Global Trends in Health Information/Record Management Education in India, 2004

HB Joshi

It is my pleasure to be on the international panel to discuss and present the trends in the training of officers concerned with the management of records and collecting, collating, and disseminating of information from those records for the provision of safe and quality care and help in making administrative and clinical decisions scientific. This modern terminology of health information management has not entered the portals of hospitals in India and is yet popularly known only as medical records. What are these records? How are they kept? What information is collected is the story untold. Where we stand in the developing world is presented covering some aspects of SEARO with especially India.

The science of Medicine in India was Ayurveda, which is now gaining popularity in western countries as herbal medicine. Thus, the history repeats itself that the science of medicine was transmitted from East to West and was translated in many languages. The original language was Sanskrit. Indian scriptures advocate health maintenance by disciplining the body languages by way of Yogasna and meditation. Which is also now practiced in most of the Western countries. The records for all these were in sahitas like Charak & Sasruta sahitas in Sanskrit and now in English universal language. Allopathic medicine was introduced in India by the British, and records were of a colonial pattern, which we have not been able to shred even after nearly 54 years of independence. Allopathic medicine and medical practice have reached Levels of excellence in the clinical and surgical fields or say the infra structures in hospital and health fields but the administrative medicine have failed to keep pace with clinical field to augment a safe and quality service to patients.

Country Profile

India is one of the largest democracy in the world with a population of 100 crores. Eighty percent of this population is uninhabited in rural areas (country side) although health is basic human right, in our social system yet a large portion of the population still does not have access to some reasonable levels of healthcare in terms of both quality and quantity. Since independence the Govt. of India and the State Govt. have been evolving various approaches to rural development but the social aspects (the impact of development on the population) has mostly gone by default. Because the attainment of objectives calls for the adoption of modern means of technology to the process of production and management. This requires in turn, the reorganization of their traditional institutional structures and reorientation of attitudes of the providers towards modernization. For equitable distribution of health, which stimulates development through improving human productivity because, the individual is the productive unit of the society. Moreover social and economical developments are reciprocal and complimentary but are subject to political will and environmental conditions. Social investment in health is an investment in human capital and is mainly concerned with investment in human beings. Dr. M.G. Canadu former DG of WHO remarked

"Amongst the objectives of development are health and productivity they are reciprocal and complimentary. Without health productivity can hardly flourish. On the other hand productivity may increase means and opportunities for better health." (World Health, March 1969, p. 5)

Productivity is not only an economic concept and is rather unknown in the hospital and health field in developing countries but is considered an important issue and also a means of developing, minds and attitudes and encourages cheaper and safer and easier ways to produce good services. It is said that "increased production means the key to improved standards of living and it is essential in every organization to improve productivity (output per unit of labor employed), which will result in improvements in care or service quantitatively and qualitatively, but it is the management of the process which makes the difference." Thus, broadly speaking the management is the process of "organizing and utilizing man materials and machines and ideas to make something useful happen efficiently and effectively." Hospitals in India are monolithic institutions and new scientific management concepts are far from its doors. This view is supported by a study of Bombay Hospitals where a management consultant group of study of functional aspects concluded:

"Hospitals do not observe managerial techniques commonly practiced in Industry. Cost control systems needs to be setup supported by an appropriate budgetary control of system. Presently no cost standards exist and the operating cost is increasing faster than the inflation rate."

The hospital is a dynamic organization, and it needs growth and requirement changes in line with developments in other sectors, that is, External, Sociopolitical Economic, Technological, and Educational. Since Health in India's has been recognized as an Industry it has become all the more necessary to consider raising and improving productivity as in any other industry (out put per unit of labor employed). Maximization of production, time, labor and money are the basic factors. Questions arise regarding the factor of productivity and how it affects the output without input in our hospitals. Increased awareness of productivity as in Industry, will improve in managerial activities improves productivity in our hospitals and improves the quality and quantity of care. The answer lies therefore in management, which is viewed by Economists as an important factor of production, together with land labor and capital. Management in simple words is the synthesis of man, money and material thus coordinating the services of all functional or highly specialized functionaries of the Hospital. One of the functionaries is the Information Officer or Manager of Medical Records Depts. that may indirectly help or aid productivity by increasing productivity in their functional unit. Thus we are concerned with functional or operating management in Record Information/Management, This implies full utilization of resources available.

