Josh Shepherd, Freelance Writer
Completed June 19, 2012
SUMMARY: On June 23, 2012, Nicholas County Hospital in Carlisle, Kentucky will celebrate the retirement of its Director of Health Information, Mrs. Lois Gates. Lois Gates’ 50-year career as a Health Information specialist spans a significant time period in the development of Health Information Management as a critical function within the Health Care industry. She has a unique perspective coming out of rural health care to have created the Health Information Department at her hospital and navigated the department through the vast amount of change that has occurred within her field up to this date. She retires after having set in motion the implementation of the hospital’s adoption of an electronic medical record.
After 50 years of mutual respect, support, and admiration, though at times they each might have said “agitation,” Lois Gates and Nicholas County Hospital in Carlisle, Kentucky are finally calling it quits.
The celebration of Gates’ golden anniversary as director of the hospital’s health information department on June 23 will mark the end of a long-standing partnership. It will be an amicable parting. But after half a century of adapting to constant change and growth in the increasingly complex world of professional Health Information Management, Gates said her flexibility has finally worn thin.
“This tired old brain is going to the house,” Gates declared.
Lois Gates was hired in 1962 as the front desk clerk at Nicholas County Hospital. She had just graduated from high school. The hometown hospital was a 32-bed full service health care facility with an obstetrics department and a surgical suite with three surgeons performing procedures on a routine basis.
The time span of her service, from 1962 – 2012, is significant in terms of the development of the modern day health information profession. Lois Gates was in at the beginning, at the advent of the federal Medicare program which made information management a critical profession in the industry. When she started, the management of information was a one-person clerical position which she performed from the rural hospital’s registration desk. She also welcomed patients, answered the phone, and transcribed the medical notes of the staff radiologist on a manual typewriter.
The Radiologist, incidentally, was Chinese.
She also stored everyone’s basic medical information in file cabinets lined along a wall in the front lobby.
“In those days, there wasn’t much concern over the privacy of information,” Gates commented.
Gates has spent her entire professional life immersed in the world of rural health care in Kentucky. This experience imparts a unique perspective on her profession. Due simply to the size and bed capacity of the facility, rural hospitals often assigned multiple duties upon staff members, especially those duties that did not require a trained and accredited professional.
And for the management of a person’s health records, that’s the way it was in 1962. There were guidelines and some suggestions, but there were few, if any, laws or regulations governing health data. Registration forms were little more than a means to record a name and a billing address; a phone number, if the family had a phone; and the doctor’s order for admission to the hospital.
There were certain procedures proscribed by Blue Cross and Blue Shield of Kentucky, at that time one of the largest private health insurers in the state. But there was no formal training nor a professional degree required to do Gates’ job. At least, not in 1962
The fact was that the majority of people did not have insurance at all. Families were mostly self-pay and they either wrote a check at the time of discharge or arranged a payment plan. Those few individuals who lacked any means to cover their health care at all, even on a monthly schedule, could petition the local county government to help pay their health care bill. There was a federal program distantly related to Medicaid but, for Nicholas County’s service area, participants in that program were rare.
“There was a fund maintained by county governments for indigent health care. A person unable to cover the costs of their health care could petition their magistrate for assistance, then go before the county fiscal court to plead their case for assistance,” Gates said. “If approved, the county would pay $50 a day for however long the patient was in the hospital. This was a fund common to many, if not all, of the counties in our service area.”
Actually, if one had resources, there were legal ways to profit from the system. Lois recalled one patient who had health insurance policies with five different companies. “She ran me ragged preparing the paperwork for all her claims. One insurance company paid the hospital, another the doctor, and then she’d collect on all the rest. I have no idea what she paid out in premiums, but I have a feeling she made a tidy profit off her hospital care. That was a good reason for improving record keeping and accountability when Medicare got started,” Gates commented.
Just as much then as now, health care costs were a growing burden on elderly people. Those entering their 60s during the 1960s had experienced the Depression first hand. They didn’t have savings or much recourse to private insurance. A lot of people were farmers, so they didn’t even have retirement income, but they still had the same health problems as any aging population.
The advent of Medicare in 1965 was a watershed event in the history of health care access in the United States. From the time of its inception, the federal program laid the foundation for a new field in the health care industry.
