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Edited by



Baltimore and London

For Rebekah (who's always first in my book), \)^0

Nanny, Dapes, Carol, Barbara, Marc, and Rocky. I ^ O A

© 1994 The Johns Hopkins University Press

All rights reserved

Printed in the United States of America on acid-free paper

The Johns Hopkins University Press
2715 North Charles Street
Baltimore, Maryland 21218-4319
The Johns Hopkins Press Ltd., London

Library of Congress Cataloging-in-Publication Data

Documentation planning for the U.S. health care system / edited by Joan D. Krizack.
p. cm.
Includes bibliographical references and index.
ISBN 0-8018-4805-9 (acid-free paper)

1. Archives, Medical — United States. 2. Medical records — Management — United
States. I. Krizack, Joan D.
R1I9.8.D63 1994

651.5'04261'0973— dc20 94-9566


A catalog record for this book is available from the British Library.


The Johns Hopkins University Press

2715 N.Charles street
Baltimore MD 21218-4363

Anieriai's Oldest University Press / Founded 1878


For a good and valuable consideration, the receipt of which is acknowledged, The Johns Hopkins
University Press, 2715 North Charles Street, Baltimore, Maryland 21218, sells, assigns and
transfers to Joan D. Krizack of Northwestern University, Boston, Massachusetts, the
copyright to the book entitled Documentation Planning for the US Health Care System,
authored by Joan D. Krizack, with all literary property right, title and interest to and in the .
aforementioned book. The United States Copyright Registration is dated 20 May 1994, and the
registration number is TX 3-826-644.

IN WITNESS WHEREOF, I have executed this instrument in Baltimore, Maryland on
March 8, 2000



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n D. Krizack \


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List of Contributors vii
Acknowledgments ix
Introduction, Joan D. Krizack xi


Overview of the U.S. Health Care System, Joan D. Krizack 1


Facilities That Deliver Health Care, Joan D. Krizack 13


Health Agencies and Foundations, Peter B. Hirtle 43


Biomedical Research Facilities, Paul G. Anderson 73



Educational Institutions and Programs for Health Occupations,
Nancy McCall and Lisa A. Mix 1 07


Professional and Voluntary Associations, James G. Carson 149


Health Industries, James J.Kopp 181


Documentation Planning and Case Study, Joan D. Krizack 207


Selected Landmarks in the History of Health Care
in the United States 237


Health-Related Discipline History Centers 241
Index 253


Paul G. Anderson, Ph.D., Associate Director for Archives and the History
of Medicine, Washington University School of Medicine, St. Louis,

James G. Carson, Ph.D., Independent Archival Consultant, Chicago, Illi-
nois, and former Curator of the American Medical Association Historical
Health Fraud Alternative Medicine Collection

Peter B. Hirtle, M.A., M.L.S., Archives Specialist, Technology Research
Staff, National Archives and Records Administration, Washington, D.C.

James J. Kopp, Ph.D., Vice President, Library Systems, P.S.S., Ltd., Reston,

Joan D. Krizack, M.A.T., M.S., Hospital Archivist, Children's Hospital,
Boston, Massachusetts

Nancy McCall, M.L.A., Archivist, the Alan Mason Chesney Medical
Archives, the Johns Hopkins Medical Institutions, Baltimore, Maryland

Lisa A. Mix, M.L.A., Processing Coordinator, The Alan Mason Chesney
Medical Archives, the Johns Hopkins Medical Institutions, Baltimore,