It also implies full utilization of to the process of production requiring in turn reorganization of the traditional, institutional structure and reorientation of the attitudes and perceptions of people involved in the provision of care and operation of the institution. This requires change management capability, that is, knowledge through formal or informal education in the management of the whole organization i.e. the Hospital and then strengthening of the functional unit operational unit i.e. information records/management education for which we are here.

Administration in itself is now not command and control but is a team of various functionaries, specialists in the field, and in this presentation we are concerned with functional management making information not only collection of data stored in patient records but also using information to develop and producing information technology in order to improve clinical and scientific management and the provision of quality and safe care. Questions now arise as to where we are in this field as one of the functionaries of the Hospital and what has been accomplished so far.

CARE FRONT : The strategy laid down by national health policy makers is the referral system. Where in patients may be referred from one center to another more specialized center higher and back to the same center for follow up and to providing linkage and continuity of healthcare in the care system between the Periphery Healthcare and the base hospital and back to the periphery which is non operative. This chain-like linkage can establish a highway of the information system if and when it is implemented. Dr. Jungalwal's committee identified non- functioning of the referral system. However the object of primary care is to involve the grass roots level staff & people and for that reason numerous programs and schemes are implemented under the minimum needs program to provide primary healthcare relevant to the actual needs of the community in rural areas. The health sub-center is established on the basis of one sub center for a population of every 5000 totaling 130336 sub-centers, which may rise to 1.32 within five years. Linked to primary health center PHC for 30,000 people there will be one Primary Healthcare Center for every ten sub centers. (18981 functioning and likely to rise to 21802 within five years). There will be links to CHC (Community Health Centers) with specialist facilities and 30 beds for a population of 80,000 to 1.20 lakhs, which acts as a referral hospital (see Chart No. 1).

Chart 1. Referral Services

In the total concept there is about one bed for a population of 1500, which is much lower than many developed countries where the ratio of 1 to 4 beds per thousand populations with 75 percent occupancy is established. With all these efforts India has achieved a birth rate of 29 per thousand (SRS 1992) infant mortality rate of 74 per thousand and a death rate of 9.3 per thousand. Each figure shows a wide variability in these rates but shows improvements each year. The present system of healthcare is poorly oriented. Physicians dominate the system and institutions and the system is marked by a lack of quality control, cost effectiveness and it is not consumer oriented.

Evolution

The history of the evolution of medical records has taken place alongside the history of medicine, but the improvements in records keeping have not kept pace with the growing speed of development in medicine and the increasing need for information. There is lack of recognition of hospitals as healthcare organizations and of hospital administration as a specialty. The broad Evolution of Medical records has been at a snails pace and the development had been more prevalent in the South rather than in the North part of the country. The start of the evolution of medical records was by the C.M.C. (Christine Medical College) Velour which had a trained MRL (Medical Record Librarian) from USA late in 1950 in 1961 he went to Nepal as a consultant in Medical Records and started Medical Records their.

It is clear that slow progress in medical records evolution could be attributed to the non-existence of scientific hospital administration. The awareness for scientific administration was created by the visit of Dr. Mc Gibony (4) to study health and hospital administration in India and his first recommendation was the organization of medical records. "Medical records as a base for good patient care as well as medical education, need study leading to desirable and attainable uniformity, with criteria and guides for formal contents, statistical adequacy, completeness and filing, cross indexing and evaluation of the care through medical audit, the establishment of a medical record committee, and establishment of a school of training for medical records librarian."

