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University of Pennsylvania, and many state schools follow this model.) In
a second model, the school of medicine is part of a university that
contracts with several completely independent hospitals to provide teach-
ing facilities in clinical settings. (Harvard, Tufts, and some of the newer
state schools such as the medical schools at the University of South
Carolina follow this model.)

The central educational component at an academic health center is
the school of medicine. Almost all medical schools are part of academic
health centers.'^ Other components of academic health centers are, most
frequently, schools of dentistry and nursing. Schools of pharmacy, allied
health professions (such as medical technology, occupational therapy.



138



EDUCATIONAL INSTITUTIONS AND PROGRAMS FOR HEALTH OCCUPATIONS



physical therapy, and physician assistants), public health, optometry, and
veterinary medicine may also be part of an academic health center. As
well, academic health centers may offer graduate programs in health-
related scientific fields. '*°

In 1992 the Council of Teaching Hospitals recognized 123 academic
medical centers in the United States, and the Association of Academic
Health Centers (AAHC) counted 97 members. According to the 1992
Academic Health Centers Directory, approximately 60 percent of academic
health centers are publicly owned and 40 percent are private institutions.
All AAHC members are composed of one to seven schools or programs for
educating health care professionals; more than 75 percent have three or
more schools. Members own or are affiliated with between one and
twenty-seven hospitals, with the majority (about 63 percent) linked to
between two and five hospitals. The American Hospital Association's
annual statistical summary for 1990 (the 1991-1992 edition) identified
1,238 teaching hospitals, representing 19 percent of all U.S. hospitals. Of
these, about one third were government owned (18 percent state and
local, 12 percent federal) and the remainder were privately owned (67
percent not-for-profit, 3 percent for-profit).




FIGURE 5-2 A medical student study group at the Johns Hopkins University
School of Medicine, circa 1990. Source: Bill Dennisoii, photographer; the Alan Mason
Chesney Medical Archives of the Johns Hopkins Medical Institutions



THE ROLE OF ACADEMIC HEALTH CENTERS 1 39



AN ACADEMIC HEALTH CENTER: THE JOHNS HOPKINS MEDICAL
INSTITUTIONS

Like other academic health centers in the United States, the Johns
Hopkins academic health center was initially organized around a consor-
tium of professional schools, health care delivery facilities, and research
institutes for the purpose of integrating the health care delivery (patient
care and health promotion), education, and research functions. Recently,
however, Johns Hopkins and a growing number of other academic health
centers have opted to augment this consortium model to accommodate
fundamental changes in financing and health care delivery. To stabilize
the financial operations of its constituent institutions and to ensure their
cost-effectiveness, Johns Hopkins added a vareity of companies that
provide goods and services, including medical equipment, pharmaceuti-
cals, and home health services, to its consortium. Many of these compa-
nies are also incorporated to serve the public sector. As a result the
consortium includes a combination of for-profit and not-for-profit corpo-
rations, representing a notable departure from the predominantly non-
profit consortium model for academic health centers.

At Johns Hopkins the consortium does not constitute a single legal
entity. Unlike many academic health centers, the educational component
(the Johns Hopkins University) does not own the consortium's health care
delivery facilities. Thus, the educational component and the health care
delivery facilities operate as separate corporate entities within a consor-
tium that is dedicated to uniting the functions of education, patient care,
and research at its constituent institutions.

The Johns Hopkins academic health center is currently organized
around three corporate entities: the Johns Hopkins Health System Corpo-
ration, the Johns Hopkins Hospital, and the Johns Hopkins University.
The Health System includes a network of smaller corporations that are
either wholly-owned by the Health System Corporation or owned jointly
with either the Johns Hopkins Hospital or the Johns Hopkins University.
While most of these companies are not-for-profit corporations, several
have been created as for-profit corporations. The purpose of the Johns
Hopkins Health System is to provide an infrastructure of financial and
service support for patient care, education, and research in the consor-
tium.41

At Johns Hopkins the principal health care delivery facilities include
the Johns Hopkins Hospital, the Francis Scott Key Medical Center, the
Homewood Medical Center, and the Kennedy Krieger Institute. The
health divisions of the university include the School of Hygiene and Public
Health, the School of Medicine, the School of Nursing, and the Welch



1 40 EDUCATIONAL INSTITUTIONS AND PROGRAMS FOR HEALTH OCCUPATIONS



Medical Library. The Johns Hopkins consortium of educational institu-
tions, health care delivery facilities, and service corporations is one of the
largest, most diverse, and most highly specialized academic health centers
in the country.