My first debts of gratitude are to the National Historical Publications and
Records Commission, which funded this project, and to the Andrew J.
Mellon Foundation, the Research Division of the National Endowment for
the Humanities, and the University of Michigan for funding earlier re-
search on hospitals. A special thanks is due to Andre Mayer for his
insightful criticism and unflagging support throughout. I also wish to
thank fellow archivists who offered advice and encouragement: Frank
Boles, Megan Sniffin-Marinoff, David W. Nathan, Jeffrey L. Storchio,
Joan Warnow-Blewett, and Nancy W. Zinn. Thanks to Helen W. Samuels
and the Mellon group: Bruce H. Breummer, Bridget Carr, Terry Cook,
James M. O'Toole, and D. Gregory Sanford, for stimulating discussions of
functional analysis which resulted in refinements of this work. Co-con-
spirators Paul G. Anderson, James G. Carson, Peter B. Hirtle, James J.
Kopp, Nancy McCall, and Lisa A. Mix deserve thanks and congratulations
for enduring my seemingly endless requests for revisions. Several Johns
Hopkins University faculty and staff members offered valuable criticism:
Karen Butter, Elizabeth Fee, Alan Lyles, Harry Marks, and Robert Miller.
I also wish to thank Wallace Daly for unlocking the mysteries of RUN and
Peter Carini for providing eleventh-hour reference service. Finally, I am
indebted to Anne Malone and Peggy Slasman for allowing me to refine the
documentation planning process at Children's Hospital and to the rest of
the staff of the Development and Public Affairs Office for their computer
expertise, friendship, and support.




During the 1970s, the archival profession began to question the methods
it used to select records for preservation. In a series of seminal articles, F.
Gerald Ham challenged archivists to rethink their traditional approach to
appraisal and devise a methodology suited to selecting modern records
produced by modern institutions.^ Several archivists accepted Ham's chal-
lenge and wrote books grounded in the assumption that appraisal is based
on disciplinary or institutional functions and activities.^ For reasons that
are not apparent, this approach to appraisal first took hold in the fields of
science and technology, but by the mid- 1 980s archivists began to translate
the new methodology to other fields.^

All of this work was based on the belief that archivists need to
understand the context in which records are created (i.e., the functions
and activities that generate records) before they can make appropriate
appraisal decisions. The principle that appraisal must be grounded in an
understanding of context had been advocated at least since the mid-
1950s,4 but it had not previously been incorporated into selection meth-

The focus of appraisal research shifted from disciplines to institutions
after Helen Willa Samuels introduced the "documentation strategy" con-
cept in 1985.' As defined by Patricia Aronsson, Larry Hackman, and
Samuels, a documentation strategy is an interinstitutional approach to
documenting an "ongoing issue, activity, or geographic area."^ Samuels's
article and the documentation strategy concept reinforced the notion that
analysis and planning are necessary first steps in the appraisal or selection
process. Samuels also assumed the absolute necessity of an active ap-


proach to selecting documentation, something that Howard Zinn, Hans
Booms, F. Gerald Ham, and others had begun advocating in the 1970s7

The archival community had mixed reactions to the concept of docu-
mentation strategy, which was often interpreted in ways other than had
been intended; nonetheless, several archivists boldly attempted to apply
the concept. The proposed documentation strategy for the high-technol-
ogy companies located around Route 128 in Massachusetts by Alexander
and Samuels never advanced beyond the hypothetical level,^ and Cox's
actual but unfinished attempt to carry out a documentation strategy for
western New York raised substantive issues about the concept's practical-
ity and viability.^ Two retrospective applications of the documentation
strategy concept — one to analyze the range of topics of collections already
held by manuscript repositories and the other applied to a historical topic,
nineteenth-century quartz mining in Northern California — were more
successful. ^°

In conducting research on the U.S. health care system and thinking
about how to apply the documentation strategy concept to health care in
Massachusetts, I came to the conclusion that the theory underlying docu-
mentation strategy could best be applied at the institutional level. ^ ' In fact,
if the documentation strategy concept is to be employed, it will most
successfully be employed among a group of institutions that have already
embraced the concept internally.

