n f o r m a t i o n which i n f a c t belongs to the p a t i e n t . Yet, t h i s r e l u c t a n c e by p h y s i c i a n s and h o s p i t a l s to use the medical records i n l e g a l cases p r i m a r i l y i n the s e r v i c e of the p a t i e n t s ' i n t e r e s t i s s t i l l n o t i c e a b l e today. Notwithstanding the importance and the value of the medical records as d i s c u s s e d above, i t i s w e l l known, w i t h i n the h e a l t h f i e l d , t h a t the medical records have been h e l d i n low esteem by the p h y s i c i a n s . Three major reasons are o f f e r e d as an attempt to e x p l a i n t h i s a t t i t u d e : 1) Medical science i s an a r t as w e l l as an a p p l i e d s c i e n c e with s t i l l many unknowns which render the p r a c t i c e of medicine impond-erable and mysterious. Furthermore, each human being i s unique in some ways i n h i s / h e r r e a c t i o n s to disease and to care, and t h i s 22 . f a c t a l s o l e n d s u n c e r t a i n t y t o t h e p r a c t i c e o f m e d i c i n e . Conse-q u e n t l y , p h y s i c i a n s a r e r e l u c t a n t t o r e v e a l t h e i r m e d i c a l t h i n k i n g a t t h e e a r l y s t a g e s o f c a r e . 2) W i t h i n t h e h o s p i t a l s , t h e m e d i c a l s t a f f i s n o t bound t o t h e i n s t i t u t i o n by an e m p l o y e r - e m p l o y e e r e l a t i o n s h i p , b u t has t h e s t a t u s o f p r i v a t e e n t r e p r e n e u r ; i t s g o a l s a r e , t h e r e f o r e , p r o f e s s i o n -o r i e n t e d as o p p o s e d t o h o s p i t a l - o r i e n t e d ( 3 4 ) . The c o m p l e t i o n o f t h e m e d i c a l r e c o r d i s c a t e g o r i z e d by t h e m e d i c a l s t a f f as an a d m i n i s t r a t i v e r e q u i r e m e n t t o f u l f i l l t h e l e t t e r o f t h e m e d i c a l b y - l a w s and o f t h e a c c r e d i t a t i o n program ( 9 3 ) , and hence t h e m e d i c a l a t t i t u d e became t h a t t h e r e c o r d s have t o be c o m p l e t e d f o r t h e h o s p i t a l . T h i s m i s c o n c e p t i o n a l l o w e d r e s e n t m e n t t o b u i l d up and t h e a d v e n t o f t h e l a y a d m i n i s t r a t i o n model o f h o s p i t a l manage-ment a l i e n a t e d t h e m e d i c a l s t a f f even more. The i n s i s t e n c e o f t h e C a n a d i a n C o u n c i l on H o s p i t a l A c c r e d i t a t i o n upon m e d i c a l r e c o r d s a l s o c o n t r i b u t e d t o t h e c l i m a t e o f r e s e n t m e n t . 3) M e d i c i n e i s a w e l l o r g a n i z e d p r o f e s s i o n , w i t h a s t r o n g s e n s e o f p r o f e s s i o n a l autonomy a c c o r d i n g t o w h i c h t h e p h y s i c i a n s a r e a c c o u n t a b l e t o t h e p r o f e s s i o n . Y e t , i n a h o s p i t a l s i t u a t i o n , t h e m e d i c a l r e c o r d s b e l o n g t o t h e h o s p i t a l , w h i l e t h e c o n t e n t i s s a i d t o b e l o n g t o t h e p a t i e n t s (113) , and, t h e r e f o r e , t h e d o c u m e n t a t i o n o f t h e p h y s i c i a n s ' p e r f o r m a n c e s i s n o t under the c o n t r o l o f t h e p r o f e s s i o n . To a n a l y z e t h e s i t u a t i o n a l i t t l e more, one s e e s t h a t t h e i n f o r m a t i o n t h a t t h e p h y s i c i a n s r e c e i v e d i n t r u s t from t h e i r p a t i e n t s has t o be e n t e r e d i n t h e r e c o r d s , f o r o t h e r s t o r e a d , a n a l y z e and u s e . T h e r e f o r e , t h e e n t i r e p r o c e d u r e o f com-p l e t i n g r e c o r d s and o f s u r r e n d e r i n g them t o t h e h o s p i t a l d e s t r o y s t h e i d e a l o f p r o f e s s i o n a l t r u s t w o r t h i n e s s as e x p r e s s e d i n t h e 2 3 . p h y s i c i a n s ' codes of e t h i c s , and undermines t h e i r conception of p r o f e s s i o n a l autonomy. For these very s e n s i t i v e reasons, the p o t e n t i a l s of the medical r e c o r d as a very s p e c i f i c t o o l f o r the e v a l u a t i o n of the performance of the medical p r o f e s s i o n have been l a r g e l y ignored and the records kept at a minimum. Because h o s p i t a l s are e n t i r e l y dependent on t h e i r medical s t a f f f o r t h e i r o p e r a t i o n s , they have d e f e r r e d to the medical p r o f e s s i o n on many i s s u e s , medical records being one of them, and most h o s p i t a l a d m i n i s t r a t o r s appear more concerned with p e a c e f u l r e l a t i o n s h i p s with the medical s t a f f than with the q u a l i t y of care as r e f l e c t e d i n the medical records (124). CLINICAL RECORDS The c l i n i c a l r e c o r d as compared to medical r e c o r d i s the aggregate of a l l the observ a t i o n s made by the h e a l t h p r o f e s s i o n s , i n c l u d -ing medicine", which render d i a g n o s t i c , t h e r a p e u t i c and s o c i a l s e r v i c e s to the p a t i e n t s . In that sense, the c l i n i c a l r e c o r d emerges as a means of communication and of c o o r d i n a t i o n among the var i o u s h e a l t h occupations i n v o l v e d i n the care of the p a t i e n t s , and the r e c o r d i n g s of each h e a l t h occupation have ac q u i r e d some prominence i n the e v a l u a t i o n of the q u a l i t y of care w i t h i n a d i s c i p l i n a r y as w e l l as a c r o s s - d i s c i p l i n a r y forum. The Canadian C o u n c i l on H o s p i t a l A c c r e d i t a t i o n r e g u l a r l y r e -viewing i t s requirements came to use the terms of medical, c l i n i c a l or p a t i e n t s ' records i n t e r c h a n g e a b l y , and prov i d e s the d e f i n i t i o n of c l i n i c a l r e c o r d as being "the organized r e p o r t of the d i a g n o s t i c and treatment a c t i v i t i e s c a r r i e d out by a l l of the p r o f e s s i o n a l d i s c i p l i n e s concerned with the care of the p a t i e n t " (27, p.xx). G e n e r a l l y , the term "medical" was superseded by " c l i n i c a l " because t h i s l a t t e r term c l e a r l y encompassed a l l the h e a l t h o c c u p a t i o n s . 24 . T h i s t r a n s i t i o n from m e d i c a l t o c l i n i c a l r e c o r d was f a c i l i t a t e d by some major e v e n t s t h a t were s h a p i n g t h e h e a l t h f i e l d . (1) The f e d e r a l government program o f h e a l t h g r a n t s w h i c h s t a r t e d i n 1949 f o l l o w e d by t h e p r o m u l g a t i o n o f t h e H o s p i t a l i n s u r a n c e and D i a g n o s t i c S e r v i c e s A c t i n 1957 and t h e M e d i c a l C are A c t o f 1967 r e s u l t e d i n t h e s p e c t a c u l a r g r o w t h o f t h e h e a l t h i n d u s t r y . To f i l l t h e l a r g e need f o r a d d i t i o n a l manpower a c t i v e b u t u n c o o r d i -n a t e d t r a i n i n g programs i n t h e h e a l t h o c c u p a t i o n s began (26) . (2) S c i e n t i f i c and t e c h n o l o g i c a l a d v a n c e s were a c c e l e r a t i n g a t an u n p r e c e d e n t e d r a t e and r e s u l t e d i n i n c r e a s e d s p e c i a l i z a t i o n and d i v i s i o n o f l a b o u r . The m e d i c a l model o f h e a l t h c a r e was c h a l l e n g e d by t h e a m b i t i o u s a l l i e d h e a l t h o c c u p a t i o n s , p a r t l y b e c a u s e t h e s e l a t t e r s e i z e d upon many o f t h e t a s k s f o r m e r l y b e l o n g i n g t o t h e m e d i c a l t e r r i t o r y , p a r t l y b e c a u s e t h e y wanted t o f r e e t h e m s e l v e s from t h e p h y s i c i a n ' s a u t h o r i t y , b u t a l s o p a r t l y b e c a u s e t h e y wanted f o r t h e m s e l v e s as much p r e s t i g e as t h a t e n j o y e d by t h e m e d i c a l group ( 3 4 ) . C l i n i c a l p s y c h o l o g i s t s f o r example even c l a i m e d " t h e s u p e r i o r i t y o f t h e p s y c h o l o g i c a l a p p r o a c h o v e r t h e m e d i c a l one, and wanted t h e r i g h t t o d i a g n o s e d i s e a s e s and t o p r e s c r i b e m e d i c a t i o n s ( 1 2 4 ) . (3) C o m p u t e r i z a t i o n r e a c h e d t h e h e a l t h i n d u s t r y , and t h e m e d i c a l r e c o r d s came t o be a b s t r a c t e d and coded i n t o a machine r e a d a b l e f o r m . The i m p a c t upon p h y s i c i a n s was enormous; s t a n d a r d i z a t i o n r e q u i r e d t h e d e f i n i t i o n o f b a s i c r e q u i r e m e n t s f o r t h e many d i a g -n o s t i c e n t i t i e s as w e l l as t h e r e c o r d i n g o f e v e n t s i n an o b j e c t i v e form w h i c h c o u l d t h e n be c o d i f i e d . To r e s o l v e t h e p h y s i c i a n s ' s t r u g g l e w i t h a u t o m a t i o n , Dr. L . L . Weed i n t r o d u c e d h i s c o n c e p t o f p r o b l e m - o r i e n t e d c a r e and r e c o r d (136, 1 3 7 ) . T h i s new c o n c e p t was f i r m l y g r o u n d e d on two p r i n c i p l e s : 1) t h e p a t i e n t i s n o t m e r e l y a 25 . diseased member or organ, but a whole unique person w i t h i n a de f i n e d course of l i f e and s p e c i f i c h e r e d i t a r y , s o c i a l and economic m i l i e u s j 2) over and above the main p r e s e n t i n g complaint, the p a t i e n t s ' concurrent problems have to be i d e n t i f i e d and t r e a t e d so that the p a t i e n t can be r e s t o r e d to h i s / h e r p r o d u c t i v e r o l e i n s o c i e t y . The problem-oriented approach to care f i r m l y e s t a b l i s h e d the team concept: once the p a t i e n t ' s problems were i d e n t i f i e d , they could be addressed to by the most a p p r o p r i a t e h e a l t h occupa-t i o n . The problem o r i e n t e d r e c o r d s t r o n g l y r e l i e s on a l l the h e a l t h occupations being able to make s c i e n t i f i c and p r o f e s s i o n a l l y f a c t u a l o b s e r v a t i o n s and to record these i n an o b j e c t i v e manner. In a d d i t i o n , the h e a l t h p r o f e s s i o n a l s have to express what they assess the s i t u a t i o n to be and what they plan to do f o r the p a t i e n t i n r e l a t i o n to these o b j e c t i v e o b s e r v a t i o n s . The concept of pro-f e s s i o n a l a c c o u n t a b i l i t y emerges very c l e a r l y , and the h e a l t h p r o f e s s i o n a l s , through t h e i r r e c o r d s , have to submit to i n t e r -d i s c i p l i n a r y s c r u t i n y . S u b j e c t i v e e n t r i e s can a l s o be made; these w i l l r e f l e c t comments made by the p a t i e n t as w e l l as d i f f e r e n c e s i n p e r c e p t i o n between p r o f e s s i o n a l s , and a l s o o b s e r v a t i o n s which cannot be f i r m l y supported by some form of a p p r o p r i a t e measurement, such -as temperature, blood pressure or l a b o r a t o r y f i n d i n g s . Because of t h i s segregation of o b j e c t i v e from s u b j e c t i v e , the p a t t e r n of e n t r i e s i n a problem-oriented r e c o r d are c o l o q u i a l l y s t a t e d to f o l l o w a SOAP format: S_ubjective, O b j e c t i v e , Assessment and Pl a n . G e n e r a l l y , the problem-oriented r e c o r d has not met with much success. The main cause of t h i s f a i l u r e i s the i n a b i l i t y of the h e a l t h occupations to recognize that the problem-oriented r e c o r d i s not a mere technique, but r a t h e r r e s t s on the v a l i d i t y and r e l i a b i l i t y of the p r o f e s s i o n a l t h i n k i n g as w e l l as on the a p p l i c a t i o n of the p r i n c i p l e s of l o g i c i n d i f f e r e n t i a t i n g between o b j e c t i v e and sub-j e c t i v e o b s e r v a t i o n s . HEALTH RECORDS The new concept of h e a l t h records takes i t s o r i g i n i n the emphasis placedon h e a l t h as opposed to the t r a d i t i o n a l foCUs on d i s e a s e . Events r e l a t i n g to h e a l t h maintenance and to p r e v e n t i o n of disease should be recorded and l i n k e d with a l l events of d i s e a s e . The link a g e of a l i f e t i m e of h e a l t h events i s s c i e n t i f i c a l l y and s o c i a l l y d e s i r a b l e f o r the b e t t e r understanding of the p r e d i c t a b i l i t y of di s e a s e , the segr e g a t i o n of ge n e r i c i n f l u e n c e s , and the maintenance and the promotion of h e a l t h . With the advent of the computer, the lin k a g e of h e a l t h records on i n d i v i d u a l , f a m i l i a l , geographic, d i a g n o s t i c , e t c . bases i s t e c h n i c a l l y , and even economically feas i b l e . Linkage i m p l i e s exchange of i n f o r m a t i o n between a u t h o r i z e d p a r t i e s as the i n t e r e s t s of the pat.i.ent and/or the economics of the h e a l t h care system demand. This w i l l presuppose the formation of a pledge of t r u s t between those p a r t i e s who w i l l be able to access the data from a data bank, which w i l l be the major r e p o s i t o r y . The concept of l i n k a g e w i l l c e r t a i n l y gain r e c o g n i t i o n i n the f u t u r e , mostly because the s h i f t toward ambulatory care has e s t a b l i s h e d the importance of follow-up procedures, the n e c e s s i t y of c o - o r d i n a t i n g v a r i o u s types of care, and of u n i f y i n g a l l the obse r v a t i o n s made by h e a l t h care teams. The a c c e p t a b i l i t y of i n t e g r a t i o n of a l l h e a l t h events i n t o a u n i f i e d r e c o r d hinges more on s o c i a l c o n s i d e r a t i o n than on any other f a c t o r . T h i s i n t e g r a t i o n r e q u i r e s the use of a unique p a t i e n t i d e n t i f i e r , a n d tremendous 27 . s o c i a l concern has been expressed about the p o s s i b i l i t y of leakage of c o n f i d e n t i a l i n f o r m a t i o n to unauthorized people as w e l l as about the prospect of becoming a mere number and l o s i n g human i d e n t i t y . Unknown to the p u b l i c at l a r g e , l i n k a g e already e x i s t s i n a small or r a t h e r u n p u b l i c i z e d form, f o r example through the s o c i a l insurance number, and the i n t r o d u c t i o n of an o f f i c i a l h e a l t h r e c o r d f o r each Canadian w i l l be a p o l i t i c a l d e c i s i o n to be made i n the near f u t u r e . The main d i f f e r e n c e between h e a l t h r e c o r d and i n f o r m a t i o n i s that the r e c o r d i s the p h y s i c a l format, where i n f o r m a t i o n i s the immaterial core. This substance may not always be recorded a c c u r a t e l y and i n i t s e n t i r e t y . The Ontario C o u n c i l of Health i n i t s r e p o r t on Health Information and S t a t i s t i c s (1975) s t a t e s that " h e a l t h i n f o r m a t i o n i s considered to encompass a l l forms of knowledge i n the h e a l t h f i e l d . Within i t s scope, i t i n c o r p o r a t e s two separate but i n t e r r e l a t e d types of h e a l t h knowledge: that which i s represented by f a c t s or data of a numerical nature that are r e q u i r e d f o r the p l a n n i n g and o p e r a t i o n of the h e a l t h care system, and that which i s concerned with promoting and m a i n t a i n i n g the h e a l t h and meeting the h e a l t h needs of the p r i v a t e i n d i v i d u a l " (p.5) . The Ontario d e f i n i t i o n i s based on the subsequent use of the recorded inform-a t i o n : a) f o r the p a t i e n t ' s i n t e r e s t ; b) f o r the needs of the o r g a n i z a t i o n and of the h e a l t h care system; but t h i s i s not to say that there are two kinds of h e a l t h i n f o r m a t i o n . A t e n t a t i v e d e f i n i t i o n of p a t i e n t h e a l t h i n f o r m a t i o n i s suggested: the sum of a l l data p e r t a i n i n g to a person's h e a l t h s t a t u s , s t a r t i n g with b i r t h and g e n e t i c h i s t o r y , and i n c l u d i n g a l l o b j e c t i v e and pro-f e s s i o n a l o b s e r v a t i o n s of a l l f a c t s and events of the nature of disease p r e v e n t i o n , h e a l t h maintenance, disease d i a g n o s i s and therapy u n t i l death. These data should be generated, v e r i f i e d 28 . m o d i f i e d , acted upon, used and exchanged by the v a r i o u s h e a l t h occupations under s t r i c t e t h i c a l and l e g a l c o n t r o l p r i m a r i l y f o r the p a t i e n t ' s best i n t e r e s t . Health i n f o r m a t i o n i s then broader than h e a l t h records because i t encompasses a l l the data or p o t e n t i a l i n f o r m a t i o n which today i s f r e e l y and l o o s e l y exchanged without such exchanges being docu-mented or l e g i t i m a t e d , that i s e t h i c a l l y , l e g a l l y or p r o f e s s i o n a l l y warranted, and a l l the i n f o r m a t i o n that many t h e r a p i s t s do not r e c o r d f o r q u e s t i o n a b l e reasons of c o n f i d e n t i a l i t y , or of mistaken concept of p r o p r i e t o r s h i p , or simply omission, or even lac k of competence. A b r i e f review of the value of h e a l t h i n f o r m a t i o n would show co n s i d e r a b l e expansion on the views of MacEachern (80) and of Huffman (93). From the p a t i e n t ' s p o i n t of view, h e a l t h i n f o r m a t i o n would transcend the person and take on geneologic dimensions, because the unborn generations can be g e n e t i c a l l y c o n t r o l l e d . Health i n f o r m a t i o n would encompass the r e c o r d i n g of a l l the events which a f f e c t the person's sta t u s of h e a l t h . On the b a s i s of the present s t r u c t u r e of the h e a l t h care d e l i v e r y system, c o n t i n u i t y of care i s p o s s i b l e and would in s u r e a more adequate and r a p i d s e r v i c e wherever and whenever the p a t i e n t ' s need i s r e c o g n i z e d . From the s o c i o - l e g a l aspect, the i n d i v i d u a l ' s r i g h t to p r i v a c y w i l l be eroded, as l i n k a g e i m p l i e s a m u l t i p l i c i t y of uses and u s e r s . But because i t w i l l no longer be c o n f i n e d to one h o s p i t a l or one doctor, h e a l t h i n f o r m a t i o n w i l l , one may assume, p r i m a r i l y guard the p a t i e n t ' s i n t e r e s t s while a l s o s e r v i n g the p h y s i c i a n s ' and the h o s p i t a l s ' i n t e r e s t . For.'-.the p h y s i c i a n , h e a l t h inform-a t i o n w i l l be a must as he no longer i n v o l v e s h i m s e l f with the disease e n t i t y only but with the person and, by e x t e n s i o n , with the 29 . f a m i l y , present and f u t u r e . Health i n f o r m a t i o n w i l l a l s o document the long-term e f f e c t s of the care given at times of disease and of non-health s t a t u s . Medical s e l f - e v a l u a t i o n w i l l become p o s s i b l e , at the o f f i c e l e v e l as w e l l as at the h o s p i t a l and community l e v e l s . From the e t h i c a l p o i n t of view, i n order to j u s t i f y the p a t i e n t ' s t r u s t i n him/her, the p h y s i c i a n may s a t i s f y h i s / h e r own standards of performance as w e l l as h i s own sense of autonomy. Accurate h e a l t h i n f o r m a t i o n w i l l f u r n i s h adequate documentation f o r b i l l i n g e i t h e r the p a t i e n t and/or the insurance company, or the government c a r r i e r , on the f e e - f o r - s e r v i c e b a s i s that i s the p r e f e r r e d method of payment i n Canada. On the same b a s i s as the former medical r e c o r d s , h e a l t h i n f o r m a t i o n w i l l be a d m i s s i b l e i n c o u r t , t h e r e f o r e , m a i n t a i n i n g the value a t t r i b u t e d to the former medical re c o r d s ; but as h e a l t h i n f o r m a t i o n r e s t s on l i n k a g e and can be accessed from s e v e r a l d i r -e c t i o n s , i t f o l l o w s that the records may serve p r i m a r i l y the i n t e r e s t s of the p a t i e n t s . For the h o s p i t a l , h e a l t h i n f o r m a t i o n generation and management w i l l become a generic process that w i l l apply e q u a l l y to a l l the v a r i o u s types of p a t i e n t s : i n - and o u t p a t i e n t s , day care, day surgery, extended care p a t i e n t s , and so on. The c o l l e c t e d h e a l t h i n f o r m a t i o n w i l l be the b a s i s of a p r o f e s s i o n a l a c c o u n t a b i l i t y system e v a l u a t i n g the processes and the outcomes of p a t i e n t care. The i n t e g r a t e d h e a l t h i n f o r m a t i o n w i l l allow the long-term e v a l u a t i o n of the care given, that i s assess the r o l e of the h o s p i t a l i n the community; h e a l t h i n f o r m a t i o n w i l l a l s o allow g r e a t e r c o o p e r a t i o n with the p u b l i c h e a l t h s e c t o r f o r the purpose of h e a l t h promotion w i t h i n the community. The r e s u l t s of these e v a l u a t i o n processes could then be r e l a t e d to the o p e r a t i o n a l c o s t s , the u t i l i z a t i o n of r e s o u r c e s , and used i n f i n a n c i a l c o n t r o l and i n government r e p o r t i n g . A newer trend i n 30 the h e a l t h f i e l d p o i n t s to the emergence of f i n a n c i a l standards i n r e l a t i o n to disease e n t i t i e s and o p e r a t i o n s ; these w i l l evolve by comparing the h o s p i t a l s ' performances l o c a l l y , r e g i o n a l l y , p r o v i n -c i a l l y and n a t i o n a l l y , arid w i l l be used to make c r i t i c a l economic d e c i s i o n s a t a l l l e v e l s . L e g a l l y , the aggregate of h e a l t h i n f o r m a t i o n would p r i m a r i l y serve the p a t i e n t s ' i n t e r e s t . This means that the court w i l l be able to evaluate the care rendered by the h o s p i t a l on the b a s i s of the h e a l t h i n f o r m a t i o n . At the present time, h o s p i t a l s may expurgate the records before s u r r e n d e r i n g them to the c o u r t . Records of c r i t i c a l i n c i d e n t s o c c u r r i n g i n h o s p i t a l s are never p a r t of the records f o r the simple reason that these may i n d i c a t e some form of c u l p a b i l i t y v i s - a - v i s the p a t i e n t , and may r e s u l t i n a court case. This custom i s , of course, e n t i r e l y u n e t h i c a l and t e s t i f i e s to the f a c t that under c e r t a i n c o n d i t i o n s of c o n f l i c t of i n t e r e s t , the h o s p i t a l w i l l u n e r r i n g l y chose i t s own i n t e r e s t over and above the p a t i e n t ' s . The value of h e a l t h i n f o r m a t i o n to the government would be i n the p r o v i s i o n of an accounting system from the h o s p i t a l s to the govern-ment as w e l l as from the government to i t s c o n s t i t u e n t s . Health-i n f o r m a t i o n w i l l y i e l d i n d i c e s r e l a t i n g to the h e a l t h s t a t u s of the n a t i o n and more f a c t u a l i n f o r m a t i o n on which to base d e c i s i o n -making processes and s o c i a l p o l i c i e s . STATUS OF HEALTH INFORMATION In an e f f o r t to b r i e f l y analyze the st a t u s of h e a l t h i n f o r m a t i o n i n Canada, i t must be s a i d that the value of c l i n i c a l records as opposed to medical records has mostly been recognised by now; however, t h a t r e c o g n i t i o n i s mostly academic and i s not n e c e s s a r i l y true i n p r a c t i c e . The h e a l t h occupations do not yet communicate 31 . at the same l e v e l with one another. Communications among them have the very s e n s i t i v e c h a r a c t e r of p r o f e s s i o n a l c h a l l e n g e and s c r u t i n y . The records are not used e f f i c i e n t l y as the o f f i c i a l channel of communication; r a t h e r much o r a l exchange takes plac e i n which d e f i n i t i o n s , o b j e c t i v e s and standards are l e f t comfortably vague and u n c l a r i f i e d . Acceptance of the n e c e s s i t y of r e c o r d i n g i s not uniform among the h e a l t h occupations, nor among the v a r i o u s h e a l t h i n s t i t u t i o n s . For example, i n one of the major Canadian teaching h o s p i t a l s , the p h y s i o t h e r a p i s t s are r e q u i r e d to r e p o r t n e i t h e r t h e i r treatment m o d a l i t i e s nor the p a t i e n t s ' responses to these; i n s t e a d only a short summary i s i n c l u d e d i n the c l i n i c a l r e c o r d . The records that p h y s i o t h e r a p i s t s maintain f o r t h e i r own p r o f e s s i o n a l requirements are kept i n t h e i r department, under v a r i o u s c o n d i t i o n s of c o n f i -d e n t i a l i t y , and destroyed p e r i o d i c a l l y , p o s s i b l y i n v i o l a t i o n of the p r o v i n c i a l s t a t u t e of l i m i t a t i o n s (124). L i t t l e or no e f f o r t i s being expanded i n d e f i n i n g the complete-ness of records and what they should c o n t a i n because there i s l i t t l e acceptance of p a t t e r n s of care with r e f e r e n c e to s p e c i f i c d i s e a s e s , and d e v i a t i o n s from such p a t t e r n s are not n e c e s s a r i l y considered a d e f i c i e n c y i n the q u a l i t y of care. Although q u a l i t y of care programs, medical and nur s i n g a u d i t s are commonplace, they are s t i l l o f t e n p u n i t i v e i n c h a r a c t e r and any r e p r e s e n t a t i v e of one of the h e a l t h occupations w i l l r e a d i l y -admit that the d i s c i p l i n i n g of a co l l e a g u e i s a most unpleasant task, and thus i t i s f r e q u e n t l y pushed aside i n the hope that the problem w i l l solve i t s e l f . T h erefore, records are mistakenly seen as means of d i s c i p l i n a r y measure against i n d i v i d u a l t h e r a p i s t s as opposed to 3 2 . being accepted as e d u c a t i o n a l t o o l s . G e n e r a l l y the h e a l t h occupations are doing t h e i r best to magnify the asymmetry of i n f o r m a t i o n that e x i s t s between the h e a l t h occu-p a t i o n s themselves, between the h e a l t h occupations and the p a t i e n t s , and between the h e a l t h occupations and the management of the h e a l t h i n s t i t u t i o n s . A p e r f e c t example of t h i s statement occurs with n u r s i n g which i s i n the throes of o r g a n i z i n g nursing a u d i t s and q u a l i t y of care programs. Nursing has not been able to d e f i n e c r i t e r i a acceptable to the e n t i r e p r o f e s s i o n , s i n c e some f a c t i o n s s t a t e that n e i t h e r the medical nor the nursing p a r t s of the r e c o r d are s u i t a b l e to t h e i r a u d i t s , and contend that they have to devise s p e c i f i c n u rsing diagnoses i n order to focus on and evaluate the s p e c i a l i z e d n u r s i n g tasks; these nursing diagnoses would bear only very general r e l a t i o n s h i p to the medical diagnoses. A l l h e a l t h occupations are being taught b a s i c p r o f e s s i o n a l t h i n k i n g emphasizing the concept of p r o f e s s i o n a l autonomy. This concept u n f o r t u n a t e l y p l a c e s the h e a l t h worker i n a s i t u a t i o n of c o n f l i c t : on one side i s the d e s i r e to document the care rendered i n order to a f f i r m one's c o n t r i b u t i o n to the management of the p a t i e n t , and to be recognized as v a l u a b l e by the other h e a l t h occupations and accepted at par i n the h e a l t h care team; on the other s i d e i s the d e s i r e to be considered " p r o f e s s i o n a l " which d i c t a t e s a quest f o r autonomy. From t h e i r vantage p o i n t , the h e a l t h occupations view the h o s p i t a l o r g a n i z a t i o n i n which they work as an h i e r a r c h i c a l a u t h o r i t y . Although e n t i r e l y incompetent i n the s p e c i a l i z e d s k i l l s of the h e a l t h occupations, t h i s a u t h o r i t y i s n e v e r t h e l e s s engaged i n e v a l u a t i n g them i n terms of output, as i f they were mechanical means of p r o d u c t i o n . T h i s process of e v a l u a t i o n denies the occupations 33 . the freedom of c o n t r o l l i n g and s c h e d u l i ng t h e i r own work, as p r o f e s s i o n a l autonomy would have i t . This p e r c e p t i o n of the org-i z a t i o n s by the h e a l t h occupations breeds a n o t i c e a b l e r e s i s t a n c e to the b u r e a u c r a t i c a l l y enforced s u p e r v i s i o n , and a f e e l i n g of a l i e n a t i o n from the management of the o r g a n i z a t i o n s ; by e x t e n s i o n , the a l i e n a t i o n i s d i r e c t e d toward the government which they see as the r e a l c u l p r i t r e s p o n s i b l e f o r the t y r a n n i c a l and i n e f f e c t i v e b u r e a u c r a t i c p r o c e s s . In h o s p i t a l s i t u a t i o n s , the r e l a t i o n s h i p between h e a l t h p r o f e s s i o n a l s and h e a l t h i n f o r m a t i o n i s governed by the p o l i c i e s of the organ-i z a t i o n ; t h i s holds true even f o r the independent medical s t a f f . As the Health Record A d m i n i s t r a t i o n occupation i s not considered to be one of the a l l i e d occupations because i t does not render d i r e c t s e r v i c e s to the p a t i e n t s , i t f o l l o w s that the Health Record Admini-s t r a t i o n occupation i s c a t e g o r i z e d as an arm of management, t h e r e f o r e , a mechanism of the b u r e a u c r a t i c p r o c e s s . Health occu-pa t i o n s resent the "paper work" which i s r e q u i r e d by the o r g a n i z a -t i o n , and most a c t i v e l y search f o r t h e i r own system of i n f o r m a t i o n which would give them, what they, p r o f e s s i o n a l s , want. The main problems to overcome may perhaps be s t a t e d to be: none of the h e a l t h occupations accept h e a l t h i n f o r m a t i o n as being an agent of s y s t e m a t i z a t i o n and of i n t e g r a t i o n ; n e i t h e r do they have any d e s i r e f o r s y s t e m e t i z a t i o n or i n t e g r a t i o n . The h e a l t h occupations would r a t h e r continue to r e s i s t inroads i n t o t h e i r t e r r i t o r i e s , that i s they would r a t h e r pursue t h e i r r e s t r i c t e d p r o f e s s i o n a l o b j e c t i v e s . U n t i l these sharp p r o f e s s i o n a l t e r r i t o r i a l imperatives are r e s o l v e d and u n t i l more encompassing, i n t e g r a t i v e o b j e c t i v e s are recognized, the s t a t u s of h e a l t h i n f o r m a t i o n w i l l be low. 34 . However, the f i r s t stage toward the i n t e g r a t i o n of o b j e c t i v e s among the h e a l t h occupations would perhaps be the alignment of t h e i r pro-f e s s i o n a l o b j e c t i v e s with the main goals of the o r g a n i z a t i o n i n which they have to f u n c t i o n . On the other hand, i f managed a p p r o p r i a t e l y , i t i s conc e i v a b l e that h e a l t h i n f o r m a t i o n w i l l take the r o l e of agent of change, f o c u s i n g p r i m a r i l y on the p a t i e n t , and emphasizing o c c u p a t i o n a l account-a b i l i t y as opposed to p r o f e s s i o n a l o b j e c t i v e s , simply because h e a l t h i n f o r m a t i o n i s v i t a l to the performance of a l l the h e a l t h occupations . 