Hospital Documentation Planning: the Concept and the Context

16 American Archivist / Vol. 56 / Winter 1993

Research Article Downloaded from http://meridian.allenpress.com/american-archivist/article-pdf/56/1/16/2748466/aarc_56_1_18534n31m7132j2p.pdf by guest on 27 September 2021

Hospital Documentation Planning: The Concept and the Context

JOAN D. KRIZACK

Abstract: Documentation planning is defined in this article as a process within an institution to select an appropriate documentary record for the institution. The author describes the functions and component institutions of the U.S. health care system, identifies the functions of hospitals within the system, offers an analysis of hospital activities and administrative organization, and presents a typology of hospitals. This information provides the informational context within which a documentation plan can be developed for a particular hospital. A similar planning approach may also be applied to other types of institutions, organizations, and corporations.

About the author: Joan D. Krizack is the hospital archivist at the Children's Hospital, Boston. This article was written as a product of the author's participation in the 1988 and 1989 Research Fellowship Program for Study of Modem Archives, administered by the Bentley Historical Library, University of Michigan, and funded by the Andrew W. Mellon Foundation, the Research Division of the National Endowment for the Humanities, and the University of Michigan. It was initially submitted for publication in 1989. The author wishes to thank the individuals who commented on earlier drafts of the article: Andre Mayer; Barbara L. Craig; Joel D. Howell, M.D.; Helen W. Samuels; and the staff and 1988-1989 research fellows of the Bentley Historical Library. The author is also the principal investigator of a project, "Documenting the U.S. Health Care System: Analysis, Assessment, and Planning, "funded by the National Historical Publications and Records Commission, the end result of which is a book, tentatively titled Documentation Planning for the U.S. Health Care System, to be published in 1993. Hospital Documentation Planning 17

"ANALYSIS," ACCORDING TO T. R. Schel- (3) the importance of cooperation—be- lenberg, "is the essence of archival ap- tween archivists, records creators, and re- praisal."1 Deciding what material to collect, searchers and between archivists in different the archivist's most intellectually stimulat- repositories. Larry Hackman, one of the ing task, has become progressively more foremost proponents of the documentation challenging since the middle of this century strategies concept, has argued that "by def- Downloaded from http://meridian.allenpress.com/american-archivist/article-pdf/56/1/16/2748466/aarc_56_1_18534n31m7132j2p.pdf by guest on 27 September 2021 because the nature of institutions and or- inition ... a documentation strategy cannot ganizations has changed. In modern soci- be formulated by archivists within a single ety, institutions are often components of institution, or carried out by a single re- multinational conglomerates or divisions of pository, or even developed or executed only holding companies; even freestanding in- by archivists."2 stitutions are not self-contained but are linked Whether or not one agrees with the need to other institutions and organizations, both for, or efficacy of, large-scale cooperative public and private, through cooperative documentation-strategies initiatives, it agreements, funding arrangements, and should be clear that decisions on selecting government regulations. These intercon- the records of a single institution for pres- nections complicate the archivist's task by ervation, whether by an archivist employed increasing the duplication of information and by that institution or one working at a his- physically dispersing records. At the same torical society or other collecting repository time, reprographics and communications that has acquired a body of institutional technologies have become more sophisti- records, should also be informed by an un- cated, increasing the quantity of records derstanding of the place of that institution produced and the amount of information in the larger universe and by consultation stored. To address these changes, the ar- with creators and users of the records. In- chival profession must adopt a proactive deed, it could be argued that large-scale, approach to documenting institutions and interinstitutional documentation strategies pay increasing attention to the several lev- are possible only if the participating insti- els of analysis underlying the archival se- tutional archives have first come to terms lection process. with their internal issues. In order to ac- Archivists have written and spoken ex- centuate the distinction from the documen- tensively in recent years about the need for tation strategists' call for interinstitutional such an activist approach to the purposeful, planning and cooperation, the internal systematic selection of records with endur- process advocated in this article will be re- ing value. Proponents of the documentation ferred to as documentation planning. strategies concept have emphasized several Archivists can meet the challenge of points: (1) the need for conscious, inten- documenting contemporary institutions by tional planning; (2) the need to make spe- carefully deciding what they are going to cific appraisal decisions based on an awareness of the universe of available documentation and an understanding of the ac- 2Larry Hackman, "To the editor," American Ar- chivist 52 (Winter 1989): 8. Similar expressions can tivities from which the records resulted; and be found in Helen Willa Samuels, "Who Controls the Past," American Archivist 49 (Spring 1986): 115; and Larry Hackman and Joan Warnow-Blewett, "The Documentation Strategy Process: A Model and a Case 'Theodore R. Schellenberg, "The Appraisal of Study," American Archivist 50 (Winter 1987): 14. Modern Public Records" in Maygene F. Daniels and For an overview of the way the documentation strat- Timothy Walch, eds., A Modern Archives Reader: egy concept has evolved in archival literature, see Basic Readings on Archival Theory and Practice Terry Abraham, "Collection Policy or Documenta- (Washington, D.C.: National Archives and Records tion Strategy: Theory and Practice," American Ar- Service, 1984), 68. chivist 54 (Winter 1991): 44-52. 18 American Archivist / Winter 1993

document and then formulating systematic article is to provide the analysis necessary plans that lead to the deliberate selection to devise a hospital documentation plan. of an appropriate documentary record. A The information presented here should ben- documentation plan is formulated in two efit not only archivists employed by hos- stages: pitals but also those at historical societies, • analysis of the institution, its relation to university libraries, or other collecting re- Downloaded from http://meridian.allenpress.com/american-archivist/article-pdf/56/1/16/2748466/aarc_56_1_18534n31m7132j2p.pdf by guest on 27 September 2021 other institutions of the same general type, positories that may have acquired hospital and its larger societal context, and records. It includes a brief overview of the • selection of the functions to be docu- U.S. health care system, an analysis and mented, and deciding which departmen- typology of hospitals, and a description of tal, laboratory, office, or other unit their place within the system.6 The follow- activities or projects will be chosen to ing pages outline the functions of our health support the selected functions.3 care system, identify the institutions and This strategic plan is formulated by an organizations that carry out these func- archives advisory committee, comprising tions, and analyze the administrative or- the archivist, records manager, legal coun- ganization and selected activities of hospitals sel, medical records specialist, and appro- in relation to their specific functions within priate administrators, physicians, and the overall system. Thus, the article pro- historical researchers; the committee con- vides the basis for hospital documentation siders both internal administrative needs and planning. external research uses. In this planning process, a general knowledge of historical Overview of the U.S. Health Care trends, historiographic techniques, and tra- System ditional appraisal criteria remains critically important, as does a specific understanding Since World War II, the American health of the institution's mission, culture, and re- care system has grown into a "vast indus- 4 try," accounting for 11.6 percent of the sources. Although the documentation 7 planning model is focused on hospitals in gross national product. In 1989 the nation spent $604.1 billion on health care, more this article, it is applicable to a variety of 8 types of institutions. In fact, Schellenberg per person than any other country. The health care system in this country, complex suggested a somewhat similar strategy for 5 and constantly changing, may best be de- appraising government records. scribed as decentralized and competitive.9 Hospitals, like many other modern insti- Indeed, if a health care system is defined tutions, have become part of an intricate as "a group of curative and preventative and complex web of regulations and rela- tionships, which raises difficult issues for archivists concerned with maintaining a Tor the purposes of this article, the U.S. health representative record. The purpose of this care system is defined to exclude alternative forms of health care, such as acupuncture and homeopathy. 7Paul Starr, The Social Transformation of American Medicine: The Rise of a Sovereign Profession and the 3It is important to understand that there is not a Making of a Vast Industry (New York: Basic Books, onc-to-onc correlation between functions and depart- 1982). ments. A department may support several functions. "Julie Rovner, "Congress Feels the Pressure of "An actual documentation plan devised for Chil- Health Care Squeeze," Congressional Quarterly dren's Hospital, Boston will be included in the au- Weekly Report, 16 February 1991, 415; "Pay Now, thor's forthcoming book on documenting the U.S. Pay Later," Economist, 24 June 1989, 67. health care system. 9J. Rogers Hollingsworth, A Political Economy of 'Theodore R. Schellenberg, Modern Archives: Medicine: Great Britain and the United States (Bal- Principles and Techniques (Chicago: University of timore: Johns Hopkins University Press, 1986), 3, Chicago Press, 1956), 52. * 163. Hospital Documentation Planning 19