To accentuate the distinction from the documentation strategists' call
for interinstitutional planning and cooperation, the internal process advo-
cated in this book is referred to as documentation planning. The term
documentation plan, first used by German archivist Hans Booms to describe
the proactive approach to selecting an appropriate documentary record
for society, ^^ was redefined almost twenty years later to apply to specific
types of institution, namely, hospitals and colleges and universities.'^ In
Canada the term macro-appraisal theory has recently arisen to refer to the
underlying assumption of documentation planning: selecting documenta-
tion from the top down (i.e., beginning with an analysis of the institution's
functions and the records' context) rather than from the bottom up (i.e.,
beginning with an examination of various record series). ''^

This book includes in the documentation planning process an addi-
tional tier of analysis, system analysis, which is an analysis of the larger
system of which the institutions to be documented are a part (in this case,
the U.S. health care system). The book provides background information
on the U.S. health care system and the functions of the various types of
institution and organization within it, thus establishing the context neces-
sary to undertake the planning stage of the documentation planning


process. Adding this analysis to a general knowledge of historical research
trends, historiographic techniques, traditional appraisal criteria, ^^ and a
specific understanding of their institution's history, mission, culture, and
resources will enable archivists to prepare effective documentation plans,
thus ensuring the deliberate selection of appropriate archival materials. In
addition, the overviews and typologies presented in this work will be
useful to students, historians, and other researchers who need to under-
stand and assess the "big picture" before they can focus on more special-
ized aspects of the U.S. health care system.

This work also describes the second element of documentation plan-
ning, the planning process, and provides as an example a portion of the
documentation plan devised for Children's Hospital, Boston. The Chil-
dren's Hospital documentation plan illustrates the concept of documenta-
tion planning and is, therefore, meant to be descriptive rather than
prescriptive. Applying the documentation planning process and devising
an actual documentation plan have not previously been attempted; there-
fore, the Children's Hospital documentation plan provides a necessary test
case and model for other institutions, both within and outside of the
health care field.

As T. R. Schellenberg noted, "analysis is the essence of archival
appraisal. "^^ Deciding what material to collect, the archivist's most intel-
lectually stimulating task, has become progressively more challenging
since the middle of the twentieth century because the nature of institu-
tions and organizations has changed. In modern society, institutions arc
often components of multinational conglomerates or divisions of holding
companies; even freestanding institutions are not truly self-contained but
are linked to other institutions and organizations, both public and private,
through cooperative agreements, funding arrangements, and governmen-
tal regulations. Such interconnections complicate the archivist's task by
increasing the duplication of information and physically dispersing re-
cords. At the same time, more sophisticated reprographic and communi-
cations technologies have increased the quantity of records (electronic
and hard copy) produced and the amount of information stored. To cope
with these changes, the archival profession needs to adopt a proactive
approach to documenting institutions and to pay increasing attention to
the several levels of analysis underlying the archival selection process:
institutional analysis, interinstitutional analysis, and system analysis. ^^

Whether or not one agrees with the need for, or efficacy of, large-scale
cooperative documentation strategy initiatives, it should be clear that
decisions on selecting the records of a single institution for preservation,
whether by an archivist employed by that institution or by one working at


a historical society or other collecting repository that has acquired a body
of institutional records, should also be informed by an understanding of
the place of that institution in the larger universe. Indeed, it could be
argued that large-scale documentation strategies are possible only if the
participating institutional archives have first come to terms with their
internal issues.

Archivists can meet the challenge of documenting contemporary
institutions by carefully planning what aspects of their institution they are
going to document — in other words, by formulating specific plans that
outline the deliberate selection of appropriate records. Documentation
plans also identify functions and activities that are poorly documented, in
which cases it might be desirable for the archivist to create records (e.g.,
oral histories) to fill in the gaps. A documentation plan is formulated in
two stages, analysis and selection. The first stage consists of three tiers of
analysis: (1) an institutional analysis, (2) a comparison of the institution
with others of the same type, and (3) an analysis of the relationship of the
institution to the larger system of which it is a part — in this case, the U.S.
health care system. ^^ The selection stage consists of making decisions
about what to document at three levels: (1) the function, (2) the activity
or project, and (3) the record series. An added benefit of documentation
planning is that it increases archivists' understanding of their institutions
and how they operate, which will be helpful when performing other
archival activities such as processing and reference. Furthermore, the
documentation planning process increases the visibility of the archives