35 . CHAPTER IV ASSOCIATION DEVELOPMENT AND PROFESSIONALIZATION OF THE HEALTH RECORD ADMINISTRATORS: From the beginning of t h i s century, a strong emphasis had been placed on the medical records by the American C o l l e g e of Surgeons and the program of s t a n d a r d i z a t i o n they developed and sponsored. This emphasis was expressed p u b l i c l y through the H o s p i t a l Manage-ment Review: "Records are a prime e s s e n t i a l i n any program of h o s p i t a l s t a n d a r d i z a t i o n . . . . the case records are the v i s i b l e e v i -dence of what the h o s p i t a l i s accomplishing" (80, p.21). Thus, the Congress of the American C o l l e g e of Surgeons held on October 11, 1928 d i f f e r e d from the usual annual event i n as much as i t s t o p i c r e l a t e d to medical r e c o r d s , and that Dr. T. MacEachern, D i r e c t o r of the S t a n d a r d i z a t i o n Program, had i s s u e d a s p e c i a l i n v i -t a t i o n to the s t a f f s of the medical re c o r d departments of American h o s p i t a l s to p a r t i c i p a t e . As an outcome of t h i s Congress, the workers of the medical re c o r d departments of h o s p i t a l s recognized themselves as a group, to which the American C o l l e g e of Surgeons had appealed f o r c o l l a b o r a t i o n with them i n improving the records of the p a t i e n t s , and i n d e v i s i n g adequate record-keeping methods. Motivated by t h i s appeal, the A s s o c i a t i o n of Record L i b r a r i a n s of North America was formed on that same day, and s t a t e d i t s main o b j e c t i v e to be: "to e l e v a t e the standards of c l i n i c a l records i n h o s p i t a l s , d i s p e n s a r i e s and other d i s t i n c t l y medical i n s t i t u t i o n s " (80, p.23). The 58 c h a r t e r members of the newly formed A s s o c i a t i o n of Record L i b r a r i a n s of North America organized t h e i r a s s o c i a t i o n on the model of other p r o f e s s i o n a l a s s o c i a t i o n s and formulated t h e i r own code of e t h i c s . By 1935, e d u c a t i o n a l standards had been set and some schools had opened i n h o s p i t a l s which were v o l u n t a r i l y 36 . assuming the r e s p o n s i b i l i t y to t r a i n medical r e c o r d l i b r a r i a n s as p a r t of t h e i r education f u n c t i o n s . C o n c u r r e n t l y a r e g i s t r y was set up, and a r e g i s t r a t i o n examination was devised f o r the admission of new members; to r e i n f o r c e the r e s t r i c t i o n s to entry i n t o the occupation, the i n s p e c t i o n and the a c c r e d i t a t i o n of the e d u c a t i o n a l program was placed under the C o u n c i l on Medical Education & H o s p i t a l s (80). The f o r m a l i z e d group had staked out i t s t e r r i t o r y and was endeav-ouring to enlarge i t under the sponsorship of the medical p r o f e s s i o n . Had the group not been formed at the time of the American C o l l e g e of Surgeons' Congress, would there be an occupation today? Although the question i s academic, to support i t , one may mention that i n Europe where doctors and h o s p i t a l s have a much longer h i s t o r y , few c o u n t r i e s — w i t h the exception of England--have an occupation s i m i l a r to the American Health Record A d m i n i s t r a t o r s , and where such groups e x i s t , (West Germany, Holland) they are of q u i t e recent formation. In Canada, where the p o p u l a t i o n , and consequently the h o s p i t a l s were much l e s s numerous, the A s s s o c i a t i o n of Medical Record L i b r a r i a n s f o r the p r o v i n c e of Ontario was founded i n 1935 and a r e g i s t r y e s t a b l i s h e d . The formation of the Canadian group was g r e a t l y f a c i l i t a t e d by the f a c t that at that time the J o i n t C o u n c i l on H o s p i t a l A c c r e d i t a t i o n , which had evolved from the p r e v i o u s l y mentioned program of s t a n d a r d i z a t i o n , was surveying j o i n t l y the American and the Canadian h o s p i t a l s , and was c r e a t i n g requirements f o r s i m i l a r standards of h o s p i t a l o p e r a t i o n and of medical p r a c t i c e . In 1942, the Canadian A s s o c i a t i o n of Medical Record L i b r a r i a n s (CAMRL) was formed, and subsequently obtained i t s Dominion Charter i n 1949 (124). The t o t a l number of members was low, as f o r example, there were only three r e g i s t e r e d r e c o r d l i b r a r i a n s i n B.C. at that time. I t s main o b j e c t i v e remained the improvement of medical r e c o r d s . 37 . Strong a s s o c i a t i o n - o r i e n t e d goals were a l s o e s t a b l i s h e d r e l a t i n g to the r e s t r i c t i o n of entry i n t o the a s s o c i a t i o n , the establishment of a s p e c i f i c body of knowledge and the s t a k i n g out of a t e r r i t o r y of o p e r a t i o n . H o s p i t a l - s c h o o l s p a t t e r n e d on the American model were s t a r t e d i n 1936. The e d u c a t i o n a l t r a i n i n g , p a r t l y theory, p a r t l y p r a c t i c e , was of one year d u r a t i o n . Entrance was l i m i t e d to students with the e q u i v a l e n t of a Grade 13 O n t a r i o . A f t e r graduating from the h o s p i t a l -school program, the students became e l i g i b l e to w r i t e the r e g i s t r a -t i o n examination of the Canadian A s s o c i a t i o n of Medical Record L i b r a r i a n s . In the 1950's, Canadian h o s p i t a l s had s t a r t e d t h e i r a c c e l e r a t e d p e r i o d of growth subsequent to the f e d e r a l program of h e a l t h grants of 194 9 (34), and f o l l o w i n g the p a t t e r n e s t a b l i s h e d over the previous two decades, became eager to h i r e t r a i n e d r e g i s t e r e d r e c o r d l i b r a r i a n s . Recognizing the acute need f o r such a c l a s s of h o s p i t a l workers, the Canadian A s s o c i a t i o n of Medical Record L i b r -a r i a n s c o l l a b o r a t e d with the Canadian H o s p i t a l A s s o c i a t i o n i n s e t t i n g up a two-year correspondence program f o r persons who were already employed i n the Medical Record Department of h o s p i t a l s . The ed u c a t i o n a l requirements f o r these persons could not be as s t r i c t as f o r the students e n t e r i n g an o f f i c i a l h o s p i t a l - s c h o o l . The correspondence c l a s s e s accepted l a r g e groups of students f o r s e v e r a l years u n t i l 1960. The graduates of the correspondence program became known as Medical Record L i b r a r i a n s (M.R.L.) and became e l i g i b l e to w r i t e t h e i r r e g i s t r a t i o n examination a f t e r f i v e years of experience i n a Medical Record Department. L a t e r , t h a t clause was repealed and the MRLs could write t h e i r r e g i s t r a t i o n only i f they had the e q u i v a l e n t of Grade 13 On t a r i o . For those 38 . MRLs who wanted to upgrade themselves, the a s s o c i a t i o n allowed a 5-year p e r i o d a f t e r completion of the correspondence course. Few MRLs were w i l l i n g to undertake an a d d i t i o n a l e d u c a t i o n a l program as they were q u i t e secure i n t h e i r jobs due to s c a r c i t y . The a s s o c i a -t i o n became concerned about the i n c r e a s i n g percentage of medical re c o r d l i b r a r i a n s with lower e d u c a t i o n a l standards. This concern prompted the d e c i s i o n to end the correspondence course f o r MRLs in 1960. But, i n order to supply t r a i n e d manpower to meet the demand, as w e l l as to keep e n l a r g i n g i t s power-base the a s s o c i a t i o n s t a r t e d a correspondence course f o r a Medical Record T e c h n i c i a n l e v e l : the d u r a t i o n of the program became one year. The r e q u i r e -ments f o r p a r t i c i p a t i o n remained the same: employment with the Medical Record Department of a h o s p i t a l . The timing f o r t h i s d e c i s i o n was unfortunate from the p o i n t of view of the Medical Record L i b r a r i a n s ' education. In the 1960's, i n Canada, the p o l i t i c a l d e c i s i o n had been made to phase a l l educa-t i o n a l programs i n t o the o f f i c i a l e d u c a t i o n a l stream; and the Canadian A s s o c i a t i o n of Medical Record L i b r a r i a n s had j u s t docu-mented the need f o r a lower l e v e l of education f o r some of i t s members by implementing the t e c h n i c i a n program. The a s s o c i a t i o n b i d u n s u c c e s s f u l l y f o r a u n i v e r s i t y education to match the standards of the American Medical Record L i b r a r i a n s A s s o c i a t i o n which had by then moved i t s programs i n t o degree-granting i n s t i t u t i o n s . This f a i l u r e was due to the i n a b i l i t y of the Canadian A s s o c i a t i o n of Medical Record L i b r a r i a n s to s p e c i f y and s u b s t a n t i a t e the e d u c a t i o n a l requirements of i t s members, as w e l l as to the l a c k of p o l i t i c a l power. When the time came to phase-in the h o s p i t a l - s c h o o l s i n t o the community c o l l e g e s , the a s s o c i a t i o n , very concerned i n m a i n t a i n i n g the l i b r a r i a n s t a t u s f o r the e x i s t i n g R e g i s t e r e d Record L i b r a r i a n s , consented to the establishment of two-year programs f o r t e c h n i c i a n s . The f i r s t two such programs were e s t a b l i s h e d at Niagara C o l l e g e and the B.C. I n s t i t u t e of Technology. With the ending of the c o r r e s -pondence course f o r the t r a i n i n g of Medical Record L i b r a r i a n s , the phasing out of some h o s p i t a l - s c h o o l s , and the reduced output of some of these remaining h o s p i t a l - s c h o o l s ( f o r example, i n New Westminster, B.C., the school l o c a t e d at the Royal Columbian H o s p i t a l graduated, i n some yea r s , one student only or even no students at a l l ) , the percentage of R e g i s t e r e d Record L i b r a r i a n s was d e c r e a s i n g w i t h i n the a s s o c i a t i o n , while the p o p u l a t i o n made up of lower sta t u s members was i n c r e a s i n g due to the vigorous p r o d u c t i o n of new t e c h n i c i a n s . This imbalance prompted the assoc-i a t i o n to grant the r i g h t to t r a i n medical r e c o r d l i b r a r i a n s (who w i l l be e l i g i b l e to w r i t e t h e i r r e g i s t r a t i o n examination) to newly opening two-year c o l l e g e programs; c o n c u r r e n t l y , one-year programs were s t a r t e d at other community c o l l e g e s to graduate Record Tech-n i c i a n s . Consequently, s e r i o u s i n c o n s i s t e n c i e s e x i s t w i t h i n the a s s o c i a t i o n ' s e d u c a t i o n a l p a t t e r n s . Perhaps the major f a c t o r r e s p o n s i b l e f o r the departure from the American e d u c a t i o n a l p a t t e r n was that the sponsorship of the Canadian Medical A s s o c i a t i o n was e i t h e r not sought or not obtained as i n the case of l a b o r a t o r y t e c h n i c i a n s , e t c . The occupation r e l i e d upon i t s own resources to conduct a program of education and a c c r e d i t a t i o n , the r e s u l t s of which are confusing and u n s a t i s f a c t o r y . In the 1960's, i n Canada, the concept of h e a l t h a c q u i r e d momentum: focus on h e a l t h became more important than focus on d i s e a s e , and a person was recognized to be more than the sum of h i s / h e r episodes of i l l - h e a l t h . During the same p e r i o d , automation spread to 40 . h o s p i t a l s and one of i t s impacts was the p o s s i b i l i t y of l i n k i n g a l l the in f o r m a t i o n r e l a t i n g to the h e a l t h s t a t u s of a person. Sensing that these developments were to a f f e c t the Medical Record L i b r a r i a n s and T e c h n i c i a n s , and perhaps p r o p e l them toward the much d e s i r e d p r o f e s s i o n a l s t a t u s , the Canadian A s s o c i a t i o n of Medical Record L i b r a r i a n s sought to adapt i t s e l f to these developments, by t r y i n g to modify the occupation's image. In 1973, i t changed i t s name to Canadian Health Record A s s o c i a t i o n . F o l l o w i n g the prece-dent of other p r o f e s s i o n a l a s s o c i a t i o n s , t h i s newly formed a s s o c i a -t i o n kept the socio-economic powers f o r i t s e l f , but vested i t s s t a n d a r d - s e t t i n g and a c c r e d i t i n g powers i n the Canadian C o l l e g e of Health Record A d m i n i s t r a t o r s . T h i s change was traumatic to the members, who could l i t t l e understand the reasons f o r such a move and were puzzled by the new names they would have to use. The Reg i s t e r e d Record L i b r a r i a n ' s name, which expressed an occupation as w e l l as a s t a t u s , was changed to C e r t i f i c a n t , which r e f e r r e d only to a rank w i t h i n the a s s o c i a t i o n . The members s u f f e r e d , and s t i l l do, a l o s s of i d e n t i t y ; to be a " l i b r a r i a n " was an occupa-t i o n which they, as w e l l as ot h e r s , could understand and p l a c e i n t o some o r g a n i z a t i o n a l and s o c i a l niche; but how do you convey to others that you are a " c e r t i f i c a n t " ? The name of Health Record A d m i n i s t r a t o r seemed incongruous to the many who hold subordinate and t e c h n i c a l p o s i t i o n s w i t h i n o r g a n i z a t i o n s . Although the r e -o r g a n i z a t i o n of the occupation's a s s o c i a t i o n and i t s change of name were intended to r a i s e the occupation to a p r o f e s s i o n a l s t a t u s , these events cr e a t e d l i t t l e i n t e r e s t i n the h e a l t h f i e l d , and even today "medical r e c o r d l i b r a r i a n " i s o f t e n the a p p e l a t i o n used." The new a s s o c i a t i o n a l h i e r a r c h y c r e a t e d was: ' ° 41. a) A s s o c i a t e : the lowest s t a t u s which comprises the c l e r k s , the t e c h n i c i a n s and the former medical r e c o r d l i b r a r i a n s who could not o b t a i n t h e i r r e g i s t r a t i o n . b) C e r t i f i c a n t : t h i s i s the b a s i c l e v e l and i t comprises the former R e g i s t e r e d Record L i b r a r i a n s . c) Fellow: the h i g h e s t s t a t u s , which, to date, has not been achieved by anyone, as i t i s p o o r l y d e f i n e d . To complicate matters, the p r o g r e s s i o n from the lowest to the highest s t a t u s i s not yet c l e a r l y e s t a b l i s h e d . T h i s p r o g r e s s i o n i s based p a r t l y on f u r t h e r education, p a r t l y on the accumulation of c r e d i t s f o r attendance at a s s o c i a t i o n a l events, p a r t l y on work experience. A great deal of c o n f u s i o n i s caused by the ladk of s p e c i f i c i t y i n d e s c r i b i n g d e s i r a b l e academic s u b j e c t s ; f o r example a t e c h n i c i a n who would earn a b a c c a l a u r e a t e degree i n p h y s i c s , may not be allowed to progress because p h y s i c s may perhaps be thought to be i r r e l e v a n t to the occupation; on the other s i d e , a t e c h n i -c i a n who has s u c c e s s f u l l y completed the Canadian H o s p i t a l A s s o c i a t i o n correspondence course i n Departmental Management would have accumulated one h a l f of a l l the c r e d i t s r e q u i r e d . There are, t h e r e f o r e , s e r i o u s doubts as to what i s the body of knowledge s p e c i f i c to t h i s occupation; furthermore what l e v e l of education corresponds to the r e s p e c t i v e s t a t u s l e v e l s w i t h i n the a s s o c i a t i o n i s not c l e a r l y e s t a b l i s h e d and i s not r e l a t e d to s t a t u s at work. In s p i t e of the unresolved s t a t e of such major i s s u e s as education and standards of performance, the Canadian A s s o c i a t i o n of Medical Record L i b r a r i a n s and i t s successor the Canadian C o l l e g e of Health Record A d m i n i s t r a t o r s have t r i e d u n s u c c e s s f u l l y to o b t a i n l e g i t i -mation f o r t h e i r members from the p r o v i n c i a l and f e d e r a l govern-ments as w e l l as from the Canadian C o u n c i l on H o s p i t a l A c c r e d i t a t i o n . These attempts had been made i n order to r e s t r i c t employment i n 42 . the Medical Record Departments of h o s p i t a l s to members of the CAMRL, subsequently CCHRA, and to c o r r e l a t e s t a t u s w i t h i n the assoc-i a t i o n with s t a t u s w i t h i n the job s i t u a t i o n s . From the s o c i o l o g i c a l p o i n t of view, the development of the occu-p a t i o n of Health Record A d m i n i s t r a t o r s e x h i b i t s some of the c h a r a c t e r i s t i c s a t t r i b u t e d by s o c i a l s c i e n t i s t s to the process of p r o f e s s i o n a l i z a t i o n : a s s o c i a t i o n , r e s t r i c t e d entry, code of e t h i c s , and even an attempt at c r e a t i n g a new image by the change of name. However, the body of s p e c i a l i z e d knowledge was not expanded adequately i n r e l a t i o n to the s e r v i c e s expected by others and i n r e l a t i o n to the r e v o l u t i o n a r y i n c r e a s e i n knowledge obvious i n our s o c i e t y . The e d u c a t i o n a l standards remained unclear and the standards of p r a c t i c e undefined. From the f i d u c i a r y p o i n t of View, s e r v i c e s to the p a t i e n t s , being of an i n d i r e c t nature, pass un-n o t i c e d ; t h e r e f o r e , no t r u s t r e l a t i o n s h i p has developed, and the p u b l i c i s , g e n e r a l l y , unaware of the e x i s t e n c e of the HRA. The r e a l c l i e n t s themselves,that i s the p h y s i c i a n s , the nurses, the h o s p i t a l a d m i n i s t r a t o r s , the h e a l t h planners and the governments, possess bodies of knowledge which exceed by f a r the l e v e l of the HRA's, and have commensurate s o c i a l s t a t u s and power; thus i t i s u n r e a l i s t i c to expect the development of a t r u s t r e l a t i o n s h i p between HRAs one side and t h e i r c l i e n t s , the p h y s i c i a n s , the a d m i n i s t r a t o r s and the governments on the other s i d e w i t h i n the c l a s s i c a l paradigm " p r o f e s s i o n a l - c l i e n t " . Because of t h i s l a c k of t r u s t , and a l s o because of the communication b a r r i e r s e r e c t e d by the h e a l t h occupations between themselves, as mentioned e a r l i e r , the HRA occupation i s w e l l i n s u l a t e d from any other group w i t h i n the o r g a n i z a t i o n , much ag a i n s t i t s w i l l . O r g a n i z a t i o n a l l e g i a n c e never q u i t e developed because of the o r i g i n a l attachment to the medical p r o f e s s i o n p e r s i s t s to t h i s day, and the HRA occupation would be q u i t e w i l l i n g to p l a c e i t s e l f under the p a t e r n a l i s t i c and p r o t e c t i v e dominance of the medical s t a f f . HRAs have given a l l t h e i r a t t e n t i o n to the c l i n i c a l needs f o r information,and have not developed the u s e f u l n e s s of the same i n f o r m a t i o n f o r management and f o r the p l a n n i n g of h e a l t h s e r v i c e s . P r o f e s s i o n a l autonomy never e x i s t e d , as the HRAs have always per-formed w i t h i n an o r g a n i z a t i o n . T h e i r p r a c t i c e has always been s t r o n g l y governed by the requirements of the government, of the Canadian C o u n c i l on H o s p i t a l A c c r e d i t a t i o n , and by the medical s t a f f and the h o s p i t a l ' s by-laws. Furthermore, the d e s i r e f o r autonomy i s not s u b s t a n t i a t e d i n any way, as s e l f - d i s c i p l i n e and s e l f - e v a l u a t i o n programs are v i r t u a l l y n o n - e x i s t e n t . EVOLUTION OF THE PRESENT ROLE AND POSITION OF THE HEALTH RECORD ADMINISTRATOR The h i s t o r i c a l development of the r o l e of the Health Record Admini-s t r a t o r w i l l show that the occupation was always bound to the h o s p i t a l - o r g a n i z a t i o n . At the beginning, the tasks were l i m i t e d to s t o r i n g and r e t r i e v i n g the medical r e c o r d s , mostly a c u s t o d i a l f u n c t i o n . L a t e r , the q u a n t i t a t i v e a n a l y s i s of the discharged p a t i e n t s ' records was added; the J o i n t Committee on H o s p i t a l A c c r e d i t a t i o n which had succeeded the S t a n d a r d i z a t i o n program of the American C o l l e g e of Surgeons, had e s t a b l i s h e d more s p e c i f i c standards about the documentation r e q u i r e d from the p h y s i c i a n s . As the number of Medical Record L i b r a r i a n s had i n c r e a s e d , the a n a l y s i s came to be performed r o u t i n e l y . T h i s a n a l y s i s l i m i t e d i t s e l f i n i d e n t i f y i n g the r e p o r t s present i n the r e c o r d and i n r e q u e s t i n g from the p h y s i c i a n s those which were m i s s i n g . This was the p o i n t at which the work of the medical r e c o r d l i b r a r i a n s became s e n s i t i v e . 44 . I f the standards e s t a b l i s h e d by the J o i n t Committee were to be adhered t o , so that the h o s p i t a l would r e c e i v e or maintain a c c r e d i -t a t i o n s t a t u s , t h e n the Medical s t a f f would have to cooperate with the medical record l i b r a r i a n s i n the completion of the r e c o r d s . G e n e r a l l y , the medical s t a f f d i d not r e a c t f a v o r a b l y to the requests of the medical r e c o r d l i b r a r i a n s . The requests were i n f a c t implying that there were d e f i c i e n c i e s i n the work of the p h y s i c i a n s , t h e r e -f o r e , they became u n p a l a t a b l e . The mediocrely t r a i n e d Medical Record L i b r a r i a n s d o g m a t i c a l l y i n s i s t e d t h a t doctors comply to the l e t t e r with the a c c r e d i t a t i o n standards and the medical s t a f f by-laws i f these l a t t e r e x i s t e d . To render the s i t u a t i o n even more complex, h o s p i t a l s were s h i f t i n g or had s h i f t e d toward the l a y a d m i n i s t r a t i o n model, and, g e n e r a l l y the a d m i n i s t r a t i o n of the h o s p i t a l had to back - ever so s l i g h t l y - the medical r e c o r d l i b r a -r i a n because of the concern over the a c c r e d i t a t i o n s t a t u s . A t e n t a t i v e s o l u t i o n to t h i s deep problem was the formation of a Medical Record Committee, composed of p h y s i c i a n s , which would concern i t s e l f with the p o l i c i n g of the medical s t a f f as f a r as completion of records was concerned. These committees l i m i t e d t h e i r r e s p o n s i b i l i t y to the p h y s i c a l e x i s t e n c e of the i n f o r m a t i o n , and decreed that the a n a l y t i c a l element i n the r o l e of the Medical Record L i b r a r i a n was to remain s t r i c t l y q u a n t i t a t i v e . The a c c r e d i t a t i o n process a l s o r e q u i r e d the maintenance of diagnos-t i c , s u r g i c a l and p hysicians' indexes, and manual indexes were e s t a b l i s h e d n e c e s s i t a t i n g the use of a c o d i f i e d c l a s s i f i c a t i o n . Coding of the medical r e c o r d was done by the medical r e c o r d l i b r a r -i a n s . However, problems of terminology occurred immediately; the medical diagnoses were a f f i x e d q u i t e l o o s e l y - i n the sense that 45 . they were not expressed i n exact codable medical terms, were o f t e n r e c o r d i n g symptoms as diagnoses,and recorded mostly the main problems only; the n o t a t i o n N.Y.D. f o r "not yet diagnosed" was common. The coding of the disea s e s according to the accepted nomenclatures had become a d i f f i c u l t task r e q u i r i n g a more thorough a n a l y s i s of the rec o r d s , an a n a l y s i s more q u a l i t a t i v e than the medical p r o f e s s i o n wanted to allow. C l e a r l y , the medical p r o f e s s i o n had to evaluate i t s own work. Medical a u d i t s s t a r t e d to become known; some form of a u d i t had to be e s t a b l i s h e d i n each h o s p i t a l a c c ording to the American as w e l l as the Canadian a c c r e d i t i n g bodies. The medical s t a f f submitted, but to s e l f - s c r u t i n y o nly. Medical a u d i t commit-tees were formed to review the r e c o r d s , which were provided by the medical r e c o r d l i b r a r i a n s a c c ording to s p e c i f i c c r i t e r i a set f o r t h by the medical s t a f f . However, u s u a l l y one a d d i t i o n a l c r i -t e r i o n •allowed the medical r e c o r d l i b r a r i a n s to b r i n g to the committee's a t t e n t i o n any records which were thought to need review. The a n a l y t i c a l f u n c t i o n was beginning to take on more obvious q u a l i t a t i v e and e v a l u a t i v e c h a r a c t e r i s t i c s . Approximately two decades ago-, automation h i t the h e a l t h f i e l d . In the U.S. a commercial, but n o n - p r o f i t computer system company began to s e l l i t s s e r v i c e s to the h o s p i t a l s . Again the a c c r e d i t i n g bodies acted as agent of change by modifying t h e i r requirements to in c l u d e o p e r a t i o n a l and u t i l i z a t i o n of resources data, as w e l l as analyses of the diagno s t i c and t h e r a p e u t i c s e r v i c e s . Automation meant that a g r e a t e r amount of data could be c o l l e c t e d about each discharged p a t i e n t . By c o l l a t i n g the data u n i f o r m l y from a l l the h o s p i t a l s , c e r t a i n standards would evolve, f o r example: the number of days before the surgery; the number of days a f t e r surgery; the 46 . types of d i a g n o s t i c and t h e r a p e u t i c s e r v i c e s p r ovided; and so f o r t h ; then, each h o s p i t a l could compare i t s r e s u l t s with those averaged from the e n t i r e p o p u l a t i o n of h o s p i t a l s under study. A d e t a i l e d a n a l y s i s of the records was needed, which meant s t r i c t e r standards of i n f o r m a t i o n generation by the p h y s i c i a n , and more q u e s t i o n i n g by the medical records l i b r a r i a n s . The q u a l i t a t i v e aspect of r e c o r d a n a l y s i s had deepened and expanded. The tremendous amount of computerized data a v a i l a b l e created the task of data a n a l y s i s f o r the purpose of Compiling the r e s u l t s obtained, comparing those with those d e s i r e d and making the neces-sary adjustments. The American and Canadian a c c r e d i t i n g bodies had become very keen about the assessment of the q u a l i t y of care rendered by the h o s p i t a l s ; f e d e r a l and the p r o v i n c i a l governments, as they were paying the c o s t s , were a l s o i n t e r e s t e d i n the u t i l i -z a t i o n of the r e s o u r c e s . The l o g i c a l person w i t h i n the h o s p i t a l s t r u c t u r e to perform these s t a t i s t i c a l analyses was the medical r e c o r d l i b r a r i a n , who had compiled the data and possessed the source-documents. At t h i s p o i n t , t h e problems s t a r t e d to compound: a) the p r o v i n c i a l governments, which i n Canada, ought to be i n t e r e s t e d i n the q u a l i t y of care produced and dispensed with the h e a l t h d o l l a r , i n s t i t u t e d t h e i r own v a r i o u s computer systems, and the medical r e c o r d departments d u p l i -cated much work by sending the same data to the government and to the computer s e r v i c e . The government i t s e l f d u p l i c a t e d the work of the medical r e c o r d departments by r e - a f f i x i n g codes to diseases and o p e r a t i o n s , o f t e n using a d i f f e r e n t nomen-c l a t u r e . b) the a d m i n i s t r a t i o n of the h o s p i t a l i s h a r d l y t r a i n e d i n computer s c i e n c e , s t a t i s t i c s and the methods of e v a l u a t i n g the q u a l i t y of care. 4 7 . c) the medical s t a f f s i m i l a r l y l a c k s i n t e r e s t i n computers as w e l l as i n s t a t i s t i c s ; furthermore they cons i d e r the evalua-t i o n of the q u a l i t y of care as t h e i r p r o f e s s i o n a l domain, and openly o b j e c t to o r g a n i z a t i o n a l and governmental i n t e r f e r e n c e s . d) the medical r e c o r d l i b r a r i a n s were not t r a i n e d i n computer science and s t a t i s t i c s , nor i n management and s o c i a l and b e h a v i o r a l s c i e n c e s ; consequently they were not a b l e , with few e x c e p t i o n s , to r i s e to the t e s t . T h e i r education of one or two years post high school l e f t them unprepared f o r e d u c a t i o n a l , p r o f e s s i o n a l and o r g a n i z a t i o n growth, and d i d not make them acceptable to the other d i s c i p l i n e s . One may even venture to say that t h i s e d u c a t i o n a l gap was, perhaps one of the most important f a c t o r s i n the c r e a t i o n of problems, because the medical r e c o r d l i b r a r i a n was expected to work as a f a c i l i t a t o r between the medical s t a f f , the a d m i n i s t r a t i o n and the computer group, a r o l e r e q u i r i n g not only competence i n computers, s t a t i s t i c s and management, but a l s o a great deal of t a c t and of understanding, as w e l l as an a b i l i t y to teach and advise without being obvious about i t . The f a i l u r e on the p a r t of the medical r e c o r d l i b r a r i a n was the most n o t i c e d because of the f r u s t r a t e d e x p e c t a t i o n s on the p a r t of the o r g a n i z a t i o n s and of the h e a l t h d i s c i p l i n e s . Even today, the q u a l i t y of care programs f u n c t i o n without set standards and i n a very patchy way; the a d m i n i s t r a t o r s r e c e i v e p e r t i n e n t and t i m e l y data n e i t h e r about the care rendered by the h o s p i t a l , nor about the u t i l i z a t i o n of r e s o u r c e s , and the h e a l t h planners are being fed e n t i r e l y u n r e l i a b l e s t a t i s t i c s as HRAs cannot d i s t i n g u i s h between c l i n i c a l and o p e r a t i o n a l and p l a n n i n g needs f o r i n f o r m a t i o n . The Medical Record L i b r a r i a n s may have 48 . ^  become Health Record A d m i n i s t r a t o r s , but they have not overcome t h e i r d e f i c i e n c i e s , and the h e a l t h d i s c i p l i n e s may be on the p o i n t of c o n s i d e r i n g any other occupation's s e r v i c e s which w i l l p r ovide them with the i n f o r m a t i o n they r e q u i r e . Strong candidates f o r t h i s p o s i t i o n may be the computer s c i e n t i s t , or perhaps the epidemiolo-g i s t , the medical s t a t i s t i c i a n , or the nurse a d m i n i s t r a t o r , o r . . . ? Should another occupation enter the h e a l t h i n f o r m a t i o n arena with a more a p p r o p r i a t e body of knowledge, the Health Record A d m i n i s t r a t o r s would be f i r m l y set at the t e c h n i c a l l e v e l of coding, s t o r i n g and r e t r i e v i n g data u n t i l the computer w i l l take those tasks completely over . In a d d i t i o n to s t a t i s t i c a l a n a l y s i s , another major area of f u n c t i o n was c r e a t e d by automation: the l i n k a g e of the h e a l t h - r e l a t e d i n f o r -mation had become t e c h n o l o g i c a l l y f e a s i b l e . O v e r a l l , such l i n k a g e would g r e a t l y b e n e f i t s c i e n c e and s o c i e t y through the accumulation of new o b s e r v a t i o n s and knowledge, and c o n t r i b u t e to cost c o n t a i n -ment by the e l i m i n a t i o n of d u p l i c a t i o n and by b e t t e r c o o r d i n a t i o n . One of the main t e c h n i c a l o b s t a c l e s to l i n k a g e i s the poor q u a l i t y of the i n f o r m a t i o n recorded, and i t s p a t c h i n e s s . The other main o b s t a c l e i s a t t i t u d i n a l : n e i t h e r the medical p r o f e s s i o n , nor the a l l i e d h e a l t h occupations, nor the a d m i n i s t r a t i o n and even l e s s the HRA group f e e l comfortable with the concept of l i n k a g e . W e l l -t r a i n e d HRAs would have promoted the values of l i n k a g e , even e s t a b l i s h e d some rudimentary l i n k a g e s with perhaps the d o c t o r s ' o f f i c e s i n the community, the c l i n i c s and the other h o s p i t a l s . Linkage could have s t a r t e d i n a manual form as a sub-system u n t i l a l l of these agencies acquire access to a computer. Once estab-l i s h e d , the system could have been s t u d i e d and evaluated, and the experience recorded f o r the b e n e f i t of s e l f and o t h e r s . B a s i c a l l y , -49. l i n k a g e should e x i s t between h o s p i t a l s , a l l the other o u t l e t s of h e a l t h care d e l i v e r y i n c l u d i n g h e a l t h c e n t r e s , c l i n i c s , d o c t o r s ' o f f i c e s , as w e l l as the h e a l t h e d u c a t i o n a l system, and f i n a l l y the governments, and form sub-systems i d e n t i f i a b l e at the l o c a l , r e g i o n a l , p r o v i n c i a l and n a t i o n a l l e v e l s . Such l i n k a g e would i n e v i t a b l y expose the h e a l t h occupations to mutual s c r u t i n y , down to the i n d i v i d u a l members as they p r a c t i c e t h e i r c a l l i n g i n rendering s e r v i c e s to the p u b l i c . The r e l u c t a n c e of these occupations i s obvious. Much to the r e l i e f of the h e a l t h occupations, r e l u c t a n c e i s a l s o noted on the p a r t of the p u b l i c which seems to acquire a new i n t e r e s t i n s e c u r i n g the i n d i v i d u a l ' s r i g h t to p r i v a c y . I n e v i t a b l y , one may p r e d i c t t h at p u r e l y on economic grounds, computers w i l l win, and any occupation which can c o n t r i b u t e to the implementation and the monitoring of the f i n a n c i a l r e s t r i c t i o n s by documenting the s e r v i c e s rendered and the r e s u l t s w i l l be i n demand. The HRA group could become that occupation, but only by c o n s i d e r a b l e expansion of i t s body of knowledge. With regard to the l e g a l aspects of i n f o r m a t i o n h a n d l i n g , the body of Canadian Health Law i s s t i l l very meager, and none of the h e a l t h occupations i s being adequately t r a i n e d i n the s u b j e c t . In the past, because, i n l e g a l cases, the records were o f t e n subpoenaed, the custodian of the records had to appear i n court and present the requested r e c o r d s . The frequency of these cases i n c r e a s e d over the years and the medical r e c o r d l i b r a r i a n s endeavoured to e s t a b l i s h some standard procedures to guide t h e i r behavior i n c o u r t . These procedures have now been f o r m a l i z e d by most h o s p i t a l s and o f f i c i a l h o s p i t a l p o l i c y has been decreed and today the HRAs are f r e q u e n t l y c o n s u l t e d on l e g a l matters, by the medical s t a f f and the admini-s t r a t i o n . 