Health Information Management: Integrating Information Technology ...

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Netherlands and the UK the family doctor as ‘trusted adviser’ played a central
role in health care (which he continues to have to this day), in America the
hospital became ‘the heart and mind’ of the health care system (Mansholt 1931).
Moreover, it was in this period that the medical profession managed to secure
its central, autonomous position in society. The reform of medical training in the
United States—under the aegis of the American Medical Association (AMA) —
led to a reduction of the number of medical schools and the number of licensed
physicians. The ensuing concentration of medical training and the establishment
of common performance standards caused a consolidation of the professional
authority of the AMA.
The American College of Surgeons was equally engaged in the effort to create
a tight, homogeneous professional group. It also embraced a centralized
approach and established official nationwide standards to be met by surgeons
throughout the country. These ‘Fellows of the College’ had to possess the proper
expertise and were not allowed ‘to split their fees with doctors who referred
patients to them’ (Stevens 1989). To this end, an in-depth study of the skills and
practices of surgeons was set up around 1915. Surgeons were asked to send in
case histories of patients they had operated upon, so that the College could
evaluate their work. It turned out, however, that neither the surgeons nor the
hospitals were able to submit the appropriate records needed for such a study.
Many hospitals simply failed to have general procedures for medical reporting.
Only the better hospitals had wards where doctors kept track of the progression of
the patients on the ward in a logbook. In such a ‘ward record’, physicians would
enter basic information on their patients, each entry simply following the
previous one. Not much information was recorded: a poor patient admitted to
one of the leading US East coast hospitals in 1900 with a broken leg might have
spent some six weeks there, and have one or two entries in the ward record. Data
on individual patients were difficult to trace: information on a single patient was
scattered throughout the log, and only if a good index was available could this
information be aggregated. In addition to these ward records, physicians kept
track of their patient’s case history by jotting down catchwords on a note-pad or
in a notebook, or simply from memory.
Furthermore, the circumstances under which surgeons had to operate appeared
to be so varied that a proper comparison of the case histories was virtually
impossible. Some hospitals had operating theatres that were new, sterile and
equipped with electric lighting, while operating theatres in other hospitals hardly
differed from the average wardroom. In some hospitals one would find
specifically trained nursing staff for providing assistance during operations and
regular autopsies, while in other hospitals such facilities were nonexistent.
Because of these widely divergent circumstances, the College decided that the
quality of surgeons’ performance could only be guaranteed if the hospitals where
they worked satisfied specific minimum requirements. Laboratory facilities, x-
ray facilities, and clean and well-lighted operating theatres with a specially