Documentation planning takes a holistic or contextual approach to
record selection and appraisal by adding the third and most general level
of analysis to the process, thereby providing archivists with a bird's-eye
view of their own institution's situation in relation to the larger systems of
which they are part. When archivists are faced with the challenge of
making their way through the labyrinth of appraisal, a bird's-eye view is
preferable to a ground-level view. Selecting and appraising records, like
mastering a labyrinth, can be accomplished more efficiently and effec-
tively if archivists have an overview, if they carefully plan a course of
action instead of making each decision as the need arises. Without this
"map" or understanding of the institution in its larger context, archivists
are forced to rely on luck, instinct, or precedent when making selection

Chapter 1 of this work describes the U.S. health care system in terms
of its functions and the institutions and organizations that carry out those
functions. Chapters 2 through 7 describe the types of institution and


organization composing the health care system in terms of their functions
and discusses some of the activities through which those functions are
fulfilled. Because archivists are most often responsible for documenting
institutions or organizations and because the U.S. health care system's
structure is formed to a great extent by institutions and organizations,^^
this approach is appropriate. Furthermore, functional analysis enables
archivists to work across departmental lines, which may shift, and to
devise documentation plans based on what the institution does instead of
how it is organized at the moment. ^'^ This type of analysis provides
archivists with the topical, societal, and institutional contexts they need to
design effective documentation plans. The analyses presented in Chapters
1 through 7 categorize and classify aspects of health care institutions,
enabling archivists to select consciously which aspects to document more
fully than others. Assuming that the available resources are not sufficient
to document in great detail every aspect of every institution, archivists can
use the analysis as a tool to assist them in making difficult decisions about
which aspects to document and to what extent — in other words, to assist
them in devising documentation plans.

The approach to selecting documentation presented here is suggestive
rather than prescriptive. Archivists are encouraged to adapt as necessary
the documentation process and plan presented in Chapter 8 to suit their
specific institution. The goal is to provide the context and guidance
necessary to support the development of plans for all types of institution
and organization in the U.S. health care system, not to dictate what
records should be preserved.

It is important for archivists to realize that the health care environ-
ment is rapidly changing. Regulations, technologies, diseases, and meth-
ods of treatment and financing are constantly evolving. Although it is not
likely that the nation's health care system will be nationalized in the near
future, the Clinton administration is expected to implement significant
reforms. Most of these reforms will directly affect how health care deliv-
ery is financed. They may affect the configuration of health care institu-
tions, but the functions of the U.S. health care system will remain the

During a period of great change for the health care system, much of
which is motivated by a desire to contain costs, the documentation
planning process remains viable and indeed takes on special importance
for health care institutions. Because the functions of the health care
system will not change, they provide a base from which to gauge institu-
tional and organizational change and on which to make archival selection
decisions. As the health care system becomes more highly integrated.


moreover, the emphasis of the documentation planning process on inter-
institutional and system analyses also becomes more significant. With the
increasing incidence of consolidations, alliances, and mergers among
health care institutions and departments within these institutions, docu-
mentation planning can provide a foundation for preserving the records of
emerging or reconfigured institutions and those that no longer exist.

In this new world, the traditional justifications for archival programs
continue to apply. Archival programs can conserve resources by eliminat-
ing the costly storing of unnecessary records, and they can improve
efficiency by providing access to important information that is needed for
current institutional operations. Thus, even though the institutions and
organizations described in this book will change in nature and type, the
book presents a glimpse of the U.S. health care system at a particular point
in time, and the concept of documentation planning and the documenta-
tion planning process remain effective tools for selecting appropriate
records to document health care institutions and organizations.


1. F. Gerald Ham, "The Archival Edge," American Archivist 38 (January 1975):
5-13; "Archival Strategies for the Post-Custodial Era," American Archivist 44
(Summer 1981): 207-16; and "Archival Choices: Managing the Historical
Record in an Age of Abundance," American Archivist 47 (Winter 1984): 1 1-22.