50 . Touching upon the l e g a l i s s u e , i s the problem of i n f o r m a t i o n use. This i s another area where the medical r e c o r d l i b r a r i a n s had to e s t a b l i s h t h e i r norms of conduct i n order to handle e t h i c a l l y the many requests from the insurance companies which p a i d e i t h e r the h o s p i t a l i z a t i o n c osts or d i s a b i l i t y or l i f e b e n e f i t s to some of the h o s p i t a l ' s p a t i e n t s and former p a t i e n t s . Insurance companies have always wanted to peruse the records themselves, and were o f t e n s u c c e s s f u l i n doing so. The Medical Record L i b r a r i a n s had to base t h e i r conduct p r i m a r i l y on the i n t e r e s t s of the p a t i e n t s and s t r i c t l y c o n t r o l the amount of i n f o r m a t i o n they could r e l e a s e . The law was not very e x p l i c i t on the matter of i n f o r m a t i o n t r a n s m i s s i o n from the p a t i e n t s r e c o r d s , and h o s p i t a l p o l i c y and procedures p r a c t i -c a l l y n o n - existent or inadequate. This s e r v i c e o r i e n t a t i o n , One of the claimed c h a r a c t e r i s t i c s of p r o f e s s i o n s , i s l a r g e l y unrecognized, because the c l i e n t s were unaware that they had r e c e i v e d such c o n f i -d e n t i a l s e r v i c e s . On the other hand, the insurance companies always considered the Medical Record L i b r a r i a n s ' behavior to be o b s t r u c t i v e . Because the HRAs could - on a general l e v e l - achieve acceptance n e i t h e r by the medical and a l l i e d h e a l t h s t a f f s , nor by the admini-s t r a t i o n , i t ensued that they were p o o r l y l i s t e n e d to when endea-vouring to e s t a b l i s h such procedures of r e l e a s e of i n f o r m a t i o n that would p r o t e c t the p a t i e n t s ' r i g h t to p r i v a c y . Rozowsky (113) w i l l argue that Canadians have r e l i n q u i s h e d t h e i r r i g h t to p r i v a c y when they voted f o r the f e d e r a l h e a l t h care system. However, Canadian s o c i e t y , dismayed by the amount of i n f o r m a t i o n that can be c o l l a t e d about any one i n d i v i d u a l , i s becoming very concerned about the degree of c o n f i d e n t i a l i t y that should be granted to the very p e r s o n a l and int i m a t e i n f o r m a t i o n r e l a t i n g to i n d i v i d u a l s ' h e a l t h s t a t u s . 51 . This problem i s i n some form of abeyance, and i s solved l o c a l l y and a r b i t r a r i l y ; but should the p u b l i c concern gain momentum, h o s p i t a l s and other h e a l t h care f a c i l i t i e s w i l l need a p p r o p r i a t e counsel on l e g a l matters r e l a t i n g to the use and the users of h e a l t h inform-a t i o n . On the o r g a n i z a t i o n a l l e v e l , w i t h i n the h o s p i t a l s t r u c t u r e , the medical r e c o r d l i b r a r i a n s were o r i g i n a l l y granted middle management p o s i t i o n s . This was consistent, -with, xthe •cfeheneex'isfcing; p_aitit«a?nc: £ g e n e r a l l y , no other a d m i n i s t r a t i v e department head was more q u a l i f i e d academi-c a l l y ; exceptions were perhaps the pathology l a b o r a t o r y and the X-ray departments wherever these could be headed by s p e c i a l i z e d p h y s i c i a n s , and the pharmacy. Nurses were at the h o s p i t a l - s c h o o l l e v e l , while the business o f f i c e and the a d m i n i s t r a t o r s were o f t e n promoted from the s t a f f of the h o s p i t a l , and had u s u a l l y a minimum of formal education. However, a dramatic change has taken plac e over the past decades, and the h o s p i t a l management group today i s at l e a s t at the b a c c a l a u r e a t e l e v e l , 'but mostly at the master and doctorate l e v e l s . The average h e a l t h r e c o r d a d m i n i s t r a t o r i s not able to f u n c t i o n p r o d u c t i v e l y among such high-powered group. This a d d i t i o n a l f a i l u r e of the HRA to provide adequate managerial s e r v i c e s a l i e n a t e d the a d m i n i s t r a t i o n of h o s p i t a l s . In many i n s t a n c e s t h i s r e s u l t e d i n the i n s e r t i o n of a new l e v e l of s u p e r v i s i o n between the a d m i n i s t r a t i o n and the HRA, r e l i n q u i s h i n g t h i s l a t t e r to a lower l e v e l . This new s u p e r v i s o r y l e v e l was f i l l e d with non-HRA personnel of v a r i o u s q u a l i f i c a t i o n s , o f t e n with r e t i r e e s from the armed f o r c e s . In other i n s t a n c e s , the HRAs' middle management p o s i t i o n was maintained, but the incumbent to the p o s i t i o n was r e p l a c e d with non-HRA perso n n e l , o f t e n a d m i n i s t r a t i v e nurses, or business managers at the b a c c a l a u r e a t e or master l e v e l . This l a t t e r s i t u a t i o n has become q u i t e n o t i c e a b l e i n Toronto and Onta r i o , and has caused great concern to the Canadian C o l l e g e of Health Record A d m i n i s t r a t o r s . At present, the a s s o c i a t i o n f i n d s i t s e l f i n the d i f f i c u l t p o s i t i o n of not knowing how to p r o t e c t the i n t e r e s t s of i t s members. The body of knowledge has not been s u f f i c i e n t l y expanded i n accordance with the changes i n the h e a l t h f i e l d and i n s o c i e t y , and has stayed at the t e c h n i c a l l e v e l ; n e i t h e r a s s o c i a t i o n nor i t s members have been r e c e p t i v e to the needs and requirements of the medical s t a f f , the other h e a l t h occupations, and the a d m i n i s t r a t i o n . R e s p o n s i b i l i t i e s and tasks have i n c r e a s e d , h o s p i t a l p o s i t i o n s have developed, but the HRA incumbents have, g e n e r a l l y , stagnated. Today, h o s p i t a l s s t i l l form the main environment of the HRAs' f u n c t i o n i n g . H o s p i t a l s are p r o v i d i n g an i n c r e a s e d number of s e r v i c e s , consequently there are s e v e r a l types of p a t i e n t s , f o r example, day surgery, day care, emergency, extended care, i n - and o u t p a t i e n t s . Yet, the HRAs s t i l l f u n c t i o n almost e x c l u s i v e l y i n r e l a t i o n to the i n p a t i e n t p o p u l a t i o n . Too o f t e n , the care given to the v a r i o u s types of p a t i e n t s i s not documented according to the same standards, and the records o r i g i n a t i n g i n the d i f f e r e n t departments of the same h o s p i t a l may not even be i n t e g r a t e d i n t o a unique r e c o r d . G e n e r a l l y , HRAs are i n charge of the i n p a t i e n t i n f o r m a t i o n system; o u t p a t i e n t s extended care, emergency and other types of p a t i e n t s o f t e n have t h e i r own separate systems. This s i t u a t i o n i s more obvious i n Ontario than i n B.C., perhaps because the occupation, developing l a t e r i n B.C. had to face a d d i t i o n a l c h a l l e n g e s . Computerized o r g a n i z a t i o n a l systems are being c o n s t r u c t e d , but seldom under the d i r e c t i o n of an HRA. 5 3 Few HRAs are working at the p r o v i n c i a l governmentjjs l e v e l , but u s u a l l y t h e i r a d v i s o r y r o l e i s o r i e n t e d toward the h o s p i t a l HRAs and not toward the government. Ne i t h e r at the l o c a l h o s p i t a l l e v e l nor at any higher r e g i o n a l or p r o v i n c i a l l e v e l i s input from the HRA occupation r e q u i r e d whenever d e c i s i o n s are made with regard to some aspect of h e a l t h i n f o r m a t i o n . One may surmise again, that t h i s i s because other occupations have been assessed as more l i k e l y to provide the i n f o r m a t i o n s e r v i c e s that are planned or r e q u i r e d ; the c o m p u t e r - s c i e n t i s t group, i n p a r t i c u l a r , appears to be c o n s i d -ered more d e s i r a b l e than the HRA. In summary, i n s p i t e o f the f a c t t h a t h e a l t h i n f o r m a t i o n has gained i n importance, the occupation p r o f e s s i n g to manage i t has only grown n u m e r i c a l l y without i n c r e a s i n g s u b s t a n t i a l l y i t s knowledge base. At t h i s p o i n t , s e v e r a l occupations may stake a c l a i m to the management of h e a l t h i n f o r m a t i o n , but the HRA occupation has e i t h e r not yet recognized the chall e n g e and the danger, or i s o b l i v i o u s to i t , or does not know what c o r r e c t i v e behaviors to adopt. The Delphi Study which f o l l o w s was aimed at f i n d i n g how the other h e a l t h occupations see the f u t u r e f u n c t i o n s of the HRA i n r e l a t i o n to t h e i r own occupation's needs f o r h e a l t h i n f o r m a t i o n and h e a l t h i n f o r m a t i o n management s e r v i c e s . 54 . CHAPTER V. THE DELPHI TECHNIQUE LITERATURE REVIEW AND CRITIQUE The now h i s t o r i c a l P r o j e c t Delphi conducted by the Rand C o r p o r a t i o n i n the 1950's f o r the United States Defence used a new method of survey which has now become known as the Delphi method through the p u b l i c a t i o n s of Dalkey and Helmer i n the 1960's. This method i s a means of communications w i t h i n a group, the members of which do not come i n t o f a c e - t o - f a c e c o n t a c t ; the technique e x p l o i t s c o l -l e c t i v e i n t e l l i g e n c e and knowledge to f a c i l i t a t e a consensus by using the simple pen-and-paper method as opposed to speech and person-to-person i n t e r a c t i o n . B a s i c a l l y , a c o o r d i n a t o r , or a co-o r d i n a t i n g group, i n t e r r o g a t e s a panel of experts on a w e l l - d e f i n e d t o p i c . The i n t e r r o g a t i o n f o l l o w s t h i s s c e n a r i o : the f i r s t p a r t i s i n q u i s i t i v e and h e u r i s t i c , and probes the t h i n k i n g of the members of the panel with regard to some aspects of the f u t u r e i n r e l a t i o n to the t o p i c i n q u e s t i o n . A c o n t r o l l e d feedback i s pre-pared by the c o o r d i n a t o r and returned to the panel summarizing the group response of the f i r s t round; the panel members can gauge t h e i r r e l a t i v e p o s i t i o n w i t h i n the group. Then a second round of i n q u i r y i s sent out a l l o w i n g the members to j o i n the group's o p i n i o n or to maintain t h e i r own, and s u b s t a n t i a t e t h e i r d e c i s i o n . This procedure i s repeated u n t i l some form of consensus i s reached or u n t i l the sub j e c t i s considered explored. Fundamentally, three main c h a r a c t e r i s t i c s d i s t i n g u i s h the Delphi method from any other group encounter: 1) anonymity. There are two l e v e l s of anonymity to c o n s i d e r : f i r s t , the members of the panel may be anonymous to one another. 55 . thus most of the s o c i o - p s y c h o l o g i c a l pressures common to f a c e - t o -face meeting may be e l i m i n a t e d ; the second l e v e l of anonymity guarantees that no response can ever be t r a c e d to any member by another member; t h i s anonymity i s p a r t i c u l a r l y of i n t e r e s t when, i n c e r t a i n s t u d i e s , the members are taken from an a v a i l a b l e c o l -l e c t i v e o r g a n i z a t i o n , t h e r e f o r e , are known to one another, and f e e l f r e e to d i s c u s s the t o p i c and to sound out each other's o p i n i o n s on the s u b j e c t ; i n such cases, anonymity w i l l guard the responses and allow the members to respond according to t h e i r own b e l i e f s , f r e e i n g themselves from the well-known h a l o - e f f e c t c r e a t e d by the dominant members of t h e i r group. A more inten s e degree of anony-mity would guarantee that not even the c o o r d i n a t o r could t r a c e the responses back to s p e c i f i c members, the i n t e n t i o n being that such t o t a l anonymity would encourage candid and unguarded responses. 2) c o n t r o l l e d feedback of the responses. The r e t u r n s of each round of i n q u i r y are presented to the members a l l o w i n g them to assess t h e i r r e l a t i v e standing w i t h i n the group, and to maintain or modify t h e i r o r i g i n a l responses. Here, i t must be remarked that i f the s u b s t a n t i a t i o n of the choices and the e l u c i d a t i o n of the f a c t o r s r e s p o n s i b l e f o r the changes of o p i n i o n s are important aims of a study, then anonymity w i l l be a f f e c t e d i n such a way that the c o o r d i n a t o r w i l l have to know at a l l times the responses of the panel members i n order to make the a p p r o p r i a t e comparisons and measurements. 3) s t a t i s t i c a l group d e c i s i o n . A consensus may be the aim of a Delphi e x e r c i s e ; the judgment s u r v i v i n g may not represent the best judgment, but r a t h e r a compromise. Such a r t i f i c i a l consensus may have some merit i n c e r t a i n circumstances, f o r example i n estab-l i s h i n g o r g a n i z a t i o n a l o b j e c t i v e s or p u b l i c p o l i c i e s . More emphasis seems to be placed now on the e x p l o r a t i o n of the d i f f e r e n c e s of 56 . o p i n i o n s , thus s t a t i s t i c a l group d e c i s i o n may not always be a c h a r a c t e r i s t i c of a Delphi study. The panel i s recognized to be one of the most important f e a t u r e s of the D e l p h i - e x e r c i s e . The q u a l i t y of the output of the Delphi exer-c i s e appears to depend l a r g e l y on the e x p e r t i s e of the panel and on the a b i l i t y of i t s members to p r e d i c t f u t u r e events. Expert i s not o f t e n d e f i n e d i n the Delphi l i t e r a t u r e . Molnar and Kammerud (100) merely s t a t e t h at an expert i s someone who knows about the s p e c i f i c s u b j e c t , but i s not n e c e s s a r i l y a p r o f e s s i o n a l . P i l l (107) says that an expert could be anyone who can c o n t r i b u t e r e l e v a n t i n p u t s . These d e f i n i t i o n s are very l o o s e , and they would allow any c o o r d i n a t o r to assemble a l l those persons who w i l l l i k e l y support what he/she set out to prove by the Delphi survey. For H i l l and Fowles (77, p.187) , "an expert i s someone who commands a s p e c i a l i z e d body of knowledge". The Rand l i t e r a t u r e r e f e r s to experts as h i g h l y educated and experienced s p e c i a l i s t s , and Helmer (69, p.3) looks at experts "....as o b j e c t i v e i n d i c a t o r s comparable to measuring instruments". Brockhoff (90, p.295) d e f i n e s e x p e r t i s e as "....knowledge upon which p r o f e s s i o n a l c e r t a i n t y can be founded. This expert knowledge can be proven by demonstration or by recourse to c o n f i r m a t i o n through t h i r d p a r t i e s . " For s o c i a l s c i e n t i s t Wilensky (144, p . v i i ) an expert i s "a man of knowledge i n the sense that he b r i n g s to the problem at hand a body of s p e c i a l i z e d i n f o r -mation and s k i l l a c q uired through formal education/or t r a i n i n g on the job." While these d e f i n i t i o n s are more demanding than the former ones, they s t i l l leave a great deal of freedom to the c o o r d i -nator i n the assembly of the p a n e l s . The s e l e c t i o n of the members of the panel i s r e p o r t e d to occur according to the category of e x p e r t i s e r e q u i r e d , and the number and the q u a l i t y of experts a v a i l a b l e , i f these are i n s u f f i c i e n t numbers, the most experts among them should be chosen. Methods of panel s e l e c t i o n are seldom d i s c u s s e d , and only i n the most general terms. More o f t e n than not, i n the s t u d i e s p u b l i s h e d the c r i t e r i a used f o r the assembly of the panel are not s p e c i f i e d . Helmer (74) sets importance on c r i t e r i a such as the r e l i a b i l i t y and the accuracy of judgment as i d e n t i f i a b l e from p u b l i c a t i o n s , l e c t u r e s , conferences and other media of p u b l i c e x p r e s s i o n s . While these c r i t e r i a are commendable, they may preclude the use of experts who have not pu b l i s h e d s u f f i c i e n t l y , l i m i t s e v e r e l y the r o s t e r of experts a v a i l a b l e , and lead to i n - b r e e d i n g , even narrowness of outlook because of extreme s p e c i a l i z a t i o n . Helmer a l s o r e p o r t s (73) that most c r i t i c s deny the v a l i d i t y and the r e l i a b i l i t y of a consensus reached by a pa n e l , the members of which have not been s e l e c t e d according to the p r i n c i p l e s of random s e l e c t i o n . He emphasizes t h a t , although consensus i s one of the aims of a Delphi study, t h i s consensus does not inte n d to r e p r e -sent the opin i o n s of the general p o p u l a t i o n at l a r g e ; t h i s popu-l a t i o n would be, i n g e n e r a l , unable to give considered judgment on the s p e c i f i c t o p i c s which are the sub j e c t s of Delphi s t u d i e s . I f one co n s i d e r s that even the most s c i e n t i f i c methods of re s e a r c h are s u b j e c t to sharp c r i t i c i s m s , i t appears reasonable to expect that an i n d i v i d u a l i s t i c and s u b j e c t i v e method of survey as the Delphi would a t t r a c t a host of p r o t e s t s . Many of the c r i t i c i s m s center around the panel of exp e r t s , and, thus around the r e l i a b i l i t y and the v a l i d i t y of the f o r e c a s t s . Sackman (114), one of the best known c r i t i c s of the Delphi method, wants to see the parameters of the panel members e x p l i c i t y measured and recorded, the s p e c i f i c a t i o n s of t h e i r s k i l l s to meet o p e r a t i o n a l d e f i n i t i o n s , and anonymity a b o l i s h e d because i t leads to pe r s o n a l u n a c c o u n t a b i l i t y and to " e l i t i s m and d e l i b e r a t e m anipulation of the r e s u l t s to s a t i s f y vested i n t e r e s t " . He a l s o b e l i e v e s that f o r e c a s t i n g may be dangerous and should be avoided u n t i l a p r e c i s e ' s c i e n t i f i c methodology can be v a l i d a t e d . However, Sackman does not i n d i c a t e how to accumulate a h i s t o r y of s u c c e s s f u l precedents without experimenting. He expressed the o p i n i o n that the Delphi technique does not have any s c i e n t i f i c value because i t cannot be t e s t e d by the co n v e n t i o n a l psychometric methods, and he does not admit to the Delphi to be t e s t e d by the D e l p h i . A l b e r t s o n and C u t l e r (5) express the view that the experts i n a p a r t i c u l a r f i e l d would use the same l i m i t e d framework and have the same narrow outlook to formulate t h e i r o p i n i o n s , t h e r e f o r e , t h e i r f o r e c a s t i n g would r e f l e c t t h e i r s p e c i a l i z e d b i a s e s . P i l l (107) co n s i d e r s the Delphi method "a s p e c i a l i z e d p a r t of the whole f i e l d of s u b j e c t i v e s c a l i n g " (p. 57) and concurs with Sackman on the p o i n t that the use of the Delphi technique cannot add to the s c i e n t i f i c body of knowledge because i t deals with events which because they have not yet occurred, belong r a t h e r to the realm of the metaphysics. Yet P i l l agrees that r a t h e r than do nothing, the Delphi represents an attempt to harness the f u t u r e , but he cautions that i t should be a l l i e d with some other form of study using a b e t t e r t o o l . H i l l and Powles (77) thin k that the method needs d e f i n i t e pro-ced u r a l s t r e n g t h e n i n g to achieve some r e l i a b i l i t y and v a l i d i t y , p a r t i c u l a r l y i n the areas of panel s e l e c t i o n , panel a t t r i t i o n . They b e l i e v e that the v a l i d i t y of the technique i s threatened by the pressure to reach a consensus, and mostly by the lack of s t a n d a r d i z a t i o n of the procedure. Proponents of the Delphi argue that the shortcomings of the t e c h -nique do not n e c e s s a r i l y negate i t s u s e f u l n e s s and i t s r e l a t i v e v a l i d i t y . Morris (103) expresses t h i s view e l e g a n t l y : "we f o r g e t that some of the most important steps forward, s c i e n t i f i c d i s c o v e r i e s or product development have been the r e s u l t of c r e a t i v e , i m a g i n a t i v e leaps which made use of, but not being d i c t a t e d to by hard f a c t s and f i g u r e s " . He adds that the dynamicity of events and t h e i r interdependence to a g r e a t e r or l e s s e r degree render the o b j e c t i v i t y of hard f a c t s more apparent than r e a l " . Examined as a means of communication w i t h i n a d e f i n e d group, the v a l i d i t y of the Delphi r e s u l t s has been t e s t e d by s e v e r a l e x p e r i -menters i n that context. Brokhoff t e s t e d banking experts through the Delphi and through f a c e - t o - f a c e meetings, but a b s t a i n s from f o r m u l a t i n g a d e f i n i t e o p i n i o n (90). Mulgrave and Ducanis (90) r e f u t e d the argument that the Delphi method reduces or e l i m i n a t e s the p s y c h o l o g i c a l f o r c e s i n e f f e c t i n f a c e - t o - f a c e meetings, and intended to prove that the group median re p o r t e d i n the feedbacks between rounds may have the e f f e c t of "perceived a u t h o r i t y " . M i l k o v i c h et a l (98) used the Delphi technique i n manpower f o r e -c a s t i n g and found that the Delphi y i e l d e d more accurate r e s u l t s than the c o n v e n t i o n a l r e g r e s s i o n methods as compared to the a c t u a l manpower p o l i c y adopted by the f i r m s t u d i e d . However, h i s study does not s u b s t a n t i a t e the a c t u a l p o l i c y adopted by the f i r m as being the optimal p o l i c y . Van de Ven and Delbecq (132) c o n t r a s t e d the e f f e c t i v e n e s s of the Nominal Group Technique, the Delphi and the i n t e r a c t i n g group decision-making pro c e s s e s . The Nominal Group technique was a 60 . s t r u c t u r e d format of idea g e n e r a t i o n i n w r i t i n g f o l l o w e d by d i s -c u s s i o n , and s i l e n t v o t i n g . They found the Nominal Group technique (NGT) s u p e r i o r to the other two, but found the D e l p h i approximating c l o s e l y the r e s u l t s of the NGT; the i n t e r a c t i n g group processes scored p o o r l y , p a r t i c u l a r l y i n the generation of i d e a s . I t must be remarked that the NGT was developed by the authors. Within l a r g e o r g a n i s a t i o n s , Lachman (86) found that the Delphi technique allows f o r the f o r m u l a t i o n of a democratic o p i n i o n , thus reduces sharp o p p o s i t i o n s . He concludes that the Delphi i s a u s e f u l management t o o l , but that i t must be used with i n f i n i t e c a u t i o n , because the consensus obtained cannot n e c e s s a r i l y be equated with an optimal c h o i c e . Amra (7) compared the c h a r a c t e r i s t i c s of conferences, i n t e r v i e w s , c o n t r o l l e d sample p o p u l a t i o n p o l l i n g and computer-assisted meetings with the Delphi technique. These v a r i o u s methods of group i n t e r -a c t i o n processes have t h e i r r e l a t i v e advantages, and the s e l e c t i o n of the most a p p r o p r i a t e method should be made i n view of the i n f o r m a t i o n sought, the users of t h i s i n f o r m a t i o n , and the time and the costs i n v o l v e d . He views that v a r i o u s combinations of these techniques may be p r o d u c t i v e l y r e s o r t e d t o . The Delphi technique i s a p p l i c a b l e to s t u d i e s concerned with the f u t u r e , a f u t u r e , which i n some ways has to be invented. I t i s p a r t i c u l a r l y used f o r f o r e c a s t i n g s which w i l l become provable over time. In such cases the Delphi r e l i e s g r e a t l y on the t h e o r i e s of the hard and a p p l i e d s c i e n c e s , and the scientific;.na'ture--.o;'f ::.th.e Delphi i s made q u i t e obvious by the h i g h l y s o p h i s t i c a t e d c r o s s -impact analyses which are weighting the p r o b a b i l i t i e s of occurrence of c e r t a i n events, the time sequence of occurrence and t h e i r 61 . l i k e l y i n f l u e n c e s upon one another ( 7 , 31 , 32 , 45 , 51 , 56 , 90) . Delphi s t u d i e s are a l s o used f o r p l a n n i n g i n the f i e l d s of manpower, s o c i a l p o l i c y , urban a f f a i r s , corporate environment, h e a l t h and other areas i n which i n t u i t i v e and value judgments as w e l l as p e r s o n a l e x p e c t a t i o n s have great i n f l u e n c e . R e l i a n c e upon subjec-t i v i t y appears acceptable because the outcome d e s i r e d i s a form of democratic consensus. The Delphi e x e r c i s e appears an i d e a l type of technique i n such cases ( 2 5 , 53 , 65 , 74 , 86, 90 , 98) . The extensive use of the Delphi i n e d u c a t i o n a l s e t t i n g s ( 4 8 , 9 0 , 140) w i l l no doubt p o p u l a r i z e the Delphi as one of the e f f e c t i v e methods to communicate w i t h i n a group. Whereas the method may be thought to be lengthy, the use of the computer w i l l r e a d i l y a l l e v i a t e t h i s problem. Computer c o n f e r e n c i n g , making use of anonymity i n order to encourage the g e n e r a t i o n of ideas and l i b e r a t e d d i s c u s s i o n s , as w e l l as e x p l o r a t i o n of the divergences of o p i n i o n s w i l l l i k e l y become the most popular channel f o r the a p p l i c a t i o n of the Delphi techn ique. In summary, the D e l p h i method i s an a v a i l a b l e t o o l f o r probing the f u t u r e through c o l l e c t i v e i n t e l l i g e n c e i n s i t u a t i o n s where exact s c i e n t i f i c methods are not a p p l i c a b l e . Whereas the r e l i a b i l i t y and the v a l i d i t y of the method are not confirmed, the f i n d i n g s of a Delphi study may be used as guidance and r e f e r e n c e i n d e c i s i o n -making processes because they r e p r e s e n t the considered and pooled o p i n i o n s of people who are deemed to be knowledgeable i n the p a r t i c u l a r s u b j e c t , a f a c t which i n comparison renders the a l t e r -n a t i v e s to the Delphi method l e s s encompassing and l e s s thorough. Enzer, quoted by Strauss and Z i e g l e r ( 1 2 3 , p. 185) e x p l a i n e d that the mission of f u t u r e r e s e a r c h i s to "....broaden our time horizons and enable us not only to a n t i c i p a t e long-term changes per se, but a l s o to see how by c o n t r o l l i n g such changes we can i n c r e a s e the range of our a l t e r n a t i v e s . . . " . Even i f one cannot hope to c o n t r o l the f o r c e s of change, there i s l i t t l e excuse f o r not employing a l l known acceptable means at man1 d i s p o s i t i o n to prepare s e l f f o r a demanding f u t u r e of change which w i l l r e q u i r e a high degree of i n t e l l e c t u a l and p s y c h o l o g i c a l a d a p t a b i l i t y , and f o r not using d i s c e r n i n g judgment i n the s e l e c -t i o n of the p o s s i b l e a l t e r n a t i v e s . Any group convinced that i t serves a s p e c i f i c s o c i a l purpose has the r e s p o n s i b i l i t y to pl a n f o r i t s f u t u r e a c t i v i t i e s . Because of v i t a l interdependence with the other groups i n the same arena and upon events which have not yet occurred and may not even have been p r e d i c t e d , such p l a n n i n g cannot use the co n v e n t i o n a l methods of resear c h and has to r e l y upon s u b j e c t i v e analyses and i n f e r e n c e s grounded on the e x p e r t i s e a v a i l a b l e . The Delphi method seemed the s u i t a b l e t o o l to i n v e s t i g a t e and c o l l e c t the opin i o n s of the va r i o u s h e a l t h occupations as to what f u t u r e they v i s u a l i z e f o r the Health Record A d m i n i s t r a t o r group. For s i m p l i c i t y ' s sake, the p o s t u l a t i o n of the f u t u r e of the Health Record A d m i n i s t r a t o r was not made contingent upon the occurrence of any s p e c i f i c events but r e l a t e d only to very general trends w e l l known i n the h e a l t h f i e l d , such as ambulatory care, automation of records and l i n k a g e , and i n t e g r a t i o n of the v a r i o u s h e a l t h s e c t o r s . The f i n d i n g s of t h i s study may e v e n t u a l l y be confirmed or denied as the f u t u r e approaches and phases i n t o p r esent, then becomes past, and they may then serve as bench-marks a g a i n s t which to measure or evaluate past performances, and to use the experience f o r f u t u r e p l a n n i n g . 