Dr. E. Burdick a specialist with a planning commission of the Govt. of India Health Division New Delhi in April 1958 submitted a project report to (ICMR) Indian Council of Medical Research" to improve General Hospital records". He said the records are essential for a good Hospital and fulfill at least three functions. The enable the hospital to be administered efficiently, and helps in evaluating hospital and research work. A complete project report and funding for a period of five years from different Aid programmes was produced. It was a self contained project report calling "for the establishment of central medical record system in a leading teaching hospital in each state and teaching 14 Chief Medical Record to establish a uniform system and assisting individuals from other hospitals to installing the procedure". An ultimate aim of the project was to develop teaching hospitals record system for inpatients in teaching hospitals.

There have been another consultants to the Ministry of Health (Dr. Forest E. Linder Director of the US National Survey on the reorganization of health statistics in India to the Directorate General of Health and said "a prerequisite to the collection of any useful and accurate morbidity data relating to inpatients will be established and improvements of record system in the hospital from which reports are to be received and for this need to establish a demonstration cum teaching center for medical records". "He also recommended or organizing a State Bureau of Health Intelligence for standardizing the collection of statistics. Though bureaus have been established but there had been to demonstration centers were not established.

Dr. J.R. Mc Gibony (consultant Ministry of Health Govt. of India) and was stationed at (AIIMS), All India Institute of Medical Sciences reiterated earlier recommendations about medical records and prepared a brochure "Planning Guide to Medical Records" and this brochure along with other brochures was distributed to all teaching hospital and medical libraries and in 1961 two programs were organized for Deans and Medical Superintendents of medical college hospital in order to create awareness of medical records in 1961 organized is seminar. He also accepted a preceptorship and accepted the supervision of students undertaking MHA (Master Hospital Administration) in Australia as administrative resident for thesis (Mr. Joshi as a student of MHA established dept. of medical records as for his thesis. (Medical records in teaching hospital in India).

Dr. Mc Gibony emphasized that a "Well trained individual in the specialty of Medical Record should be included on the staff of the proposed Health Bureau of Intelligence to be available Nationally for consultancy. The seminar was organized on Medical Record where I had participated and presented paper. The resultant of Dr. McGibony visit (and his gift) was the Establishment of the Indian Hospital association and I had privilege to be its founder secretary and secretary general until 1968. During this period seminars on Medical records were organized along with exhibitions of filing and mechanized equipment designed to stimulate interest and motivate improvements in medical records.

In 1961 the Health Survey Committee of the Govt. of India 1961 known as Mudaliar (5) Committee recommended that "Medical Records in Out-Patient Departments should be properly kept as morbidity statistics of the population of the area should be obtained and they will be of great value to the patient the hospital and to the physician. However nothing was mentioned about inpatients medical records except that the members of the medical audit committee should look at the medical record room to evaluate results and should be well informed on the work going on in the hospital. Implied in this recommendation was the evaluation of inpatient record for medical audit purposes.

The first organized medical record was setup at CMC (Christian Medical College) Vellore and later Mr. Joshi was appointed as an administrative resident under Dr. McGibony established the department of MR at the AIIMS. Then Post Graduate Medical Education and Research in Chandigarh where training program for diploma courses were developed. Which was approved by the visiting team from WHO "desired to come if and when the training programme get going". Which never happened because of financial constraints. A project report was submitted for computerization of records and arranged from University of Punjab preparing some records material for demonstration for the faculty. The Health Bureau of Intelligence Govt of India New Delhi organized seminars from time to time.

A workshop in Bangkok-Thailand was held in 1962 Countries represented were Thailand, Buma, Afghanistan, Nepal, Ceylon, and Indonesia.

Hospital statistics should be regarded as an important element in the national health program of each country and should be developed as part of the national system of vital and health statistics. The following principles should apply:

1. That Medical Records department should be established as an integral part of all major hospitals and that their eventual status should be on a level with that of other departments and that these departments should be adequately staffed and equipped and they should be situated in accessible positions within the hospital.
2. There should be organized and supported training courses within the region for hospitals records officers and technicians. There should be consultant assistance to countries in the establishment of medical records in major hospitals. There should also be fellowships for special training in this field.
3. A manual on hospital morbidity statistics should be published and that manuals should also be prepared on (a) administration statistics. And (b) the organization of hospital records depts.
4. Countries in the region should consider to what extent the International Classification of Diseases meets their particular needs, they should study such proposals for revision as may be circulated to them by WHO and should submit to WHO their own suggestions for this revision as soon as possible.
5. WHO should continue to promote the development of hospital records and statistics in the region and should periodically review the progress that is being achieved.