The governance and administration of the Johns Hopkins academic
health center is atypical in that there is no overarching governance
structure and each of the corporate entities has its own chief executive
officer and individual governance and administrative structure. Thus the
Johns Hopkins Hospital, Health System, and University coexist as separate
corporations with their own boards of trustees and chief executive offi-
cers. There is, however, cross-representation from the different corpora-
tions on the boards and within the administrative structure of the various
organizations. For example, the president of the Hospital is also chief
executive officer of the Health System; and the president of the University
is chief executive officer of the health division of the University. Each of
the professional schools in the health divisions is administered by a dean
who reports to the president of the University. The director of the library
reports to the dean of the School of Medicine who also serves as the vice
president for the health divisions of the university. In addition, each of the
university's health divisions has a faculty advisory board and each health
care delivery facility has a medical staff advisory board.



OVERVIEW OF ARCHIVAL/RECORDS MANAGEMENT
PROGRAMS AT ACADEMIC HEALTH CENTERS

The scarcity of published information about archival and records manage-
ment programs at academic health centers led the Medical Archives of the
Johns Hopkins Medical Institutions to conduct two surveys. In 1987 the
staff sent questionnaires to 1 16 institutions designated as academic medi-
cal centers by the Council of Teaching Hospitals, and received completed
questionnaires from 78. A majority of the respondents (53) reported that
their institutions had repositories for historical records. In January 1988,
the Medical Archives staff conducted a follow-up telephone survey of
these 53 respondents. Although 40 institutions reported having archival
programs, only 14 reported having records management programs. Inter-
estingly, 13 institutions reported having both archival and records man-
agement programs, but in only four of these institutions were the two
programs jointly administered. The survey results indicated that two of
these joint programs were administered by university libraries, one by a
history of medicine department, and one by the central administration of
the medical center.'*^ A majority of the archivists and records managers



ISSUES IN DOCUMENTING INSTRUCTIONAL PROGRAMS IN THE HEALTH FIELDS 141



who were polled expressed alarm about the abundant production and
accumulation of documentation at their academic medical centers. They
were particularly concerned about the lack of archival and records man-
agement guidelines for the health fields. Many of them indicated the need
for appraisal guidance that focuses on the special characteristics of docu-
mentation from the health fields. Determining what documentation
should be selected and preserved seemed to be a priority in their work.



ISSUES IN DOCUMENTING INSTRUCTIONAL PROGRAMS IN THE
HEALTH FIELDS

Degree programs in the health fields are generally based in institutions of
higher education, and as such, their documentation falls under the pur-
view of their institutional archives. While there is a need for appraisal
guidance for documentation of these specific types of instructional pro-
grams, most colleges and universitites have an archival program in place.

Certificate and other non-degree programs, by contrast, are often
ephemeral, as are many of the institutions that conduct them because
they cannot appropriate sufficient funding. Those institutions that survive
often lack archival programs. The archives of defunct specialized institu-
tions are sometimes placed with the archives of their professional associa-
tions or accrediting bodies, which may themselves be deposited in large
repositories. For example, records from various midwifery programs are
located in the archives of the American College of Nurse-Midwives which
are deposited in the National Library of Medicine.

A number of legal and regulatory requirements contain stipulations
about the long-term retention of certain types of records from institutions
in the U.S. health care system. In general provisions are made for retain-
ing student records in both the degree and certificate programs. These
records are regularly used throughout the careers of graduates. When
graduates of these programs seek new licenses or admission to other
educational programs, the application process nearly always requires that
the degree- and certificate-granting institutions verify the graduates' aca-
demic credentials.