6 3 . CHAPTER VI. DELPHI SURVEY OF THE FUTURE ROLE OF THE HEALTH RECORD ADMINISTRATOR PHILOSOPHY, ASSUMPTIONS AND OBJECTIVES. The b a s i c philosophy u n d e r l y i n g t h i s study i s the one p r o f e s s e d by the Canadian government and the Canadian s o c i e t y , namely that a l l Canadians are e n t i t l e d to the best h e a l t h care s e r v i c e s that can be provided as u n i f o r m l y and e q u i t a b l y as p o s s i b l e from coast to coast. Whether t h i s e n t i t l e m e n t i s meant as a r i g h t or as a p r i v i l e g e i s not r e l e v a n t to t h i s study. In t h i s century, o r g a n i z a t i o n and management have proven to y i e l d more p r e d i c t a b l e r e s u l t s than the former a u t h o r i t a r i a n and a r b i t -r a r y models, i t appears, t h e r e f o r e , r a t i o n a l to a n t i c i p a t e that the e f f i c i e n t o r g a n i z a t i o n and management of the h e a l t h resources w i l l produce b e t t e r care and more e q u i t a b l e d i s t r i b u t i o n of the h e a l t h s e r v i c e s among the p o p u l a t i o n . The r e q u i r e d "nervous system" r e s p o n s i b l e f o r the f u n c t i o n i n g of a w e l l organized h e a l t h care d e l i v e r y system of a dependable h e a l t h i n f o r m a t i o n system. The occupation of Health Record A d m i n i s t r a t o r purports to admini-s t e r t h i s h e a l t h i n f o r m a t i o n system. In agreement with Tabenhaus (127) that the most promising resource i s the manpower that i s already t h e r e , i t would a l s o appear r a t i o n a l t h a t before under-t a k i n g the t r a i n i n g of a new occupation which would assumedly do a b e t t e r job of h e a l t h i n f o r m a t i o n management, the e x i s t i n g r e s o u r c e , the Health Record Administrators'' group, • be evaluated and i t s t r a i n i n g d e f i n e d i n terms of i t s expected f u t u r e r o l e . With the e x c e l l e n t means our s o c i e t y has developed to study and analyze past experiences, i t would be u n f o r g i v a b l e to approach the f u t u r e b l i n d l y and unarmed. Consequently the present study was set up and i t s o b j e c t i v e s were d e f i n e d to be: 1) to c o l l e c t the opini o n s of the r e p r e s e n t a t i v e s of d i v e r s e h e a l t h occupations as to the f u n c t i o n s of the HRA of the f u t u r e , i n terms of the h e a l t h i n f o r m a t i o n s e r v i c e s r e q u i r e d by t h e i r r e s p e c t i v e d i s c i p l i n e s ; 2) on the b a s i s of the above, o u t l i n e the fu t u r e r o l e expected from the HRA by other h e a l t h occupations. METHODOLOGY STRUCTURE OF THE STUDY A body of op i n i o n s had to be c o l l e c t e d from the panel about the fundamental q u e s t i o n : i n terms of t h e i r knowledge of the h e a l t h f i e l d and t h e i r experience and e x p e r t i s e i n t h e i r p r o f e s s i o n s as we l l as i n terms of the fu t u r e developments that would take p l a c e i n the h e a l t h f i e l d would the panel t h i n k that the HRA occupation has a f u t u r e r o l e to p l a y , and i f yes, could they v i s u a l i z e the a c t i v i t i e s to be performed by the f u t u r e HRA w i t h i n s p e c i f i e d areas of the h e a l t h f i e l d , such as c l i n i c a l s t u d i e s , i n f o r m a t i o n systems or h e a l t h - r e l a t e d agencies. To i n s u r e that the responses would be c o l l a t a b l e , and that the major f a c e t s of the HRA r o l e would be covered, twenty areas of f u n c t i o n were suggested to cover the f o l l o w i n g aspects of h e a l t h i n f o r m a t i o n management: a) working with the medical and a l l i e d h e a l t h s t a f f s ; b) working with the a d m i n i s t r a t i o n and the government groups c) automation and s y s t e m a t i z a t i o n of h e a l t h i n f o r m a t i o n ; d) i n t e g r a t i o n of agencies and s e c t o r s c o l l e c t i n g h e a l t h i n f o r m a t i o n ; e) r e s p o n s i b i l i t y to s o c i e t y and compliance with the law. For each area of f u n c t i o n , the panel would examine the r e l a t i o n s h between the HRA and the p a r t i c u l a r item, f o r example HRA and q u a l i t y of care programs, and i f a r e l a t i o n s h i p was p e r c e i v e d to e x i s t , s t a t e the a c t i v i t i e s t h a t were expected from the HRA to render the r e l a t i o n s h i p p r o d u c t i v e . The panel was requested to favor the c r i t e r i o n of d e s i r a b i l i t y as opposed to f e a s i b i l i t y . I t was f e l t t h a t the c r i t e r i o n of f e a s i b i l i t y would subordinate the expres s i o n of the needs f o r h e a l t h i n f o r m a t i o n management s e r v i c e s to today's r e a l i t y as opposed to a d e s i r e d f u t u r e . The study was o r i g i n a l l y designed to have three rounds, but e v e n t u a l l y two rounds proved s u f f i c i e n t due to the formation of a spontaneous m a j o r i t y . The l e v e l s of agreement were d e f i n e d as being: a) consensus: that i s unanimity, means that 100% of the respondents have agreed on a s p e c i f i c i s s u e (36); b) m a j o r i t y means at l e a s t 50% of the respondents (36); c) p l u r a l i t y means a percentage of respondents at l e a s t equal to 20% but l e s s than 50%. The consistency^ of responses by i n d i v i d u a l members-,was not t e s t e d f o r two main reasons: a) t o t a l anonymity had been given, the respondents could not be followed f o r c o n s i s t e n c y or change between the two rounds. b) Rounds 1 and 2 provided very d i f f e r e n t s t i m u l i to the panel, p o s s i b l y t r i g g e r i n g d i f f e r e n t responses. Round 1: M a i l contact was made with the p r o s p e c t i v e panel members. M a t e r i a l p r e s e n t i n g the phil o s o p h y , the major goal of the study was sent to them along with the i n s t r u c t i o n s and the l i s t of the twenty areas of f u n c t i o n which c o n s t i t u t e d the s t r u c t u r e of the 66 . i n q u i r y . (See Appendix 1 ) . This round was to be a b r a i n - s t o r m i n g s e s s i o n i n which o r i g i n a l c o n t r i b u t i o n s were requested. No t a n g i b l e i n c e n t i v e s were o f f e r e d , but the s t r i c t e s t c o n f i d e n t i a l i t y was promised; no response could be t r a c e d by anyone to anyone. A sample completed response form i s found i n Appendix 2. The Random House d i c t i o n a r y and Roget's Thesaurus were used to break down the responses i n t o manageable form. The members of the panel had been requested to use a c t i v e verbs expressing the behaviors expected from the f u t u r e HRAs, and the f o l l o w i n g s i x c a t e g o r i e s of a c t i v i t y emerged: 1) p a r t i c i p a t e i s the key word of t h i s category and d e s c r i b e s a r o l e of c o l l a b o r a t i o n and c o n t r i b u t i o n ; 2) organize expresses a r o l e of i n i t i a t i n g , s t r u c t u r i n g , p l a n n i n g and d i r e c t i n g ; 3) i n t e g r a t e means to l i n k , mediate, coordinate and c o n s o l i d a t e ; 4) advise designates an e d u c a t i o n a l and c o n s u l t a t i v e r o l e ; 5) evaluate s i g n i f i e s review, monitor, v a l i d a t e , s t a n d a r d i z e ; 6) no change from present r o l e . To allow f o r gr e a t e r freedom of e x p r e s s i o n , a seventh category "Others" was added (See Appendix 3 ) . The f r e q u e n c i e s of responses i n each category were computed and fed back to the panel members. As exp l a i n e d i n the feedback (Appendix 3 ) , the frequency of responses a l s o i n d i c a t e the f r e -quency of respondents because only one response per category of a c t i v i t y was c r e d i t e d to each respondent f o r each area of f u n c t i o n , to ease the c a l c u l a t i o n of p l u r a l i t y , m a j o r i t y or consensus. (See Appendix 3 ) . Round 2: Based on the feedback of Round 1, a matrix was designed r e l a t i n g the twenty areas of f u n c t i o n to the emerged s i x c a t e g o r i e s 67 . n •. and a c t i v i t y ; a- seventh - category- t i t l e d - -OTfherlF" "aTIowing freedom of .response: (See Appendix 4) . The panel was requested to s e l e c t the three c a t e g o r i e s of a c t i v i t y f e l t to be the most important with-i n each of the twenty areas of f u n c t i o n and to rank them as choices 1, 2, and 3. To weight the responses ;two s e l f - r a t i n g s c a l e s were de v i s e d : a) a t h r e e - p o i n t s c a l e of e x p e r t i s e adjoined each area of f u n c t i o n ; b) a f i v e - p o i n t s c a l e attached at the end recorded the degree of e x p e r t i s e . A "Not knowledgeable" r a t i n g i n e i t h e r s c a l e caused the responses to be e l i m i n a t e d s i n c e i t was f e l t that the responses would rep-resent random choices which could have been provided by anyone as opposed to the learned type of responses that were s o l i c i t e d from experts i n the h e a l t h f i e l d . (See Appendix 5). Weighting f o r the t h r e e - p o i n t s c a l e and f o r the three choices was arranged as f o l l o w s : Choice #1 Choice #2 Choice #3 Knowledgeable 3 2 1 Expert 6 4 2 The s e l f - r a t i n g s of the f i v e - p o i n t s c a l e were used to form sub-groups according to t h e i r r a t e d e x p e r t i s e and to compare the r e s -ponses among the groups. STATISTICS Simple f r e q u e n c i e s of responses were c a l c u l a t e d by area of f u n c t i o n s and by c a t e g o r i e s of a c t i v i t y . Percentages r e l e v a n t to the i d e n t i -f i c a t i o n of consensus or of m a j o r i t y were c a l c u l a t e d . The s e l f -r a t i n g s c a l e s were put i n a matrix form and the numbers of Knowledg-eable and Expert were determined by area of f u n c t i o n and category 68 . of a c t i v i t y . Subsequently the responses of Round 2 were weighted and grouped according to the above-mentioned s c a l e s , and the r e s -ponses compared among the v a r i o u s sub-groups. The r e s u l t s are presented i n t a b u l a r form and are supplemented by graphs where a p p r o p r i a t e . The X 2 goodness of f i t was used to t e s t two hypotheses: 1) i n Round 2, the responses could have been provided by a random sample of the general p o p u l a t i o n ; 2) i n Round 2, the panel members i n d i c a t e d t h e i r three choices at random. The percentages of responses by area of f u n c t i o n and by c a t e g o r i e s f o r Rounds 1 and 2 were t e s t e d by the Wilcoxon paired-sample t e s t f o r the n u l l hypothesis that there were no s i g n i f i c a n t d i f f e r e n c e s i n the percentages f o r the two rounds. SELECTION OF THE'PANEL The formation of the panel r e s t e d on the f o l l o w i n g assumptions: a) the h e a l t h occupations would recognize that h e a l t h i n f o r m a t i o n s e r v i c e s are necessary to them f o r the performance of t h e i r c a l l i n g ; b) they would be able to v i s u a l i z e the f u t u r e and express t h e i r needs i n terms of h e a l t h i n f o r m a t i o n s e r v i c e s ; c) the s e l e c t e d panel members would r e s p o n s i b l y assume represen-t a t i o n of t h e i r occupations, and recognize that by being i n v i t e d to become a panel member a c e r t a i n degree of recog-n i t i o n and of e x p e r t i s e was c o n f e r r e d upon them. P r o s p e c t i v e panel members had to s a t i s f y two b a s i c c r i t e r i a : 1) membership i n one of the h e a l t h occupations and 2) i n t e r e s t i n h e a l t h i n f o r m a t i o n . Three major d i f f i c u l t i e s arose: a) to a s c e r t a i n the e x p e r t i s e of the p r o s p e c t i v e panel members i n t h e i r r e s p e c t i v e occupations; 69 . b) to a s c e r t a i n t h e i r i n t e r e s t i n h e a l t h i n f o r m a t i o n ; c) to i n s u r e t h e i r i m p a r t i a l i t y so that they would not be chosen to prove what the c o o r d i n a t o r of t h i s study assumedly would want to prove. F i r s t l y , expert was d e f i n e d to mean an educated and experienced person s p e c i a l i z i n g in one of the ..health occupations, and-able to c o n t r i b u t e r e l e v a n t input to the study q u e s t i o n . Then a l l three problems were solved at once by r e q u e s t i n g the members of the t h e s i s commit-tee to recommend h e a l t h p r o f e s s i o n a l s who, to t h e i r knowledge, enjoy the r e s p e c t of t h e i r peers, t h e r e f o r e , may be termed experts i n t h e i r r e s p e c t i v e s p e c i a l i t i e s , and who are known to recognize that h e a l t h i n f o r m a t i o n management i s an important i s s u e . Thus the nucleus of the panel was formed to comprise seventeen names. Thenthe "snow-ball" technique was used and these p r o s p e c t i v e panel members were requested to suggest f u r t h e r names, thus a l i s t of f o r t y - f i v e p r o s p e c t i v e panel members was drawn comprising: e i g h t p h y s i c i a n s / c l i n i c i a n s , three medical d i r e c t o r s of h o s p i t a l s , three r e p r e s e n t a t i v e s of h e a l t h agencies, a l l three being p h y s i c i a n s , f i v e r e p r e s e n t a t i v e s of the f e d e r a l and the p r o v i n c i a l m i n i s t r i e s of h e a l t h of which three were p h y s i c i a n s , four r e p r e s e n t a t i v e s of p r o f e s s i o n a l a s s o c i a t i o n s of which two were p h y s i c i a n s , e i g h t h o s p i t a l a d m i n i s t r a t o r s , f i v e h e a l t h p r o f e s s i o n a l s i n academic p o s i t i o n s , f i v e h e a l t h r e c o r d a d m i n i s t r a t o r s , two nurses, one s o c i a l worker, and one i n t e r n . The s i n g l e group most h e a v i l y represented i s the medical p r o f e s s i o n , the members of which number twenty and form approximately 44% of the p a n e l . Whereas t h i s number may appear l a r g e , i t must be remarked that the medical p r o f e s s i o n i s v i t a l l y dependent on h e a l t h i n f o r m a t i o n . Some care was a l s o given to i n c l u d e i n t h i s group 70 . p h y s i c i a n s i n a v a r i e t y of p o s i t i o n s i n the h e a l t h f i e l d as w e l l as have them represent general p r a c t i c e , and the medical and sur-g i c a l s p e c i a l t i e s . Many p h y s i c i a n s are found i n key p o s i t i o n s w i t h i n the h e a l t h h i e r a r c h y where they are at vantage p o i n t s i n o v e r l o o k i n g the o p e r a t i o n of the h e a l t h care d e l i v e r y system, t h e r e f o r e , may foresee and i d e n t i f y f u t u r e changes. F i n a l l y , the w i l l i n g n e s s of the medical p r o f e s s i o n to p a r t i c i p a t e i n t h i s study was taken as evidence of the importance of the i s s u e . In terms of g e o g r a p h i c a l d i s t r i b u t i o n , s i x t e e n members were drawn from O n t a r i o , three from the Maritimes, two from Saskatchewan, two from the United States and twenty-two from B r i t i s h Columbia. 71 . F i n d i n g s : ROUND 1.' Of t h e f o r t y - f i v e p e o p l e c o n t a c t e d , t h e r e were 29 r e s p o n d e n t s t o Round 1, and t h e y p r o v i d e d a t o t a l o f 710 r e s p o n s e s , u n e v e n l y d i s -t r i b u t e d o v e r t h e 20 a r e a s o f f u n c t i o n . These r e s p o n s e s were o r i g i n a l c o n t r i b u t i o n s and r e f l e c t e d t h e t h i n k i n g o f t h e members of t h e p a n e l . A f t e r t h e c o l l a t i o n o f t h e raw r e s p o n s e s , s i x c a t e g o r i e s o f a c t i v i t y emerged,a s e v e n t h was added, t i t l e d " o t h e r s " (as d e s c r i b e d under M e t h o d o l o g y ) and t h e f r e q u e n c i e s o f r e s p o n s e s f o r e ach o f t h e twenty a r e a s o f f u n c t i o n a r e r e p o r t e d on T a b l e I f o r Round 1 and on T a b l e I I f o r Round 2. The h y p o t h e s i s t h a t t h e f r e q u e n c y o f r e s p o n s e s i n Round 2 shows no s i g n i f i c a n t d i f f e r e n c e from t h e f r e q u e n c y o f r e s p o n s e s t h a t would have been g i v e n by a random sample o f t h e g e n e r a l p o p u l a t i o n was t e s t e d . The a l t e r n a t e h y p o t h e s i s s t a t e d t h a t t h e f r e q u e n c y o f r e s p o n s e s o b s e r v e d i n Round 2 c o n s t i t u t e d s i g n i f i c a n t c h o i c e s . The X 2 goodness o f f i t method was u s e d as a measure o f agreement or d i s a g r e e m e n t between o b s e r v e d and e x p e c t e d f r e q u e n c i e s . The 2 2 K ( f i — F i ) f o r m u l a X = ^ was u s e d , where K = 20 a r e a s o f i = l F i f u n c t i o n , f i t h e f r e q u e n c y o f r e s p o n s e s o b s e r v e d and F i t h e f r e q u e n c y e x p e c t e d i n c l a s s i , t h a t i s 3 c h o i c e s f o r each a r e a o f f u n c t i o n from e a c h o f t h e 25 r e s p o n d e n t s . The c a l c u l a t i o n s a r e p r e s e n t e d i n A p p e n d i x 6. W i t h 19 d e g r e e s o f f r e e d o m , a t t h e 0.01 2 2 s i g n i f i c a n c e l e v e l , X = 36.191; t h e r e f o r e , t h e X o f 68.088 o b t a i n e d i s n o t i n t h e c r i t i c a l r e g i o n . The n u l l h y p o t h e s i s t h a t t h e r e s u l t s c o u l d have come from t h e g e n e r a l p o p u l a t i o n was r e j e c t e d , a n d t h e a l t e r n a t i v e h y p o t h e s i s a c c e p t e d . A s e c o n d n u l l h y p o t h e s i s was t e s t e d , namely t h a t t h e r e i s no s i g -n i f i c a n t d i f f e r e n c e between th e c h o i c e s made by t h e p a n e l members 72 . and those they would have made at random. The a l t e r n a t e hypothesis s t a t e d that the respondents expressed s p e c i f i c c h o i c e s among the 2 c a t e g o r i e s , assumedly i n the l i g h t of t h e i r e x p e r t i s e . The X good-2 2 K ^ ( f i — F i ) ness of f i t method was used again. The formula i s X =. ,s. — ^ i = l F i where K = 7 c a t e g o r i e s , f i the frequency of responses observed, F i the frequency expected i f the responses had been e q u a l l y d i s t r i b u t e d 2 among the 7 c a t e g o r i e s , that i s 1195:7 = 170.7. A x of 448.083 was obtained (see Appendix 6 ) . At the s i g n i f i c a n c e l e v e l of 0.01 2 2 with 6 degrees of freedom, X = 16.812. The X obtained not being i n the c r i t i c a l zone, the n u l l hypothesis was r e j e c t e d and one con-cluded t h a t , indeed, the respondents d i s c r i m i n a t e d among the cate -g o r i e s (Appendix 6 ) . As only one response was counted per category f o r each respondent, the frequency of responses i n d i c a t e s a l s o the frequency of respon-dents (see Methodology P.64 and Appendix 3 ) . For each area of f u n c t i o n , the scores of the two l e a d i n g c a t e g o r i e s were t r a n s l a t e d i n t o percentages of respondents and of responses to a s c e r t a i n the formation of p l u r a l i t y , m a j o r i t y or consensus as d e f i n e d e a r l i e r . TABLE I Frequencies of responses and of respondents by area of function and category of a c t i v i t y ROUND 1 *Percentage of respondents/Number of responses/respondents/Percentage of Responses Areas of func-t i o n Categories of a c t i v i t y TOTALS , 1 2 3 4 5 6 7 Respon-dents Resp-onses 1 19 66% 31% 16 55% 26% 2 6 11 6 1 29 61 2 15 52% 33% 10 34% 22% 10 34% 22% 9 — 2 — 28 46 3 6 14 48% 33% 17 59% 40% 1 3 — 2 27 43 4 10 34% 29% 4 8 28% 24% 8 28% 24% 2 — 2 26 34 5 6 21% 17% 16 55%44% 5 3 4 2 — 24 36 6 10 34% 23% 17 59% 39% 9 4 4 — 27 44 7 7 24% 18% 15 52% 38% 6 5 5 1 — 22 39 8 13 45% 37% 1 2 4 13 45% 37% — 2 22 35 9 13 45% 34% 13 45% 34% 6 2 3 1 — 24 38 10 14 48% 47% 4 1 3 10% 4 4 22 30 11 — 12 41% 41% 12 41% 41% 2 3 — — 22 29 12 9 31% 29% 9 31% 29% 5 2 3 10% 3 10% — 23 31 13 2 11 38% 31% 11 38% 31% 7 20% 4 — — 22 35 14 3 9 31% 23% 17 59% 44% 6 3 1 — 22 39 15 3 9% 15 52% 44% — 5 11 38% 32% — — 26 34 16 4 12 41% 40% 7 24% 23% 2 3 2 — 25 30 17 4 16%' 4 9 . 31%36% 3 4 1 — 21 25 18 4 3 17 59% 57% 2 7% 4 — — 22 30 19 4 5 17% 25% 8 28% 40% 1 2 _ — 19 20 20 1 6 — 13 15% 42% 9 31% 29% 2 — 26 31 Totals 147 21% 196 28% 152 21% 88 12% 95 13% 25 4% 7 1% 29 710 * Percentages are indicated f o r the two leading categories N = 29; Consensus = 29; Majority = 15 to 28; P l u r a l i t y = 9 to 14 7.4. TABLE II Frequencies of responses and of respondents by area of function and category of a c t i v i t y ROUND 2 *Percentage of respondents/Number of responses/respondents/Perdentage of responses Areas of func-t i o n Categories of a c t i v i t y — — , TOTALS 1 2 3 4 5 5 7 Respon-dents Resp-onses 1 21 84% 33% 14 56% 22% 9 8 9 2 1 24 64 2 23 92% 34% 11 13 52% 19% 13 52% 19% 6 1 1 25 68 3 12 13 52% 22% 16 64% 27% 7 9 2 — 23 59 4 15 60% 24% 13 11 17 68% 27% 4 1 1 23 62 5 16 64% 27% 20 80% 33% 10 7 6 1 _ 25 60 6 20 80% 30% 16 64% 24% 13 10 6 1 — 25 66 7 15 60% 23% 21 84% 33% 12 10 5 1 — 25 64 8 21 84% 34% 4 6 13 52% 21% 13 52% 21% 3 1 24 61 9 17 68% 31% 14 56% 25% 7 13 2 2 — 22 55 10 17 68% 30% 10 3 20 80% 36% 4 2 — 23 56 11 9 16 64% 25% 19 76% 30% 13 6 1 — 25 64 12 19 76% 34% 7 13% 7 8 11 44% 20% 2 2 22 56 13 9 13 52% 24% 10 18% 13 52% 24% 8 2 — 23 55 14 12 8 13% 16 64% 26% 16 64% 26% 8 1 23 61 15 15 60% 22% 23 92% 34% 2 14 12 18% — 1 25 67 16 12 48% 22% 16 64% 29% 12 48% 22% 7 6 1 1 23 55 17 16 64% 26% 11 16 64% 26% 11 8 — — 24 62 18 10 10 17 68% 31% 11 44% 20% 6 1 — 23 55 19 9 10 40% 19% 17 68% 31% 7 8 2 1 22 54 20 8 9 4 17 68% 33% 9 36% 18% 4 — 21 51 Totals 296 25% 259 22% 220 18% 234 20% • 146 12% 30 2% 9 1%" 25 1195 *Percentages are indicated only f or the two leading categories. N = 25; Consensus = 25; Majority = 13 to 24; P l u r a l i t y = 8 to 12. 75' . The p e r c e n t a g e s o f r e s p o n d e n t s by a r e a o f f u n c t i o n and c a t e g o r y o f a c t i v i t y and t h e i r changes from Round 1 t o Round 2 a r e p o r t r a y e d on F i g u r e 1. The p e r c e n t a g e s v a r y g r e a t l y between t h e two r o u n d s , s t r o n g l y c u l m i n a t i n g i n Round 2, and r e a c h i n g m a j o r i t y i n a l l i n s t a n c e s b u t one i n a r e a o f f u n c t i o n #16, where c a t e g o r i e s o f a c t i v i t y 1 and 3 were s e l e c t e d by o n l y 48% o f t h e r e s p o n d e n t s . O n l y one o r two l e a d i n g c a t e g o r i e s a r e shown f o r e a c h a r e a o f f u n c t i o n , a t o t a l o f 37 c a t e g o r i e s . C o n s i s t e n t l y t h e same c a t e -g o r i e s o f a c t i v i t y a t t r a c t e d t h e h i g h e s t p e r c e n t a g e s o f r e s p o n d e n t s i n Rounds 1 and 2, w i t h t h e e x c e p t i o n o f a r e a #10, c a t e g o r y 4. F i g u r e 2 compares t h e p e r c e n t a g e s o f r e s p o n s e s i n Rounds 1 and 2 by a r e a o f f u n c t i o n and c a t e g o r y o f a c t i v i t y . A g a i n , o n l y t h e one or two l e a d i n g c a t e g o r i e s a r e i n d i c a t e d f o r each a r e a o f f u n c -t i o n , r e s u l t i n g i n a t o t a l o f t h i r t y - n i n e c a t e g o r i e s . I t can r e a d i l y be n o t i c e d t h a t t h e r e i s c o n s i s t e n c y i n t h e s e l e c t i o n o f the c a t e g o r i e s . In t h i r t y - t h r e e i n s t a n c e s , t h e p a n e l s e l e c t e d t h e same c a t e g o r i e s i n Rounds 1 and 2 even t h o u g h t h e s t i m u l i f o r Rounds 1 and 2 were c o n s i d e r a b l y d i f f e r e n t . To t e s t i f t h e d i f f e r e n c e s between r o u n d s i n t h e p e r c e n t a g e s o f r e s p o n s e s by a r e a o f f u n c t i o n and by c a t e g o r y o f a c t i v i t y were s t a t i s t i c a l l y s i g n i f i c a n t , t h e W i l c o x o n - p a i r e d sample t e s t was c o n d u c t e d (See A p p e n d i x 7 ) . In a t w o - t a i l e d h y p o t h e s i s , t h e c r i t i c a l v a l u e o f T a t t h e 0.05 s i g n i f i c a n c e l e v e l , w i t h 43 d e g r e e s o f f r e e d o m , i s 310. The v a l u e o f t h e T o b t a i n e d i s 370; t h e r e f o r e , T i s n o t i n t h e c r i t i c a l r e g i o n , and t h e n u l l h y p o t h e s i s was n o t r e j e c t e d , and t h e d i f f e r -e n c e s i n p e r c e n t a g e s were n o t c o n s i d e r e d t o be s t a t i s t i c a l l y s i g n i f i c a n t . A l t h o u g h c o n s e n s u s was n o t r e a c h e d , e i t h e r m a j o r i t y o r p l u r a l i t y were d e m o n s t r a t e d i n b o t h r o u n d s . F u r t h e r m o r e , t h e 70 -J 50 4 40 I 30 4 20 J, 10 J. P e r c e n t a g e s o f f r e q u e n c y o f r e s p o n d e n t s and t h e i r changes between Rounds 1 & 2 FIGURE 1. by a r e a o f f u n c t i o n and c a t e g o r y o f a c t i v i t y ** # Round 1 n Round 2 0 ! i 1 i l l . 6 i l l 2 1 3 1 1 4 1 ' 5 II 6 1 7 1 1 8 ' > 1 1 10 l l i J 12,' 12 1 3 2 3 1 o a i ; t t — i — r — t -9 a 9 4 1 2 12 1 2 1 5 12" 14 ,„ 1 1 ' ' 1 2 l o 13 M " 'I m 34 15 + 20 16 17 18 19 2 3 1 3 3 3 4 • C a t e g o r i e s i n w h i c h t h e p e r c e n t a g e s o f r e s p o n d e n t s a r e unmatched i n t h e two ro u n d s A r e a s o f f u n c t i o n & ** O n l y t h e two l e a d i n g c a t e g o r o e s o f ea c h a r e a o f f u n c t i o n a r e shown f o r Round 1 as categories of a c t i v i t y w e l l as f o r Round 2 cn P e r c e n t a g e s o f f r e q u e n c y o f r e s p o n s e s and t h e i r by a r e a o f f u n c t i o n and c a t e g o r y o f a c t i v i t y ** changes between Rounds 1 & 2 FIGURE 2-60 4 50 4 20 J. 10 I ft S I* L i X Round 1 A Round 2 1 A A 1 -t-12 13 23 14 12 12 I 1 1 1 I I 12 I l l 3 ' | | I 14 I I 15 | 16 | | 17 | | l e | [LJ I |2o' 7 I I 8 I 19 I | 101  ' 113 12 1 5 12 1 4 23 1^ 234 * 4e ic * • C a t e g o r i e s i n w h i c h t h e p e r c e n t a g e s o f r e s p o n s e s a r e unmatched i n t h e two ro u n d s ** O n l y t h e two l e a d i n g c a t e g o r i e s o f e a c h a r e a o f f u n c t i o n a r e shown f o r Round 1 as w e l l as f o r Round 2. 3 4 2 23 1 3 34 32 4 A r e a s o f f u n c t i o n & c a t e g o r i e s o f a c t i v i t y c o n s i s t e n c y i n the percentages of responses and i n the s e l e c t i o n of the c a t e g o r i e s lead one to thin k that there was nothing to gain by a t h i r d round, as consensus was not a dominant goal of the study. O v e r a l l r e s u l t s show that i n Round 1 (Table I ) , a l l 29 respondents addressed themselves to area #1, HRA and p V a l i t y of Care programs, g i v i n g t h i s area the g r e a t e s t number of responses: 61 (Table I, top row, T o t a l s ) . With r e s p e c t to the c a t e g o r i e s of a c t i v i t y , category 2, Organize, captured the l a r g e s t percentage of responses, 28%; c a t e g o r i e s 1, 'Participate-, and 3, i n t e g r a t e , r e c e i v e d each 21% of the responses (Table I, bottom row). In Round 2 (Table I I ) , a l l 25 respondents addressed themselves to areas #2, HRA and Research and S t u d i e s , #5, HRA and Health Informa-t i o n Systems, #6, HRA and Computerized Records, #7, HRA and Health Information Linkage, #11, HRA and Admitting and other Health Record-keeping departments, and #15, HRA and C o n f i d e n t i a l i t y . The hi g h e s t number of responses, 68, was r e c e i v e d by area #2, HRA and Research and Studies (Table I I , r i g h t hand side T o t a l s ) . With r e s p e c t to the c a t e g o r i e s of a c t i v i t y , category 1, P a r t i c i p a t e , captured the highest percentage of responses: 25%, category 2, Organize, was second with 22% (Table I I , bottom row). Round 2 was provided with two s c a l e s of s e l f - a s s e s s m e n t : i n a d d i t i o n to the t h r e e - p o i n t s c a l e attached to each area of f u n c t i o n , a f i v e - p o i n t s c a l e measuring the degree of e x p e r t i s e i n Health Record A d m i n i s t r a t i o n was attached to Round 2 t a s k s , and t h i s l a t t e r s c a l e was used to subdivide the panel i n t o three groups . As re p o r t e d e a r l i e r (see Methodology P.64) groups 1 and 2 were e l i m i n a t e d , t h e r e f o r e , only groups "Knowledgeable 3", "Knowledgeable 4", and "Expert 5", were s t u d i e d . Appendix 5 i n d i c a t e s the number of r e s -pondents i n each s u b d i v i s i o n , and the shaded area shows the r e s -THERE IS NO PAGE-. ponses e l i m i n a t e d . In nineteen areas of f u n c t i o n , the Knowledgeable group i s the most numerous; the exception i s area Of f u n c t i o n 13, HRA and Schools and I n d u s t r i e s Health Records, where 13 members i n d i c a t e d that they were Not Knowledgeable, The Expert c l a s s i f i -c a t i o n was used s p a r i n g l y by the panel members and t o t a l s only 73 s e l f - r a t i n g s d i s t r i b u t e d over the twenty areas of f u n c t i o n . Three areas have only one Expert each, #12, HRA and C o s t - e f f e c t i v e n e s s , #14, HRA and Health Agencies, and #20, HRA and Health Law. The area of f u n c t i o n d i s p l a y i n g the l a r g e s t number of Experts i s area #6, HRA and Computerized Re cc/r'ds , with a t o t a l of 7 E x p e r t s . Tables I I I , IV and V r e p o r t the number of responses, the weighted responses and the percentages of weighted responses by each area of f u n c t i o n and category of a c t i v i t y f o r each of the three groups. The group "Knowledgeable 3" (Table III) was composed of 9 members. The areas of f u n c t i o n r e c e i v i n g the h i g h e s t number of responses, 25 out of a p o s s i b l e 27, were: #1, HRA and Q u a l i t y of Care Programs, #11, HRA and Admitting and other Health Record-Keeping Departments, and #15, HRA and C o n f i d e n t i a l i t y . In terms of weighted responses, area #6, HRA and Computerized Records, i s l e a d i n g with a score of 72. (Table I I I , r i g h t side T o t a l s ) . The graphic d i s p l a y i n F i g u r e 3 i l l u s t r a t e s the d e t a i l e d r e s u l t s , and a l s o shows that i n most areas of f u n c t i o n the o p i n i o n s of the panel as to d e s i r a b l e a c t i v i t y were q u i t e d i s t r i b u t e d over the c a t e g o r i e s . The area a t t r a c t i n g the h i g h e s t percentage of weighted responses i s seen to be area #2, HRA and Research and S t u d i e s , i n which category of a c t i v i t y 1, P a r t i c i p a t e , was r a t e d to be the most important ( F i g . 