Professional profi les Marianne Carter: A varied HIM career in retrospect

Marianne Carter

Why did I study Medical Record Librarianship? speech pathologist and the pharmacist became By sheer default! Having made an early departure lifelong friends. from a dietetics course, I obtained a position as a clerk in the Medical Records Department of the United Kingdom and Italy Queen , Melbourne, Victoria.1 In 1971 I ventured overseas and, having spent I’d never actually heard of Medical Records six weeks on a boat, I arrived straight into the Librarianship but my parents emphasized the Northern Hemisphere winter with a great suntan! importance of a professional career so I followed I was extremely fortunate to obtain a position at their advice and obtained a tertiary qualification. St Mary’s Hospital, Paddington, working with Dr Felicity Tunbridge to establish the Staff Health My career journey Clinic. This gave me a great insight into the workings of the British National Health Service. Victoria The position was part time and I also worked as I graduated as a Medical Record Librarian (MRL) a coder at St Mary’s and the University College in 1968. In 1969 I commenced working at , London. I then commenced tripping Warrnambool Base Hospital and stayed there for around Europe with two friends in a Morris Minor 12 months as the Medical Record Librarian. I then and, along the way, obtained a position teaching moved to the Base Hospital for another English at the European School in Sardinia, Italy. 12 months as the Medical Record Librarian. I recall initially not even really knowing where The work was straightforward at both of these Sardinia was, but once I became established there facilities. However, the then management staff at I enjoyed a memorable and exciting experience, Bendigo hospital were absolutely fantastic and and my love of Italy has remained. I have only thoroughly supportive of the Medical Records once returned to this wonderful country but live Department. The department at Bendigo was new in hope that I may visit again. and had been designed by MRL Joyce Jackel. It was a joy to work in this department as it was Victoria again well situated near Admissions and Emergency, On returning to Australia after a year overseas, I so the patient flow from our perspective was took up the temporary relief position of Deputy excellent. I shared a hospital house with a physi- MRL at in 1972. Later in the otherapist, a pharmacist, a speech pathologist year I was appointed to a newly created position and a dietician; I won’t say we partied every night with the Victorian Cytology Service based at but we certainly had a tremendous time, and the Prince Henry’s Hospital (this hospital, like the Queen Victoria, has also since closed and been incorporated into the ). 1 This hospital has since closed and moved to be incorporated into the Monash Medical Centre.

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New South Wales indebted to Phyllis for her guidance over many In 1973, I married someone who wanted to years. farm! So in 1975 we moved to Peak Hill in NSW and have lived there ever since, during which Then the light dawned! time we have raised our family. My first MRL It was at about this time that I came to realise position in the region was with NSW Central that the Medical Record is the most important West Health Services. At the time when I first document in the health system. (With the acuity of moved to NSW, the state had just undergone hindsight, I wonder now if I had been rather slow the first of many Regional and Area Health in grasping this truth). Nevertheless, even then Service restructures. I was extremely fortunate I realised that I actually had quite a passion for that the then CEO created the Regional position Medical Records. (which I might add was funded by the Federal I left the Regional position to have a family Government for some reason) and this was and my successor was Helen Brolly, who subse- probably my biggest challenge up to this point quently completed her Masters degree in Medical in my career. However, it was made considerably Records in the then Orana and Far West and easier than it might have been as several months Central West Health Regions. earlier the late Betty James had undertaken a In 1979, I returned to work in a part time review of several of the facilities in the region capacity for a few years at Dubbo Base, Orange and had made some substantial recommenda- and Parkes Hospitals, as the Medical Record tions for the implementation of Medical Record Administrator (MRA); this was the first profes- standards for the maintenance and storage of sional name change. My roles usually included Medical Records (i.e. allocation of Medical Record managing the department and coding. I have Numbers, that Patient Master Index (PMI) cards always fully understood the importance of be kept, ordering of clinical forms, filing medical coding, and in later years strongly supported records numerically and in folders instead of coder education through HIMAA. I was successful envelopes, and that a person on staff should have in making it mandatory that only HIMAA coder specific responsibility for maintenance of medical qualifications were acceptable in the AHS, where records). Betty had developed and written a I was employed. policy document on Medical Records for NSW Then came my next big challenge! In 1989 I Health2. These were the days when registration was successful in obtaining a full-time position of patients was very casual; for example, age was with the Central Western Health Region as the noted on the record rather than date of birth. Regional MRA and Quality Assurance (QA) I spent a short time at the Royal Prince Alfred Officer. The latter role represented a steep Hospital with Professor Phyllis Watson, who gave learning curve for me, and one which, upon me a remarkable understanding of what was reflection, was where I really had to apply the going on in NSW at the time and the direction skills I had learned as a MRA. Quality Assurance in which the state was heading. I am indeed in this organisation was related not only to Medical Records, but to all disciplines within the health services. We had meetings for the engineering and maintenance staff, allied health 2 It is interesting to note that this document has only just been reviewed by NSW Health more than 30 years after it was written! staff, community health staff, and while all this

