In the beginning
Some of these records were on cards that measured mostly 20 x 12.5 cm, but some where 10 x 7.5 cm cards. There were also various arrangements for family groups. Some had a separate card for each member of the family, with every member filed separately; while some had a different card for each member but with all dependent family members stapled together and catalogued under the name of the responsible family member. Other records were entered on a family card, with each consultation after the other for the whole family, and recorded in chronological order.
It is difficult to comprehend how such systems could function with today’s mass of information, but we tend to forget that the practice of medicine was very different before the early 1970s. Very little pathology was available for general practitioners (GPs), and by current standards, medical treatment was almost primitive. For example, a patient with congestive cardiac failure would have been treated with digoxin, mersalyl or thiomerin injections (usually three times a week) and probably phenobarbital; while a patient with type 2 diabetes had the alternative of diet or insulin.
The bulkiest part of the medical record in those days was the consultant’s letter.
By the 1960s, people were beginning to realise that medical records were important in the process of ongoing care of the patient. Probably the first person to propagate the importance of the medical record was American psychiatrist, Dr Lawrence Weed, who in 1964 published the paper Medical records, medical education and patient care. He went on to develop the concept of the problem orientated medical record (POMR).1
In Australia, Dr Wes Fabb, who in the 1960s was chair of the National Practice Management Committee (and later, national director of the Family Medicine Programme [FMP]), was experimenting with an A4-sized paper in a folder not dissimilar to the present format of the RACGP record system.
Dr Monty Kent-Hughes, one of the early presidents of the RACGP, was also experimenting with a folder system which was numerically filed.
In 1972, the first World Organization of National Colleges and Academies (WONCA) conference was held in Melbourne, chaired by Dr Kent-Hughes. Dr Edward (Ted) Gawthorn, one of the organisers, invited Dr Weed as a keynote speaker – it was here that he attracted overflow audiences at conference presentations.
Malcolm McHarg was an accountant interested in medical management and developed the Medrecord System which had many of the features lauded by Dr Weed. He attracted support from a number of practices.
Dr Weed’s presentation stimulated a lot of interest in medical records and the Practice Management Committee of Council (PMCC), under the chairmanship of Dr Clive Auricht, decided to investigate the development of a POMR for Australian general practice, along the lines of the Weed, Fabb and Kent-Hughes models. This was to be an A4 folder system accompanied by an A5 personal health record.
The members of PMCC at this time (1973) were Dr Auricht from South Australia, Dr King Kinder from New South Wales, Dr Gawthorn from Victoria, Dr John North from Tasmania, Dr Graeme Simpson from Western Australia and Dr Frank Fry, author of this paper, from Queensland.
At that point, the RACGP operated with five committees (Education, Examination, Practice Management, Research, and Preventive and Community Medicine) at both state level and federally. The state chairs of each committee met twice each year, usually in Melbourne. The college was funded, as it still is, by annual subscriptions from members. State faculties were funded by the college, as were the expenses of committees.
A meeting of the PMCC in 1973 was held in Adelaide at the request of the chair, Dr Auricht, to coincide with the meeting of Council. Normally, most meetings were held in Melbourne as this venue was the most economical.
At this PMCC meeting, held in the ballroom at the Australia Hotel in North Adelaide, members had been asked to provide all the different types of primary health records available in each state. The result was little stacks of primary healthcare records all around the ballroom (Tasmanian Health sent 200 kg of records). All these stacks were examined to assess what was worth keeping and to develop a POMR along the lines of the Weed model.
By early 1974, PMCC had developed a prototype A4 folder with loose leaf inserts for a health summary and progress notes. This prototype was tested at three Melbourne practices.
To be successful, the object of the project would necessitate the conversion of as many as possible of the GP records in Australia to a POMR. This was obviously a major undertaking. The first thing to do was to convince the RACGP Council of the need for the project, then to develop the record and market it.
There had been a change of government in 1972 (Labor was elected after 23 years of Conservative rule), and big changes were afoot. In early 1973, the new government announced that they were to open a multidisciplinary community health centre in Canberra. It was obvious that they would need an efficient medical record system, and PMCC had a prototype. There had been a PMCC meeting in Melbourne on the weekend of the announcement, so Dr Auricht, then chair, instead of returning to Adelaide went at his expense to Canberra for the opening of the new centre. There he met one of the GPs and found that they were to use a quarto-sized blank paper page held together by a metal clip in a cardboard folder. Dr Auricht was telling this GP about the prototype PMCC record system when the conversation was overheard by Dr Brian Hennessy, who was second in charge to Dr Sidney Sax, chair of the Hospitals and Health Services Commission (H&HSC).
Dr Hennessy suggested that Dr Auricht meet Dr Sax, who was most interested in the project. Dr Sax then introduced Dr Auricht to Rosemary Goulston, who was in charge of the medical record section of H&HSC and president of the Australian Federation of Medical Record Librarians (AFMRL).
During the subsequent discussion, Dr Auricht explained that the RACGP did not have the funds to launch the record system into production, that it was yet to be tested, and a system of distribution had not been established in each state. Dr Sax asked for an estimate of the cost. PMCC had not reached the stage of estimating costs and time was required to work out an estimate. After some consultation, a figure of $80,000 was arrived at, which included the funding of a multidisciplinary workshop to be held in Canberra. The object of this workshop was to test the product and look at its management, legal and other issues. Dr Sax accepted PMCC’s figure.
This all happened in a very short space of time, and there had been no opportunity to inform RACGP Council, but there was to be a Council meeting the next weekend and Dr Auricht, who was to attend the meeting, was given permission to put forward the proposal.