3). :- 81. TABLE I I I GROUP KNOWLEDGEABLE 3 Percentages of weighted responses by areas of f u n c t i o n and cat e g o r i e s of a c t i v i t y Number of responses/Weighted Responses/Percentage of Weighted Responses Areas of Categories of a c t i v i t y TOTALS func-t i o n 1 2 3 4 5 6 7 1 9/25/42 5/13/22 2/4/7 4/10/17 4/5/8 1/2/3 25/59/100% 2 9/28/56 3/6/12 6/8/16 5/7/14 1/1/2 24/50 3 3/4/10 4/10/24 7/17/40 2/5/12 4/5/12 1/1/2. 21/42 4 6/16/30 4/10/19 4/8/15 7/15/28 1/1/2 1/3/6 1/1/2 24/54 5 4/12/22 5/16/29 5/16/29 3/6/11 1/2/4 1/3/5 ..- 19/55 6 6/23/32 6/24/33 3/14/9 2/6/8 2/5/7 - 19/72 7 4/12/24 6/19/38 3/12/24 3/7/14 - - - 16/50 8 8/20/37 1/2/4 2/2/4 4/12/22 6/14/26 2/4/7 . - 23/54 9 4/10/24 4/14/34 2/3/7 4/12/29 - 1/2/5 - 15/41 10 4/12/27 2/8/18 2/5/11 5/15/33 1/1/2 1/4/9 - 15/45 11 3/8/12 5/18/27 8/22/33 5/12/18 3/4/6 1/2/3 - 25/66 12 5/11/31 3/7/19 2/3/8 1/2/6 2/3/8 1/6/17 1/4/11 15/36 13 1/1/4 2/5/22 2/6/26 3/6/26 2/2/9 1/3/13 - 11/23 14 2/2/7 2/5/19 3/9/33 3/6/22 2/2/7 1/3/11 13/27 . 15 5/12/17 8/27/38 2/7/10 5/10/14 5/15/21 - - 25/71 16 4/8/23 6/13/37 5/12/34 1/1/3 1/1/3 - 17/35 17 5/10/21 3/11/23 6/15/32 3/6/13 3/5/11 - - 20/47 18 2/2/6 2/4/12 6/16/48 3/7/21 2/2/6 1/2/6 - 16/33 19 1/3/14 2/4/19 4/11/52 1/1/5 2/2/10 - - 10/21 20 1/1/3 2/4/14 5/14/48 5/9/31 1/1/3 - - 14/29 'TOTALS 86/220/24 75/220/24 79/204/22 69A55/17 43/71/8 13/35/4 2/5/1 367/910 i N = 9 % of, w e i g h t e d r e p o n s e s 60 I 50 1 40 30 + 20 + 10 + 1 N GROUP KNOWLEDGEABLE 3 P e r c e n t a g e s o f w e i g h t e d r e s p o n s e s by a r e a o f f u n c t i o n and c a t e g o r y o f a c t i v i t y 5&1 2 4 3 T O 6 TT 4 TT 3 t| _4 1 TT TT T 5 14 s I 5 FIGURE 3 is! 5 S A r e a s o f f u n c t i o n Is 16 17 18 19 20 83 . . O v e r a l l , t h i s group r a t e d c a t e g o r i e s 1 and 2, P a r t i c i p a t e and Organize, of equal importance g i v i n g these 24% of the weighted responses; Category 3, I n t e g r a t e , followed with 22% of the weighted responses. (Table I I I , bottom row). The group "Knowledgeable 4"; (Table IV) was composed of 12 members, t h e r e f o r e , each area of f u n c t i o n could p o s s i b l y a t t r a c t 36 responses The area with the hi g h e s t number of responses i s #15, HRA and Con-f i d e n t i a l i t y , with 30 responses. With r e s p e c t to the weighted scores, area #15, HRA and C o n f i d e n t i a l i t y leads with a score of 76. (Table IV, r i g h t s i d e t o t a l s ) . F i g u r e 4 d i s p l a y s the percentages of weighted responses by c a t e g o r i e s of a c t i v i t y f o r each area of f u n c t i o n . This group gave the hi g h e s t percentage of responses to area #13, HRA and Schools and I n d u s t r i e s Health Records, with category 2, Organize, as the most important a c t i v i t y to be c a r r i e d out by HRAs. TABLE IV GROUP KNOWLEDGEABLE 4 Percentages of weighted responses by area of function and category of a c t i v i t y Number of Responses/Weighted Responses/Percentage of Weighted Responses Areas of func-t i o n Categories of a c t i v i t y TOTALS i 1 | 2 3 4 j 5 6 7 1 9/27/38 6/13/18 6/14/19 2/4/6 4/7/10 1/1/1 1/6/8 29/72/100% 2 9/27/37 4/9/12 2/9/12 5/13/18 5/8/11 1/1/1 1/6/8 27/73 3 5/15/23 5/16/25 5/16/25 4/12/19 3/5/8 - - 22/64 4 5/12/27 5/14/32 4/5/11 5/10/23 1/3/7 - . - 20/44 5 8/20/31 10/30/46 3/4/6 4/8/12 3/3/5 - - 28/65 6 9/28/42 8/19/29 6/9/14 3/7/11 2/3/5/ - - 28/66 7 5/12/21 8/22/39 5/14/25 4/7/13 1/1/2 - - 23/56 8 11/32/51 1/3/5 3/7/11 6/12/19 4/6/10 - 1/3/5 26/63 9 8/22/44 6/13/26 3/8/16 4/6/12 1/1/2 - - 22/50 10 9/26/38 6/11/16 LO/31/46 - - - 25/68 11 4/10/20 8/21/43 6/8/16 4/10/20 - - - 22/49 12 9/21/46 2/6/13 2/3/7 4/6/13 3/7/15 - 1/3/7 21/46 13 2/3/10 7/18/60 2/4/13 2/5/17 - - - 13/30 14 5/8/19 3/5/12 4/11/26 6/15/35 2/4/9 - - 20/43 15 8/18/24 11/30/39 - 6/15/20 4/7/9 - 1/6/8 30/76 16 5/13/26 6/16/32 3/8/16 2/8/16 2/2/4 - 1/3/6 19/50 17 5/15/35 4/11/26 4/8/17 3/6/14 2/3/7 - - 18/43 18 3/8/20 2/5/13 5/12/30 :4/12/30 - - 1/3/8 15/40 19 6/14/29 3/6/12 7/18/37 3/4/8 3/4/8 - 1/3/6 23/49 20 5/11/24 3/6/13 4/4/9 7/20/43 1/2/4 1/3/7 - 21/46 TOTAL 130/342/31 108/274/2f 5 74/162A- 1 > 88/211/19 4 V66/6 3/5/0 i 1 8/33/3 ( 452/1093 N = 12. o f 60 1 50 40 30 20 10 w e i g h t e d r e s p o n s e s E73 2 . 3 GROUP KNOWLEDGEABLE 4 P e r c e n t a g e s o f w e i g h t e d r e s p o n s e s by a r e a s o f f u n c t i o n and c a t e g o r i es o f a c t i v i t y . Is 7 1 4 4 2 sj 4 3 s| 7 FIGURE 4, 4-3 3 N=12 10 11 12 13 14 15 16 17 . 18 19 20 Areas of function 86 . O v e r a l l , t h i s group r a t e d category 1, P a r t i c i p a t e , the h i g h e s t , g i v i n g i t 31% of the weighted responses; category 2, Organize,was second with 25% of the weighted responses. (Table IV, bottom row). The Expert 5 group was composed of two members only, and a l l the twenty areas of f u n c t i o n r e c e i v e d the maximum s i x responses. Fi v e areas of f u n c t i o n r e c e i v e d the hi g h e s t weighted score of 24, because both panel members coded "Expert 3" on the s e l f - r a t i n g s c a l e s ; the areas are #1, HRA and Q u a l i t y of Care Programs, #2, HRA and Research and Studies,#9, HRA and Management, I n s t i t u t i o n a l and Departmental, #11, HRA and Admitting and other Health Record-Keeping Departments and #15, HRA and C o n f i d e n t i a l i t y . (Table V, r i g h t side T o t a l s ) . As seen on F i g u r e 5, the percentages of weighted responses reach the 50% mark i n s i x areas of func t i o n ; #3, HRA and Ambulatory and Home Care Programs, #5, HRA and Health Information Systems, #10, HRA and P o l i c y Formulation re Health Information, #15, HRA and C o n f i d e n t i a l i t y , and #19, HRA and P r e v e n t i v e Care. TABLE V 87. GROUP EXPERT 5 Percentages of weighted responses by area of function and category of a c t i v i t y Number of Reponses/Weighted Responses/Percentage of Weighted Responses Areas °.f func-t i o n Categories of a c t i v i t y TOTALS 1 2 3 4 5 6 7 1 1/6/25 2/10/42 1/2/8 2/6/25 - - - 6/24/100% 2 1/6/25 2/8/33 1/8/33 1/2/8 6/24 3 1/2/11 2/9/50 1/4/22 1/1/6 L/2/11 6/18 4 1/2/11 2/7/39 - 2/5/28 L/4/22 6/18 5 1/2/11 2/9/50 2/3/17 L/4/22 6/18 6 1/3/17 - 2/5/28 2/4/22 L/6/33 6/18 7 1/3/17 1/2/11 1/2/11 2/5/28 L/6/33 6/18 8 1/3/17 1/2/11 1/1/6 1/4/22 >/8/44 6/18 9 2/10/42 2/10/42 2/4/17 6/24 10 2/6/33 2/9/50 2/3/17 6/18 11 - 2/10/42 1/6/25 1/2/8 V6/25 6/24 12 1/1/8 1/3/25 2/4/33 2/4/33 6/12 13 1/1/6 1/2/11 2/8/44 1/3/17 L/4/22 6/18 14 - 1/3/17 2/8/44 2/3/17 L/4/22 6/18 15 - 2/12/50 - 2/6/25 V6/25 6/24 16 2/5/28 2/6/33 1/1/6 L/6/33 6/18 17 1/1/6 1/3/17 1/4/22 2/4/22 L/6/33 6/18 18 1/2/11 2/5/18 1/4/22 1/1/6 L/6/33 6/18 19 1/2/11 2/9/50 1/1/6 1/4/22 L/2/11 6/18 20 - 2/3/17 - 2/9/50 V6/33 6/18 TOTAL 17/50/13 32/121/32 23/70/18 28/67/17 20/76/20 120/384 N = 2 % o f ; 60" s i g h t e d r e s p o n s e s GROUP EXPERT 5 P e r c e n t a g e s o f w e i g h t e d r e s p o n s e s by a r e a s o f f u n c t i o n and c a t e g o r i e s o f a c t i v i t y FIGURE 5, 50 + 40 + 30-20 10 1 2 N = 2 3 io T T T3—IT" 1—T5 -*——~rf—is 1 19 A r e a s o f f u n c t i o n B9 . O v e r a l l , the group rated category 2, Organize, highest by g i v i n g / 32% of the weighted responses to i t ; next was category 3, I n t e g r a t e , which r e c e i v e d 18% of the weighted responses. (Table V, bottom row). Figure 6 p o r t r a y s the percentages of weighted responses f o r the l e a d i n g category of each area of f u n c t i o n f o r each one of the three groups. In two areas of f u n c t i o n , a l l three groups s e l e c t e d the same category 2, Organize; area #5, HRA and Health Information Systems, and area #15, HRA and C o n f i d e n t i a l i t y . In the remaining eighteen areas, at l e a s t two of the groups chose the same cate -g o r i e s ; i n ten of these areas, groups Knowledgeable 3 and 4 agreed i n t h e i r c h o i c e s ; i n five- areas, groups Knowledgeable 4 and Expert 5 agree; i n three areas group Knowledgeable 3 and Expert 5 agree . • . . 4 Within the group Expert .5 the most powerful combination of Expert 5 in Health Record A d m i n i s t r a t i o n and Expert 3 i n some s p e c i f i c areas of f u n c t i o n w i l l be found. The choices of t h i s Top Expert group i s port r a y e d on Table VI. In f i v e areas of f u n c t i o n both.members rat e d themselves Expert, and these are a s t e r i s k e d on Table Ul . None of the two members considered themselves Expert i n area of f u n c t i o n 12, HRA and Cost E f f e c t i v e n e s s . Overall, the s e l e c t i o n of category of a c t i v i t y 2, Organize, as being the most important can b e ' q u i c k l y observed. Another o b s e r v a t i o n i s the s e l e c t i o n of category. 5, Evaluate, i n a l l but four of the twenty areas of f u n c t i o n . P e r c e n t a g e o f W e i g h t e d R e s p o n s e s i n t h e h i g h e s t s c o r i n g c a t e g o r y f o r t h e g r o u p s P e r c e n t a g e K n o w l e d g e a b l e 3, K n o w l e d g e a b l e 4 and E x p e r t 5 ofI w e i g h t e d r e s p o n s e s 60+ X-FIGURE 6. 50 404. • Da 301 a r a a I . 4 o • a aa D * D 2ot-.10h l l I i l l ! *3| | l4| ! 5l| Ifi ' l l |7l! I i\ I IrTToj |llj I l l | ||l l3|||l'4 | | l l | 16l | j i j j }8| | | Jo | | 12 123 2 3 1 2 2 3 12 5 2 5 1 5 1 2 2 4 23 1 3 4 2 3 4 34 2 2 3 1 3 5 345 23 3 4 A r e a s o f f u n c t i o n & c a t e g o r i e s o f a c t i v i t y • K n o w l e d g e a b l e 3 ^ K n o w l e d g e a b l e 4 1X1 Q E x p e r t 5 o TABLE VI TOP EXPERT Selections of Expert 5 i n combination with s e l f - r a t i n g 3 Expert i n areas of function Area of function Categories of a c t i v i t y P a r t i -cipate Organize Integrate Advise Evaluate 1* HRA and Quality of Care Programs 2 1 • 2 * 2 H.R.A.and Research and Studies 3 1 1 3 HRA and Ambulatory and Home Care Programs 1 2 3 4 HRA and A l l i e d Health Pro-fessions 1 3 2 5 HRA and Health Information Systems 1 3 2 6 HRA and Computerized Records 2 3 1 7 HRA and Health Information Linkage 3 2 1 8 HRA and A c c r e d i t a t i o n 3 2 1 * 9 HRA and Management, I n s t i t u -t i o n a l & Departmental 1 1 3 10 HRA and P o l i c y Formulation re Health Information 2 1 3 * 11 HRA and Admitting & other health record-keeping depts. 1 2 2 12 HRA & Cost-effectiveness - - - - -13 HRA & Schools and Industries Health Records 3 1 2 14 HRA & Health Agencies 1 3 2 * 15 HRA S C o n f i d e n t i a l i t y 1 2 2 16 HRA S Government Reporting ' 3 2 17 HRA s V i t a l S t a t i s t i c s 2 3 l 18 HRA & Public Health 3 2 l 19 HRA & Preventive Care • 1 2 3 20 HRA & Health Law 3 2 1 *Both members indicated Expert 3 on the three-point r a t i n g scale measuring expertise i n each area of function. In summary, the r e s u l t s of the combination of a l l three groups are presented on Table V I I . From t h i s t a b l e , i t can be noted that no category of a c t i v i t y a t t r a c t e d a l l of the 23 respondents to achieve a p e r f e c t consensus. The h i g h e s t number of 31 respondents i s found i n category 2, Organize, of area #15, HRA and C o n f i d e n t i a l i t y ; next f o l l o w s category 1, P a r t i c i p a t e , of areas 1 and 2, HRA and Q u a l i t y of Care Programs and HRA and Research and Studies respec-t i v e l y with 19 respondents. The f i n a l ranking of the twenty areas of f u n c t i o n on the b a s i s of t h e i r weighted scores i s presented as Table V I I I . The t a b l e a l s o i n d i c a t e s the two c a t e g o r i e s of a c t i v i t y s e l e c t e d by the panel as being the most important, and the r e s p e c t i v e percentages of weighted responses assigned to them. The area of f u n c t i o n r a t e d f i r s t i s #15, HRA and C o n f i d e n t i a l i t y and Organize i s the major a c t i v i t y expected with 40% of the weighted responses. The second area of f u n c t i o n i s #6, HRA and Computerized Records, with P a r t i c i p a t e being designated as the expected a c t i v i t y . The t h i r d area i s #1, HRA and Q u a l i t y of Care Programs, with P a r t i c i p a t e being the main act i v i t y . At the other end of the s c a l e , area #13, HRA and Schools and I n d u s t r i e s Health Records, was r a t e d the l e a s t important. With regard to the c a t e g o r i e s of a c t i v i t y , c a t e g o r i e s 1 and 2, P a r t i c i p a t e and Organize r e s p e c t i v e l y were r a t e d e q u a l l y , each r e c e i v i n g 26% of the weighted responses. S i m i l a r l y , c a t e g o r i e s 3 and 4, I n t e g r a t e and A d v i s e , r e c e i v e d an equal percentage of the weighted responses: 18%. Evaluate r e c e i v e d only 9% of the weighted responses. TABLE V I I ALL THREE GROUPS Number of responses/weighted Responses/Percentage of Weighted Responses 93. j Areas j of j func- | t i o n I Categories of a c t i v i t y ' TOTALS 1 i 2 i 3 I 4 i i i 5 6 1 ! 1 19/58/37 13/36/23 9/20/13 ! 8/20/13 8/12/8 j 2/3/2 i 1/6/4 j 60/155 2 19/61/41! 9/23/16 9/25/17 j 11/22/15 6/9/6 1/1/1 I - | 57/147 3 9/21/17j 11/35/28 13/37/30 7/18/15 8/12/10 1/1/1j - 1 49/124 i ! i 4 12/30/26 11/31/27 8/13/11 14/30/26 3/8/7 1/3/3 1/1/1 j 50/116 5 13/34/25 17/55/40 10/23/17 7/14/10 5/9/7 1/3/2 - 53/138 6 16/54/35 14/43/28 11/28/18 7A7/11 5/14/9 - - 53/156 7 10/27/22 15/43/35 9/28/23 9/19/15 2/7/6 - 45/124 8 20/55/41 3/7/5 6/10/7 11/28/21 L2/28/21 ;2/4/3 1/3/2 55/135 9 14/42/37 12/37/32 7/15/13 8/12/16 1/1/1 jl/2/2 - 43/115 10 15/44/34 10/28/21 2/5/4 17/49/37 1/1/1 1/4/3 - 46/13 11 7/18/12 15/49/35 15/36/26 10/24/17 5/10/7 1/2/1 - 53/139 12 15/33/35 6/16/17 6/10/11 7/12/13 5/10/11 1/6/6 2/7/7 42/94 13. 4/5/7 10/25/35 6/18/25 6/14/20 3/6/8 1/3/4/ - 30/71 14 7/10/11 6/13/15 9/28/32 11/24/27 1 5/10/11 1/3/3 j - 39/88 15 13/30/18 21/69/40 2/7/4 13/31/18 11/28/16; - |1/6/4 61/171 16 9/21/20 14/34/33 10/26/25 4/10/10 4/9/9 j - |1/3/3 42/103 17 11/26/24 8/25/23 11/27/25 8/16/15 6/14/13: - . - 44/108 18 6/12/13 6/14/15 12/32/35 8/20/22 3/8/9 1/3/3 37/91 19 8/19/22 7/19/22 12/30/34 5/9/10 l 6/8/9 - |1/3/3 39/88 | 20 6/12/13 7/13/14 | 9/18/19 14/38/41 4/9/10 1/3/3 j - 41/93 Totals i 233/612/26 ! 215/615/26 176/436/1 3 185/433/1 8 104/213 16/4C • ) 10/38 I /2 j 939/2387 94. TABLE VIII ALL THREE GROUPS Ranking of the areas of function by weighted responses RANK Areas of function Most important categories of a c t i v i t y %-age %-age 1 15 HRA and C o n f i d e n t i a l i t y of Health Information Organ-iz e 40 P a r t i c i p a t e Advise .18 " 18 2 6 HRA and Computerized Records P a r t i -cipate 35 Organize 28 3 1 HRA and Quality of Care Programs P a r t i -cipate 37 Organize 23 4 2 HRA and Research and Studies P a r t i -cipate 41 Integrate 17 5 11 HRA and Admitting and other health record-keeping departments Organ-iz e 35 integrate 26 6 5 HRA and Health Information Systems Organ-iz e 40 P a r t i c i p a t e 25 7 8 HRA and A c c r e d i t a t i o n P a r t i -cipate 41 Advise Evaluate 21 21 8 10 HRA and P o l i c y Formulation re health information Advise 37 P a r t i c i p a t e 34 9 3 HRA and Ambulatory and Home Care Programs Inte-grate 30 Organize 28 10 7 HRA and Health Information Linkage Organ-ize 35 Integrate 23 11 4 HRA and A l l i e d Health Professions Organ-iz e 27 P a r t i c i p a t e Advise 26 26 12 9 HRA and Management, I n s t i t u t i o n a l and Department P a r t i -cipate 37 Organize 32 13 17 HRA and V i t a l S t a t i s t i c s Inte-grate 25 P a r t i c i p a t e Organize 24 23 14 16 HRA and Government Reporting Organ-ize 33 Integrate 25 15 12 HRA and Cost-effectiveness P a r t i -cipate 35 Organize 17 16 20 HRA and Health Law Advise 41 Integrate 19 17 18 HRA and Public Health Inte-grate 35 Advise 22 18 14 HRA and Health Agencies Inte-grate 32 Advise . » i 19 19 HRA and Preventive Care Inte-grate 34 P a r t i c i p a t e Organize 22 I 22 20 13 HRA and Schools and Industries Health Records Organ-iz e 35 Integrate 25 On Table IX, the s e l e c t i o n s made by the Top Expert group (Tabic VI) are compared with those made by the three groups combined (Table VIII) The comparison has not' y i e l d e d much v a l u a b l e i n f o r m a t i o n . In twelve areas of f u n c t i o n , only two c a t e g o r i e s could be matched, and only in three areas of f u n c t i o n d i d the three choices of the two groups match i n terms of category, but not i n terms of rank i n g . 96. TABLE IX Comparison between the choices made by the Top Experts and those made by A l l Three Groups Area of function Expert 3 Groups Categories of a c t i v i t y P a r t i -cipate Organize Integrate Advise Evaluate 1 HRA S Quality of Care Programs E 3 2 1 1 2 3 2 3 2 HRA S Research and Studies E 3 3 1 1 3 1 2 3 HRA S Ambulatory S Home Care Programs E | 3 i 3 1 2 2 1 3 4 HRA & A l l i e d Health Professions E j 3 1.2 1 1 3 2 2 5 HRA S Health Information Systems E 1 3 ! 2 1 1 3 3 2 6 HRA S Computerized Records E I 3 ! 1 2 2 3 3 1 7 HRA & Health Informa-t i o n Linkage = ! 1 3 1 3 l 1 3 2 2 1 8 HRA and A c c r e d i t a t i o n E ; j 3 3 I 1 i 2 2 1 2 9 HRA & Management, I n s t i -t u t i o n a l & Departmental E j 1 1 1 3 i 1 ! 2 3 3 10 HRA and P o l i c y Formu-l a t i o n re Health inform-ation E | 2 ! 1 3 | 2 ! 3 I | 3 1 11 HRA S Admitting & other health-record-keeping departments E 3 i 1 1 1 i 2 •2 3 ••• 2 12 HRA and Cost effectiveness E 3 i ! i . - . ... 3 •• • -13 HRA and Schools and Indus-t r i e s Health Records E | 3 ... I 1 - - 1 2 3 .... 2 14 HRA and Health Agencies E 3 3 • • 1 1 3 • 2 .... 2 15 HRA & C o n f i d e n t i a l i t y E 3 2 1 1 2 • 2 • • 2 16 HRA and Government Reporting E 3 2 3 1 2 3 .. .1. .. . 17 HRA & V i t a l S t a t i s t i c s E 3 2 3 2 1 3 ••• .... i 18 HRA and Public Health E 3 3 3 2 • • •• 1 2 •• 1 19 HRA and Preventive Care E 3 2 1 2 1 2 3 20 HRA and Health Law E 3 3 3 2 2 1 1 97 . DISCUSSION One p o s i t i v e f i n d i n g i s that 64% of the people contacted responded, even though Round 1 was inquisitive;: and time-consuming. The panel members c o n t r i b u t e d generously with t h e i r thoughts. One could i n t e r p r e t t h i s c o operation as being commensurate with the i n t e r e s t the respondents bore to the i s s u e at hand. Due to the high degree of c o n f i d e n t i a l i t y maintained i n t h i s study, the exact make-up of t h i s group i n r e l a t i o n to the d i s c i p l i n e s i n v i t e d i s not known. The 9% a t t r i t i o n that occurred i n Round 2 i s d i f f i c u l t to e x p l a i n , p a r t i c u l a r l y s i n c e the task was simpler and l e s s time-consuming than i n Round 1. One may c o n j e c t u r e that some members of the panel f e l t that they had s u f f i c i e n t l y shared t h e i r views i n Round 1; others may have o b j e c t e d to the f o r c e d - c h o i c e technique of Round 2; others again may not have a s s o c i a t e d themselves very s t r o n g l y with the t o p i c . However, t h i s a t t r i t i o n - e v e n t i s not s p e c i f i c to t h i s study, and i s w e l l documented i n the Delphi l i t e r a t u r e as one of the weaknesses of the method. Another i n t e r e s t i n g f i n d i n g of t h i s study i s that from the twenty areas of f u n c t i o n suggested to s t r u c t u r e the r.esp.ons.es to Round 1, none were d i s c a r d e d as non-relevant by the panel i n s p i t e of the f a c t t h a t few of these f u n c t i o n s are p a r t of today's Health Record A d m i n i s t r a t o r s ' r o l e . True, one or two members could not v i s u a l i z e the HRA i n one or two of these areas, and i n d i c a t e d d e f i n i t e response of "not a p p l i c a b l e " , which was duly recorded under "No change". One could assume that by responding the r e s -pondents acknowledged h e a l t h i n f o r m a t i o n as being v i t a l to a l l twenty areas of f u n c t i o n , and recognized the need f o r competent i n f o r m a t i o n management s e r v i c e s . Those twenty areas are by no means a l l encompassing, yet no other area of f u n c t i o n was added, perhaps because the twenty suggested represented already a monu-mental development. The c o l l a p s i n g technique used to c o l l a t e the responses i n Round 1 di d not preserve some of the panel's c o n t r i b u t i o n s . Two c e n t r a l ideas could not thus be p r o j e c t e d . The f i r s t one i s that the responses were made contingent on a c o n s i d e r a b l e improvement i n the education of the HRA. I f one chooses to be o p t i m i s t i c , one could i n t e r p r e t t h i s contingency clause as expressing that there i s , at l e a s t to the b e l i e f of the pa n e l , some p o t e n t i a l f o r development i n the HRA occupation. The other c e n t r a l idea was that the HRA of the f u t u r e should be working on the ward "where the a c t i o n i s " . The ward i s the forum of the h e a l t h o c c u p a t i o n s ' a c t i v i t i e s ; i t i s the p l a c e where the in f o r m a t i o n i s generated, t r a n s m i t t e d to those who need i t to give prompt and a p p r o p r i a t e care to the p a t i e n t ; the ward i s where the i n f o r m a t i o n should be evaluated, amended i f necessary, coded and used f o r p r o s p e c t i v e analyses and s t u d i e s . This new concept w i l l be d i s c u s s e d f u r t h e r i n the p r e s e n t a t i o n of the f u t u r e r o l e of the HRA. With res p e c t to consensus or unanimity as i t was o p e r a t i o n a l l y d e f i n e d , t h i s was not reached, but then, i t was not an important o b j e c t i v e of t h i s study. The e a r l y m a j o r i t y that developed i n ei g h t areas of f u n c t i o n i n Round 1, and the p l u r a l i t y noted i n the remaining twelve were c o n s o l i d a t e d i n t o a s o l i d m a j o r i t y i n Round 2 over the twenty areas of f u n c t i o n , reaching the 80% or higher i n e i g h t areas (see F i g . 1); p a r t i c u l a r l y o u t s t a n d i n g were areas #2, HRA and Research and S t u d i e s , and #15, HRA and C o n f i d e n t i a l i t y , both a t t r a c t i n g 92% of the respondents. One p o s s i b l e reason f o r t h i s great i n c r e a s e i n percentages by category of a c t i v i t y could be 99 . that the task of s e l e c t i n g among a l t e r n a t i v e s may have appeared e a s i e r than the task of c o n t r i b u t i n g o r i g i n a l thoughts; i n that sense one may assume that the matrix of Round 2 provided some easy s l o t s to the respondents. In examining the percentages of r e s -ponses i n F i g u r e 2, i t can be noted that almost a l l the percentages f o r Round 2 are lower than those f o r Round 1, that i s , show a trend reverse to that of the percentages of respondents. Three p o s s i b l e reasons are submitted to e x p l a i n t h i s phenomenon: a) i n Round 1, a respondent could c o n t r i b u t e at l e a s t to s i x c a t e g o r i e s i n each areaof f u n c t i o n ; only a c o n t r i b u t i o n to the category "No change" would precl u d e any other. In Round 2, the respondents could make three choices only, t h e r e f o r e , the t o t a l p o s s i b l e number of responses was g r e a t l y . r e d u c e d . b) because of the f o r c e d - c h o i c e s i t u a t i o n set up i n Round 2, some respondents experienced d i f f i c u l t i e s i n making t h e i r s e l e c -t i o n s ; some i n d i v i d u a l s i n d i c a t e d one choice only, or perhaps two. c) most members r a t i n g s e l v e s "Not knowledgeable" i n a s p e c i f i c area of f u n c t i o n would enter no choice f o r t h a t area; furthermore, as mentioned i n the methodology s e c t i o n , the responses given by "Not Knowledgeable" respondents were e l i m i n a t e d . P o i n t s b) and c) may argue f a v o r a b l y a g a i n s t the s l o t h y p o t h e s i s . Furthermore, 2 the f o l l o w i n g n u l l hypotheses had been t e s t e d by the X goodness of f i t method: 1) the responses to round 2 could have been provided by a random s e l e c t i o n of the general p o p u l a t i o n ; 2) the members of the panel assigned t h e i r c hoices at random, and were duly r e j e c t e d . And f i n a l l y , the s e l f - r a t i n g s c a l e attached to each area of f u n c t i o n would prevent handy-slotted choices on s e l f - e s t e e m b a s i s . 100 . Some areas of f u n c t i o n d e f i n i t e l y a t t r a c t e d more responses than ot h e r s , f o r example #15, HRA and C o n f i d e n t i a l i t y , was ra t e d the most important and t h i s choice seems to ass i g n a s o c i a l importance to the fu t u r e r o l e of the HRA, perhaps i n d i c a t i n g the emergence of a t r u s t r e l a t i o n s h i p between the HRA and the p u b l i c . Some trends n o t i c e a b l e i n today's s o c i a l l i f e may support the p o s s i b i l i t y of such a r e l a t i o n s h i p developing i n the f u t u r e . One of the trends i s t h a t the p u b l i c i s more and more allowed to access t h e i r own h o s p i t a l r e c o r d s , thus may develop a gradual a s s o c i a t i o n with the HRA occupation,an a s s o c i a t i o n i n which i t w i l l be asked to pl a c e i t s t r u s t i n the HRA f o r the safeguarding of the p r i v i l e g e d inform-a t i o n . Another trend i s an i n t e n s i f y i n g p u b l i c demand f o r pro-t e c t i o n a g a i n s t the tampering with i n f o r m a t i o n that i s c o l l e c t e d 'about i n d i v i d u a l s by other i n d i v i d u a l s and/or o r g a n i z a t i o n s ; t h i s demand fo r p r i v a c y i s p a r t i c u l a r l y emphatic with regard to h e a l t h inform-a t i o n . In On t a r i o , a Royal Commission on the C o n f i d e n t i a l i t y of Health Records has been c a l l e d to i n v e s t i g a t e the s u b j e c t . Semi-o f f i c i a l l y r eported p r e l i m i n a r y f i n d i n g s t e s t i f y to a p p a l l i n g abuses. The f u l l r e p o r t i s expected before the end of t h i s year. The r e s u l t s of the study, i f p u b l i c i z e d , may w e l l p r o p e l p r i v a c y to the rank of s o c i a l v a l u e . The second h i g h e s t ranked area of f u n c t i o n i s HRA and Computerized Records. This ranking can be exp l a i n e d i n the l i g h t of the advanced developments i n computer technology and of the r e c o g n i t i o n that i n the f u t u r e , computers w i l l be the medium of communication i n h e a l t h as w e l l as i n the i n d u s t r y . The h e a l t h occupations sense the need f o r an i n f o r m a t i o n s p e c i a l i s t to mediate between them and the computer s c i e n t i s t s . But perhaps the choice can be b e t t e r e x p l a i n e d i n r e l a t i o n to the i s s u e of c o n f i d e n t i a l i t y which has been 101 . p r e v i o u s l y d i s c u s s e d , as well:as i n r e l a t i o n to the next two areas which were recognized as most important, namely c l i n i c a l s t u d i e s and q u a l i t y assurance programs. There i s need f o r the c o n t r o l and the monitoring of the computer to guard the i n f o r m a t i o n a g a i n s t tampering, as w e l l as to a s c e r t a i n the r e l i a b i l i t y and the v a l i d i t y of the input data so i t can make s i g n i f i c a n t c o n t r i b u t i o n s to the q u a l i t y of care programs. The high ranking of HRA and Computerized Records i s of p a r t i c u l a r i n t e r e s t because t h i s area of f u n c t i o n comprised the highest number of experts (See Appendix 5). Other popular areas were #1, HRA and Q u a l i t y of Care Programs, and #2, HRA and Research and S t u d i e s . These high rankings r e f l e c t the medical p r o f e s s i o n ' s needs f o r a c o l l a b o r a t o r group who w i l l take r e s p o n s i b i l i t y f o r the o r g a n i z a t i o n and s t a t i s t i c a l tasks that form the s t r u c t u r e of these programs. They need a c o l l a b o r a t o r capable of c o n s i s t e n t performance as opposed to sporadic i n t e r e s t i n order to o b t a i n c o n t i n u i t y of r e s u l t s f o r t h e i r evaluation pro-grams . These kinds of a d m i n i s t r a t i v e tasks do not s u s t a i n the i n t e r e s t of the medical s t a f f as a group, as p r o f e s s i o n a l s are t r u l y dedicated to t h e i r primary p r o f e s s i o n a l c a l l i n g . At present, many i n d i v i d u a l p h y s i c i a n s show i n t e r e s t i n o r g a n i z i n g Q u a l i t y of Care programs, but they cannot s u s t a i n t h e i r e f f o r t because t h e i r time i s f a r too expensive; and because medical t r a i n i n g i s not r e q u i r e d to perform many of the t a s k s , the programs become i n -e f f i c i e n t and uneconomical. This i s an area of p o t e n t i a l p r o f e s s i o n a l growth f o r the HRA, as the Q u a l i t y of Care programs have to be developed v o l u n t a r i l y by the medical and a l l i e d h e a l t h s t a f f s , and the h e a l t h o r g a n i z a t i o n s , l e s t they wish governmental i n t e r f e r e n c e i n s e t t i n g up p r o f e s s i o n a l 10 2. •» and o r g a n i z a t i o n a l accounting programs f o l l o w i n g the precedents e s t a b l i s h e d i n the U.S. That these areas have been given high p r i o r i t y by the panel may a l s o r a i s e the p o s s i b i l i t y t h a t a t r u s t r e l a t i o n s h i p could develop between the f u t u r e HRAs and t h e i r c l i e n t s provided that the HRAs w i l l be able to make s u b s t a n t i a l c o n t r i -butions . The areas of f u n c t i o n judged to be the l e a s t important i n c l u d e d P u b l i c Health, Health Agencies, P r e v e n t i v e Care. The low p r i o r i t y given to these areas of f u n c t i o n p o s s i b l y r e f l e c t s the f a c t t h a t w i t h i n the h e a l t h i n d u s t r y , o r g a n i z a t i o n s and s e c t o r s are allowed a f a i r amount of independence, an independence which they h i g h l y value; they wish to maintain these l i m i t e d freedoms, and are i n c l i n e d to recognize the same r i g h t s to o t h e r s . The panel members very l i k e l y a s s o c i a t e d themselves with t h i s quest f o r autonomy, not u n l i k e the t r a d i t i o n a l autonomy of the p r o f e s s i o n s . Another p o s s i b l e e x p l a n a t i o n would be the newness of the idea that the HRA occupation may