In 1968, the Minister for Health Govt. of India when inaugurating the Indian Hospital Association said, "another area in hospital setup that has not received adequate attention is the medical record keeping. The increasing complexity of hospital medicine demands a high standard of medical record keeping. The records should not only be accurately written but they must also be reliable summarized to yield material value for various kinds of clinical research. It is no longer sufficient to record what happens in hospitals; record keeping must be organized in such a way as to demonstrate how hospitals may improve and how their future organization can be planned with few exceptions unfortunately the system of medical record in the country is rudimentary. Trained medical record officers do not exists in our country and it is unrealistic to expect the hospitals make much progress in medical records keeping without them." Dr. K.N. Rao former Director General of Health Services stressed that one of the most crucial and emerging issues in hospital care is the growing demand for processing, extracting and analyzing correct data to aid administrative, clinical & financial decision-making. He further said that it is impossible to make comparative study of hospital services with similar institutions in order to attempt to make and cost of a unit. Which is rather conspicuous by their absence. Uniform systems of cost accounting based on the heading of financial accounting should be adopted on the basis of data available from medical record data or say professional accounting system.

Hospitals are only concerned with only one type of accounting system i.e. financial business accounting system and no importance is given to professional service accounting (Medical Record) which can be obtained from the files of patients treated by the physician and is more important than the financial accounting system because it costs lives . Though the objective of the professional accounting system is similar to that of a financial accounting system but the language of the former is applied to the professional activities of Doctors, Nurses and other units involved in direct or indirect care and it encompasses that not the supplies and equipment are available and also the maintenance of personal details and facilities together with reasonable standard and adequate expenditure system and a profit balance system in human lives is maintained. These are required to prepare review reports (audits) on profit loss statements to be determined as necessary control system to what we call in financial accounts. Medical audit cannot be conducted in the absence of adequate record keeping.

Traditionally no one controlled or coordinated the delivery of health hospital care from admission to discharge and thereafter. The opportunity is now and an important issue to manage a customer focused system which would be a major transition intended to encourage the application of continuity of care and to improve quality of care provided and improved outcomes of care. With the recognition of health as an industry the consumer has gained great strength and can stand on a platform with the Clinician and provider of care to question about the quality of care. For industries the Govt. has established the Indian Standards Institute the main function of which is to standardize the consumer products and services. A seal is stamped "ISI" to indicate the safety and quality of the product. As a watchdog of the Health services the Govt. of India promulgated an Act known as "Consumer Protection and Grievance Redressal Act. 1986 and all care activities are covered under the preview of the act and consumer courts have been established in each state thus assuring consumers of quality, and checking and preventing flagrant practice where it exists. In a workshop held in Pondichery (UT) in December 1993 organized by the Educator or Quality Update and Indian Physician (EQUIP) with the support of the International Organization for Consumer Union IOCU develop a Guidelines of principles laying down the rights and responsibilities of patients. (FEMINA 15 th Feb 1997) The emphasis here was on standardization of parameters. For hospital and healthcare delivery which are absent without adequate recording systems. The Honorable Vice President Govt. of India addressing the Physicians in Alwar (Rajasthan) asked or advised the physician to set CHIKITSA JAGAT KE NIRMAN! (Standards of care) but the question arises who should identify minimum standards, which will serve as yardstick for making scientific decision by the consumer forum that will be beneficial. Should Consumer Research Forum drive this project and take a leading role in this direction?