service components—organized, coordi- institutions and organizations that interact nated, and controlled to achieve certain and overlap with one another, each encom- goals," then our "system" is, in fact, more passing one or more functions in its mis- accurately described as a nonsystem, largely sion, sometimes along with other functions because of the predominance of free enter- that are not related to health care. The in- prise and the absence of nationalized health stitutions may be classified as: Downloaded from http://meridian.allenpress.com/american-archivist/article-pdf/56/1/16/2748466/aarc_56_1_18534n31m7132j2p.pdf by guest on 27 September 2021 care.10 • Health care delivery facilities, e.g., Far more than other nations, the U.S. is hospitals, nursing homes, and hospices characterized by a mix of public and pri- • Health agencies and foundations, e.g., vate health care institutions and organiza- the U.S. Department of Health and Hu- tions. The resulting "system" is stable and man Services, National Health Council, resilient because it is decentralized and di- and the Robert Wood Johnson Founda- verse and because the medical profession tion itself exercises tremendous power through • Biomedical research facilities, e.g., organizations such as the American Medi- Boston Biomedical Research Institute, cal Association. The government's role is and Acupuncture Research Institute of also powerful and is primarily exercised Monterey Park, California through government regulations, especially • Facilities for educating health profes- regarding third-party payment mechanisms sionals, e.g., Massachusetts College of and health care standards. Pharmacy and Allied Health Sciences, Broadly viewed, the health care system Forsyth Dental Center School for Dental has six major functions: Hygienists, Bowman Gray School of • Patient care, comprising diagnosis and Medicine treatment • Associations of health professionals and • Health promotion, including activities volunteers, e.g., the American Medical such as fitness programs and information Association, the American Association campaigns of Health Care Administrators, the • Biomedical research American Cancer Society • Education and training of health care • Health industries, e.g., Merck, Cod- professionals man and Shurtleff, Johnson and John- • Policy formulation and regulation: son, Blue Cross and Blue Shield.11 policy formulation involves coordinat- They are funded by government, voluntary ing health care services within a speci- contributions, investors, philanthropic fied region or jurisdiction on a foundations (notably the W.K. Kellogg, suprainstitutional level; regulation es- Robert Wood Johnson, and Rockefeller tablishes standards for institutions and Foundations), or a combination of these practitioners. methods. • Provision of goods and services, such The matrix in figure 1 provides a graphic as pharmaceutical, wheel chairs, diag- representation of the conjunction of the nostic and therapeutic equipment, and health care system's functions and institu- malpractice and health insurance. tional components. Although necessarily These functions are carried out by diverse artificial and schematic, the matrix provides a context for understanding how hospitals fit into the overall health care system. '"James M. Rosser and Howard E. Mossberg, An Analysis of Health Care Delivery (New York: John Wiley and Sons, 1977), 1. See also Milton I. Roemer, "Adapted from Rosser and Mossberg, Analysis of An Introduction to the U. S. Health Care System (New Health Care Delivery, 24-63, and Roemer, U.S. Health York: Springer, 1986), 2. Care System, 5-12. 20 American Archivist / Winter 1993 Downloaded from http://meridian.allenpress.com/american-archivist/article-pdf/56/1/16/2748466/aarc_56_1_18534n31m7132j2p.pdf by guest on 27 September 2021 o co

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Hospitals' Place in the System ernment agencies. Neither are they involved in health care policy formulation at Of all the institutions that engage in health the national level. Hospitals do, however, care delivery, hospitals are the most central influence health care policy and regulation to the United States health care system. at the local level and nationally through the Downloaded from http://meridian.allenpress.com/american-archivist/article-pdf/56/1/16/2748466/aarc_56_1_18534n31m7132j2p.pdf by guest on 27 September 2021 Hospitals were not always the focus of lobbying activities of state hospital asso- medical practice, as they are today. In the ciations and the American Hospital Asso- eighteenth and nineteenth centuries, only ciation. the sick poor went to hospitals. The upper and middle classes received medical care Types of Hospitals at home. Since the early part of this century, however, the hospital has become A hospital may be broadly defined as a "central to the delivery of patient care, to health care treatment facility with six or 15 the training of health personnel, and to the more inpatient beds. Hospitals in this conduct and dissemination of health-related country comprise a heterogeneous, decen- research."12 Because of the proliferation of tralized, and fragmented grouping of insti- the use of expensive medical technology in tutions about which it is extremely difficult 16 both diagnosis and treatment, however, the to generalize. Nevertheless, it is impor- hospital has become the one pervasive and tant to attempt to categorize them and de- indispensable institution in our health care scribe their similarities and differences, thus system. In 1990 there were 6,821 hospitals providing a broad context within which ar- in the United States, as compared to 3,457 chivists can construct documentation plans. institutions of higher education.13 In the As with most efforts at classification, some same year $194.2 billion was spent on hos- hospitals cannot be neatly placed into one pital services, representing 39 percent of category (e.g., mobile hospitals) or fit the $494.1 billion spent on all health care.14 equally well into several categories (wom- Hospitals perform four of the six func- en's and children's hospitals). tions of the U.S. health care system. In For the purpose of this study, hospitals addition to the patient care, education, and will be categorized in terms of five char- research functions, many hospitals have acteristics: (1) ownership or control; (2) health promotion programs (although it whether the hospital is freestanding or part should be noted that, historically, the U.S. of a larger organization; (3) type of patient health care system has emphasized treat- treated or services provided; (4) whether or ment over prevention). Regulation is not a not the hospital is involved in education function of hospitals, which are themselves and training; and (5) whether or not the regulated by federal, state, and local gov- hospital engages in biomedical research. (See figure 2.) The first three characteristics—ownership or control, whether the hospital is part 12Stcphcn J. Williams and Paul R. Torrcns, Intro- duction to Health Services (New York: Wiley, 1984), of a larger organization or freestanding, and 172. "American Hospital Association, Hospital Statis- tics, 1988 Edition (Chicago: American Hospital As- 15American Hospital Association, Guide to the Health sociation, 1988). Unless otherwise noted, all subsequent Care Field, 1987 Edition (Chicago: American Hos- statistics are from the 1989-90 edition of the same pital Association, 1987), A13. For the purpose of this publication. "Fact File: Number of Colleges by En- article, homeopathic and osteopathic hospitals, which rollment, Fall 1987," Chronicle of Higher Education, fall outside the scope of conventional medical prac- 16 August 1989, A2. tice, are excluded from this definition. "Katharine R. Levit, et al., "National Health Ex- '"John Z. Bowers, An Introduction to American penditures, 1990," Health Care Financing Review 13 Medicine-1975 (Washington, D.C.: U.S. Depart- (Fall 1991): 29-54. ment of Health, Education, and Welfare, 1977), 121. 22 American Archivist / Winter 1993