expand i n t o o r g a n i z a t i o n s such as P u b l i c Health, or V i t a l S t a t i s t i c s . Yet these areas r e q u i r e competent h e a l t h i n f o r m a t i o n s e r v i c e s j u s t as much as the d i r e c t h e a l t h care f a c i l i t i e s to i n t e g r a t e them i n the o v e r a l l h e a l t h system, and some panel members seemed to concur. These o r g a n i z a t i o n s would a l l represent new t e r r i t o r i e s of a c t i v i t y f o r the HRA occupations. The l e a s t important area was judged to be HRA and Schools and I n d u s t r i e s Health Records. This area i s removed from the h e a l t h f i e l d , but w i l l have to be s t a n d a r d i z e d , i f the h e a l t h i n f o r m a t i o n l i n k a g e i s to be implemented. One most i n t e r e s t i n g r e s u l t i s the r e l a t i v e i n d i f f e r e n c e p a i d to area of f u n c t i o n #9, HRA and Management, I n s t i t u t i o n a l and Depart-mental. One p o s s i b l e e x p l a n a t i o n f o r t h i s low ranking i s that the 10 3 . panel was mostly composed of p h y s i c i a n s , who, as i s w e l l known, have l i t t l e i n t e r e s t i n management. According to the p r o f e s s i o n a l -i z a t i o n t h e o r i e s p r e v i o u s l y d i s c u s s e d , p r o f e s s i o n a l s are s a i d to preserve the values of t h e i r primary p r o f e s s i o n , i n t h i s case, medicine. This assumption i s somewhat supported by the f a c t t h at the same i n d i f f e r e n c e h i t areas of f u n c t i o n #12, HRA and Cost E f f e c t i v e n e s s , and #16, HRA and Government Reporting. Within the h e a l t h f i e l d these areas of f u n c t i o n have been g a i n i n g progres-s i v e l y more and more importance over the past decade i n the pursu-ance of cost containment. Could one surmise that panel members merely wanted to de-emphasize these areas i n order to uphold t h e i r h i g h l y r a i s e d p r o f e s s i o n a l autonomy, and p r o t e c t t h e i r p r o f e s s i o n a l p r a c t i c e from too much a d m i n i s t r a t i v e and governmental i n t e r f e r e n c e s ? Another p o s s i b l e reason i s that the present poor performance of the HRAs i n management f u n c t i o n s was p r o j e c t e d i n t o the f u t u r e , and that the panel members may have considered " f e a s i b i l i t y " as opposed to d e s i r a b i l i t y . A t h i r d reason could be that the choices i n d i c a t e d by the panel member express the d e s i r a b i l i t y of a s h i f t i n the a l l e g i a n c e of the HRA back toward the medical p r o f e s s i o n , a co n j e c t u r e which has already been made e a r l i e r ; hence the panel reduced the importance of management. With resp e c t to expected a c t i v i t i e s the c a t e g o r i e s 1, P a r t i c i p a t e and 2, Organize were ra t e d e q u a l l y by the pa n e l . Complexity c h a r a c t e r i z e s most f u n c t i o n s i n h e a l t h as w e l l as i n industry, and d i v i s i o n o f labor and s p e c i a l i z a t i o n are the most e f f e c t i v e and economical ways of d e a l i n g with i t ; on the other hand, the i n t e r -dependence of the f u n c t i o n s on one another has been amply documented i n the management l i t e r a t u r e , p a r t i c u l a r l y so s i n c e the i n t r o d u c t i o n of the''•.s:y stem': concept.'"".Thus one may conceive of P a r t i c i p a t e and 104 . Organize as being i n tandem; P a r t i c i p a t i o n of the HRA w i l l be r e q u i r e d because of the HRA s p e c i a l o r g a n i z a t i o n a l and communi-c a t i o n s k i l l s ; and, O r g a n i z a t i o n w i l l be accepted because of the value of the p a r t i c i p a t i v e s k i l l s . Health i n f o r m a t i o n i s a resource needed by a l l the h e a l t h p r o f e s -s i o n s , and i t may be s a i d to be an agent of c o o r d i n a t i o n among them determining the areas over which the v a r i o u s p r o f e s s i o n s i n t e r f a c e . The occupation which purports to manage t h i s inform-a t i o n w i l l then have to be a p a r t i c i p a n t i n the h e a l t h care team. Although P a r t i c i p a t e i n t h i s study acquired r e l a t e d , yet somewhat d i f f e r e n t meanings according to the areas of f u n c t i o n , (See Appendix 3), i t n e v e r t h e l e s s c a r r i e s the connotation of "give v a l u a b l e c o n t r i b u t i o n " . In the l i g h t of the t r a i n i n g of the HRA, p a r t i c i p a t i o n means the c o n t r i b u t i o n of s p e c i a l i z e d s k i l l s i n o r g a n i z i n g , managing and using h e a l t h i n f o r m a t i o n f o r the b e n e f i t of the p a t i e n t s , the medical and a l l i e d h e a l t h occupations, the a d m i n i s t r a t i o n of h e a l t h o r g a n i z a t i o n s and the government. Integrate and Advise were r a t e d somewhat lower by the p a n e l , but were given equal s t a n d i n g . These two a c t i v i t i e s gained importance over the areas of f u n c t i o n which today are o u t s i d e the HRA 1s t e r r i t o r y . The panel members recognized that there was c o n s i d e r a b l e need f o r the i n t e g r a t i o n of the v a r i o u s near-autonomoUs s e c t o r s that make up the h e a l t h f i e l d . This i n t e g r a t i o n process pre-supposes the adoption of s i m i l a r standards of i n f o r m a t i o n , a n a l y s i s , " e v a l u a t i o n , storage, r e t r i e v a l , and use. To achieve such a monu-mental task, a great deal of a d v i s o r y work, and of p l a n n i n g i s r e q u i r e d . These s e c t o r s w i l l have to be convinced on a v o l u n t a r y b a s i s r a t h e r than through l e g i s l a t i o n that the process w i l l be b e n e f i c i a l to the p u b l i c , and to them because i t w i l l enhance t h e i r 105 . a b i l i t y to render t h e i r s p e c i a l s e r v i c e s . The p r o v i s i o n of a c t i v e and p r o d u c t i v e p r o f e s s i o n a l c o n s u l t a t i o n s r e l a t i n g to the perform-ance of h e a l t h i n f o r m a t i o n systems may be seen as a key a c t i v i t y , a f a c i l i t a t i n g agent of change, i f you w i l l . Comparatively, the E v a l u a t i v e aspect of the r o l e of the f u t u r e HRA was not empha-s i z e d ; however, i t was not denied e n t i r e l y . The t r a d i t i o n a l pro-f e s s i o n a l autonomy p r e s c r i b e s s e l f - r e g u l a t i o n and s e l f - d i s c i p l i n e to the p r o f e s s i o n s . S o c i e t y , the governments and the law concur with and accept t h i s p r i n c i p l e of p r o f e s s i o n a l autonomy; t h e r e f o r e , the a c t i v i t y "Evaluate" could not have crea t e d a strong i n t e r e s t among t r a d i t i o n a l p r o f e s s i o n a l s . However, the interdependence of the h e a l t h occupations w i l l submit them i n c r e a s i n g l y to m u l t i -d i s c i p l i n a r y s c r u t i n y . As these s e l f - e v a l u a t i o n programs depend h e a v i l y on accurate, complete and p e r t i n e n t i n f o r m a t i o n , the e v a l u a t i v e aspect of the HRA had to be given some r e c o g n i t i o n . An a m p l i f i c a t i o n of t h i s r o l e w i l l be contingent on the t r u s t r e l a t i o n s h i p that can be developed between the HRAs and t h e i r c l i e n t s . The equal emphasis p l a c e d on a c t i v i t i e s P a r t i c i p a t e and Organize, then Int e g r a t e and Advise c l e a r l y i n d i c a t e s that no a c t i v i t y p a t t e r n can be dominant. A l l the types of a c t i v i t i e s s e l e c t e d by the panel are i n t e g r a l p a r t s of an e v o l v i n g r o l e which w i l l take the HRAs out of t h e i r customary environment. To s u c c e s s f u l l y assume t h i s new r o l e , the HRAs w i l l r e q u i r e a great deal of know-ledge, s e l f - d i s c i p l i n e , t a c t and s e n s i t i v i t y to p e r c e i v e which a c t i v i t y should be emphasized i n s p e c i f i c s i t u a t i o n s , i n order to meet the expe c t a t i o n s of the h e a l t h p r o f e s s i o n s , the admini-s t r a t i o n , the government and the p u b l i c . An attempt w i l l be made to present t h i s new r o l e by r e f e r r i n g to 106. the o r i g i n a l c o n t r i b u t i o n s of the panel members. FUTURE ROLE OF THE HEALTH RECORD ADMINISTRATOR According to the panel of t h i s D e l p h i - e x e r c i s e , four major types of a c t i v i t y w i l l determine the r o l e of the f u t u r e HRA. 1) PARTICIPATE: the word denotes c o l l a b o r a t i n g , c o n t r i b u t i n g a c t i v i t i e s . I n i t i a t i v e w i l l not be the main i n g r e d i e n t , r a t h e r involvement with the programs i n i t i a t e d by the medical and a l l i e d h e a l t h p r o f e s s i o n s . For these programs to be u s e f u l , the HRA w i l l be r e q u i r e d to c o n t r i b u t e the competence and the time that the h e a l t h p r o f e s s i o n s l a c k . The degree of involvement i s con-t i n g e n t on the HRA's e x p e r t i s e and a b i l i t y to communicate. Con-sequently, the body of knowledge of the HRA w i l l have to i n t e r -face adequately with the r e s p e c t i v e bodies of knowledge of the h e a l t h p r o f e s s i o n s , the e f f o r t s f o r t h i s i n t e r f a c i n g process being e n t i r e l y on the HRA's s i d e . At the i n s t i t u t i o n a l l e v e l , the p a r t i c i p a t i v e r o l e of the HRA w i l l be performed i n great p a r t on the wards, at the " a c t i o n c e n t r e s " . The i n f o r m a t i o n generated there w i l l be immediately analyzed, assessed, coded, used and routed toward those who w i l l proceed to make the ap p r o p r i a t e c l i n i c a l and a d m i n i s t r a t i v e d e c i s i o n s . The computer w i l l be an i n d i s p e n s a b l e t o o l , and the design of systems of s t u d i e s and researches w i l l r e q u i r e the HRA's i n t e n s i v e c o l l a b o r a t i o n with the computer s c i e n t i s t i n order to f a c i l i t a t e p r o d u c t i v e communications between t h i s group and the medical and a l l i e d h e a l t h p r o f e s s i o n s . Sustained emphasis w i l l be pl a c e d on the q u a l i t y assurance pro-grams. The HRA w i l l be r e q u i r e d to p a r t i c i p a t e i n s t r u c t u r i n g these programs, i n developing a p p r o p r i a t e standards and i n d i c a t o r s to measure and evaluate the care rendered i n the i n s t i t u t i o n , and 107 . i n comparing the r e s u l t s obtained with r e g i o n a l , p r o v i n c i a l and/ or n a t i o n a l standards, as w e l l as with the r e s u l t s r e p o r t e d i n the l i t e r a t u r e . As li n k a g e w i l l make l a r g e p o p u l a t i o n bases a v a i l a b l e , the p r o s p e c t i v e - t y p e of s t u d i e s w i l l be favored to evaluate the long-term e f f e c t s of care on i n d i v i d u a l s and t h e i r f a m i l i e s ; e p i -d e m i o l o g i c a l s t u d i e s endeavouring to uncover the f a c t o r s i n f l u - •" encing the h e a l t h s t a t u s of the communities w i l l a l s o be conducted i n great numbers. The v o l u n t a r y a c c r e d i t a t i o n movement w i l l expand c o n s i d e r a b l y to a l l types of h e a l t h care f a c i l i t i e s . I t w i l l be i n s t r u m e n t a l i n i n t e n s i f y i n g the need f o r the HRA's p a r t i c i p a t i o n i n i n t e r -p r e t i n g the a c c r e d i t a t i o n requirements and monitoring the i n d i c a t o r s used. At the n a t i o n a l l e v e l , the HRA w i l l c o n c e i v a b l y be a member of the a c c r e d i t a t i o n team i n order to a s c e r t a i n the func-t i o n i n g of the l o c a l h e a l t h i n f o r m a t i o n systems, to p a r t i c i p a t e i n the establishment of standards and i n the f o r m u l a t i o n of p o l i c i e s r e l a t i n g to h e a l t h i n f o r m a t i o n management and use i n the d i f f e r e n t types of h e a l t h care f a c i l i t i e s , and to recommend a p p r o p r i a t e developments and improvements. 2) ORGANIZE: t h i s denotes a more vigorous a c t i v i t y r e q u i r i n g i n i t i a t i v e and acceptance of r e s p o n s i b i l i t y f o r decision-making, implementing and e v a l u a t i n g the outcomes. The o r g a n i z a t i o n of a program to i n s u r e the c o n f i d e n t i a l i t y of h e a l t h i n f o r m a t i o n was designated to be the most important f u n c t i o n . Within the i n s t i t u t i o n , a p p r o p r i a t e p o l i c i e s w i l l have to be formulated with regard to the use and the r e l e a s e of the p r i v i l e g e d i n f o r m a t i o n that has been e l i c i t e d or uncovered by the medical and a l l i e d h e a l t h s t a f f s i n s i t u a t i o n s of t r u s t . To honour t h i s r e l a t i o n s h i p of t r u s t between p a t i e n t s and h e a l t h p r o f e s s i o n a l s 108 . the i n f o r m a t i o n has to be r e a d i l y a v a i l a b l e to those who need to serve the p a t i e n t ; otherwise, the access w i l l have to be s t r i c t l y c o n t r o l l e d and c o n f i d e n t i a l i t y p reserved. The i m p l i c a t i o n of t h i s r o l e i s that the HRA w i l l become accountable to the p u b l i c f o r the management of t h i s p r i v i l e g e d i n f o r m a t i o n , and may w e l l acquire a s o c i a l i d e n t i t y . The HRA w i l l a l s o organize and manage the i n s t i t u t i o n ' s h e a l t h i n f o r m a t i o n system, d i r e c t the i n f o r m a t i o n centre which w i l l i n c l u d e a d m i t t i n g , and c o o r d i n a t i n g the handling of h e a l t h i n f o r m a t i o n i n the e n t i r e i n s t i t u t i o n , thus cut across the now e x i s t i n g depart-mental boundaries. Cost e f f e c t i v e n e s s s t u d i e s , although not emphasized by the pa n e l , w i l l be r e q u i r e d by the government, and w i l l l i k e l y be s t r u c t u r e d according to d i a g n o s t i c e n t i t i e s . The HRA w i l l organize and c o n t r o l the program to prevent.- the leakage of c o n f i d e n t i a l i n f o r -a t i o n . As the l i n k a g e of h e a l t h i n f o r m a t i o n w i l l be implemented, the i n s t i t u t i o n ' s system w i l l be the sub-system of the community, prov i n c e and nation-wide systems, and these could c o n c e i v a b l y be designed and d i r e c t e d by the f u t u r e HRA. Through these systems v i t a l i n f o r m a t i o n w i l l be exchanged and used f o r government r e p o r t i n g and cost c o n t r o l on the management s i d e , and f o r the e v a l u a t i o n of care on s h o r t - and long-term bases as w e l l as f o r c l i n i c a l r e s e a r c h and education on the medical s i d e . The concept of h e a l t h i n f o r m a t i o n l i n k a g e p r e s c r i b e s that a l l the h e a l t h i n f o r m a t i o n accumulated on the i n d i v i d u a l be compiled i n one unique r e c o r d . To achieve t h i s i n t e g r a t i o n , the h e a l t h records now kept by schools and by v a r i o u s i n d u s t r i a l and com-m e r c i a l o r g a n i z a t i o n s w i l l have to be organized s y s t e m a t i c a l l y according to the same standards that w i l l be r e g u l a t i n g the h e a l t h i n f o r m a t i o n system of the h e a l t h i n d u s t r y . T h i s area of f u n c t i o n would c o n s t i t u t e an e n t i r e l y new t e r r i t o r y f o r the e x p e r t i s e of the HRA. 3) INTEGRATE denotes a c o o r d i n a t i n g a c t i v i t y r e q u i r i n g s p e c i a l i z e d knowledge and communication s k i l l s . I n t e g r a t i o n w i l l occur at the i n s t i t u t i o n l e v e l where, at present, v a r i o u s types of p a t i e n t s are handled d i f f e r e n t l y c l i n i c a l l y and a d m i n i s t r a t i v e l y , and where the departments ge n e r a t i n g and using h e a l t h i n f o r m a t i o n have t h e i r own system independently of one another. The i n t e g r a t i o n process w i l l have to encompass other s e c t o r s of the h e a l t h f i e l d which today operate on a quasi-autonomous way. The h e a l t h i n f o r m a t i o n systems of P u b l i c Health, P r e v e n t i v e Care and other s i m i l a r s e c t o r s w i l l have to be organized a c c o r d i n g to the then p r e v a i l i n g acceptable standards and channelled i n t o the main stream f o r ^ . q u a n t i t a t i v e and q u a l i t a t i v e a n a l y s i s , avoidance of d u p l i c a t i o n , p l a n n i n g of s e r v i c e s , cost c o n t r o l and other l e g i t i -mate uses. Voluntary and autonomous h e a l t h agencies w i l l be s i m i l a r l y r e g u l a t e d , and the HRA w i l l act as agent of c o o r d i n a t i o n and i n t e g r a t i o n i n order to implement h e a l t h i n f o r m a t i o n l i n k a g e , at the same time preserve the p u b l i c ' s r i g h t t o p r i v a c y . Nearly without ex c e p t i o n , these areas w i l l c o n s t i t u t e new t e r r i t o r i e s f o r the HRA of the f u t u r e . 4) ADVISE: rep r e s e n t s an e d u c a t i o n a l and promotional a c t i v i t y , supplemented by p e r t i n e n t recommendations. To advise on p o l i c y f o r m u l a t i o n r e g a r d i n g the use of h e a l t h i n f o r m a t i o n w i l l be a major area of f u n c t i o n f o r the f u t u r e HRA. The t r a n s m i t t i n g and the r e l e a s e of p r i v i l e g e d i n f o r m a t i o n have to be r e g u l a t e d and \2 110 . monitored to guard a g a i n s t computer tampering, and the c a s u a l and u n c o n t r o l l e d use of hard c o p i e s . Another major area of f u n c t i o n i n an a d v i s o r y r o l e i s the complex domain of h e a l t h law. Within the i n s t i t u t i o n - , the HRA i s expected to assume an e d u c a t i o n a l r o l e on the s u b j e c t of p a t i e n t ' s r i g h t s , v a l i d i t y of consents, r e l e a s e of h e a l t h information;, and court b e h a v i o r s . The a d v i s o r y r o l e of the HRA should not be l i m i t e d to the i n s t i t u t i o n , but should reach the l e g i s l a t i v e bodies and achieve d i r e c t input i n t o the f o r m u l a t i o n of laws touching upon the s u b j e c t of h e a l t h i n f o r m a t i o n . 5) EVALUATE: although the e v a l u a t i v e r o l e of the HRA was not emphasized by the p a n e l , i t n e v e r t h e l e s s r e c e i v e d some i n t e r e s t . The p a r t i c i p a t i o n of the HRA i n the s e l f - e v a l u a t i o n programs of the h e a l t h p r o f e s s i o n s , i n the q u a l i t y assurance and U t i l i z a t i o n review programs i m p l i e s the use of the HRA a n a l y t i c a l and evalua-t ive s k i l l s . Reviewing t h i s r o l e , one n o t i c e s some fundamental changes: a) the work environment w i l l s h i f t to the ward; b) the approach to i n f o r m a t i o n management and a n a l y s i s w i l l be p r o s p e c t i v e as opposed to h i s t o r i c a l ; c) HRA e x p e r t i s e w i l l not be c o n f i n e d to the h o s p i t a l i n p a t i e n t s only, but encompass a l l types of p a t i e n t s and a l l s e c t o r s of the h e a l t h f i e l d and i n t e g r a t e them i n t o one main system; d) the HRA may f u n c t i o n at higher a d m i n i s t r a t i v e l e v e l s w i t h i n the i n s t i t u t i o n s and operate higher l e v e l systems w i t h i n the main h e a l t h care system; e) h e a l t h i n f o r m a t i o n kept i n other s e c t o r s , such as s c h o o l s , and i n d u s t r i e s w i l l a l s o abide by the same s t r i n g e n t r u l e s as the h e a l t h f i e l d . I l l But the most s i g n i f i c a n t change r e l a t e s to the t h i n k i n g and a t t i t u d e of the panel members. By v i r t u e of t h e i r e x p e r t i s e i n the h e a l t h f i e l d , they are a l l aware of some important f a c t o r s : a) Resources are s c a r c e , and have to be managed competently i f the costs are to stay a f f o r d a b l e : b) P r o f e s s i o n a l a c c o u n t a b i l i t y w i l l have to be implemented v o l u n t a r i l y , otherwise i t w i l l be imposed by law: c) Health i n f o r m a t i o n l i n k a g e i s i n e v i t a b l e i f the demands fo r more and b e t t e r s e r v i c e s are to be c o n t r o l l e d and i f the h e a l t h s e r v i c e s are to be e q u i t a b l y d i s t r i b u t e d . Health i n f o r m a t i o n i s the common l i n k , and the HRA occupation appears to o f f e r to the medical and a l l i e d h e a l t h p r o f e s s i o n s the o p p o r t u n i t y of developing t h e i r own t o o l s of assessment and c o n t r o l . Hence the c a s t i n g of the HRA of the f u t u r e i n strong p a r t i c i p a t i v e and o r g a n i z a t i o n a l r o l e , working alongside the h e a l t h p r o f e s s i o n s as an i n d i s p e n s a b l e member of the team, i n a l l s e c t o r s of the h e a l t h f i e l d . T his author f e e l s that the panel has somewhat minimized the r o l e of the f u t u r e HRA i n the management of the i n s t i t u t i o n s . Information management's b a s i c t o o l ; i t p r o v i d e s them with the means of making d e c i s i o n s , of r e p o r t i n g , of c o n t r o l l i n g and of a c c e p t i n g respon-s i b i l i t y f o r the o p e r a t i o n of the i n s t i t u t i o n . S i m i l a r l y , the r o l e of the HRA w i l l expand with r e s p e c t to government r e p o r t i n g , as more and more i n f o r m a t i o n i s r e q u i r e d to account f o r the spending of the h e a l t h d o l l a r . And h e a l t h i n f o r m a t i o n w i l l always be used to support o p e r a t i o n a l c o s t s . For t h i s reason, c o s t - e f f e c t i v e n e s s s t u d i e s w i l l become commonplace and the HRA, i n c o n t r o l of the i n f o r m a t i o n , w i l l c o l l a b o r a t e with the group i n c o n t r o l of the f i n a n c e s . Because there has been l i t t l e d i s t i n c t i o n made between the c l i n i c a l and the management needs f o r h e a l t h i n f o r m a t i o n , another important 112 . f u t u r e r o l e of the HRA has been undetected by the p a n e l , namely the one r e l a t i n g to the f u t u r e involvement of the HRAs i n the pl a n n i n g of h e a l t h s e r v i c e s . At present, the need f o r pl a n n i n g i s openly recog-n i z e d ; most h o s p i t a l s , regions and pr o v i n c e s have plan n i n g o f f i c e s and boards; but very l i t t l e has been done about the p r o v i s i o n of accurate, adequate and r e l e v a n t i n f o r m a t i o n t o these p l a n n e r s . Yet there i s no doubt that the s h i f t toward the p r o s p e c t i v e a n a l y s i s of the h e a l t h data w i l l y i e l d more r e l i a b l e and a c t u a l h e a l t h inform-a t i o n . The HRAs, i n c o l l a b o r a t i o n with the h e a l t h planners, w i l l be able to monitor the i n d i c a t o r s p r e d i c t i v e of needs, trends or changes . As a f i n a l comment, should t h i s r o l e evolve, the HRA body of knowledge would have to expand c o n s i d e r a b l y ; a d d i t i o n a l f u r t h e r s p e c i a l i z a t i o n should be considered f o r the c o l l a b o r a t i o n with the medical and a l l i e d h e a l t h p r o f e s s i o n s , f o r the design, o r g a n i z a t i o n and manage-ment of h e a l t h i n f o r m a t i o n systems, f o r e d u c a t i o n a l or c o n s u l t a t i v e c a r e e r , and f o r management of departments and of o r g a n i z a t i o n s . W i l l the HRA of the f u t u r e be considered a p r o f e s s i o n a l ? The question i s academic, because i n a decade or more, perhaps the words p r o f e s s i o n and occupation w i l l have d i f f e r e n t c o n n o t a t i o n s , and p r o f e s s i o n may no longer enjoy the same s o c i a l r e c o g n i t i o n as today, and be a d e s i r a b l e s t a t u s . On the assumption, that the d i f f e r e n c e s between p r o f e s s i o n and occupation w i l l not have eroded, one may say that the achievement of p r o f e s s i o n a l s t a t u s by the HRA of the f u t u r e w i l l depend almost e n t i r e l y on the development of a t r u s t r e l a t i o n s h i p between the HRAs and t h e i r c l i e n t s , the p h y s i c i a n s , the a l l i e d h e a l t h occupations, the management of i n s t i -t u t i o n s , and the government. The process of p r o f e s s i o n a l i z a t i o n would have a gr e a t e r chance of being s u c c e s s f u l i f the HRAs became 113 . r e l a t e d , i n the p u b l i c ' s eye, to the s o c i a l values of h e a l t h and p r i v a c y . Achievement of the p r o f e s s i o n a l s t a t u s w i l l a l s o depend to a great extent on the s e l f - r e g u l a t o r y system of the occup a t i o n , the expan-s i o n of i t s body of knowledge, the o r g a n i z a t i o n of s e l f - e v a l u a t i o n programs to monitor the q u a l i t y of t h e i r s e r v i c e s , and become responsive to the changing needs of t h e i r c l i e n t s . The p r o f e s s i o n w i l l always be marginal on autonomy and w i l l always be organization-bound. However, these c h a r a c t e r i s t i c s w i l l be shared by the other h e a l t h o c c u p a t i o n s . Perhaps the i s s u e of p r o f e s s i o n a l autonomy w i l l have become antiquated as not even the medical p r o f e s s i o n w i l l be able to maintain t h i s h i g h l y - p r a i s e d p r i v i l e g e . H o s p i t a l s and h e a l t h f a c i l i t i e s w i l l have g r e a t e r power over the p h y s i c i a n s , p a r t i c u l a r l y i n the area of admission p r i v i l e g e s . In the past few years, s e v e r a l h o s p i t a l s have been s u c c e s s f u l i n e s t a b l i s h i n g r e s t r i c t i o n s i n that sense and t h i s power may i n c r e a s e i n the f u t u r e , unless a shortage of p h y s i c i a n s w i l l be a r t i f i c i a l l y c r e a t e d . Another p o s s i b l e development i s that more and more p h y s i c i a n s may be bound o r g a n i z a t i o n a l l y to the i n s t i t u t i o n s i n which they p r a c t i c e . CONCLUSION AND RECOMMENDATIONS: With res p e c t to the value of t h i s study, i t must be remarked that i t i s assumed to be one of the f i r s t of i t s k i n d . Perhaps one may say that the study may have been s u c c e s s f u l i n e s t a b l i s h i n g some grounds f o r comparison as the f u t u r e u n f o l d s . The r e s u l t s could c o n c e i v a b l y be used by the HRA p r o f e s s i o n f o r guidance i n the modi-f i c a t i o n of t h e i r standards and behaviors as they wish to progress along the p r o f e s s i o n a l i z a t i o n pathway. They may provide the HRA occupation with the op p o r t u n i t y of c o n s i d e r i n g a l t e r n a t e f u t u r e s 114 . f o r t h e i r members, and of programming a l t e r n a t e modes of p r a c t i c e . They could a l s o be used as g u i d e l i n e s i n the s e t t i n g of e d u c a t i o n a l programs whose g r e a t e s t r e s p o n s i b i l i t y i s to t r a i n f o r the f u t u r e , a f u t u r e that appears n e a r l y unfathomable. With resp e c t to the technique used, the Delphi may be considered very s u i t a b l e to i n v e s t i g a t e i s s u e s , even i f a consensus i s not sought, as was the case i n t h i s study. The technique, by g r a n t i n g anonymity, allows f o r the e x p r e s s i o n of o p i n i o n s without the p ressure to j o i n the dominant members of the group. C o n t r a r i l y to Sachman and other c r i t i c s of the D e l p h i , t h i s author does not b e l i e v e that anonymity p r o v i d e s an escape from r e s p o n s i b i l i t y ; s e l f - r e s p e c t i n g people and p r o f e s s i o n a l s w i l l r a t h e r d e c l i n e to p a r t i c i p a t e than respond i r r e s p o n s i b l y . One of the most d i f f i c u l t tasks of t h i s study was to motivate the members of the panel to respond. This d i f f i c u l t y was probably more acute because the members were s e l e c t e d from higher s o c i o - p o l i t i c a l and p r o f e s s i o n a l spheres, with c o n s i d -e r a b l e r e s p o n s i b i l i t i e s and commitments, t h e r e f o r e , d i s p o s i n g of very l i m i t e d time f o r p a r t i c i p a t i o n i n extraneous p r o j e c t s . In a d d i t i o n , the f i r s t round probed the member's p r o f e s s i o n a l t h i n k i n g and requested o r i g i n a l i n p u t s , t h e r e f o r e , was time and energy-consuming. No i n c e n t i v e of any kind could be o f f e r e d ; and t h i s co-o r d i n a t o r f e l t somewhat powerless knowing that no e x h o r t a t i o n could provide p o s i t i v e r e s u l t s i f the members of the panel could not be s u f f i c i e n t l y i n t e r e s t e d i n the i s s u e at hand. Another d i f f i c u l t y was the tremendous demand made upon the i n t e g -r i t y of the c o o r d i n a t o r i n conducting the study, c o l l a p s i n g the responses, and f i n a l l y i n t e r p r e t i n g the r e s u l t s . For t h i s l a s t reason, annonymity i s not only recommended, but should be mandatory. The concept of t o t a l anonymity proved very u s e f u l i n e l i c i t i n g 115. candid responses, as these were val u e d . However, t h i s concept of t o t a l anonymity cannot be implemented i f the a n a l y s i s of the r a t e s of change of o p i n i o n i n the s u c c e s s i v e D e l p h i round i s of importance, as w e l l as the e x p l o r a t i o n of the reasons f o r change. Perhaps one could recommend t h a t any subsequent D e l p h i - e x e r c i s e s organized f o r a s i m i l a r purpose should segregate the v a r i o u s h e a l t h occupations i n t o sub-groups. T h i s can e a s i l y be organized without s a c r i f i c i n g anonymity. The advantage would be that the a n a l y s i s of the s i m i l a r i t i e s and the d i f f e r e n c e s of the h e a l t h occupations? o p i n i o n s as to f u t u r e needs, and t h e i r imagery of the f u t u r e would provide more p r e c i s e f i n d i n g s a g a i n s t which f u t u r e developments may be compared. Other advantages would be to a f f o r d a c l e a r e r comparison between t h e i r r e s p e c t i v e o u t l o o k s , and to explore the v a r i a t i o n s i n , t h e i r p r o f e s s i o n a l t h i n k i n g . Another suggestion would be the o r g a n i z a t i o n of a D e l p h i - e x e r c i s e on an i n t e r n a t i o n a l s c a l e , forming sub-groups of na t i o n s to probe the r e s p e c t i v e developments t h a t p r e d i c t changes. The f i n d i n g s of such grand-scale study could provide i n t e r e s t i n g comparison among the n a t i o n s , l e a d to the development of s t a n d a r d i z e d performances and have d e f i n i t e impacts i n the area of s o c i a l p o licy-making. Although the D e l p h i - t e c h n i q u e i s mostly used to f o r e c a s t the f u t u r e , i t s r e l i a b i l i t y and v a l i d i t y are yet unproven. T h e r e f o r e , no pre-d i c t i o n value can be attached to the v i s i o n of the panel of t h i s e x e r c i s e . The value of the v i s i o n may simply l i e i n the f a c t that the members of t h i s panel are occupying important p o s i t i o n s through-out the h e a l t h f i e l d and a c t i v e l y c o n t r i b u t e to the f o r m u l a t i o n of n a t i o n a l and p r o v i n c i a l s o c i a l and h e a l t h p o l i c i e s . In summary, the present HRAs are not o f f e r i n g the f u l l range of 116. h e a l t h i n f o r m a t i o n s e r v i c e s r e q u i r e d by the v a r i o u s h e a l t h p r o f e s -s i o n s . A study using the Delphi-technique has been organized to i n v e s t i g a t e the types of h e a l t h i n f o r m a t i o n s e r v i c e s that w i l l be expected from the f u t u r e HRAs. The panel of respondents, r e p r e s e n t -ing the major h e a l t h d i s c i p l i n e s , p r e d i c t e d the need f o r a strong c o l l a b o r a t i o n i n the areas of q u a l i t y assurance programs, p r o f e s -s i o n a l assessment programs, and medical and c l i n i c a l r e s e a r c h and s t u d i e s . Many s e c t i o n s of the h e a l t h i n d u s t r y and many types of h e a l t h i n f o r m a t i o n not yet served by HRAs should be organized according to the then acceptable standards, and i n t e g r a t e d i n t o the main h e a l t h care system. A dependable e d u c a t i o n a l and ad v i s o r y r o l e i s expected from the f u t u r e HRAs'. v i s - a - v i s the h e a l t h pro-f e s s i o n s i n the areas of h e a l t h law and c o n f i d e n t i a l i t y of h e a l t h i n f o r m a t i o n . 