Granting agencies and philanthropic foundations are beginning to set
more stringent requirements for the long-term retention of research
documentation. In the meantime, insurance companies, professional as-
sociations, and federal and state agencies continue to impose many re-
quirements for the long-term retention of clinical documentation. Be-
cause academic health centers in particular receive capital from many
diverse yet highly regulated funding sources, they are obligated to follow



1 42 EDUCATIONAL INSTITUTIONS AND PROGRAMS FOR HEALTH OCCUPATIONS



varied requirements for the retention of fiscal documentation. As new
data and information management technologies are introduced to institu-
tions in the health fields, archivists at these institutions are challenged by
numerous technical issues in the preservation and long-term use of
institutional documentation.'*'

In summary, archivists at institutions with instructional programs in
the health fields face many complex problems associated with the selec-
tion, organization, preservation, and ongoing use of documentation at
their institutions. They need to be apprised of legal and regulatory re-
quirements and well-informed about the ethical, social, economic, scien-
tific, and technological issues associated with the institution's patient care,
education, and research functions. These issues are indeed formidable,
challenging archivists at these institutions to seek creative yet responsible
solutions for the selection and long-term management of institutional
documentation. Because of the need to plan carefully for the selection of
documentation to be preserved, it is important for archivists to have an
overview of the context of instructional programs at educational institu-
tions and health care delivery facilities. By comparing their programs with
others nationally, they will be able to identify the program's common and
unique features which will help them to set priorities regarding the
functions and activities selected for documentation. In concluding, our
hope is that this chapter will provide useful background information for
archivists as they develop documentation plans for institutions with in-
structional programs in the health fields.



ACKNOWLEDGMENTS

We are particularly grateful for the assistance of the following individuals
from Johns Hopkins in the preparation of this chapter: Louise Cavag-
naro — former vice president of the Johns Hopkins Hospital; Frances
Dukissis, administrative secretary — Medical Archives; Elizabeth Fee, pro-
fessor of health policy and managment — School of Hygiene and Public
Health; Mary E. Foy, assistant dean and registrar — School of Medicine;
Gloria Freeman, administrator for continuing education — School of Medi-
cine; Carol J. Gray, dean — School of Nursing; Edward Morman, director
of historical collections — Institute of the History of Medicine; Richard S.
Ross, dean emeritus — School of Medicine; Patricia Stephens, director of
scientific editing services — Welch Medical Library; and Arlowayne Swort,
former associate dean for academic affairs — School of Nursing. We also
extend special thanks to William G. Rothstein, professor of sociology —
University of Maryland, Baltimore County, for reading earlier drafts of



NOTES 1 43



this chapter, and to Helen W. Samuels, head of special collections at the
Massachusetts Institute of Technology, for sharing with us drafts of her
work Varsity Letters: Documenting Modern Colleges and Universities.



NOTES

1 . The functions that we ascribe to instructional programs in the health fields are
corollaries to the functions that Helen Willa Samuels ascribes to institutions of
higher education. In Varsity Letters: Documenting Modern Colleges and Universities
(Metuchen, N.J.: Scarecrow Press, 1992), Samuels states that institutions of
higher education embody the following seven funaions: ( I ) confer
credentials, (2) convey knowledge, (3) foster socialization, (4) condua
research, (5) sustain the institution (institutional administration), (6) provide
public service, and (7) promote culture.

2. The U.S. Department of Education uses the term instructional programs to
encompass educational and training programs.

3. In a personal communication with the authors, Arlowayne Swort (16 July
1993) noted that nursing programs have been especially costly to operate.
She cites studies done in the 1970s and 1980s that showed that some
hospital-based diploma nursing schools were more expensive than either
associate or bachelor's degree programs. The cost imbalances between the
hospital-based diploma programs and the nursing degree programs based in
educational institutions led to the eventual closing of many hospital-based
diploma programs. One probable explanation for the cost variables is insti-
tutional infrastructure. Because instruction for nursing as for other occu-
pations in the health fields is labor intensive and heavily regulated, the cost of
operating these programs is especially high. When clusters of these programs
are based in educational institutions, many basic administrative and instruc-
tional costs may be shared. By contrast, the stand-alone diploma programs
must assume the full brunt of administrative and instructional costs.

4. Council of Teaching Hospitals, Association of American Medical Colleges,
Committee Structure and Membership Directory 1991 (Washington, D.C.:
Association of American Medical Colleges, 1991).

5. William G. Rothstein, letter to the authors, 24 Jan. 1993.

6. Ibid.

7. William G. Rothstein, American Medical Schools and the Practice of Medicine: A
History (New York: Oxford University Press, 1987), 85-88.

8. Richard H. Shryock, Medical Licensing in America, 1650-1965 (Baltimore: Johns
Hopkins University Press, 1967).

9. William G. Rothstein, letter to the authors, 24 Jan. 1993.

10. James Bordley III and A. McGehee Harvey, Two Centuries of American Medicine:
1776-1976 (Philadelphia: W. B. Saunders, 1976), 10.