Figure 2. Typology of Hospitals Figure 2. Continued

• Ownership/Control (see figure 3) o Maternity hospitals o Orthopedic hospitals

^- Freestanding or Part of Larger Downloaded from http://meridian.allenpress.com/american-archivist/article-pdf/56/1/16/2748466/aarc_56_1_18534n31m7132j2p.pdf by guest on 27 September 2021 o Physical rehabilitation hospitals Organization o Psychiatric hospitals • Freestanding • Larger organization • Hospital Engages in Education o Holding company and/or Training o Health maintenance • Hospital Engages in Biomedical organization Research o Health care company o Multi-hospital system or chain o Part of a university, industry, business the type of patient treated or services provided—are the most important character- • Patients Treated or Services istics from an archival standpoint, because Provided they have the greatest impact on the types • Type of Patient Treated o African-American hospitals of records created and where they are lo- o Geriatric hospitals and nursing cated. If a hospital engages in educational homes activities or biomedical research, their rec- o Hospitals for employees of ords will obviously reflect these activities. specific businesses/industries Conversely, if a hospital does not engage o Hospitals serving American in education or biomedical research, no Indians/Alaskan natives records reflecting these activities will exist. o Military hospitals Because the patterns of hospital ownership o Pediatric hospitals and control are relatively complex and var- o Prison hospitals ied (see figure 3), as are the configurations o School/university infirmaries in which a hospital is part of a larger or- o Veterans hospitals ganization, they are described in detail be- o Women's hospitals (sometimes includes children's hospitals) low. • Type of Service Provided Government owned or controlled. The o Alcohol/drug abuse hospitals federal government, most states, and many o Bum hospitals local governments own and operate hospi- o Cancer hospitals tals. In 1988 the federal government ran 5 o Chronic disease hospitals/ percent of the nation's hospitals; state and hospices local governments operated 23 percent. o Communicable diseases In the federal government the organiza- hospitals tion most directly concerned with health care o Diabetes hospitals is, of course, the Department of Health and o Epilepsy hospitals Human Services (DHHS). In turn, the di- o Eye and/or ear, nose and throat hospitals vision of the DHHS most directly con- o General medical and surgical cerned with health care delivery is the Public hospitals Health Service (PHS) which comprises eight o Hospitals for the mentally agencies: the Agency for Health Care Pol- retarded icy and Research; the Agency for Toxic o Immunology and respiratory Substances and Disease Registry; the Al- (inc. tuberculosis) hospitals cohol, Drug Abuse, and Mental Health o Leprosaria Administration; the Centers for Disease Hospital Documentation Planning 23

Figure 3. Hospital Ownership or Control; the Food and Drug Administra- Control tion; the Health Resources and Services Administration; the Indian Health Service; • Government Ownership and the National Institutes of Health. Within • Federal the PHS, for example, the Alcohol, Drug o Dept. of Health and Human Abuse, and Mental Health Administration Downloaded from http://meridian.allenpress.com/american-archivist/article-pdf/56/1/16/2748466/aarc_56_1_18534n31m7132j2p.pdf by guest on 27 September 2021 Services, Public Health jointly administers, with the District of Co- Service lumbia, St. Elizabeth's Hospital in Wash- • Health Resources and ington, D. C, which is a psychiatric hospital Services Admin. for residents of the District of Columbia • Indian Health Service and the Virgin Islands; the Health Re- • National Institutes of Health's Clinical Center sources and Services Administration pro- o Department of Defense vides health care services to Hansen's • Army disease (leprosy) patients and others at the • Navy Gillis W. Long Hansen's Disease Center in • Air Force Carville, Louisiana; the Indian Health Ser- o Department of Veterans Affairs vice runs hospitals for American Indians o Department of Justice, Bureau and Alaskan natives; and the National In- of Prisons stitutes of Health's Warren Grant Magnu- o Department of Transportation, son Clinical Center consists of a 540-bed U.S. Coast Guard hospital and laboratory complex.17 • State Other departments of the federal govern- o State health agencies (long- term facilities for the chronically ment are also involved with health care de- ill, mentally retarded, and men- livery. The Department of Defense, for tally unstable) example, controls U.S. Army, Navy, and o State prison/reformatory Air Force hospitals, both in this country hospitals and abroad, providing health care services o State university medical school to military personnel and their dependents. hospitals Through the Department of Veterans Af- • Local fairs, the federal government also operates o District hospitals approximately 165 veterans hospitals, the o County hospitals majority of which are general hospitals, but o City/county joint hospitals some of which are psychiatric hospitals. The o City hospitals Health Services Division of the Department • Private Ownership of Justice's Bureau of Prisons provides • Voluntary (nonprofit) health care services for prisoners in federal o Church or religious order institutions and runs the Medical Center for o Private university Federal Prisoners, a large referral hospital. o Fraternal organization o Business/industry The Department of Transportation runs U.S. o Community group Coast Guard hospitals in Kodiak, Alaska, o Health maintenance organiza- and New London, Connecticut. tion State governments operate long-term fa- o Health care cooperative/ cilities providing care for the mentally ill collective • Proprietary (for-profit) o Individual owner "The Clinical Center provides patient care only to o Partnership individuals with illnesses that are being studied at one of the institutes; general diagnostic, treatment and o Corporation emergency services are not offered. 24 American Archivist / Winter 1993