2. The first of these was Joan Warnow et al., A Study of Preservation of Documents at
Department of Energy Laboratories (New York: American Institute of Physics,
1982). There followed Joan K[rizack] Haas, Helen Willa Samuels, and
Barbara Tripple Simmons, Appraising the Records of Modern Science and
Technology: A Guide (Cambridge: MIT 1985; distributed by the Society of
American Archivists); Bruce H. Bruemmer and Sheldon Hochheiser, The
High-Technology Company: A Historical Research and Archival Guide
(Minneapolis: Charles Babbage Institute, University of Minnesota, 1989); and
American Institute of Physics Study of Multi-Institutional Collaborations in High-
Energy Physics (New York: American Institute of Physics, 1991 ).

3. See, for example, Patricia Aronsson, "Appraisal of Twentieth-Century
Congressional Collections," in Nancy E. Peace, ed.. Archival Choices: Managing
the Historical Record in an Age of Abundance (Lexington, Mass.: Lexington
Books, 1984), 81-104; and Joan D. Krizack, "Hospital Documentation
Planning; The Concept and the Context," American Archivist 56 (Winter
1993): 16-34. (The latter article was submiued for publication in its final form
in December 1989.) Aronsson's work was recently expanded in The
Documentation of Congress: Report of the Congressional Archivists Roundtabk Task
Force on Congressional Documentation ( 1 992).


4. See Theodore R. Schellenberg's 1956 article, "The Appraisal of Modern Public
Records/' reprinted in Maygene F. Daniels and Timothy Walch, eds., A
Modern Archives Reader: Basic Readings on Archival Theory and Practice
(Washington, D.C.: National Archives and Records Service, 1984).

5. Helen Willa Samuels, "Who Controls the Past?" American Archivist 49 (Spring
1986): 109-24.

6. Ibid., 115.

7. Howard Zinn, "Secretary, Archives and the Public Interest," Midwestern
Archivist 2 (1977): 14-26; Hans Booms, "Society and the Formation of a
Documentary Heritage; Issues in the Appraisal of Archival Sources,"
Archivaria 24 (Summer 1984): 69-107 (original German version published in
1972); Ham, "The Archival Edge"; and Patrick M. Quinn, "The Archivist as
Activist," Georgia Archive 5 (Winter 1977): 25-35.

8. Philip N. Alexander and Helen W. Samuels, "The Roots of 128: A
Hypothetical Documentation Strategy," American Archivist 50 (Fall 1987):

9. Richard J. Cox, "A Documentation Strategy Case Study: Western New York,"
American Archivist 52 (Spring 1989): 192-200.

10. Judith E. Endleman, "Looking Backward to Plan for the Future: Collection
Analysis for Manuscript Repositories," American Archivist 50 (Summer 1987):
340-53; and Maureen A. Jung, "Documenting Nineteenth-Century Quartz
Mining in Northern California," American Archivist 53 (Summer 1990): 406-18.

1 1. Krizack, "Hospital Documentation Planning."

12. Booms, "Society and Documentary Heritage," 105.

13. Krizack, "Hospital Documentation Planning," and Helen Willa Samuels
Varsity Letters: Documenting Modern Colleges and Universities (Metuchen, N.J.:
Society of American Archivists and Scarecrow Press, 1992).

14. For example, Richard Brown, "Records Acquisition Strategy and Its
Theoretical Foundation: The Case for a Concept of Archival Hermeneutics,"
Archivaria 33 (Winter 1991-1992); 34-56; and Terry Cook, "Mind over
Matter: Toward a New Theory of Archival Appraisal," in Barbara L. Craig, ed..
The Archival Imagination: Essays in Honour of Hugh A. Taylor (Ottawa:
Association of Canadian Archivists, 1992), 38-70.

15. For traditional appraisal criteria, see Schellenberg, "Modern Records," and F.
Gerald Ham, Archives and Manuscripts: Appraisal and Accessioning (Chicago:
Society of American Archivists, 1992). Also, Frank Boles and Julia Marks
Young identified and categorized appraisal criteria in Archival Appraisal (New
York: Neal-Schuman, 1991).

16. Schellenberg, "Modern Public Records," 68.

17. It should be noted that Schellenberg was writing about governmental archives
and referring to the need for analysis at the agency and record series levels.

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