HEALTH INFORMATION MANAGEMENT JOURNAL Vol 38 No 3 2009 ISSN 1833-3583 (PRINT) ISSN 1833-3575 (ONLINE) 65 Professional profi les was being undertaken, Casemix was hot on the space required to store all the paper records. Government agenda. I cannot say these were The work in preparing the submissions for the halcyon days; rather, they were just days that Area Health Service, the ReBOB Planning Team, were extremely busy, while I managed a raft of NSW Health and the Treasury was unbeliev- different issues, including a three-month second- ably daunting and the HIMs involved in the ment to NSW Health in Sydney, where I reviewed preparation of the required information (Kathy coding systems to be used in the Community Borschtsch, Leanne Fletcher, Sharyn MacCallum Health Information Management Enterprise and Jennifer Hughes) must be acknowledged. (CHIME). The money was found after much negotiation, and Infomedix, a Melbourne firm, was contracted Continuing to learn to install the system. The project has now been On reflection, these were the years where I in place for two years at Bathurst Base Hospital came to understand the most significant issues and commenced at Orange Base Hospital in 2009. concerning medical records, and my passion for In 2010, it will be introduced at Blooomfield the profession continued to grow. Healthcare was Hospital. continuing to change rapidly and in order for the Then in 2004, yes, another restructure! Medical Record Administrators and our service in Midwestern Area joined with the Macquarie Area the Central West to stay abreast of things, I had to and Far West Area Health Services to become the be politically astute. I also had to manage a fairly Greater Western Area Health Service (GWAHS), large budget. MRAs at the facilities were not the largest AHS in NSW, the size of Germany in responsible to me, but I always maintained that area. However, while it does not have the popula- in the regional position, I must ensure ongoing tion of the Metropolitan AHS (or Germany!), the training, support; in other words, I had to be 47 facilities and 50 Community Health Centres prepared to go in to bat for them when issues and many outreach services had to be managed arose. I worked with some truly inspiring MRAs over great distances, and in many instances with in those years. limited or problematic technology services. In 2005, while the new Executive staff were Favourite action of NSW Health: busy sorting out the structure of the new AHS, I RESTRUCTURE (regardless of returned to the ‘grass roots’, as the HIM at Dubbo outcome)! Base. This was extremely refreshing for me, as it In 1993, the first of the ‘recent restructures’ in had been a number of years since I had managed Area Health Services commenced, along with a staff in a Department and been involved with change in government, and the Districts were all the issues in a Medical Record Department. created. The NSW Central West region was It was also at this time that the new Patient divided into three Districts and Orana and Far Administration System (PAS) was being imple- West divided into four Districts. I remained as mented; for us it was iPM, from the company the Health Information Manager (HIM) for the iSOFT. It is interesting to note that at one stage three districts in the old Central West, then in (and this may still be the case), NSW Health had 1996 another restructure occurred. Believe it or four different Patient Administration Systems in not, we were more-or-less back to the original operation. The then PAS implementation team Regions! I was now the Area HIM for MidWestern was headed by HIM Jacqui Burford, with Robyn Area Health Service (our second professional Sheridan as one of the Business Analysts and name change) and the major issue at the time Maree Carolan as one of the trainers. They did a was the redevelopment of Bathurst, Orange truly brilliant job and had iPM implemented in and Bloomfield Hospitals, known as ReBOB. record time with minimal disruption, a tribute to My recommendation that all medical records be the skills of HIMs. scanned on discharge was accepted. There was, in fact, no other alternative! Given legislative requirements for general mainstream and psychi- atric medical records, we were not allocated the