117 BIBLIOGRAPHY 1. ABEL-SMITH, A... A history of the Nursing Profession Heinemann, London, 1964. 2. ABRAHAMSON, B. Conditions for participating i n Treatment Organizations: a research note F i r s t International Sociology Conference, Dubrovik, Yugoslavia December 13-17, 1972. 3. AGNEW, G.H. <" Fi f t y years a 'growin': accreditation, the greatest stimulus ever received by hospitals Canadian Hospital, Vol. 46, Oct. 1969, pp.70-71. 4. AGNEW, G.H. Canadian Hospitals, 1920 to 1970: a dramatic half century University of Toronto Press, Toronto 1974. 5. ALBERTSON, L. & CUTLER, T. Delphi and the image of the future Futures, Vol. 8, No. 5, 1976, pp 397-404. 6. ALFORD, R. R. Health Care Po l i t i c s University of Chicago, 1975. 7. AMARA, R. Some methods on Future research Institute for the future, Menlo Park, Califcrnia 1975 Working Paper 23. 8. American College of Surgeons Manual for-Hospital Standardization, reprint 1946. 9. ANDERLA, G. Information i n 1985 Organization for economic cooperation and development Document 1973. 10. ANDERSON, O.W. Utilization Review American College of Hospital Acininistrators-Unpublished 11. ANDERSON, O.W. Toward a framework for analyzing health services systems Social and Economic Administration, 1:16, 1967. 12. ANDERSON, T.R. & WARKOV, S. Organizational size and functional complexity: a study of administration i n hospitals American Sociological Review, 26:23-28, 1961. 118 13. ATKINSON, P. et alv Medical Mystique: Interminacy and models of professional process University of Edinburgh, February 1973. 14. BADGLEY, R. F. et a l . International studies of health manpower: a sociological perspective Medical Care, Vol. 14, No. 3, pp. 235-252, 1971 15. BARKER, R. L. & BRIGGS, T. L. Differential use of social work manpower National Association of Social Workers, N.Y., 1968. 16. BARNES, L.W.C.S. The changing stance of the professional employee Industrial Relations Center, Queen's University, Kingston, October 1975, Research Series No. 29. 17. PAUERSCHMIDT, A. The hospital as a prototype organization Hospital Administration, Vol. 15, Spring 1970, pp. 6-14. 18. BAYLISS, D. Some recent trends i n forecasting Centre for environmental studies Working paper, Sept. 1968, London, N.W.I. 19. BERLANT, J. L. Profession and Monopoly: a study of Medicine i n the United States and Great Britain University of California, 1975. 20. BIANCO, E.A. The medical audit: powerful tool for upgrading care Hospital Progress, Vol. 51, pp. 72-74, July 1970. 21. BIDDLE, B.J. & THOMAS, E.J., Eds. Role Theory: concepts and research John Wiley & Sons, N.Y., 1966. 22. BLISHEN, B.H. Doctors and Doctrines University of Toronto Press, 1961. 23. BOGUSLAW, R. The new Utopians: a study of system design and social change Prentice-Hall, Englewood C l i f f s , N.J., 1965. 24. BRANDEIS, J.F. Health Informatics: Canadian experience '-.IFIP Medical Informatics Monograph Series Vol, 2. North Holland Publ. Co., Amsterdam 1976. 119 25. CAMPBELL, R.M. & HICHIN, D. The Delphi technique: implementation i n the corporate environment Management Services, Nov-Dec. 1968, pp- 37-42. 26. CANADA YEAR BOOK SERIES 27. CANADIAN COUNCIL ON HOSPITAL ACCREDITATION Guide for Hospital Accreditation Toronto 1972. 28. CANADIAN HOSPITAL ASSOCIATION Hospital Organization and Management Correspondence Course 1973-1975. 29. CARR-SAUNDERS, A.M. & WILSON, P.A. The Professions Frank Cass & Co., Oxford University Press 1964. 30. CASSELL, W.A. et a l . The development of a comprehensive computerized medical and s t a t i s t i c a l record linking system i n a total population Canadian Journal of Public Health, Vol. 61, May-June 1970. 31. CETRON, M.J. & BERNSTEIN, G.G. SEER: a Delphic approach applied to information procession Technological Forecasting and Social Change, Vol. 1, 1969, pp. 33-54. 32. CETRON, M.J. & RALPH, CA. Industrial applicationsof the technological forecasting Wiley & Sons, N.Y., 1971. ~ 33. CCCMBS, C.H. . A theory of data John Wiley & Sons, N.Y. 1964. 34. CRICHTON, A. HCEP 502 Class Notes 35. CYPHERT, R. & GRANT W.L. The Delphi-technique: a tool for collecting opinions i n teacher education The Journal of Teacher Education, Vol. 21, No. 3, 1970, pp 417-425. 36. ADJANI, J.S., SINCOFF, M.Z. & TALLEY, W.K. Stability and Agreement c r i t e r i a for the termination of Delphi studies Technological Forecasting and Social Change, Vol. 13, 1979 pp. 83-90 37. DALKEY, N.C. The Delphi study: an experimental study of group opinion The Rand Corporation, RM-5888-Pr., 1969. 120 3 8 . D A L K E Y , N . C . e t a l . S t u d i e s i n t h e q u a l i t y o f l i f e . L e x i n g t o n B o o k s , L e x i n g t o n , M a s s . , 1 9 7 2 . 3 9 . D A E S C H E L , W . F . D . W i l l C a n a d a a d o p t t h e u n i v e r s a l h e a l t h n u m b e r ? C a n a d i a n H o s p i t a l , V o l . 4 9 , N o . 3 , M a r c h 1 9 7 2 , p p 2 1 - 2 2 . 4 0 . D E C K E R , R. L . I j i m i t a t i o n s a s a m e t h o d o l o g i c a l d e v i c e F u t u r e s , V o l . 5 r N o . 3 , 1 9 7 3 , p p . 3 1 4 - 3 1 6 4 1 . D E C K E R , R . L . F u t u r e e c o n o m i c d e v e l o p m e n t s : a D e l p h i - s u r v e y F u t u r e s , V o l . 6 , 1 9 7 4 , p p . 1 4 2 - 1 5 2 . 4 2 . D E N S E N , P . M . T h e q u a l i t y o f m e d i c a l c a r e Y a l e J o u r n a l o f B i o l o g y a n d M e d i c i n e , V o l . 3 7 , J u n e 1 9 6 5 p p . 5 2 3 - 5 3 6 . 4 3 . DENTON, J . A . M e d i c a l S o c i o l o g y H o u l t o n M i f f l i n C o . , U . S . A . 1 9 7 8 4 4 . D e p a r t m e n t o f H e a l t h , E d u c a t i o n a n d W e l f a r e A m b u l a t o r y m e d i c a l c a r e r e c o r d s : u n i f o r m n a n i m u m b a s i c d a t a s e t P u b l i c a t i o n N o . 7 5 - 1 4 5 3 , R o c k v i l l e , M d . , A u g u s t 1 9 7 4 . 4 5 . D E R I A N , J . C . & M O R I Z E , F . D e l p h i i n t h e a s s e s s m e n t o f R & D p r o j e c t s F u t u r e s , V o l . 5 . , 1 9 7 3 , p p . 4 6 9 - 4 8 3 . 4 6 . D I C K E Y , F . G . T h e s o c i a l v a l u e o f p r o f e s s i o n a l a c c r e d i t a t i o n J A M A , V o l . 2 1 3 , J u l y 1 9 7 0 , p p . 5 9 1 - 5 9 3 . 4 7 . D C N A B E D I A N , A . P r o m o t i n g e q u a l i t y t h r o u g h e v a l u a t i n g t h e p r o c e s s o f p a t i e n t c a r e M e d i c a l C a r e , V o l . 6 , N o . 3 , 1 9 6 8 , p p . 1 8 1 - 2 0 2 . 4 8 . DOYON, L . R . , S H E E H A N , T . V . & ZAGOR, H . I . C l a s s r o o m e x e r c i s e i n a p p l y i n g t h e D e l p h i - m e t h o d f o r d e c i s i o n -m a k i n g S o c i o - e c o n o m i c P l a n n i n g S c i e n c e s , V o l . 5 , 1 9 7 1 , p p . 3 6 3 - 3 7 5 . 4 9 . D U N K L E Y , J . C e n t r a l i z a t i o n o f M e d i c a l R e c o r d H o s p i t a l A d m i n i s t r a t i o n i n C a n a d a , V o l . 1 4 , O c t . 1 9 7 2 . 5 0 . DURAND, J . A n e w m e t h o d f o r c o n s t r u c t i n g s c e n a r i o s F u t u r e s , V o l . 4 , 1 9 7 2 , p p . 3 2 5 - 3 3 0 . 121 51. ENZER, S. Deophi and cross-impact techniques Futures, Vol. 3, 1971, pp. 48-61. 52. ETZIONI, A. The semi-professions and their organizations The Free Press, N.Y., 1969. 53. FAMILY AND COMMUNITY MEDICINE INFORMATION SYSTEMS PROGRAM STEERING CCMVLITTEE Studies of f i l e handling and other staff a c t i v i t i e s , Patient record use and Patient v i s i t time i n the Family Practice offices, University of Toronto, December 1975. 54. FELDMAN, S. The administration of mental health services National Institute of Mental Health, Rockville Charles C. Thomas, Springfield, 111., pp. 161-162. 55. FEMINGER, L.D. Health Manpower and the education of health personnel Inquiry Supplement, March 1973, pp. 56-60. 56. FONTELA, E. & GABAS, A. Events.and Economic forecasting models Futures, Vol. 6., 1974, pp. 329-333. 57. FREIDSCN, E. Professional dominance: the social structure of medical care Atherton, N.Y., 1970. 58. FREIDSON, E. The professions and their prospects Sage Publ., Beverley H i l l s , C a l i f . , 1973. 59. FROCM, J. et a l . An integrated system of the recording and the retrieval of medical data i n a primary care setting The Family Medicine program, University of Rochester, Highlan Hospital - Unpublished form. 60. GORDON, G. Role theory and Illness College & University Press, New Haven 1966. 61. GORDON P.C. et a l . A model for the routine evaluation of a hospital program The N.S. Medical Bulletin, Oct. 1973, pp. 194-199. 62. GORDON, T.J. & HELMER, 0. Report on long-range forecasting study Rand Corporation, 1964. 122 63. GRIMES, R.M. & MOSELEY, S.K. An approach to an index of hospital performance Health Services Research, F a l l 1976, pp. 288-301. 64. GULTiTKSEN, H. Psychological scaling: theory and application John Wiley & Sons, N.Y., 1960. 65. HAHN, W.A. & GORDON, K.F. Assessing the future and policy planning Gordon & Breach Science Publ., N.Y. 1970. 66. HARDYMENT, A.F. Peer Group analysis: a form of medical audit Its role i n continuing medical education Canadian Medical Association Journal, Vol. 104, June 1971. pp. 104-106. 67. HARD, A.S. Methods of informatipn, .in medicine Journal of Methodology i n medical research -information  and documentation, Vol. 2, No. 1, Jan. 1972. — — 68. HEDLNGER, F.R. The systems approach to health services: a framework Health Care Research Series No. 11, University of Iowa, 1968. 69. HELMER, 0. The systematic use of expert judgment i n Operation Research Rand Corp.., Santa Monica, C a l i f , Sept, 1963. 70. HELMER, 0. Social,, Technology Basic Books Inc., Publ., N.Y. 1966. 71. HELMER, O. Analysis of the future: the Delphi-method Rand Corp., March 1967. 72. HELMERf 0. The cross-impact gaining Futures, Vol. 4, 1972, p. 159. 73. HELMER, O. Problems i n future research: Delphi and casual cross-impact analysis Futures, Vol. 9, 1977, pp. 17-31. 74. HELMER, 0. & RESCHEN, N. On the epistemology of the inexact sciences Rand Corp., R-353, Feb. 1960. 123 75. HESS, J.W. & LEFITT, M. New philosophers i n medical education: their effect on recognition of competence JAMA, Vol. 213, Aug. 16, 1970, pp. 1009-1012. 76. HICKS, J.T. The role of the Medical Record Librarian i n infection control procedures Hospital Management, Sept. 1969, pp. 48-62. 77. HILL, J.Q., & FOWLES, J. The methodological worth of the Delphi forecasting technique Technological Forecasting and Social Change, Vol. 7, 1975, pp. 179-192. 78. HOLDER, A.R. Failure to "keep-up": a negligence. JAMA, Vol. 224, No. 10, June 4, 1973. 79. HUCKFELDT, V.E. & JUDD, R.C. Issue i n large scale Delphi studies Technological Forecasting and Social Change, Vol. 6 1974, pp. 75-88. 80. HUFFMAN, E.K. Medical Record Management Physician Record Co., Berwyn, 111, 1972. 81. KELLER, T.F. The Hospital Information Systems Hospital Administration, Winter 1969, Vol. 14, pp. 40-50. 82. KILPATRICK. W.A. Professionalism, Unionism and you Paper delivered at the 1969 Annual Convention of the Canadian Association of Medical Record Librarians. 83. KNUTSON, A.L. The individual, society and health behavior Russell Sage Foundation, N.Y., 1965. 84. KRAUSE, E.A. The sociology of occupations L i t t l e , Brown & Co., Boston 1971. 85. KRAUSE, E.A. JPower and Illness: the p o l i t i c a l sociology of health and  medical care Elsevier, Amsterdam 1977. 86. LACBMAN, O. Personnel Adrrdnistration i n a Delphi-study Long Range Planning, June 1972, pp. 21-24. 124 8 7 . L A L O N D E , M . A n e w p e r s p e c t i v e o n t h e h e a l t h o f C a n a d i a n s G o v e r n m e n t o f C a n a d a , O t t a w a , A p r i l 1 9 7 4 . 8 8 . L A R S O N , M . S . T h e r i s e o f p r o f e s s i o n a l i s m : a s o c i o l o g i c a l a n a l y s i s U n i v e r s i t y o f C a l i f o r n i a P r e s s , B e r k e l e y 1 9 7 7 8 9 . L I E B E R M A N , J . K . .The t y r a n n y o f e x p e r t s W a l k e r & C o . , N . Y . , 1 9 7 0 . 9 0 . L I N S T O N E , H . A . & T U R O F F , M . , e d s . T h e D e l p h i - m e t h o d : t e c h n i q u e a n d a p p l i c a t i o n A d d i s o n - W e s l e y P u b . C o . , D o n M i l l s , Q n t . 1 9 7 5 9 1 . LIVESEY, F . H . I n s e a r c h o f a n i n t e g r a t e d m e d i c a l r e c o r d M e d i c a l R e c o r d N e w s . , V o l . 1 0 , N o . 4 . , N o v . 1 9 6 9 . 9 2 . L L O Y D , J . S . S t a t e r e g u l a t i o n o f h e a l t h p r o f e s s i o n s H o s p i t a l P r o g r e s s , V o l . 5 1 , M a r c h 1 9 7 0 , p p . 7 0 - 7 4 . 9 3 . MACEACHERN , M . T . H o s p i t a l O r g a n i z a t i o n a n d M a n a g e m e n t P h y s i c i a n s R e c o r d C o . , C h i c a g o 1 9 6 9 . 9 4 . MACK INNON, W . J . W e i g h t i n g f o r t h e f u t u r e : P r o s p e c t i n g t h e p o s s i b i l i t y o f w e i g h t i n g D e l p h i r e s p o n s e s w i t h a g g r e g a t e s o b t a i n e d b y t h e . S P A N m e t h o d F u t u r e s , V o l . 5 , 1 9 7 3 , p p . 3 0 3 - 3 1 3 . 9 5 . MARTTNO, J . W h a t c o m p u t e r s m a y d o t o m o r r o w T h e F u t u r i s t , O c t . 1 9 6 9 , p p . 1 3 3 - 1 3 5 . 9 6 . M C L E A N , M . D o e s t h e c r o s s - i m p a c t a n a l y s i s h a v e a f u t u r e ? F u t u r e s , V o l . 8 , 1 9 7 6 , p p 3 4 5 - 3 4 9 . 9 7 . M I L E S , I. S o c i a l f o r e c a s t i n g : f r o m i m p r e s s i o n s t o i n v e s t i g a t i o n F u t u r e s , V o l . 6 , 1 9 7 4 , p p 2 4 0 - 2 5 2 . 9 8 . MILKOvTGH, G . T . , ANNONI, A . J . & MAHONEY, T . A . T h e u s e o f t h e D e l p h i - p r o c e d u r e s i n m a n p o w e r f o r e c a s t i n g M a n a g e m e n t S c i e n c e , V o l . 1 9 , N o . 4 , P a r t I, 1 9 7 2 , p p 3 8 1 - 3 8 8 , 9 9 . M I L L E R S O N , G . T h e q u a l i f y i n g _ a s s o c i a t i o n s : a s t u d y o f p r o f e s s i o n a l i z a t i o n R o u t l e d g e & K e g a n P a u l , L o n d o n 1 9 6 4 . 125 1 0 0 . MOLNAR, D. & KAMMERUD, M . D e v e l o p i n g p r i o r i t i e s f o r i r t p r o v i n g t h e u r b a n - s o c i a l e n v i r o n m e n t : a u s e o f D e l p h i S ^ i o - e c o n c m i c P l a n n i n g S c i e n c i e s , V o . 9 , 1 9 7 5 , p p 2 5 - 2 9 . 1 0 1 . MONTGOMERY, E . B . , e d . T h e f o u n d a t i o n s o f a c c e s s t o k n o w l e d g e : a s y m p o s i u m S y r a c u s e U n i v e r s i t y , N . Y . 1 9 6 8 . 1 0 2 . MOORE, J . F . I n f o r m a t i o n t e c h n o l o g i e s a n d h e a l t h c a r e : t h e n e e d f o r n e w t e c h n i q u e s t o s u p p o r t t h e c o n v e y a n c e a n d u s e o f k n o w l e d g e A r c h i v e s o f I n t e r n a l M e d i c i n e , V o l . 1 2 5 , M a r c h 1 9 7 0 , p p . 5 0 3 - 5 0 8 , 1 0 3 . M O R R I S , G . K . F o r e c a s t i n g t h e i m p a c t o f s o c i a l c h a n g e L o n g R a n g e P l a n n i n g , J u n e 1 9 7 5 , p p 6 4 - 6 9 . 1 0 4 . N E E L E Y , B . J . M e d i c a l R e c o r d S e r v i c e s : p r e s e n t a n d f u t u r e M e d i c a l R e c o r d N e w s , V o l . 4 5 , N o . 2 , A p r i l 1 9 7 4 1 0 5 . OTTMANS, S . D . L i c e n s u r e b y c r i t e r i a e v a l u a t i o n J o u r n a l o f A m e r i c a n C o l l e g e o f D e n t i s t s , V o l . 4 0 , A p r i l 1 9 7 3 1 0 6 . P E N N E L L , " M . Y . S t a t u s o f c r e d e n t i a l i n g f o r h e a l t h p e r s o n n e l J o u r n a l o f A m e r i c a n D i e t e t i c A s s o c i a t i o n , V o l . 6 3 , J u l y 1 9 7 3 . 1 0 7 . P I L L , J . T h e D e l p h i - m e t h o d : s u b s t a n c e , c o n t e x t a c r i t i q u e a n d a n a n n o t a t e d b i b l i o g r a p h y S o c i o - e c o n o m i c P l a n n i n g S c i e n c e s , V o l . 5 . , 1 9 7 1 , p p 5 7 - 7 1 . 1 0 8 . P r o c e e d i n g s S i x t h I n t e r n a t i o n a l C o n g r e s s o n M i d i c a l R e c o r d , M e l b o u r n e 1 9 7 2 . 1 0 9 . P r o c e e d i n g s S e v e n t h I n t e r n a t i o n a l C o n g r e s s o n M e d i c a l R e c o r d T o r o n t o 1 9 7 6 . 1 1 0 . P R O F F I T T , J . R . A c c r e d i t a t i o n a s a s t a b i l i z i n g f o r c e i n a l l i e d h e a l t h p r o f e s s i o n s J o u r n a l o f t h e A m e r i c a n . M e d i c a l . A s s o c i a t i o n , V o l . 2 1 3 , J u l y 1 9 7 0 , p p 6 0 4 - 6 0 7 . 1 1 1 . R E I S M A N , A . e t a l P h y s i c i a n s u p p l y a n d s u r g i c a l d e m a n d f o r e c a s t i n g : a r e g i o n a l m a n p o w e r s t u d y M a n a g e m e n t S c i e n c e , V o l . 1 9 , N o . 1 2 , A u g u s t 1 9 7 3 , p p . 1 3 4 5 - 1 3 5 4 . 126 1 1 2 . R O S E N F I E L D , V . L . A c h r o n o l o g i c a l t e a m - o r i e n t e d p a t i e n t r e c o r d H o s p i t a l A d m L n i s t r a t i o n i n C a n a d a , V o l . 1 6 , N o . 6 , J u n e 1 9 7 4 1 1 3 . R O Z O V S K I , L . E . C a n a d i a n H o s p i t a l L a w C a n a d i a n H o s p i t a l A s s o c i a t i o n , T o r o n t o 1 9 7 4 1 1 4 . S A C K M A N , H . D e l p h i c r i t i q u e , E x p e r t o p i n i o n , F o r e c a s t i n g a n d G r o u p P r o c e s s L e x i n g t o n , B o o k s , L e x i n g t o n , M a s s . 1 9 7 5 . 1 1 5 . S C H N E I D E R , J . B . P o l i c y - D e l p h i : a n a p p l i c a t i o n T e c h n o l o g i c a l F o r e c a s t i n g a n d S o c i a l C h a n g e , V o l . 3 , 1 9 7 2 , p p . 4 8 1 - 4 9 7 . 1 1 6 . S H X N D E L , S . & LONDON, M . A m e t h o d o f h o s p i t a l u t i l i z a t i o n r e v i e w U n i v e r s i t y o f P i t t s b u r g h P r e s s , 1 9 6 6 . 1 1 7 . S I B L E Y , J . C . e t a l Q u a l i t y o f c a r e a p p r i a s a l i n p r i m a r y c a r e : a q u a n t i t a t i v e m e t h o d A n n a l s o f I n t e r n a l M e d i c i n e , 8 3 : 4 6 - 5 2 , 1 9 7 5 , 1 1 8 . S L A Y T O N , P . & T R E B I L C O C K , M . J . T h e p r o f e s s i o n s a n d t h e p u b l i c U n i v e r s i t y o f T o r o n t o P r e s s , 1 9 7 6 . 1 1 9 . S M I L , V . C h i n a ' s f u t u r e : a D e l p h i f o r e c a s t F u t u r e s , V o l . 9 , 1 9 7 7 , p p . 4 7 4 - 4 8 9 . 1 2 0 . SQMERS, A . R . T o w a r d s a r a t i o n a l c c r a n u n i t y h e a l t h c a r e : T h e H u n t e r d o n m o d e l . H o s p i t a l P r o g r e s s , A p r i l 1 9 7 3 . 1 2 1 . STANDER , A . & R I C K A R D S , T . T h e o r a c l e t h a t f a i l e d L o n g R a n g e P l a n n i n g , O c t . 1 9 7 5 , p p . 1 3 - 1 6 . 1 2 2 . STOVER , J . S u g g e s t e d i m p r o v e m e n t s t o t h e D e l p h i c r o s s - i m p a c t t e c h n i q u e F u t u r e s , V o l . 5 , 1 9 7 3 , p p . 3 0 8 - 3 1 3 . 1 2 3 . S T R A U S S , H . J . & Z I E G L E R , L . H . D e l p h i , P o l i t i c a l P h i l o s o p h y a n d t h e f u t u r e F u t u r e s , V o l . 7 , 1 9 7 5 , p p . 1 8 4 - 1 9 6 , 1 2 4 . S Z A B O , I. B a c c a l a u r e a t e P r o g r a m f o r H e a l t h R e c o r d A d m i n i s t r a t o r s , N o t r e Dame U n i v e r s i t y o f N e l s o n , 1 9 7 3 - 1 9 7 7 , u n p u b l i s h e d . 127 125. TASK FORCE ON THE FUTURE ROLE OF THE MEDICAL RECORD ADMINISTRATOR Final Report Medical Record News, Ap r i l 1974. 126. TAUBENHAUS, L.J. The hospital record as a tool for assessment of physician post-graduate education needs i n the cardio-vascular f i e l d Journal of the American Geriatric Society, Vol. 17, 1969 pp. 1025-1033. =' 127. TAUBENHAUS, L.J. The most promising resource i s the manpower that's already there Modern Hospital, Vol 15, Oct 1970, pp. 90-94. 128. THOMPSON, F.G. Saskatchewan seminar on future forecasting at Prince Albert, Sask. Canadian Plains Research Centre, University of Regina, Sask., 1974. 129. TORGERSON, W.S. Theory and Methods of scaling John Wiley & Sons, N.Y., 1960. 130. TUROFF, M. The design of a policy Delphi Technological Forecasting and Social Change, Vol. 2, 1970. 131. TWISS, B. ... Book Critique: The Delphi debate by Sackman, H. Futures, Vol. 9, 1977, p. 357. 132. VAN DE VEN, A.H. & DELBECQ, A.L. The effectiveness of nominal, delphi and interacting group decision-making processes Academy of Management Journal, Vol. 17, 1974, pp. 605-621. 133. VELLA, S. A brief history of medical record keeping Medical Record News, Vol. 11, No. 4, Nov. 1970. 134. VOLLMER, H.M. & MILLS, D.L. Professionalization : lErentice-Hall, Englewood C l i f f s , N.J. 1966. 135. WALLACE, J.D. The pulse of the hospital efficiency Canadian Hospital, Vol. 50, No. 8, August 1973. 136. WEED, L.L. Medical Records that guide and teach New England Journal of Medicine, Vol. 278: 593-600, March 14, 1968 and 278:652-657, March 21, 1968. 128 137. WEED, L. L. Medical Records, Medical Education and Patient Care Western Reserve Press, Chicago 1969. 138. WEINERMAN, E.R. The quality of medical care American Academy of P o l i t i c a l and Social Sciences Annals, Vol. 273, 1951, pp. 185-191. 139. WELTY, G. Plato and Delphi Futures, Vol. 5, 1973, pp. 281-286. 140. JUDD, R.C. The use of Delphi i n Higher Education Technological Forecasting and Social Change, Vol. 4, 1973, p, 173, 141. WILENSKY, H.L. The Professionalization of Everyone American Journal of Sociology, Sept. 1970, pp. 137-58 142. GREENE, R. Assuring Quality i n Medical Care Ballinger Publ., Cambridge, Mass., 1976. 143. HALL, 0. 1 The Paramedical Occupations i n Ontario A study for the committee on the Healing Arts Queen's Printer, Toronto, 1970. 144. WILENSKY, H.L. Intellectuals i n Labor Unions The Free Press Publ., Glencoe, 111, 1956. APPENDIX 1 THE UNIVERSITY OF BRITISH COLUMBIA 2075 WESBROOK MALL VANCOUVER, B.C., CANADA Department of Health Care and Epidemiology 1 AUgUSt 1978 FACULTY OF MEDICINE HEALTH SCIENCES CENTRE Dear I am organizing a Delphi study on the future r o l e of today's Health Record Administrators. The study consists of three rounds of i n q u i r y with c o n t r o l l e d feedback of the responses received. Generally, the Delphi technique i s used to obtain some form of concensus,however, I believe that the probably wide range of outlooks and opinions w i l l also be very constructive,, There w i l l be approximately 35 panel members from across Canada, and some from the United States, a l l r e l a t e d to the health f i e l d . I should l i k e to i n v i t e your p a r t i c i p a t i o n as a panel member. The r e u l t s may have quite some impact upon the education of the HRAs. To give you a c l e a r e r idea of what i s expected of a panel member, I enclose the material f o r Round 1, and hope that you w i l l be i n t e r e s t e d i n p a r t i c i p a t i n g i n t h i s educational p r o j e c t . I thank you i n a n t i c i p a t i o n . (Mrs.) Irma Szabo, Consultant i n HRA. N.B. THere i s a d i s t i n c t p o s s i b i l i t y that I w i l l - use t h i s study f o r p u b l i c a t i o n and/or t h e s i s purposes. Enclosure. 1 3 0 T H E U N I V E R S I T Y O F B R I T I S H C O L U M B I A Health Sciences Centre Focuhy of Medicine DEPARTMENT OF HEALTH CARE AND EPIDEMIOLOGY Vancouver; Canada DEFINITION OF THE EXPERTISE OF THE HEALTH RECORD ADMINISTRATORS AS PROJECTED APPROXIMATELY TEN YEARS INTO THE FUTURE. Philosophy: The study i s based on the assumptions that a a well-organized health care d e l i v e r y system w i l l b enefit the patients as w e l l as the providers of care, u l t i m a t e l y , s o c i e t y , and that the Health Record Administrators can and should contribute to t h i s organization. Major Goal: i s to describe the future r o l e and expertise of today's Health Record Administrators (formerly Medical Record L i b r a r i a n s ) as seen to evolve over the next ten years by the various classes of health p r o f e s s i o n a l s i n terms of t h e i r s p e c i f i c needs f o r and expectations of. HRA s e r v i c e s . Method.: The Delphi technique i s used as i t affords a structured communication medium among the various health groups whose opinions can thus be brought into an arena of discussion without the psychological influences at play i n face-to-face meetings, and with the b e n e f i t of disregarding geographical distances. These various groups have been selected from the f i e l d s of medicine, government, administration, education, health agencies, a l l i e d health and current HRA p r a c t i t i o n e r s . The Study: a) Base: the present s i t u a t i o n i s expressed i n terms of e x i s t i n g r e l a t i o n s h i p s binding the HRA to the i n t e r n a l environment of the i n s t i t u t i o n and to the external environment of the health i n -dustry and of so c i e t y , as w e l l as i n terms of postulated future - r e l a t i o n s h i p s to he developed by v i r t u e of the expertise the HRA could b r i n g i n t o c e r t a i n areas i n which HRA services are s t i l l l a r g e l y unknown. 1 3 1 - 2 -b) External Context: the s c i e n t i f i c , technological, legal, p o l i t i c a l and social influences and pressures dictating changes to the health industry over the next ten years. c) Internal Context:means the health industry i t s e l f ; some changes w i l l be implemented as a result of the above forces, others w i l l be self-generated, as for example: accreditation, professional standards, quality of care. d) Progression: Modifications of the present role may entail the decrease, respectively the increase of certain functions in im-portance and in sensitivity; more crucially, some additional functions w i l l emerge. Actual construction of images of the future i s encouraged, as these should describe organized parts of an integrated national health care system (international?). Whereas some concensus may seem desirable with regard to the definition of the future role of the HRA, the range of viewpoints may be:, perhaps, of greater interest. Instructions: To give some structure to the study, a l i s t of the HRA relationships with specific areas of functioning is presented, but i t is certainly not exhaustive. For each one of these areas of function, you are invited to state the future active role-behaviors expected by your class of health professionals and specifically by you as a panel member. a) you may wish to by-pass some items on the l i s t at round 1; you may feel free to respond to these at the subsequent rounds; b) please use active verbs to f a c i l i t a t e the collation of information and the feedback; c) to each item to which you respond, limit your contribution to five role-behaviors; d) please feel free to add any other areas of funtion which you feel are important; 132 - 3 -e) please use the c r i t e r i o n of " d e s i r a b i l i t y " i n opposition to " l i k e l i h o o d " or " f e a s i b i l i t y " , i n terms of the needs of an organized health industry. To allow f o r the organization of the study, the following datelines are suggested: Round 1 due September 15 Round 2 October 31 Round 3 December 15. Round 1: i s a brain-storming session; you may wish to add to the l i s t any other areas of function which you think should be r e l a t e d to the HRA. Round 2: you w i l l r e c e ive a c o n t r o l l e d feedback of the r e s u l t s of Round 1, and w i l l be asked to consider the responses of the majority; you may wish to r e t a i n your previous p o s i t i o n or you may decide to j o i n the majority. Round 3: you w i l l again receive a feedback of the previous round and asked to e s t a b l i s h p r i o r i t i e s on the basis of a c r i t e r i o n of " d e s i r a b i l i t y " . Thank you i n advance ! Please contribute e a r l y ! July 1978. CONFIDENTIALITY IS PROMISED: NO RESPONSE CAN EVER BE TRACED BACK TO AN INDIVIDUAL PANEL MEMBER. 133 LIST OF HRA AREAS OF FUNCTION 1. HRA & Q u a l i t y of Care Programs: 2. HRA & Research and Studies: medical, nursing, social; retrospective, prospective: 134 - 2 -3. HRA & Ambulatory and Home Care Programs: 14. HRA & A l l i e d Health Professions: 5. HRA & Health Information Systems: HRA & Computerized Records: HRA & Health Information Linkage / HRA & A c c r e d i t a t i o n : 136 _ li -9. HRA & Management, institutional and departmental: 10. HRA & Policy formulation re health Information: 11. HRA & Admitting and other health record-keeping departments: 12. HRA & Cost-effectiveness: 13. HRA & Schools and Industries' Health Records: 137 11.. HHA & Health Agencies (for example: Canadian Arthritis Society, etc. 13E - 6 -IS. HRA & Confidentiality of Health Information: 16. HRA & Government reporting: 17. HRA & Vital Statistics: 139 - 7 -18. HRA & Public Health: 19. HRA & Preventive Care 20. HRA & Health Law 140 APPENDIX 2 LIST OF HRA AREAS OF FUNCTION HRA & Qu a l i t y of Care Programs: Quality of Care Programs rely heavily on measurement, evaluation and feedback. Therefore, the informational content of such programs is invariably large. The importance of informational matters in Quality of Care Programs automatically determines the involvement of HRA's in this area. F i r s t l y , the HRA is (^involved ,V/ith the mechanical aspects of c l i n i c a l data recording. Secondly.^the^'HRA is in an excel lent posit ion to .recommend' • ways to extract those parameters from the records which are the mos"t" appropriate for qual i ty of care evaluation. Thirdly, the HRA should be involved in the planning of new systems which are s pec i f i c a l l y constructed for the purposes of monitoring qual i ty of care. Often in these cases the con f i den t i a l i t y , ethical and psychological obstacles are more severe than o rd ina r i l y . HRA & Research and Studies: medical, n u r s i n g , s o c i a l ; r e t r o s p e c t i v e , p r o s p e c t i v e : The HRA i s , and w i l l develop further into an invaluable assistance to researchers. In par t i cu la r , the HRA's f am i l i a r i t y with the data content of the records and the form in which they are recorded can provide invaluable assistance for those who are doing retrospective studies. For prospective studies, such assistance is no less valuable especial ly when data which is not ord inar i l y recorded must be gathered. The HRA's influence can be brought to bear to make research data recording compatible with c l i n i c a l data recording and so making everybody's l i f e much easier. Such voluntary standardization of data recording methods and formats could save large amounts of money, and in general make research and studies much more cost e f fect i ve . 