11. Edward Kremers (revised by Glenn Sonnedecker), Kremers and Urdang's
History of Pharmacy (Philadelphia: J. B. Lippincott, 1976), 227.



1 44 EDUCATIONAL INSTITUTIONS AND PROGRAMS FOR HEALTH OCCUPATIONS



12. Ruth Roy Harris, Dental Science in a New Age: A History of the National Institute of
Dental Research (Rockville, Md.: Montrose Press, 1989), 7-8.

1 3. Joseph Nathan Kane, Famous First Facts: A Record of First Happenings, Discoveries,
and Inventions in American History (New York: H. W. Wilson, 1981), 687.

14. Rothstein, American Medical Schools.

1 5 . Elizabeth Fee, Disease and Discovery: A History of the Johns Hopkins School of Public
Health, I9I6-I939 (Baltimore: Johns Hopkins University Press, 1987).

16. See AIP Study of Multi-Institutional Collaborations (New York: Center for History
of Physics/ American Institute of Physics, 1992) for a report on the findings of
this project, which aimed "to identify patterns of collaboration, define the
scope of the documentation problems, field-test possible solutions, and
recommend future actions to secure adequate documentation."

17. Elizabeth Fee, telephone conversation with the authors, October 1993.

18. For more information on professional associations, see Chapter 6.

19. Robert L. Morgan, E. Stephen Hunt, and Judith M. Carpenter, Classification of
Instructional Programs (Washington, D.C.: U.S. Department of Education,
1991 ) contains a comprehensive list of the subfields of the health, life, and
biological sciences.

20. Ibid., 169.

21. National Board of Medical Examiners, Committee on Goals and Priorities,
Evaluation in the Continuum of Medical Education: Report of the Committee on Goals
and Priorities of the National Board of Medical Examiners, (Philadelphia: National
Board of Medical Examiners, 1973).

22. Ibid., 87.

23. Ibid., 85.

24. Ibid., 87.

25. Council on Postsecondary Education, COPA Membership Directory
(Washington, D.C.: Council on Postsecondary Education, 1992).

26. The Joint Commission 1990 Accreditation Manual for Hospitals (Chicago: Joint
Commission on Accreditation of Healthcare Organizations, 1989), 318.

27. National Board of Medical Examiners, In Service to Medicine, 75th anniversary
publication (Philadelphia: National Board of Medical Examiners, 1990), I,
68-70.

28. U.S. Department of Labor, Occupational Outlook Handbook (Washington, D.C.:
U.S. Department of Labor, 1986).

29. Ibid.

30. American Medical Association, 799/ Continuing Medical Education Fact Sheet
(American Medical Association, Chicago, 1991).

31. Bordley and Harvey, American Medicine, 346.

32. Bonnie Davidson, "The New Ethical Climate of CME," Physicians' Travel and
Meeting Guide (May 1992): 44-48.

33. Rothstein, American Medical Schools, 255.

34. Ibid., 248.

35. Jeremiah A. Barondess, "The Academic Health Center and the Public Agenda:
Whose Three-Legged Stool?" Annals of Internal Medicine 115 (1991): 962-67.

36. David U. Himmelstein and Steffie Woolhandler, "Cost Without Benefit:



SELECT ANNOTATED BIBLIOGRAPHY 1 45



Administrative Waste in U.S. Health Care," New England Journal of Medicine
314, no. 7 (19xx): 411-45.

37. Association of Academic Health Centers, Directory (Washington, D.C.:
Association of Academic Health Centers, 1991).

38. Richard S. Ross, Letter to the authors, July 1993.

39. Rothstcin, American Medical Schools, 225-26.

40. Joan D. Krizack, "Assessing the Context for Archival Programs in the Health
Fields," in Nancy McCall and Lisa A. Mix, eds.. Designing Archival Programs to
Advance Knowledge in the Health Fields. (Baltimore: Johns Hopkins University
Press, 1994).

41. The Johns Hopkins Health System includes the following corporations:
Francis Scott Key Medical Center, the Johns Hopkins Medical Services
Corporation, Broadway Medical Management Corporation, the Johns
Hopkins Home Care Group, Dome Corporation, Broadway Services, Inc.,
Broadway Development Corporation, Johns Hopkins Pharmaquip, Inc.,
Johns Hopkins Home Health Services, Inc., Johns Hopkins Pediatrics-at-
Home, Inc., Kennedy Krieger Institute, and Wyman Park Medical Associates,
Inc.