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Then the HIGHLIGHT… at 60 What did the Area HIM do? years of age, really ready to retire! Well, as everyone knows, NSW Health doesn’t I was turning 60 and felt I should retire from stay still for long and soon there was a raft of the position at Dubbo; however, I was asked new programs and initiatives to take on board if I would establish the Health Information (e.g. Electronic Health Records, Pathology inte- Management Unit (HIMU) for the GWAHS. I gration with another AHS, Community Health was thrilled! What an opportunity! My proposed Data Collection). My role was clearly a manage- organisational structure was accepted by the ment/leadership role, overseeing and delegating, Executive and recruitment and appointment to ensure that the various systems were achieving began. A substantial budget had been developed what they were designed for; and setting ground for the PAS implementation so I was able to rules for cooperation between team members to build on this and incorporate the PAS and its ensure they had a full understanding of how each ongoing maintenance and training into the of their roles overlapped with others in the team. Health Information Services (HIMU). The HIMU This was also a time when three former AHS consisted of an area HIM, an operations manager were coming together and forging new relation- (HIM), a data integrity manager (HIM), a clinical ships and understanding, which required sound coding manager (HIM), two business analysts, management and leadership. It necessitated the three reconciliation officers and one part-time establishment of various committees in order to technical officer. The importance of each team plan the management of these new initiatives. member understanding how their role interre- Managing the budget and the associated “poli- lates with the role of other team members was ticking” was a great challenge but the objective soon obvious to the staff appointed and a sound of my position was to ensure correct identification working relationship was formed; for example, of the patient/client and to facilitate the process for business rules for the PAS and the mandatory access to health records and up-to-date informa- requirements for the Admitted Patient Data (APD) tion in the health record, with submission of the Collection and subsequently the Clinical Coding mandatory requirements to the state and federal must all reconcile. governments. The role of the Operations Manager was to ensure that all the facilities and the multitude of Things that I didn’t fi nd amusing: health programs maintained records in accord- The idea that the Medical Record Department ance with legislative requirements and NSW always has to be in the basement. Health Policy (i.e. that their processes were Medical Records are considered a nuisance, as well understood by clerks and Health Service they require storage space. Managers of the facilities or Program Managers). The effort it takes to convince Administrators This was an enormous job and the need to work that extra space is required. closely with the Data Integrity Manager and the Non-HIMs working on projects telling HIMs Clinical Coding Manager was recognised by all how the system should be without any prior involved. The Reconcilliation officers were faced understanding of how the system developed with the huge task of integrating more than 50 (history) or how or where the data came PMI’s into a single Area PMI with an Area Unique from. I recall being told that our PMI was a Patient Identifier. Initially, this was a monumental ‘disgrace’, and that the AHS where the non- task but huge inroads had been made by the time HIM worked was 100% ‘clean’. Now that was of my retirement. It was a task well worth the interesting to my colleagues and myself!! effort, the objective being to have a “clean” PMI and correct registration of all patients/clients Various things I remember: to ensure correct patient identification for clinical terminal Digit filing implementation care. “Unit” Record Number allocation – integration of all records into one health record

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formal registration of patients, which included were times when I did not. I think that 90% of mandatory data items, index cards prior to the time enjoyment and fulfillment is possible computerisation because of the staff or because a challenge early Morbidity Data Collection in both Vic and has been met successfully, but sometimes this NSW, the submission of which was done only is not possible due to the sheer magnitude of for selected months in the beginning, prior to an issue, project or program, or when you just the present mandatory reporting systems now don’t know how you are going to procure the in place budget or ‘get your message across’ to those training of HIMs moved from hospital base to who will either support or not support you. University However, I always enjoyed the challenge. introduction of Community Health and Problem Orientated Medical Records Final comment Patient Administration Systems introductions My career has been long and exceptionally – clinics, waiting lists and times rewarding and now, at the end, I realise how little Forms Design, managing the legal and clinical I knew at the beginning and how much more practice changes there was to learn and know along the way. We management issues – staffing, operational, can never afford to stop learning. The significant organisational and budget compliance within a impact of the people I have worked with remains department and in a facility with me and so it is with humble gratitude that I equipment /storage reflect on my varied career. Patient Matters Manual – Medical/Health Records (NSW) - desperately needs to be Marianne Carter AssocDip(MRA) reviewed Formerly: Casemix/Episode funding – data integrity Health Information Manager/Operations Manager Clinical coding – coding standards and Health Information Management Unit establishment of the NCCH Greater Western Area Health Service Medico-legal issues. NSW Department of Health North Sydney NSW 2060 Things that were important to me: AUSTRALIA The people. I have been unbelievably (Now retired) priviledged to work with many outstanding Current address: people – HIMs, Clerks and Clinicians. Over “Garth” the years I learnt so much from these people, Peak Hill NSW 2869 they were clever, interesting and challenging. AUSTRALIA They were dedicated and fully understood email: [email protected] the importance of “the health record” and its role in clinical care delivery. I shall always remember these people, as they gave to me a more profound understanding of my career – my job. Seeing staff develop. It was always important to see that staff or colleagues had the opportunity to grow or develop and have a strength in their knowledge and understanding of their job or position. Being fair and trusting. Always performing duties in a professional manner pays off. Enjoying work. Most of the time I thoroughly enjoyed my work, although there

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