141 - 2 -3. HRA & Ambulatory and Home Care Programs: At the present time ambulatory and Home Care Programs operate only with the most rudimentary recording systems. However, th is i s going to change as one can see the signs of computerized data co l lec t ion and recordkeeping systems emerging to serve this area. The experience of the HRA and her f am i l i a r i t y with the methodology and technology of recordkeeping should be a major resource in the planning process of such systems. This implies, however, that HRA's must learn a l o t more about Ambulatory and Home Care Programs since they have t r ad i t i ona l l y not been deeply involved with them. h. HRA & Allied Health Professions: There i s no doubt at a l l that .HRA's are going to be involved with a l l Health Professions to an increasing extent. This w i l l come about for two reasons. F i r s t l y , the data needs of Health Professions w i l l generally increase. Secondly, as HRA's become better qua l i f i ed and become more i dent i f i ab l y the experts in a l l aspects of data co l lec t ion _.._and recordkeeping, they w i l l be approached more often for both service -and advice. I believe that the crucia l point here is that the relat ionship of HRA's-with other Health Professions w i l l very much depend on the image the HRA's w i l l be able to develop for themselves in the health care system. The basis of a posit ive professional image is undoubtedly high professional qua l i f i cat ions and involvement. 5. HRA & Health Information Systems: Unti l f a i r l y recently, HRA's largely res t r ic ted themselves to hospital medical recordkeeping. . It |s quite clear now that our informational needs w i l l increasingly encompass'the entire health care system. It i s also clear that i t i s nonappropriate anymore to think only in terms of medical information as many other data related to l i f e s t y l e , the environment, social and economic aspects and others i s also i s of prime concern in any system that reports to deal with health and not sickness exclus ively. Thus, i t appears that the HRA should f u l f i l l a role here that i s a d i rect extension of the HRA's role in the hospital system. Nevertheless, i t again should be remembered that such a role in planning, development and perhaps future management of the health information system and i t s components can be achieved only i f the education and professional interest of the HRA encompasses the unfamiliar elements in the health care system. 142 - 3 -6. HRA & Computerized Records: The successful appl ication of computerization to health or medical records requires varied expertise. Such expertise must de f i n i te l y include both the information technology and the health care system data and informational methods. These l a t t e r should come from HRA's. It is highly desirable to have data and information experts in every i n s t i t u t i on contemplating computerization of i t s records. Such experts must understand the objectives of the i n s t i tu t i on and a l l facets of i t s operation, especial ly in terms of i t s data and informational needs. Only then can they interpret these needs for the computer experts for the i r design and planning. It i s also important that computerization ef for t s by s c i e n t i f i c and engineering personnel be monitored.by data experts. Thus i t appears that HRA's have a continuing leadership role in the computerization process. 7. HRA & Health Information Linkage: This area-has-been t r ad i t i ona l l y of interest to HRA's. As we move toward more v. in teg ra ted/heal th care systems and health care information systems, the need'fo'r record linkage is going to become more and more acute. The mechanics of suchjjinkage i s never easy to solve and HRA's have a natural role to play. " 8. HRA & Accreditation: 143 - U -9. HRA & Management, institutional and departmental: I b e l i e ve t h a t , at l e a s t i n p a r t , the HRA's r o l e i s manager ia l . The HRA must be part_of„.the-.dec-is-ion-mak.ing.-process s i nce tn - the ho sp i t a l and o t h e r l n s t i t u t i o n s the i n fo rmat i ona l and data component i s very l a rge in most i n s tances . I t i s , t h e r e f o r e , expected tha t HRA's w i l l i n c r e a s i n g l y be c a l l e d upon to p a r t i c i p a t e i n managerial dec i s i on s and, conve r se l y , they w i l l a l s o have to i n s i s t tha t t h e i r vo ice be heard i n a l l matters concerning t h e i r areas of p ro fe s s i ona l competence. In the past , there have been many mistakes made because such d i r e c t managerial i nput was ne i t he r requested nor demanded i n p lanning and ope ra t i ona l matters regard ing data and i n f o rmat i on . In some sense, the HRA's managerial r o l e i s going to be p i v o t a l i n the development of hea l th in fo rmat ion systems i n i n s t i t u t i o n s and departments. 10. HRA & Policy formulation re health Information: This quest ion must be answered in connect ion w i th Item 9 above. The HRA's involvement i n p o l i c y fo rmu la t i on regard ing hea l th i n fo rmat ion i s one of the managerial r o l e s . 11. HRA & Admitting and other health record-keeping departments: I 144 - 5 -12. HRA & Cost-effectiveness: 13. HRA & Schools and Industries' Health Records: Ik. HRA & Health Agencies (for example: Canadian Arthritis Society, etc.: 145 - 6 -15. HRA & Confidentiality of Health Information: Conf ident ia l i ty of health records has always been a prime concern of HRA's. As systems become more complex and computerized, con f ident i a l i t y problems w i l l undoubtedly increase. With th i s , there w i l l also be an increased need for individuals who f u l l y understand the con f ident ia l i t y implications of information stored and used in large inter-connected systems. Because of professional inTerest and t r ad i t i on , the HRA is the person to step into this ro le , >'Of course, the con f ident ia l i t y issue has many other aspects__and w i f l demand great f a m i l i a r i t y with not only the t rad i t iona l health record concerns but also with health care system organization, medical and paramedical concerns, health information ' systems, and computerization. l6. HRA & Government reporting: 17. HRA & Vital Statistics: 146 - 7 -18. HRA & Public Health: 19. HRA & Preventive Care 20. HRA & Health Lav ©EPTVOF HEALTH CARE & EPIDEMIOLOGY FACULTY OF MEDICINE J • UNIVERSITY OF BRITISH COLUMBIA / VANCOUVER 8, B. C. APPENDIX . FEEDBACK OF ROUND.1. 29 responses were received from 1J5 people contacted. From the r e s -ponses, the verbs and nouns expressing actions were abstracted and categorized with the use of the Randomhouse d i c t i o n a r y and the Roget Thesaurus Dictionary-form. Six main categories emerged and these were adopted throughout t h i s feedback. They are; Category 1: This category describes a p a r t i c i p a t o r y r o l e f o r the HRA: Words used by panel members: " a s s i s t , get involved, p a r t i c i p a t e , c o l l a b o r a t e , f u n c t i o n , contribute, work with;' The key word chosen to represent t h i s category i s : PARTICIPATE. Category 2: This category describes and administrative r o l e f o r the HRA: Words used by panel members:" design, d e v e l o p , . i n i t i a t e , plan, provide, organize, s t r u c t u r e , d i r e c t , fund, devise, evolve, oversee, dispense, administer, manage, handle, implement, expand, conduct, supervise, prepare, set up, define, construct-, i d e n t i f y issue, establish,," Key word: ORGANIZE. Category 3: This category describes an i n t e g r a t i v e r o l e : Words used: " i n t e g r a t e , l i n k , l i a i s e , mediate, coordinate consolidate, exchange information" Key word: INTEGRATE. Category k: This category describes an advisory and educational r o l e : Words used: "advise, consult, recommend, stimulate, encourage, promote, educate". Key word: ADVISE.. Category 5: This category describes an evaluative r o l e : Words used: " follow-up, screen', i d e n t i f y compliance, evaluate, review, monitor, v a l i d a t e , standardize". Key word: EVALUATE. 148 - 2 -Category 6 : This category describes today's r o l e , p r e d i c t i n g no change i n the future r o l e of the HRA. Words used: "supply, data, prepare data, r e t r i e v e , code" Key word: NO CHANGE. These main s i x categories w i l l be used uniformly throughout t h i s feedback f o r each one of the 20 areas of fu n c t i o n or subjects; ad-d i t i o n a l categories w i l l be used only where the responses do not f a l l i n t o any one of the above. The responses were counted as follows: most respondents contributed several ideas to each area of function or subject; i f these responses . f e l l i n t o any of the above categories, one score was assigned to each category represented; f o r example, i f one respondent wrote, within the same area of f u n c t i o n : - organize program; - evaluate according to pre—set standards ; - encourage h e a l t h workers; then, one.score was added to Categories: 2, 5, ^» r e s p e c t i v e l y ; i f , however, a respondent wrote; within the same area of f u n c t i o n : - i n i t i a t e program; - provide f o r budget funds; - administer program; then only one score was added to Category 2. For Areas of f u n c t i o n l e f t blank, no score was entered. The responses, i n general, communicated three major ideas: 1) the concept of " t o t a l p a t i e n t " , therefore of t o t a l record to document the c o n t i n u i t y of care and the i n t e g r a t i o n of s e r v i c e s ; 2) the concept of unique p a t i e n t i d e n t i f i e r ; 3) the d e c e n t r a l i z a t i o n of the HRAs to the wards or "action-centres". As each key word -or i t s synonym- was used with m o d i f i e r s , as sample sentence w i l l i l l u s t r a t e i t s i n t e r p r e t a t i o n . The main modifier o f "better education" i s of course the main reason f o r t h i s study. * * * * * 149 - 3 - . RESULTS FOR ROUND 1 NTJMTVFR OF AREAS OF FUNCTION AND CATEGORIES RESPONSES 1. HRA & QUALITY OF CARE PROGRAMS: Categories: 1. PARTICIPATE actively in .all quality of care committees 19 2. ORGANIZE hos p i t a l , regional, provincial and inter-national audits 16 3- INTEGRATE - coordinate long term effects of care 2 h. ADVISE re f e a s i b i l i t y of reviews 6 5. EVALUATE -compare with reported standards and monitor at regional, provincial and higher levels 11 6. NO CHANGE- col l e c t , abstract data, store, retrieve 6 7. The role of the HRA w i l l diminish due to'"the implementation of an "immediate-response" system. 1 2. HRA & RESEARCH AND STUDIES: Categories: 1. PARTICIPATE in a l l studies providing organization and s t a t i s t i c a l knowledge 15 2. ORGANIZE - I n i t i a t e studies on basis of preliminary survey reports 10 3. INTEGRATE - coordinate research projects 10 k. ADVISE re format of studies, validity and r e l i a b i l i t y , significance of s t a t i s t i c a l findings 9 5. EVALUATE 6. NO CHANGE: supply data as needed 2 3. HRA & AMBULATORY AND HOME CARE PROGRAMS: 1. PARTICIPATE - HRA to get involved in setting up administration 6 2. INITIATE- Plan standardized information system and adminis-ter department Ik 3. INTEGRATE with inpatients' information system 17 k. ADVISE - HRA major resource in planning for programs 1 5. EVALUATE - Review and audit programs . 3 6. NO CHANGE 7. No involvment of HRA necessary . 2 150 - It -AREAS OF FUNCTION AND CATEGORIES NUMBER OF RESPONSES k'. HRA & ALLIED HEALTH PROFESSIONS: Categories: 1. PARTICIPATE as a c t i v e member of the health care team i n reviews and audits 10 2. ORGANIZE and develop i n t e r - p r o f e s s i o n a l reviews h 3. INTEGRATE - provide coordination needed f o r team care 8 k. ADVISE and educate re documentation requirements, matters of p o l i c y and law 8 5. EVALUATE according to pre-set standards 2 6. NO CHANGE 7. Computer documentation of lab. r e s u l t s . Pharmacy r e q u i s i t i o n s only. 1 8. Maintains l i c e n s i n g r o s t e r 1 5. HRA & HEALTH INFORMATION SYSTEMS: 1. PARTICIPATE - c o l l a b o r a t e with systems analysts and management engineering group i n designing h e a l t h information system 6 2. ORGANIZE - design and implement health information systems at the. organization, region,^.province and higher l e v e l s 16 3. INTEGRATE - coordinate with community and higher systems 5 k. ADVISE re linkage of health information ' 3 5. EVALUATE - monitors system as part of the n a t i o n a l health care d e l i v e r y system h 6. NO CHANGE: supply data only 2 6. HRA & COMPUTERIZED REPORTS: 1. PARTICIPATE: - c o l l a b o r a t e with computer and h e a l t h p r o f e s s i o n a l s i n s e t t i n g up system 10 2. ORGANIZE - c o n t r o l of acces to information 17 3. INTEGRATE - mediate between health and computer pr o f e s -s i o n a l s and i n t e r p r e t needs and outputs 9 k. ADVISE computer p r o f e s s i o n a l s and department heads re development of system; also re e t h i c a l and l e g a l p o s i t i o n h 5. EVALUATE - monitor outputs, ensure r e l i a b i l i t y k 151 - 5 -, ' » • NUMBER OF AREAS OF FUNCTION AND CATEGORIES RESPONSES 7. HRA & HEALTH INFORMATION LINKAGE  Categories: 1. PARTICIPATE in establishment and setting of guidelines 7 2. ORGANIZE exchange of information, access methods, databanks - i n i t i a t e long term follow-up 15 3. INTEGRATE with higher systems 6 h. ADVISE governments re planning and common identifier 5 5. EVALUATE - monitor physicians and patients' p r o f i l e s -standardize health data 5 6 . NO CHANGE - supply accurate information quickly 1 8. HRA & ACCREDITATION 1. PARTICIPATE as member of accreditation survey team 13 2. ORGANIZE - coordinate information to determine care given in the hospital 1 3. INTEGRATE - interpret accreditation requirements 2 ADVISE re compliance with Health Discipline Act, with accreditation standards k 5. EVALUATE - monitor standards of accreditation; of health information systems functioning i n terms of legal and societal standards 13 6 . NO CHANGE 7. Lesser role due to implementation of "immediate-response" system - more attention paid to use of information than to recording and storage 2 9. HRA & MANAGEMENT, INSTITUTIONAL. AND DEPARTMENTAL 1. PARTICIPATE in management problem-solving at senior level 13 2. ORGANIZE - direct health information system and department ' 13 3. INTEGRATE smaller institutions into: regional system; act as liaison between departments re functioning of health information system 6 k. ADVISE - consultant re standards, policy-formulation with respect to the health information system . • 2 5. EVALUATE production measurements 3 6 . NO CHANGE in organization of Medical Record Departments 1 152 - 6 -AREAS OF FUNCTION AND CATEGORIES 10. HRA & POLICY FORMULATION RE HEALTH INFORMATION  Categories: 1. PARTICIPATE- involvment in policy formulation re health information systems one of major roles-2. ORGANIZE - i n i t i a t e and develop organization-wide policy re health information 3. INTEGRATE - work with provincial authorities h. ADVISE re formulation policy, ethic standards and . legislation 5. EVALUATE - review present policies - Monitors implementation 6. NO CHANGE - Supply data to Medical Advisory Committee to formulate policy 11. HRA & ADMITTING AND OTHER HEALTH RECORD-KEEPING DEPARTMENTS 1. PARTICIPATE -.2. ORGANIZE - direct patient information centres 3. INTEGRATE - coordinate - provide link re inter-departmental needs k. ADVISE hospital, provincial and national levels re standardization of information 5. EVALUATE - ensure federal, provincial and accreditation standards- Monitor health information system cutting accross departmental lines .6. NO CHANGE NUMBER OF RESPONSES 11+ h l 3 1+ 12 12 2 12. HRA & COST-EFFE CTIVENESS 1. PARTICIPATE - cooperate with financial department in developing cost-effectiveness on specific diseases 9 2. ORGANIZE - control of own department - Justification of costs of health information programs 9 3. INTEGRATE - cross-comparisons of health and financial data-coordinate units of health care with costs 5 k. ADVISE - make recommendations re costs of treatment patterns • 2 5. EVALUATE through u t i l i z a t i o n committees - Programs evaluation 3 6. NO CHANGE - No role 3 153 _ . NUMBER OF AREAS OF FUNCTION AND CATEGORIES RESPONSES 13. HRA & SCHOOLS AND INDUSTRIES HEALTH RECORDS: Categories: 1. PARTICIPATE: in epidemiological studies and research on long-term basis 2 2. ORGANIZE and develop documentation services - 11 3. INTEGRATE - link with active health information system of community, region, etc. 11 k. ADVISE organizations other than the health industry with regard to health information systems and policies 7 5. EVALUATE - audit care given outside health industry-monitor on long-term basis, particularly high risk groups k Ik. HRA & HEALTH AGENCIES 1. PARTICIPATE in research, studies 3 2. ORGANIZE - provide health information services - Set up standard of health information management 9 3. INTEGRATE into community, regional health information sys-tem- Direct link between agencies and curative system 17 k. ADVISE and consult on health planning at municipal and provincial levels- Consult to agencies on h.i.s. 6 5. EVALUATE - audit care rendered in non-health settings 3 6. NO CHANGE - no role 1 15. HRA & CONFIDENTIALITY OF HEALTH INFORMATION 1. PARTICIPATE - assist health care professionals in main-taining confidentiality 3 2. ORGANIZE- formulate policy re privileged information -control access to and release of health information 15 3. INTEGRATE . • ' UT\ ADVISE - educate public and hospital staff re legal and confidentiality requirements " ' 5 5. EVALUATE - monitor implementation of policy -uphold standards 11 154 NUMBER OF AREAS OF FUNCTION AND. CATEGORIES RESPONSES 16. HRA & GOVERNMENT REPORTING  Categories: 1. PARTICIPATE- collaborate in reporting information to account for hospital operation- Work with governments k 2. ORGANIZE accurate reporting system 12 3. INTEGRATE government-reporting into hospital's s t a t i s -t i c a l system 7 k. ADVISE and recommend streamlined systems to governments 2 5. EVALUATE - analyze aggregate data for comparisons among institutions - identify deviations 3 6. NO CHANGE - no role • 2 17. HRA & VITAL STATISTICS 1. PARTICIPATE in organization of epidemiological studies, follow-up studies; invoiced in system or-ganization k 2. ORGANIZE and supervise integrated system h 3. INTEGRATE into general health information system 9 k. ADVISE - recommend collection, storage, retrieval system consult in' system design 3 5. EVALUATE- analyze trends, rates h 6. NO CHANGE - no role 1 18. HRA & PUBLIC HEALTH 1. PARTICIPATE in epidemiological, genetic studies -assume reporting role k 2. ORGANIZE - develop information systems with coordination as aim - provide management services 3 3. INTEGRATE - link with total health information system 17 it. ADVISE on system management ....... 2 5. EVALUATE - analyze data- identify trends, conditions, hazards - evaluate care rendered in public health outlets according to standards h 155 - 9 -• NUMBER OF AREAS OF FUNCTION'AND CATEGORIES R E S P 0 N S E S 19. HRA & PREVENTIVE CARE  Categories: 1. PARTICIPATE i n screening programs and analyze data -also i n epidemiological studies k 2. ORGANIZE p r o v i s i o n o f information - major f u n c t i o n as s h i f t from episodic toward p r e v e n t i v e - s o c i a l -l i f e - s t y l e o r i e n t a t i o n 5 3. INTEGRATE - coordinate system of data generation and evaluation with t o t a l system 8 k. ADVISE re information management 1 5. EVALUATE - survey e f f e c t s of .preventive measures -monitor system ' - 2 20. HRA & HEALTH LAW 1. PARTICIPATE i n law seminars 1 2. ORGANIZE - lobby f o r l e g i s l a t i o n p e r t a i n i n g to health information - D i r e c t input into law formulation 6 3. INTEGRATE k. ADVISE re s t a f f implementation of health laws -educate s t a f f re l e g a l requirements - Leadership r o l e 13 5. EVALUATE - monitor i n s t i t u t i o n - w i d e knowledge of health laws and law abidance - i d e n t i f y need f o r s t a f f education 9 60 NO CHANGE - 2 FACULTY OF MEDICINE UNIVERSITY OF BRITISH COLUMBIA APPENDIX VANCOUVER 8, 3. C. ROUND 2 TASKS In Round 2, the AREAS OF FUNCTION OR SUBJECTS and the GATEGORIES as described in the feedback w i l l be presented to you in a matrix form.. Your tasks w i l l be: 1. Please l i s t your p r i o r i t i e s among the categories by using the code 1,2,3 to respectively indicate the three categories you judge are most expressive in terms of the future with respect to each .area ;• of function. 2. Please indicate on self-appraisal scale your expertise i n each area of function by c i r c l i n g the appropriate code number. 3. Please indicate on the single five-point scale at the end your expertise i n Health Record Administration by c i r c l i n g the ap-• propriate number. h. I f you wish to comment on the feedback, please f e e l free to do so on the blank page attached for this purpose. Make your comments objective, so they can be fed back into the system! * * * * * APPENDIX i+ ROUND 2. TASKS AREAS OF FUNCTION OR SUBJECT C a t e g o r i e s SELF-APPRAISAL SCALE . . RE AREAS OF FUNCTION. ( c i r c l e the appropriate code number.) 1. PARTICIPATE 2. ORGANIZE 3. INTEGRATE U. ADVISE 5. EVALUATE 6. NO CHANGE 7. OTHERS (in d i c a t e your three choices by propriate entering 1,2 or 3 i n the ap-columns.) 1. HRA & .. QUALITY OF CARE PROGRAMS Not knowledgeable 1 Knowledgeable 2 * Expert 3 : 2. HRA & RESEARCH AND STUDIES • Not knowledgeable 1 Knowledgeable 2 Expert 3 3. HRA & AMBULATORY AND HOME CARE PROGRAMS Not knowledgeable 1 Knowledgeable 2 -'. Expert 3 U. HRA & ALLIED HEALTH PROFESSIONS Not knowledgeable 1 .; Knowledgeable 2 Expert 3 5. HRA & HEALTH INFORMATION SYSTEM Not knowledgeable 1 • Knowledgeable 2 Expert 3 6. HRA & COMPUTERIZED RECORDS ' Not knowledgeable 1 Knowledgeable 2 Expert 3 7. HRA & HEALTH INFORMATION LINKAGE Not knowledgeable 1 Knowledgeable 2 Expert 3 - 2 -AREAS OF FUNCTION OR SUBJECT C a t e g o r i e s ! 1. PARTICIPATE 2. ORGANIZE 3. INTEGRATE k. ADVISE 5. EVALUATE 6. NO CHANGE 7. OTHERS SELF-APPRAISAL SCALE • \ . RE AREAS OF FUNCTION. : 8. HRA & ACCREDITATION Not knowledgeable 1 1; Knowledgeable 2 i Expert 3 ;'• 9. HRA & MANGEMENT, INSTITUTIONAL AMD DEPARTMENTAL Not knowledgeable 1 \ Knowledgeable 2 ' Expert 3 \ 10. HRA & POLICY FORMULATION RE HEALTH INFORMATION Not knowledgeable 1 Knowledgeable 2 Expert 3 • 11. HRA & ADMITTING AND OTHER HEALTH RECORD KEEPING DEPTS Not knowledgeable 1 Knowledgeable 2 Expert 3 12. . HRA & COST EFFECTIVENESS Not knowledgeable 1 Knowledgeable 2 Expert • 3 13, HRA & SCHOOLS AND INDUSTRIES HEALTH RECORDS Not knowledgeable 1 Knowledgeable 2 Expert 3 lU. HRA & HEALTH AGENCIES Not knowledgeable 1 Knowledgeable 2 Expert 3 15. HRA & CONFIDENTIALITY OF HEALTH INFORMATION Not knowledgeable 1 Knowledgeable 2 Expert 3 16. HRA & GOVERNMENT REPORTING Not knowledgeable 1 Knowledgeable 2 Expert 3 03 - 3 -AREAS OF FUNCTION OR SUBJECT C a t e g o r i e s • QT?T TT A P P R A T C A T C P A T T ? 1. PARTICIPATE 2. ORGANIZE 3. INTEGRATE k. ADVISE 5. EVALUATE 6. NO CHANGE 7. OTHERS re AREAS OF FUNTION. . ; IT. HRA & VITAL STATISTICS Not Knwledgeable 1 Knowledgeable 2 ; Expert 3 18. HRA & PUBLIC HEALTH • Not knowledgeable 1 Knowledgeable 2 j Expert 3 19. HRA & PREVENTIVE CARE Not knowledgeable 1 Knowledgeable 2 Expert 3 20. HRA & HEALTH LAW Not knowledgeable 1 Knowledgeable 2 '. . Expert 3 * # * * * SELF-APPRAISAL SCALE RE HEALTH RECORD ADMINISTRATION Please circle the appropriate number of the scale: 1. 2. 3. • 5. Not knowledgeable Knowledgeable Expert * # * * * You / have arrived now at the end of Round 2. If you have found that some, important feature has been left out, please feel free to comment-.on the attached page. Thank you I December 1978. Appendix 5. 160 Respondents categorized according to the three-point s e l f - r a t i n g scale attached to each area of function and to the f i v e - p o i n t s e l f - r a t i n g scale measuring expertise i n H R A. Round 2 only S e l f - r a t i n g Areas of Function H R A S e l f - r a t i n g scale Not know-ledgeable 1 Know-ledgeable 2 Know-ledgeable 3 Know-ledgeable 4 Expert 5 To t a l 1. Not know-ledgeable Knowledge-able Expert 7/, /' / / / / / ) / / / / / / - / V / / / / / / / \/</// 8 1 9 2 2 , 17 5 2. Not know-ledgeable Knowledge-able Expert / / / / / / / r / / / 2 / / / 8 1 8 2 2 17 5 3. Not know-ledgeable Knowledge-able Expert / / / / yy/ y2 / y/ V / / / / / V / / 7 3 1 1 15 4 4. Not know-ledgeable Knowledge-able Expert / / •' 1 / w, yy, / yy /// 7 1 10 1 1 19 2 5. Not know-ledgeable Knowledge-able Expert // / / < yy/y 5 3 i i i 1 1 18 5 6. Not know-ledgeable Knowledge-able Expert //, / i / A // ' / / / / / / / / '//. • / 4 / Z / 2 5 10 l i i 13 8 7. Not know-ledgeable Knowledge-able Expert / / / / / ' / 1 ' / / / \ A / r / / / / / / / A / / / V 7 \ A A / / r/s/y.A 3 3 10 I i i 14 6 8. Not know-ledgeable Knowledge-able Expert / / / / / / , / / / y // / / / V / / / / / / /. 8 1 10 l i i 19 3 9. Not know-ledgeable Knowledge-able / / ' / / / / //A Y A / / /= / / / / / / ( 5 9 14 10.Not know-ledgeable Knowledge-f able Expert 11 Not know-ledgeable Knowledge-j' able Expert 12 Not know-ledgeable Knowledge able Expert 13 Not know-ledgeable Knowledge-j able Expert 14 Not know-ledgeable Knowledge able Expert 15 Not know-ledgeable Knowledge able Expert 16 Not know-ledgeable Knowledge-) able Expert 17 Not know-ledgeable Knowledge-] able Expert 18 Not know-ledgeable Knowledge able Expert |19 Not know-ledgeable Knowledge-able Expert j 20 Not know-ledgeable Knowledge-able Expert | TOTALS : Not know-ledgeable Knowledge-able Expert 161 Appendix 6 Null hypothesis: There i s no significant difference between the results obtained and those which could have been obtained from a random sample of the general population. Alternate hypothesis: There i s significant difference between the results obtained and those which could have been expected from a random sample of the population: v2 _ K ( f i - F i ) 2  X " i=l F i where K = 20 areas of functions. f i the results observed F i the results expected i n class i , i n terms of 3 choices per panel member, that i s 3 x 25 = 75 responses. 2 X calculated at 19 degrees of freedom at the 0.01 significance level equals 36.191. (64-75)2 + (68-75)2 +(59-»75)2 + (62-75)2 + (60-75)2 + (66-75)2 + (64-75)2 + 75 75 75 75 75 75 75 (61-75)2 + (55-75)2 + (56-75)2 + (64-75)2 + (56-75)2 + (66-75)2 + (64-75)2 + 75 75 75 75 75 75 75 (67-75)2 + (55-75)2 + (62-75)2 + (55-75)2 + (54-75)2 + (51-75)2 75 75 75 75 75 75 1.613 + 0.653 + 3.413 + 2.253 + 3/0 + 1.08 + 1.613 + 2.613 + 5.333 + 4.813 + 1.613 + 4.813 + 5.333 + 2.613 + 0.853 + 5.333 + 2.253 + 5.333 + 5.88 + 7.68 = 68.088 X 2 = 68.088 X 2 . at 0.01 level = 36.191 l a Reject n u l l hypothesis 162 2 , A p p e n d i x 6 N u l l h y p o t h e s i s : T h e r e a r e n o s i g n i f i c a n t d i f f e r e n c e s b e t w e e n t h e s c o r e s o b t a i n e s b y e a c h c a t e g o r y , b e c a u s e t h e p a n e l m e m b e r s a s s i g n e d t h e i r c h o i c e s a t r a n d o m . A l t e r n a t e h y p o t h e s i s : T h e r e a r e s i g n i f i c a n t d i f f e r e n c e s b e t w e e n t h e s c o r e s a s s i g n e d t o e a c h c a t e g o r y . Y 2 _ k ( f i - F i ) 2  X ~ i = 1 F i w h e r e K = 7 c a t e g o r i e s , f i t h e f r e q u e n c y o f r e s p o n s e s o b s e r v e d F i t h e f r e q u e n c y e x p e c t e d i f t h e r e s p o n s e s h a d b e e n e q u a l l y d i s t r i b u t e d a m o n g t h e s e v e n c a t e g o r i e s , t h a t i s : 1 1 9 5 : 7 - 1 7 0 . 7 . X 2 c a l c u l a t e d w i t h 6 d e g r e e s o f f r e e d o m a t t h e 0 . 0 1 s i g n i f i c a n c e l e v e l = 1 6 . 8 1 2 , X 2 = ( 2 9 6 - 1 7 0 . 7 ) 2 + ( 2 5 9 - 1 7 0 . 7 ) 2 + ( 2 2 0 - 1 7 0 . 7 ) 2 + ( 2 3 4 - 1 7 0 . 7 ) 2 + 1 7 0 . 7 1 7 0 . 7 1 7 0 . 7 1 7 0 . 7 ( 1 4 9 - 1 7 0 . 7 ) 2 + ( 3 0 - 1 7 0 . 7 ) 2 + ( 9 - 1 7 0 . 7 ) 2 1 7 0 . 7 1 7 0 . 7 1 7 0 . 7 9 1 . 9 7 5 + 4 5 . 6 7 6 + 1 4 . 2 3 8 + 2 3 . 4 7 3 + 3 . 5 7 4 + 1 1 5 . 9 7 2 + 1 5 3 . 1 7 5 = 4 4 8 . 0 8 4 Wilcoxon Paired-Sanple Test Appendix 7 Null Hypothesis: There i s no difference between the percentages of reponses given to the areas of function and the categories of activity i n Round 1 and Round 2. Percentages Percentages Signed Areas of Categories Received i n Received i n function of Activity Round 1 Round 2 d Rank Rank 1 1 31 33 -2 3 -3 2 26 22 4 8.5 2 1 33 34 -1 1.5 -1.5 3 22 19 3 3 2 33 22 11 28 3 40 27 13 32.5 4 1 29 24 5 11.5 4 24 27 -3 5.5 -5.5 5 1 17 27 -10 22.5 -22.5 2 14 33 111 28 6 1 23 30 -7 15.5 -15.5 2 39 24 15 36 7 1 18 23 -5 11.5 2 38 33 5 11.5 8 1 37 34 3 5.5 5 37 21 16 38 9 1 34 31 3 5.5 •24- 34 25 9 18 10 1 47 30 17 40 4 10 36 -26 42.5 -42.5 11 2 41 25 16 38 3 41 30 11 28 12 1 29 34 -5 11,5 -11.5 2 29 13 16 38 5 10 20 -1Q 22.5 22.5 13 2 31 24 7 15,5 3 31 18 13 32,5 4 20 24 -4 8.5 -8,5 164 2. Areas of Percentages Percentages Received i n Received i n Appendix 7 Signed function of Activity Round 1 Round 2 d Rank Rank 14 3 44 26 18 41 2 23 13 10 22.5 15 2 44 34 10 22.5 1 9 22 -13 32.5 -32.5 5 32 18 14 35 16 2 40 29 11 28 3 23 22 1 1.5 17 3 36 26 10 22,5 1 16 26 -10 22.5 -22.5 18 3 57 31 26 42,5 4 7 20 -13 32.5 -32.5 19 3 40 31 9 18 2 19 25 -6 14 -14 20 & 42 33 9 18 5 24 18 11 28 differences with thelless frequent sign: -3 -1.5 -5.5 -22.5 -15.5 -11.5 -42.5 -11.5 -22.5 -8.5 -32.5 -22.5 -32.5 -14 246.0 = m(n-+ i) - r Y 1 = 14(43+1) - 240 = 616 - 246 y 1 = 370 m = number of ranks with less frequent sign y = sum of ranks with less frequent sign n = 43 Y0.05(2).43 = 310 f 1 y 310 -=> Accept n u l l hypothesis. 

Cite

Citation Scheme:

        

Citations by CSL (citeproc-js)

Usage Statistics

Share

Embed

Customize your widget with the following options, then copy and paste the code below into the HTML of your page to embed this item in your website.
                        
                            <div id="ubcOpenCollectionsWidgetDisplay">
                            <script id="ubcOpenCollectionsWidget"
                            src="{[{embed.src}]}"
                            data-item="{[{embed.item}]}"
                            data-collection="{[{embed.collection}]}"
                            data-metadata="{[{embed.showMetadata}]}"
                            data-width="{[{embed.width}]}"
                            async >
                            </script>
                            </div>
                        
                    
IIIF logo Our image viewer uses the IIIF 2.0 standard. To load this item in other compatible viewers, use this url:
http://iiif.library.ubc.ca/presentation/dsp.831.1-0095023/manifest

Comment

Related Items