Training: Being aware of the medical record and deteriorating conditions of the data collection and rising demand for qualified medical record personnel the Govt. of India started a certified program for one year and six months for officers and a technician course at Delhi & Pondichery. Only sponsored candidates were admitted who went back to their institutions and were employed. Some of these people lured by better prospects migrated to the Gulf countries and are doing well. "The program was discontinued. A program for one-year diploma for officers and six month for technician at CMC Vellore was changed to a B.Sc degree by Madras & Pondichery University this is a three-year program. Many of such diploma programs and degree programs have mushroomed and there is no accreditation committee to assess and set the standards. Consequently there is no uniformity of program; however, all basic subjects are contained in the programs (annexure 1),

ESCAP (Economic Social Commission for Asia and Pacific delivery of health service in Rural areas (Nov. 1979) in a meeting with the government of India under the man power development program "emphasized that "the training of doctors in management and supervision at District and PHC level is essential." They also proposed induction orientation and continued education in management of minimum resources for optimum utilization.

With all these development, progress and deficiencies it is clear that as far as talents in different fields are concerned such as humanities, social sciences, electronics, information, etc. India is second to none but in the field of health and hospital management we have to learn a good deal from the developed nations and also from industrial (progressive industrial) units which have become more cost and quality conscious with scientific management. Their is also a need to learn from our scriptures (Shrimad Bhagwat Geeta), which mentions "every person born has desire; desire motivates action and in the accomplishment of action five factors operates. 1. The Seat of action, and 2. The agent, 3 . the organs of different kinds and the 4. separate movements of divergent types and finally 5. Divya or destiny (Geeta XVIII 14) of these Adistha (seat of action) & Divya (aim) are foremost. Two courses of discipline advised; Action and Knowledge. These are like Siamese twins. Action is Karma whereas knowledge sankaya yoga (Learning) Action without knowledge is blind and knowledge not used for action gets rusty and needs constant sharpening. (education- refresher - service - continued education is the motto). This is one of essential element of the education of health information management perfection (performance for which practice is required). Karma Sukaushalm. Thus management is the process of organizing man, material, money and ideas in order to make something useful effectively perfection and efficiently (Perfection). Scripture (Geeta II) 50. Yoga Karam Sukaushalm. Yoga is efficiency or dexterity in action not only in contemplation and speculation. "Thus efficiency is the product of intelligence yoked to a great social cause, consciously and deliberately, such an awareness brings out of the worker and without stimulus in this wider reference. Without the organizational purpose no worker can achieve efficiency". Thus here importance has been given to personal for education and training. Such training program in Information Records management must proceed along with the administration of hospital because in this training the concern is only Operational or functional management. Which has been the latest realization in management field. "We are moving from the days assessing people by their IQs (Intelligence quotation) to their EQs (emotional quotient) today people talk of about SQs (spiritual quotient) i.e. that the degree to which a person can apply moral spiritual values. Harvard Business School has even introduce and elective course in moral spiritual enquiry". How do people cope with their emotions? How do they let their emotions affect the work of themselves and others"? (Prof. S. Mainikutty IIM Ahamdabad here importance is given in personal development).

Contents of such programmes should include liberal art education manpower development and new information technology and computer science. Thus management is nothing but synthesis of knowledge from related fields and the selection and acquisition of skills, It is therefore the conviction of the author that information record management education and the development of knowledge as per required job contents is essential. This will leads to new job descriptions for Information Record Managers. General education is essential for each hospital department followed by specialized training so that each individual understands how his actions will contribute to the achievement of the objectives of health hospital care administration to provide safe quality care at an affordable cost.

Thus, diploma programs in short time will equip our departments and will allow the selection of appropriate Diploma Students with education acumen be selected for post graduate courses and help in research for faculty positions. Preference will be given to professional Nurses to equip more hospitals in a short time-scale with quality health information manger. These individuals will prove to have a strong commitment and interest in the new field of information technology.