and retarded and have done so in the past tients. This task was left to public hospi- for tuberculosis patients (e.g., Glenridge tals.20 Hospital, Glenville, New York (1909-1978). Voluntary hospitals, which comprise 48 State prison, state reformatory, and state percent of U. S. hospitals (1988), are owned university medical school hospitals (e.g., and operated by seven types of organiza- Downloaded from http://meridian.allenpress.com/american-archivist/article-pdf/56/1/16/2748466/aarc_56_1_18534n31m7132j2p.pdf by guest on 27 September 2021 The University Hospital at the University tions: (1) churches or religious groups, in- of Michigan Medical School) are also con- cluding Baptist, Lutheran, and Roman trolled by state governments. Catholic churches, the Salvation Army, the Local governments embodied in dis- Sisters of Mercy and The Alexian Brothers; tricts, counties, and cities may also run (2) private universities (Boston University hospitals. District hospitals, found in a few Hospital); (3) fraternal organizations (Shri- states including California, are governed by ners); (4) industry (railroad and lumber boards of directors who are elected by dis- companies); (5) community groups com- trict residents; county hospitals are gener- posed of citizens who organize to provide ally run by county boards of supervisors health care for their community and make (e.g., Cook County Hospital, Chicago); city modest annual contributions (Beth Israel hospitals are owned by municipal govern- Hospital, Boston)21; (6) health mainte- ments and managed by appointed boards of nance organizations (Kaiser Permanente); citizens (e.g., Boston City Hospital). and (7) cooperatives that are owned by those Sometimes city and county governments who use their services (Group Health Co- jointly control a hospital. operative of Puget Sound).22 Most public hospitals were founded to Proprietary or for-profit hospitals are provide health care to the indigent who were usually set up as a partnership or corpora- not served by voluntary hospitals. Today, tion. They emerged where community public hospitals include some teaching hos- groups could not raise the funds necessary pitals, a small number of large general hos- to establish voluntary hospitals. Proprietary pitals treating primarily the indigent, some hospitals owned by individual physicians hospitals in urban areas in which the patient were also common in the late nineteenth profile is similar to that in voluntary hos- century and well into the twentieth century pitals, and many small rural hospitals.18 because it was convenient for them to set Privately owned or controlled. The up hospitals in close proximity to their of- country's "ethnic and religious diver- fices. Furthermore, by starting their own sity . . . gave rise to a sizeable voluntary hospitals, physicians who did not have ad- [hospital] sector in America."19 Histori- mitting privileges in existing hospitals could cally, voluntary or nonprofit hospitals were treat the patients who needed hospitaliza- established by community leaders or reli- tion instead of turning them over to a col- gious or ethnic groups to serve the "de- serving poor" and individuals who became ill while away from home. Voluntary hos- 2O pitals provided free care and were pater- Hollingsworth, Political Economy of Medicine, 75. nalistic toward their patients; however, they 2IIt is interesting to note that Jewish hospitals fall did not treat indigent, contagious, morally into this last category rather than the first, for they lacking, mentally ill, or chronically ill pa- are supported by members of the Jewish community but not controlled by the synagogue. Similarly the black hospitals that existed during the segregation era were community hospitals supported by the African- American community. '"Hollingsworth, Political Economy of Medicine, 22Revised and updated from Florence A. Wilson 80-81. and Duncan Newhauser, Health Services in the United "Hollingsworth, Political Economy of Medicine, 5. States (Cambridge, Mass.: Ballinger, 1985), 9. Hospital Documentation Planning 25

league. Such hospitals, once common, are the number of beds in proprietary hospitals now rare. increased by roughly 148 percent, and the During the Depression, many proprie- number of admissions by 86 percent. tary hospitals were closed or merged with Degree of independence. Whether a voluntary or public hospitals. After the pas- hospital is freestanding or part of a larger sage of Medicare and Medicaid legislation organization is important in understanding Downloaded from http://meridian.allenpress.com/american-archivist/article-pdf/56/1/16/2748466/aarc_56_1_18534n31m7132j2p.pdf by guest on 27 September 2021 in 1965, however, the number of proprie- where documentation is located. Ob- tary hospitals began to increase because they viously, if the hospital is freestanding there were now reimbursed for interest on their are fewer possibilities than if it is part of a debt, plant depreciation and capital equip- larger organization. There are several con- ment.23 When for-profit hospitals came to figurations for a hospital within a larger be reimbursed by the government for Med- organization. A hospital may be one of the icare and Medicaid patients, they became institutions comprising a holding company. more like voluntary hospitals. Further- The Massachusetts Eye and Ear Infirmary, more, voluntary hospitals became more like for example, is a nonprofit subsidiary of for-profit hospitals because the government the Foundation of the Massachusetts Eye reimbursed them for some of their charity and Ear Infirmary, which also owns a for- work. profit real estate company. A few health Prior to 1965, the American public held maintenance organizations (HMOs), such a strong prejudice against the for-profit as Kaiser Permanente, own one or more hospital sector because the practice of med- hospitals.27 Hospitals are also owned by icine had been viewed as charity or a ser- health-care corporations, such as National vice to humanity. This prejudice was Medical Enterprises, Inc., which in 1988 reduced to some extent once voluntary and owned 500 hospitals, 25 ambulatory-care proprietary hospitals became more like each centers, and 140 pharmacies. Multi-hospi- other.24 Proprietary hospitals, however, tal systems are three or more voluntary hos- continue to lag behind the hospital industry pitals (e.g., Adventist Health System) or as a whole in providing outpatient services, government hospitals (e.g., Veterans emergency services, health promotion Administration hospitals) that collaborate services, and education for medical profes- through ownership, management, or lease sionals.25 arrangements to enhance patient care. Their For the past several years the number of for-profit counterparts are hospital chains proprietary hospitals has remained stable.26 such as Hospital Corporation of America, In 1988 approximately 12 percent of hos- which was founded in 1968 by Thomas F. pitals were proprietary, representing a de- Frist, a Nashville physician, and Jack C. crease of 6 percent since 1950; however, Massey, who made Kentucky Fried Chicken a national chain.28 Finally, hospitals may be part of a university, industry, or busi- "Hollingsworth, Political Economy of Medicine, 74. 24J. Rogers Hollingsworth and Ellen Jane Holling- sworth, Controversy About American Hospitals: 27In some cases, HMOs do not own hospitals but Funding, Ownership, and Performance (Washington, have agreements with specified hospitals where their D.C.: American Enterprise Institute for Public Policy members are treated. Research, 1987), 63. 28This collaboration marked a turning point in the 25Ekaterini Siafaca, Investor-Owned Hospitals and U.S. health care system. In 1968 few hospitals were Their Role in the Changing U. S. Health Care System part of for-profit chains, but by 1983 13 percent of (New York: F & S Press, 1981), 117. nonfederal acute-care hospitals were controlled by 26Russell C. Coile, Jr., The New Medicine: Re- chains. Donald W. Light, "Corporate Medicine for shaping Medical Practice and Health Care Manage- Profit," Scientific American 255 (December 1986): ment (Rockville, Md.: Aspen, 1990), 29. 38. 26 American Archivist / Winter 1993