As this had happened without any consultation with Council, the reception was, to say the least, very cool. However, there was some appreciation of the need for a medical record system and approval was given for the workshop to go ahead. H&HSC funded the workshop which was held in Canberra from 26–28 April 1974. It was attended by 26 participants including nurses, doctors, a lawyer, bureaucrats and PMCC, all with varied interests in medical record keeping.
A report of this meeting with its recommendations was produced by Dr Auricht (PMCC representative from South Australia) and Rosemary Goulston (medical record consultant at ACT Health Services).2
This report examined medical records in care centres, their purpose, content, ownership, access and structure. It presented recommendations to the H&HSC, RACGP, AFMRL and other bodies, including the Australian Medical Association (AMA).
Over 40 years later, the report makes interesting reading for its foresight and the problems which still remain. Two important recommendations from PMCC’s point of view were that:
- the H&HSC assist in the further development of medical records
- the RACGP give consideration to founding a non-profit management and marketing organisation to sell the record.
Having established the requirements of a medical record and having support on all sides, the PMCC was now faced with the task of producing an acceptable record. This was a joint task but the major work devolved on Dr Gawthorn who excelled at drawing sample records. He worked feverishly to provide a prototype record for the April 1974 seminar, which was ‘slaughtered’ by the audience and then ceremoniously buried on the final day of the seminar. Undaunted, Dr Gawthorn and the PMCC continued and recreated the forerunner to the original RACGP Health Record.
This record was refined, and other parts evolved during practice trials of the record. Dr Kinder’s simple display at the 1975 RACGP AGM, brilliantly highlighted the terminal digit and colour coding attributes to the delegates, which made displacing/losing a record much less likely.
PMCC was fortunate in having on the committee the representative from Western Australia, Dr Simpson, who was then experimenting with computers – at the time an expensive project only viable for a few dedicated practitioners. He insisted that the record should ultimately be able to be computerised. This was a mystery to most of the PMCC, but they could see the sense of it, if not how it would happen. Due to the Computerised Standards of Primary Health Records, subsequently adopted by the college in 1980, and revised in 1988, the present computerised health record has grown from the original RACGP Health Record.
Soon, PMCC had an acceptable record. The next step was to ensure that it would work in practice. This required the printing of a sufficient number of records and finding practices to trial the record. The practices would need metal shelving to store the records, staff training and the will to carry out the changeover which would be somewhat disruptive to the everyday function of the practice. This would be an expensive exercise.
The RACGP approached H&HSC, who provided a grant of $160,000 for the project (a lot of money in 1975 – equivalent to $1–1.5 million today) to include the purchase of folders, stationery and metal shelving for the trial practices. Six trial practices were to be selected in each state, including at least one solo, one small group, and one large group, distributed throughout the state.
This was passed by Council, and PMCC was overjoyed. However, the joy was premature. Because the grant included permanent structures (the shelving), AMA objected and Council rescinded their approval. PMCC had to rethink the project. Eventually, they received a grant for $49,1473 to cover the cost of producing and distributing the medical record to the trial practices. With this, PMCC was eventually able to fund three practices in New South Wales, four in South Australia and two each in Victoria, Queensland, Tasmania and Western Australia.3
Organising a marketing structure presented something of a problem. This was something the college had not done before and they were keen to allow a commercial organisation to take over this aspect. PMCC eventually convinced Council that, should this be done, the college would lose control of the future development of the record system and the cost could become prohibitive.
Eventually, Council agreed that the system should be marketed by PMCC and Allen Fudge (FMP assistant director in New South Wales). A feasibility study was produced for the college and PMCC developed recommendations for the marketing of the health record which included, among others, that:
- ‘hard sell’ marketing should never be allowed
- a manager must be appointed for at least one year
- the manager would liaise with PMCC
- ultimate responsibility for the health record would be the RACGP Council.3
In 1976, Dorothy Ratnarajah became the marketing manager, with Helen Kludt as the assistant.
One of the marketing recommendations was that there be no ‘hard sell’, but instead, the record should be promoted by articles in professional journals. The first article, entitled ‘Introducing the RACGP Health Record’, was published in Australian Family Physician (AFP) in May 1975.4 Other articles followed in AFP and various state newsletters. Among others, Dr Tom Moreton produced ‘Problem Oriented Medical Record Handbook’, and Dr John North produced the RACGP Health Record Handbook, which was regularly updated and subsequently called the Health Record Operating Manual.5
Demonstrations were presented at various conferences and PMCC produced an article on how to conduct the changeover. It became the function of state chairmen and the records assistants in New South Wales and Victoria to advise practices that needed help.
The RACGP Health Record Trial Report, published in August 1976 described the trial.3
By 1981, it was estimated that 40% of practices were using the system, and by 1985 approximately 60% of doctors in primary care were estimated to be using the system. The gross sales totaled $1,525,000.
By 1986, there was some concern that the cost of the record would become a problem and PMCC recommended to Council that it consider seeking a sponsor. This was accepted, and subsequently, an agreement was reached with Merck Sharp & Dohme (Aust) Pty Ltd for a $200,000 sponsorship over a period of three years, in return for limited advertising. This created some dissatisfaction from some users, but PMCC considered that increasing costs would be counter-productive and limit the use of an important addition to primary care. In retrospect, we doubt if any users opted out of the system.
Today there must be very few practices which are not computerised to some degree, and indeed, not many which are not completely computerised, but I am informed that the RACGP is still selling some records. Most of the computerised medical record programs currently in use have recognisable features of the RACGP medical record system.