Conclusion

I have shared my thoughts and place them before this august body. They identify the trends in information Records Functional Management system, which are the functional and operational aspect of the healthcare industry and he whole of the hospital industry. The totality of the organization needs to be strengthened. We have the people the productivity, the technology, the language skill and processes to make hospital organization viable - but our institutional constraints are a key barrier to progress. The limiting factor is the management aspect of hospital i.e. Medical part time administrator who is managing the institute. Whilst this situation continues it will difficult to change medical attitudes without better evidence and the effectiveness and cost of the production of high quality, safe healthcare, which is need to be changed from a bureaucratic structure of organizational behavior. Thus. I can say that we can make a significant contribution to the global economy and assure a sufficient supply of manpower in every field of health administration by providing education at a Central School and establish formal standards of professional education under the new organization "the Health Management Information Association of India."

Jai Hind

References

1. Mahler G. Canadu. Director General WHO WORLD HEALTH - March 1969 P.5.
2. Bhogliwal TN (Sahitya Bhawan) 1985 P 535-55 Economics of Labour and Industrial relations.
3. SRS Govt of India publication. 1992.
4. Dr. J.McGibony a selected summary of activities and observations 1961.
5. Health and serve committee (Mudalier Committee) Govt. of India Aug 1959 Oct to 1961 Vol 1 P 8486.
6. Burcick E Douglas MD project report to improve general teaching hospital Records ICMR 1958.
7. Linder E Forest MD project report for Reorganisation of health statistics in India 1958 P. 30.
8. JR McGibony MD observations on medical administrative aspects of hospital and related program 1961.
9. Joshi H.B. Evolution of Medical records in India Hospital Adminstration Journal of IHA Vol 6. Nov. Dec. 1969 P. 51-56.
10. Joshi Seminar Report Indian Hospital Association 1961.
11. Joshi H.B NwsuxK Audi IMA JOURNAL 1972 FEB. CALCUTTA
12. Joshi H.B. The world of administration education (First international course on Health service administration 1983) Portugal.
13. Joshi H.B. Key Note Address TNI - Biennial conference Chennai 1997. (Organization Behavior in Team Building Innursing Service for effective care.)
14. Computerization report PGI Chandigarh 1976 omputerization report at MG & associated Hospital, Jodhpur 2004.
15. Prof. Smanikutty challenges in management education 21 st century seminar report AIM Jodhpur-2002.
16. Shrimad Bhagwat Geeta Chapter II-15, Chapter-18.

ANNEXURE-1

EDUCATING HEALTH RECORDS INFORMATION PERSONNEL

INDIA "2004-05"

BIRDS EYE VIEW

Theoretical Training

English & communication skills
Anatomy & physiology, pathology
Introduction to Hospital & Health services management.
Personnel management & public relations.
Basic computer sciences.
Financial accounting
Support & utility hospital services.
Computer application
Law & legal practices & Healthcare
Medical terminology
Medical Record science
Biostatics - Health statistics & analysis
Classification and coding ICD Revision Xth

Diploma Exams four semesters end.

A Hospital Management Degree 5^th & 6^th Semester
Medical Ethics & professional skills.
Medical Records planning and management.
Computer data collection and reporting.
Project writing in Medical Records.
Problem solving & communication.
Practical Training Diploma & Degree in Hospital.
Diploma Programmed for in service persons.

Elements of Hospital & Personnel management
Financial management & Statistics
Hospital supporting services & Management.
Information & coding Xth revision. (for M. R. Personal)
Planning - Introduction to Hospital & Dept. planning.
Project report on the Dept of specialty & seminars. - Practical Training.

On completion of one year and successful completion of project report concerning subject a Diploma is granted by the University, which enables them to head the department.

N ! B ! ) Post graduate diploma in India is equivalent to masters degree and is of two year practical 4 semesters program where six months for dissertation/thesis and administrative residency Degree programmed preferred in India.

Since there is no uniformity of programmed on National level there is need for accreditation committee to standardize the program.

For the present there are surplus (Employed as technicians or Medical Record Clerk though qualified but because of lack of available jobs created and difference of emoluments prevent mobility to other states.

Change and felt need for scientific management of Hospital and health services can only boost the need for improving the present status of Health information.

One University provides Masters in Hospital Management with Basic Admission Requirement as Ten plus Two. This is of five years duration of Mater degree (Trimester system) one year residence & thesis. Part practical visits are made to Hospital during close of each session.