ness. (Government could also be consid- biomedical research, and education and ered in this category of larger organizations, training—replicate the broad functions of although government ownership is dealt with the U.S. health care system, as portrayed in the previous section.) The University in figure 1. The fifth, administration, is not Hospital in Boston, for example, is owned unique to hospitals, but is a requisite part Downloaded from http://meridian.allenpress.com/american-archivist/article-pdf/56/1/16/2748466/aarc_56_1_18534n31m7132j2p.pdf by guest on 27 September 2021 by Boston University, and at the turn of the of all institutions. It is important to under- century many of the larger railroad, min- stand all of these functions and their re- ing, and lumbering companies built, owned, cord-keeping implications in terms of the and operated hospitals for their employ- distinctions between hospitals and busi- ees.29 With the dramatic rise in the cost of nesses. operating health care facilities and the in- American hospitals are similar to busi- creased availability of group health insur- nesses and have become more so since the ance, company-owned hospitals are no passage of Medicare and Medicaid legis- longer common. lation in 1965, which created a large base Regional patterns. Certain patterns of of paying population for which hospitals hospital ownership and control are more competed. Since the mid-1960s nonprofit prevalent in some areas of the country than hospitals have been forced to adopt some in others. Proprietary hospitals were begun of the management activities employed by in areas where the population was too poor for-profit hospitals, such as marketing.33 It or too scattered to support a voluntary hos- is not uncommon for nonprofit hospitals to- pital. The majority of proprietary hospitals day to have marketing departments, or (73.3 percent in 1981), therefore, are lo- marketing managers in other departments. cated in the South, West, and Southwest.30 Nonprofit hospitals were again forced to California, Texas, Florida, and Tennessee adopt some of their for-profit counterparts' claim the most proprietary hospitals.31 Vol- strategies in 1983 when the federal govern- untary hospitals are still most prevalent in ment changed its method of Medicare reim- the northeastern, mid-Atlantic, and mid- bursement from "reasonable cost" to a fixed western states where the wide variety of rate based on patient diagnosis (diagnosis- religions and ethnic groups were able to related groups, or DRGs).34 Thus, all hos- amass the necessary capital to fund hospi- pitals were forced to become more efficient tals in the late nineteenth and early twen- or they would lose money treating Medi- tieth centuries.32 care patients. Hospitals also have several important Functions of Hospitals differences that set them apart from busi- Hospitals differ from each other and from nesses. The major difference, and the one other institutions, not only by their own- that probably has the most effect on records ership and control but also according to the creation, is the nature of the hospital's or- functions that they serve. Four of the functions—patient care, health promotion, "Light, "Corporate Medicine," 42. 34DRGs are a form of prospective payment under 29Starr, Transformation of American Medicine, 202. Medicare for inpatient hospital services. Under this •"'Siafaca, Investor-Owned Hospitals, 62. system hospitals are paid a specified amount for serv- ''Hollingsworth and Hollingsworth, Controversy ices provided based on a patient's classification into About American Hospitals, 27, 62. one of approximately 500 DRGs, regardless of what 32HoIlingsworth and Hollingsworth, Controversy the care actually costs. Some adjustments are made About American Hospitals, 26-27. For more current for teaching hospitals and regional variations in cost hospital statistics broken out by region, consult the of living. Also, psychiatric, rehabilitation, children's, latest annual edition of the American Hospital Asso- and long-term hospitals are excluded from DRG reg- ciation's Hospital Statistics. ulations. Hospital Documentation Planning 27

ganizational structure. Hospital organiza- tain types of physicians, such as radiologists tion is not strictly hierarchical, but is and anesthesiologists, have traditionally been composed of two main components: the ad- salaried hospital employees. Other arrange- ministrative component and the clinical or ments between physicians and hospitals are medical component. Each component is or- now common practice (in part because of ganized differently, and there is no theo- an increase in the number of physicians, Downloaded from http://meridian.allenpress.com/american-archivist/article-pdf/56/1/16/2748466/aarc_56_1_18534n31m7132j2p.pdf by guest on 27 September 2021 retical model that integrates them.35 cost-containment pressures, and increased The administrative component, which is competition), and now hospitals routinely responsible for hospital management, is employ physicians individually or as groups. usually organized in a strict hierarchical To further complicate the issue, physicians fashion. The organization of the medical in teaching hospitals may also be employed component, which is responsible for pa- by an affiliated medical school. Whatever tient care, education and training, and the arrangement between physicians and biomedical research, is flatter and its mem- hospitals, the two-pronged organizational bers typically work in teams across depart- scheme is the prevailing pattern. ment lines. To complicate matters, the two There are several significant differences components overlap, and many hospital between hospital patients and consumers of employees report to two supervisors: an ad- business products and services. Patients are ministrator and a physician. The chief tech- not always able to comparison shop; they nician of a pathology laboratory, for generally are not concerned with the cost example, reports to the physician in charge of health care, especially if they have health of the medical operations of the laboratory insurance; and they have little control over and to the administrator responsible for the what they are buying, because the physi- laboratory's financial operations. This ad- cian decides which drug or procedure is ministrative/medical dichotomy has also best for them, although sometimes patients affected the credentials of hospital chief ex- will be offered a choice among a small ecutive officers, which have alternated his- number of treatment options. torically between management and medical Other differences between hospitals and degrees. The current trend in nonprofit hos- businesses include the fact that hospitals do pitals is toward physician chief executive not manufacture a uniform product or pro- officers. vide a uniform service; hospitals provide Another significant difference between health care services that are tailored to each hospitals and businesses is that while busi- patient. In addition, physicians signifi- nesses employ all the individuals on their cantly influence both the supply and the staffs, many physicians who work in hos- demand for a service or product, while in pitals may not be employed by the hospital. business supply and demand are deter- In the past, very few physicians were paid mined independently. Finally, technologi- by hospitals; instead, hospitals extended cal advances in business are usually cost- privileges to physicians to admit their pa- efficient; in hospitals they usually are not tients. The patient paid two fees, one to the cost-efficient, because technological ad- physician and the other to the hospital for vances increase cost, particularly as spe- use of the facilities, nursing care, diagnos- cially trained personnel are needed to operate tic tests, and medication. In contrast, cer- new and often expensive diagnostic and therapeutic equipment.36 However, some

•15Luther P. Christman and Michael A. Counte, Hospital Organization and Health Care Delivery 36Jonathon S. Rakich and Kurt Darr, eds., Hospital (Boulder: Westview Press, 1981), 28. Organization and Management: Text and Readings 28 American Archivist / Winter 1993