42. Alan Mason Chesney Medical Archives, Johns Hopkins Medical Institutions,
"Results of the Follow-up Survey of Archives and Records Management
Programs at Academic Medical Centers" (unpublished). This survey was
conducted as part of The Johns Hopkins Records Project, funded by the
National Historical Publications and Records Commission.

43. See McCall and Mix, Designing Archival Programs for an in-depth study of how
archives in the health field should function.



SELECT ANNOTATED BIBLIOGRAPHY

ACADEMIC HEALTH CENTERS

Association of Academic Health Centers. Directory. Washington, D.C.: Association
of Academic Health Centers, 1991. Defines an academic health center; lists all
members of the Association of Academic Health Centers, giving the members'
component institutions and programs.

Barondess, Jeremiah A. "The Academic Health Center and the Public Agenda:
Whose Three-Legged Stool?" Annals of Internal Medicine 115 ( 1991 ): 962-67.
Discusses the relationship between education, research, and patient care at an
academic health center.

Council of Teaching Hospitals, Association of American Medical Colleges. Commit-
tee Structure and Membership Directory 1986. Washington, D.C.: Association of
American Medical Colleges, 1991. Lists all teaching hospitals in the United
States, giving demographic information; defines the relationships between
hospitals and schools of medicine.

Krizack, Joan D. "Assessing the Context for Archival Programs in the health
fields." in Designing Archival Programs in the Health Fields, edited by Nancy



1 46 EDUCATIONAL INSTITUTIONS AND PROGRAMS FOR HEALTH OCCUPATIONS



McCall and Lisa A. Mix. Baltimore: Johns Hopkins University Press, 1994.
Uses the academic health center as a case study for a functional approach to
documentation planning.
Munson, Fred C, and Thomas A. D'Aunno. The University Hospital in the Academic
Health Center: Finding the Right Relationship, vol. 2. Washington, D.C.: Associa-
tion of American Medical Colleges and Association of Academic Health
Centers, 1987. Discusses the relationship between teaching hospitals and
educational programs in the health fields.



ARCHIVES /DOCUMENTATION PLANNING

Samuels, Helen Willa. Varsity Letters: Documenting Modern Colleges and Universities
Metuchen, N.J.: Scarecrow Press, 1992. Takes a functional approach to
documenting educational institutions.



HEALTH OCCUPATIONS

Badasch, Shirley A., and Doreen S. Chesebro. The Health Care Worker: An Introduc-
tion to Health Occupations, 2nd ed. Englewood Cliffs, N.J.: Prentice-Hall, 1988.
Provides background information about occupations in the health fields,
giving educational requirements.

Morgan, Robert L., E. Stephen Hunt, and Judith M. Carpenter. Classification of
Instructional Programs, 1990 ed. Washington, D.C.: U.S. Department of Educa-
tion, 1991. Provides comprehensive lists of the components of educational
programs in the health, life, and biological sciences.

U.S. Department of Labor, Bureau of Labor Statistics. Occupational Outlook Hand-
book, Bulletin 2250, 1986-87 ed. Washington, D.C.: U.S. Department of
Labor, 1986. Provides Department of Labor designations for occupations in
the health fields and descriptions of the educational requirements.

U.S. Department of Labor, Employment and Training Administration, U.S. De-
partment of Health, Education, and Welfare, Health Resources Administra-
tion. Health Careers Guidebook, 4th ed. Washington, D.C.: U.S. Department of
Labor, 1979. Lists all health occupations according to category; gives a de-
tailed description of each occupation, including educational requirements,
the nature of the work, and the state of the job market.



HISTORY OF THE HEALTH FIELDS / EDUCATION IN THE HEALTH FIELDS

Bordley, James, III, and A. McGehee Harvey. Two Centuries of American Medicine:
1776-1976. Philadelphia: W. B. Saunders, 1976. Covers the development of
medical schools and education programs in the United States.

Fee, Elizabeth. Disease and Discovery: A History of the Johns Hopkins School of Public
Health. Baltimore: Johns Hopkins University Press, 1987. A history of the first
school of public health in the United States.



SELECT ANNOTATED BIBLIOGRAPHY 1 47



Harris, Ruth Roy. Dental Science in a New Age: A History of the National Institute of
Dental Research. Rockville, Md.: Montrose Press, 1980. Discusses the history of


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