departments or services within a hospital, publicly identified as such. Although the such as pharmacies, gift shops (often run JCAHO is a private organization and by the auxiliary), and optical shops may be JCAHO accreditation is not mandated by run like businesses. law, Medicare and Medicaid legislation re- Administration. All institutions engage quire hospitals to meet standards equal, to in administrative activities that are neces- JCAHO standards in order to receive pay- Downloaded from http://meridian.allenpress.com/american-archivist/article-pdf/56/1/16/2748466/aarc_56_1_18534n31m7132j2p.pdf by guest on 27 September 2021 sary for them to do business. Hospitals are ment; thus, virtually all hospitals seek no exception; they engage in budgeting, JCAHO accreditation. staffing, and often marketing activities like Hospitals are the most extensively reg- other businesses. Archivists must under- ulated institutions in the United States.37 stand the administrative activities and Most of this regulation has been instituted mechanisms peculiar to hospitals, particu- since the passage of Medicare and Medi- larly accreditation and regulation, in order caid legislation in the mid-1960s, and hos- to make sense of the records that result from pital regulation has increased dramatically. the activities. Because of the nature of hos- Prior to that time, regulations were aimed pital organization noted above, the admin- mostly at the condition of the facility. To- istrative and patient-care functions overlap. day, they have been expanded to cover For this reason, many of the activities and quality and cost of care. Regulation of hos- mechanisms discussed in this section may pitals has been described as lacking in also be discussed under the patient care "consistency, parsimony and clarity."38 function. This is because they are regulated by a wide Since 1952 hospital accreditation has been range of private organizations (e.g., Blue carried out by the Joint Commission for Cross and JCAHO), and public agencies Accreditation of Healthcare Organizations representing all three levels of government, (JCAHO). Representatives of five organi- with little attempt at coordination. Often, zations comprise the Commission: the regulations of different bodies conflict with American College of Physicians, the one another. American College of Surgeons, the Amer- Hospital regulation falls into four cate- ican Dental Association, the American gories: (1) facilities regulation; (2) plan- Hospital Association, and the American ning regulation; (3) quality and Medical Association. In accrediting hos- appropriateness of care; and (4) payment.39 pitals, the JCAHO is concerned with three All states require hospital facilities to be areas: (1) quality of patient care; (2) hos- licensed, although the scope of mandatory pital organization and administration; and regulations varies from state to state, and (3) hospital facilities. The accreditation in some states JCAHO accreditation guar- process consists of an extensive survey that antees state licensure. State licensing reg- is filled out by hospital administrators and ulations usually concern hospital a site visit by a JCAHO accreditation team, organization (requiring an organized gov- consisting of a physician, one or two nurses, erning body, organized medical staff, and and sometimes a hospital administrator. Hospitals may be accredited for three years, with or without contingencies, and hospi- •17Siafaca, Investor-Owned Hospitals, 29. '"American Hospital Association, Hospital Regu- tals that are regarded as "marginal" are lation: Report of the Special Committee on the Reg- ulatory Process (Chicago: American Hospital Association, 1977), 2. •"Siafaca, Investor-Owned Hospitals, 33; and (New York: SP Medical and Scientific Books, 1983), American Hospital Association, Hospital Regulation 597-600. 1977, 113. Hospital Documentation Planning 29

administrator), provision of certain speci- view process involves considerable fied services, and standards for facilities, documentation and lengthy reviews at the equipment and personnel. State govern- local, regional, and state levels, and it may ments also have certain building code re- take up to four years to complete.41 quirements that apply to all facilities. These Quality and appropriateness of care, the include regulations regarding elevator and third type of hospital regulation, has been Downloaded from http://meridian.allenpress.com/american-archivist/article-pdf/56/1/16/2748466/aarc_56_1_18534n31m7132j2p.pdf by guest on 27 September 2021 boiler performance, waste disposal, fire in effect since passage of the 1965 Medi- safety, and electrical and plumbing facili- care legislation, which requires that the ap- ties. In addition, hospitals are subject to propriateness and necessity of care provided state and federal legislation that affects, for to Medicare patients be evaluated by ex- example, the dispensing of narcotics and amination of patient records. Because of alcohol, the disposal of hazardous waste, this regulation, hospitals established qual- radiation safety, water and air quality, la- ity assurance and utilization review com- bor practices including job safety, and ed- mittees to monitor and analyze patient ucational requirements for teaching admissions, length of stay, and allocation programs. of resources. In 1972 the federal govern- Planning is defined by the American ment legislated the creation of Professional Hospital Association as "an orderly process Standards Review Organizations (PSROs), for determining the health care needs of a composed of local physicians who are paid specific population and developing an ap- by the U.S. Department of Health and Hu- propriate health care capability to meet those man Services to monitor physician behav- needs."40 The federal government has been ior and establish standards of care that reflect involved in hospital planning regulation local patterns of practice. Since 1984 the since 1946, when the Hill-Burton Hospital review contracts have been awarded to peer Survey and Construction Act was passed. review organizations (PROs), which are This legislation provided for hospital con- nonprofit, community based, physician di- struction or renovation mostly in rural areas rected agencies, and have more authority where there was a shortage of beds. than the PSROs. PROs review admissions Currently, certificate-of-need legislation and readmissions, validate diagnoses, and at the state level controls capital expendi- review exceptional cases and quality of care. tures for construction, expansion, and If medical audits reveal unacceptable prac- modernization of health care facilities as tice, the government does not reimburse the well as the purchase of costly technology offending hospital for Medicare and Med- such as computerized tomography (CT) icaid patients. In many cases hospitals par- scanners and magnetic resonance imagers ticipate in the review process through in- (MRIs). The purpose of this legislation is house Professional Services Review De- to avoid unnecessary duplication of serv- partments, which are monitored by the PRO. ices and to control costs. If the cost of a Quality of care in hospitals is also reg- proposed renovation or piece of equipment ulated by several mandatory committees that is more than a specified amount, hospitals must acquire a certificate-of-need in order to be reimbursed under Medicare and Med- •"David Barton Smith and Arnold D. Kaluzny, The icaid legislation. The certificate-of-need re- Wliite Labyrinth: A Guide to the Health Care System (Ann Arbor, Mich.: Health Administration Press, 1986), 56; and Jesus J. Pena and Valeria A. Glesnes- Anderson, eds., Hospital Management: Winning ""Amcrican Hospital Association, Hospital Regu- Strategies for the 1980s (Rockville, Md.: Aspen, 1985), lation 1977, 11. 120. 30 American Archivist / Winter 1993

seek to ensure a high standard of patient intensity of work; (2) cost of providing the care. These committees may be overseen service; and (3) cost of physician train- by a hospital's Professional Services Re- ing.43 view Committee or another group with Just as hospitals are accredited by the quality assurance responsibilities. They in- JCAHO and licensed by the states, health clude the Credentials Committee, which care practitioners must also meet profes- Downloaded from http://meridian.allenpress.com/american-archivist/article-pdf/56/1/16/2748466/aarc_56_1_18534n31m7132j2p.pdf by guest on 27 September 2021 assures that physicians have the necessary sional accreditation standards, often set by and appropriate credentials; the Infection professional associations, and state licen- Control Committee; the Medical Records sure requirements.44 Licensure usually in- Committee, which reviews the "content, volves fulfilling certain educational appropriateness and timeliness"42 of offi- requirements and passing an examination. cial patient records; the Pharmacy Com- Which of the numerous health care profes- mittee, which reviews drug utilization and sions require licensure, however, varies patient responses; the Radiation Commit- among the states. In most states the hos- tee; the Safety Committee; and the Tissue pital is responsible for ensuring that med- Committee, which examines tissue re- ical and technical personnel meet moved from patients to determine whether government standards. Therefore, hospitals surgery was indeed necessary. often employ registrars, whose function is While the other types of regulation in- to document the credentials of physicians directly aim at controlling costs, the final and other health care practitioners. type of hospital regulation, regulation of Patient Care. Patient care, which en- payment, directly influences the cost of compasses diagnosis and treatment, is the hospital services. At both the state and lo- primary function of hospitals and what dis- cal levels, retrospective reimbursement has tinguishes them from other institutions been replaced by prospective payment. At within and outside of the health care sys- the state level, payment regulation is some- tem. Patient care is often divided into three times controlled by a rate-setting commis- levels—primary care, secondary care, and sion that prospectively approves rates for tertiary care— based on the severity of the hospital services. The federal government condition to be treated. Primary care de- controls rates for inpatient hospital care to notes care that is simple to give, or eval- Medicare and Medicaid patients through uation of a condition and referral to a diagnosis-related groups. Historically, only specialist. Although primary care does not fees for hospital services were regulated; require hospitalization, individuals may re- physicians are reimbursed according to a ceive primary care in a hospital setting. The system of "customary, prevailing, and rea- treatment of individuals with infections, or sonable" charges. This is changing with victims of minor accidents, and the provi- the adoption by federal regulators, some sion of annual physical examinations are private insurers, and other third-party pay- ers of the recently formulated Resource- Based Relative Value Scale (RBRVS) for 43William C. Hsiao, et al., "Resource-Based Rel- ative Values: An Overview," Journal of the Ameri- physician fees. Due to go into effect in 1992, can Medical Association, 28 October 1988, 2347-53. the RBRVS standardizes physician fees ac- 44The American Hospital Association defines licen- cording to three factors: (1) education and sure as "the process by which an agency of government grants permission to an individual to engage in a given occupation, upon finding that the applicant has attained the minimal degree of competency necessary to ensure that the public health, safety, and 42Donald I. Snook, Jr. and Edita M. Kaye,^ Guide welfare be reasonably well protected." (AHA, Guide- to Health Care Joint Ventures (Rockville, Md.: As- lines: Licensure of Health Care Personnel [Chicago: pen, 1987), 195. AHA, 1977], 1.) Hospital Documentation Planning 31

examples of primary care. Secondary care element in patient diagnosis. Two types of is more specialized care for conditions that laboratories—clinical pathology and re- require hospitalization. The treatment of search—may exist in a hospital, but only burn and serious accident victims and the clinical pathology laboratories are involved extraction of tonsils are examples of sec- with diagnosis. Through sample analysis, ondary care. Tertiary care is the most spe- they provide information that assists health Downloaded from http://meridian.allenpress.com/american-archivist/article-pdf/56/1/16/2748466/aarc_56_1_18534n31m7132j2p.pdf by guest on 27 September 2021 cialized and generally involves the most care personnel in diagnosing disease. advanced medical knowledge and technol- Patient treatment may be classified as in- ogy available. Academic medical health ternal therapy (medication), external ther- centers specialize in tertiary care, which in- apy (casts, bandages, advice on life-style cludes treatment for cancer and for con- changes), mental therapy, or surgery. Pa- genital and metabolic disorders.45 Some tient treatment may further be distinguished hospitals engage in all three levels of care, according to whether the patient remains in although many smaller hospitals refer pa- the hospital overnight (inpatient) or is treated tients needing tertiary care to larger hos- and released (outpatient). Hospital outpa- pitals. tient departments first appeared in the 1920s, Diagnoses may be made by health care and since then they have increased in num- professionals without the aid of technology ber, scope, and complexity.47 The services (as when they prescribe treatment on the provided on an outpatient basis are general basis of their observations or the answers diagnosis and treatment for nonemergency patients give to questions they ask) or with conditions to individuals referred by them- the aid of technology. There are three main selves or a physician and emergency care. categories of diagnostic technology: sam- It is noteworthy that in the last several years ple analysis, intrinsic energy analysis, and the length of hospital stays has decreased, external energy probes. Sample analysis and some procedures, such as cataract sur- consists of analyzing the chemical and cel- gery, that were previously performed on an lular components of body fluids and tis- inpatient basis are now performed as "am- sues. Examples of sample analysis include bulatory surgery," eliminating the need for blood tests, tumor biopsies, and spectros- an overnight hospital stay. This change is copy. Intrinsic energy analysis measures due to improved techniques and to revised internal energy conditions, such as temper- Medicare and Medicaid reimbursement ature, sound, and pulse. Electroencephal- regulations aimed at cost containment. ographs, for example, are devices that record Health promotion. Health promotion, the electrical activity of the brain. The third or consumer health education, is the process category of diagnostic technology, external of communication and education that "helps energy probes, is used to determine the size, each individual to learn how to achieve and shape, and location of internal organs. Ex- maintain a reasonable level of health ap- ternal energy probes work by shooting beams propriate to his particular needs and inter- of energy into the patient and analyzing the ests, and to be motivated to energy that comes out. Examples of exter- follow . . . health practices which contrib- nal energy probes are ultrasound and x- ute to his state of health and well-being."48 rays.46 Historically, hospitals in the United States Hospital laboratories are an important

"Milton I. Roemer, Ambulatory Health Services in America, 48 "Rosser and Mossbcrg, Analysis of Health Care 4aMyra E. Madnick, Consumer Health Education: Delivery, 16. A Guide to Hospital-Based Programs (Wakeficld, "''Williams and Torrens, Health Services, 287. Mass.: Nursing Resources, 1980), 1. 32 American Archivist / Winter 1993

have not participated very actively in health using animals or humans, must have Ani- promotion. In 1984 less than 1 percent of mal Care Committees and Human Subject the federal government's health care budget Committees. These are federally mandated was used for health promotion.49 This trend committees that closely monitor federally seems to be reversing, because by 1987 funded research involving animals or hu- health promotion programs were offered in mans. If abuses occur, committee members Downloaded from http://meridian.allenpress.com/american-archivist/article-pdf/56/1/16/2748466/aarc_56_1_18534n31m7132j2p.pdf by guest on 27 September 2021 more than one-third of U.S. hospitals.50 are obliged to report them to the National Community hospitals are especially con- Institutes of Health. scientious about health promotion, and it is Education and training. Education and not unusual for them to offer, free or at a training may occur in a hospital setting at moderate cost, literature concerning health many levels. Hospital personnel are edu- issues, and health education classes in, for cated regarding infection control and safety example, how to stop smoking, reduce procedures; laboratory and radiology tech- stress, and maintain a healthier diet. Health nicians are trained; nursing students are promotion programs may also include health provided with undergraduate education or support groups, health screening, physical specialty training; graduate students earn fitness classes, family life education, and M.S. degrees in nursing, dietetics or phys- rehabilitation. ical therapy; other graduate students work Biomedical research. Biomedical re- on research projects in hospital depart- search in a hospital setting is similar to sci- ments or laboratories, and medical students entific/technological research with a clinical have rotations, which lead to Ph.D. and dimension; thus, the records of research done M.D. degrees, respectively; physicians are in hospitals are similar to those produced given postgraduate education as residents by research in a university.51 Furthermore, or fellows; and the entire range of allied hospitals may embark on research projects health care professionals attends hospital jointly with universities or corporations, thus sponsored in-service programs or continu- affecting the location of project records. ing education courses in order to retain their Recently, the trend in hospitals has been to certification or licensure, or to update their increase research and development activi- knowledge and skills. To this end it is not ties with the goal of developing new prod- uncommon for hospitals to have an edu- ucts and business ventures. This type of cation department or for medical depart- diversification enables hospitals to remain ments to hire managers to deal primarily viable in a competitive environment.52 with education. Hospitals may also provide Biomedical research in whatever setting is the clinical facilities necessary for pro- regulated just as scientific/technological re- grams that they do not sponsor. In addition search is regulated. Hospitals, as other in- hospitals often provide trustee education, stitutions in which research is carried out management development, and patient and community health education programs. Certain hospitals are identified as teaching hospitals. According to the American •"Joseph A. Califano, America's Health Care Rev- olution: Who Lives? Who Dies? Who Pays? (New Hospital Association, a teaching hospital is York: Random House, 1986), 60. "a hospital that allocates a substantial part 5"Coile, The New Medicine, 152. of its resources to conduct, in its own name 5'For a discussion of scientific/technological research from the standpoint of its component activities, or in formal association with a college, see, Joan K[rizack] Haas, Helen Willa Samuels, and courses of instruction in the health disci- Barbara Trippel Simmons, Appraising the Records of plines that lead up to the granting of rec- Modern Science and Technology: A Guide (Cam- bridge: MIT Press, 1985). ognized certificates, diplomas, or degrees, "Coilc, The New Medicine, 35. or that are required for professional certi- Hospital Documentation Planning 33

fication or Iicensure."53 Although this def- Figure 4. Documentation Planning inition does not mention research, the reality Checklist is that more often than not, teaching hos- • Who owns or controls the hospital? pitals also engage in biomedical research. See figure 2. Although the term teaching hospitals tra- • Is the hospital freestanding or part of Downloaded from http://meridian.allenpress.com/american-archivist/article-pdf/56/1/16/2748466/aarc_56_1_18534n31m7132j2p.pdf by guest on 27 September 2021 ditionally referred to affiliation with med- a larger organization? ical schools, today it also denotes affiliation • Are the hospital's services limited to with other educational institutions. The a certain population group? See fig- Veterans Administration Hospital in Ann ure 1. Arbor, Michigan, for example, is affiliated • Does the hospital provide services with the University of Michigan Medical only for a specific condition or range of conditions? See figure 1. School and thirty-four other educational in- • Does the hospital engage in educa- stitutions. Historically, most teaching hos- tion and/or training? If so, who is pitals in the United States were public taught (hospital employees/staff, hospitals; however, more recently the ma- technicians, nurses, physicians, etc.) 54 jority of teaching hospitals are voluntary. and at what level (undergraduate, For-profit hospitals avoided engaging in graduate, post-graduate, continuing teaching and research because they were education)? Are the programs oper- not profitable activities; however, a few ated through affiliation with other in- investor-owned companies began purchas- stitutions? ing or leasing teaching hospitals in the early • Does the hospital engage in biomedi- 1980s for a variety of complex reasons.55 cal research? Is the research administered through the hospital or In 1979, 17 percent of voluntary hospitals, through an affiliated institution? Are 8 percent of public hospitals, and 1 percent other institutions involved in adminis- of proprietary hospitals were affiliated with tering, funding, regulating, conducting 56 medical schools. the research? • Does the hospital have a health pro- Hospital Classification as a Basis for motion program? Documentation Planning • What level(s) of patient care does the hospital provide: primary, secondary, Analyzing hospital functions and classi- and/or tertiary? fying hospitals enables archivists to iden- • Is this type of hospital usual or rela- tify what is routine and what is unusual tively unusual for its geographic about a particular hospital. They are then area? In what ways, if any, is it unu- able to use this information as part of the sual? Does it have significant re- context for devising institutional documen- gional/national importance? tation plans. Hospitals are classified by choosing one element from each of the five hospital characteristics: ownership or control; whether it is freestanding or part of a larger organization; type of patient treated ""Definition of a Teaching Hospital," American or services provided; whether it engages in Hospital Association Memorandum, 11-15 November education and training; whether it engages 1967, as quoted in William E. Hassam, Hospital in research. However, all possible combi- Pharmacy (Philadelphia: Lea and Febiger, 1986), 45. 54Hollingsworth and Hollingsworth, Controversy nations of hospital characteristics do not About American Hospitals, 47. exist. For example, there are no for-profit "Bradford H. Gray, ed., For-Profit Enterprise in Department of Veterans Affairs hospitals; Health Care (Washington, D. C: National Academy neither are there for-profit leprosaria, or Press, 1986), 145. 56Gray, For-Profit Enterprise, 109. voluntary religious hospitals serving Amer- 34 American Archivist / Winter 1993

ican Indians or Alaskan Natives. The Mas- fullest extent possible because it is one of sachusetts Eye and Ear Infirmary (MEEI), a few hundred medium sized, local gov- for example, would be classified as a vol- ernment owned, freestanding, general hos- untary (secular) hospital that is a subsidiary pitals; however, it is a Harvard University of a holding company. The Infirmary treats teaching hospital, which sets it somewhat patients with diseases of the eye, ear, nose, apart from city hospitals in other parts of Downloaded from http://meridian.allenpress.com/american-archivist/article-pdf/56/1/16/2748466/aarc_56_1_18534n31m7132j2p.pdf by guest on 27 September 2021 or throat, and engages in education, train- the country. The City of Cambridge might ing, and research. In addition, it is affili- decide to focus on patient care and health ated with Harvard University and is one of promotion (to document the hospital's re- only fourteen eye, ear, nose, and throat lationship to the city), and education, par- hospitals in the United States and the only ticularly in relation to Harvard Medical one in New England. Another example of School. See figure 4 for a checklist of ques- hospital classification: the Ann Arbor Vet- tions useful in classifying a specific hos- erans Administration Hospital is a federally pital and determining its place within the owned hospital that is part of a multi-hos- context of hospitals in general. pital system of approximately 165 veterans Conclusion hospitals. It serves veterans and engages in education, training, and research activities This article has presented an overview (having affiliations with 34 educational in- of the U. S. health care system from an stitutions). archival perspective, a typology of hospi- Archivists could then use this classifi- tals, and a functional analysis of aspects of cation information to make documentation hospitals that have an impact on records planning decisions. Because the Massachu- creation, location, and retention. When setts Eye and Ear Infirmary is the only eye, combined with an understanding of insti- and ear, nose and throat hospital in New tutional goals, culture, and resources and a England, a documentation plan would en- knowledge of historical trends, historio- sure, at a minimum, documentation of its graphic techniques, and traditional archival unique functions. After careful analysis the appraisal criteria, this analysis will enable MEEI archives advisory committee (as de- archivists, with the assistance of planning fined in the introductory section of the ar- committees, to assess how adequately a ticle) might decide to document the specific hospital has been or should be doc- Infirmary's education and training function umented, to devise documentation plans for only as it relates to educating Harvard specific institutions, and to devise cooper- Medical School students, but to document ative collecting agreements. This strategic certain administrative activities, biomedi- planning framework is not limited in use- cal research, patient care, and health pro- fulness to hospitals, but could be employed motion more fully. On the other hand, it equally as effectively with other types of might not be so important to document all institutions, such as museums, engineering five functions of Cambridge Hospital to the firms, and insurance companies.