Almost by itself, Medicare changed the way the health care industry stores, manages, shares, and protects an individual’s health history. It mandated conditions of participation, regulations and record-keeping protocols hospitals had to abide by in order to get reimbursed by the federal program for its services. There was greater demand on hospitals to justify procedures, treatments, and lengthy hospital stays.
“It was all an effort to keep the system from being abused and to improve the way we treated patients. It changed a lot of the way that we did things,” Gates explained. “When I started, there was nothing in my job description that demanded any more training than the business classes I had in high school.”
The retraining process required Gates to become an Accredited Record Technician through the American Health Information Association (AHIMA). That accreditation was accompanied by a requirement to participate in continuing education. Working with Dr. Van Jenkins, Gates put together the plan to get Nicholas County Hospital’s procedures and policies in line with Medicare’s requirements for billing and data gathering. These regulations were a big adjustment for caregivers and it took a great deal of training for physicians who had become accustomed to their own ways of record keeping.
The proper documentation of a death, for example, needed to have a bit more detail than doctors were used to giving. It was not unusual for a doctor’s death summary to read something like, “Patient came in, gradually went downhill, and died,” Gates said.
In Gates’ time, Health Information has metamorphosed into a professional field with specialized tasks critical to the economic well-being of health care organizations at all levels. A health information department is now comprised of dozens of employees utilizing technology on a comparative scale to clinical machinery. To perform their jobs, medical transcriptionists, forms review specialists, and coders need courses in Anatomy, Physiology, Pharmacology, and Medical Terminology. They need to understand about disease processes and treatment procedures. These are but a few examples of how Health Information has grown since Medicare, Health Insurance, and researchers began requiring more comprehensive record keeping.
“Our rural hospital is held to same standard with regard to care and record keeping as Mayo Clinic, Johns Hopkins, UK Hospital or the Saint Joseph system,” Gates said. “We don’t have the range of services, but we have to maintain the same standards and be accredited by the same organizations.”
These developments were not all the result of Medicare. Medical coding tied to reimbursement for services existed prior to the advent of the program and the subsequent adoption of the various incarnations of the International Classification of Diseases (ICD-8 and ICD-9).
Gates recalled first using the Systematized Nomenclature of Medicine codes (SNOMED-CT), which at the time was a complicated system of letters and numbers to refer to medical procedures and clinical diagnoses. With Medicare, she adjusted to ICD-8 codes.
“I was the Medical Record department by myself for ten years,” Gates said. She literally built the department herself in a small 8 x 12 room stacked floor to ceiling with folders. Gates basically handled everything, including training the physicians and staff on the proper details for the forms.
By 1972, the demands of Medical Records department were too much for one person to handle. Gates hired Georgia Gilvin to help and together they have watched the complexity of their profession grow in ways they could not have conceived when they started.
In the 60s and 70s, it was not unusual for patients to have a seven-day hospital stay. The average medical record generated from that stay was about 20 pages, Gates said. In 2012, a typical inpatient stay at a critical access hospital generates about 60 pages of records. A brief ER visit is going to generate 12 – 14 pages of records. No wonder everything is going electronic, Gates said. It has too.
The Health Information department in Nicholas County employs five people, each performing highly specialized services. One handles chart review, another does transcription, another coordinates the legal release of information and handles back up transcription and two cover the coding of inpatient and outpatient procedures.
It is hard to imagine now, but before the 1990s, the majority of the Health Information Department’s work was done on paper and stored in huge folders and specially designed filing cabinets. Many large hospitals still gather and store information this way.
There were no computers to track anything at the hospital until 1992. That was when the current hospital administrator walked into Lois’ office with a computer still sealed in its box.
“He said, ‘Hook this up and use it.’ Then he left. I didn’t know about computers. Truth was, our administrator didn’t either, except that we were all eventually going to need them,” Gates said.
But by that time, change wasn’t something Lois worried about.
Change is routine.
These days a Health Information department can barely function without electronic information. In just a few months, Nicholas County Hospital will go live with an integrated electronic medical record, the implications of which are still being debated. For Lois, though, it’s just another change, one of many she has had to accommodate over these 50 years.
That is until this June when she finally relinquishes the reins on what has to be considered a spectacular professional career.
In her office are articles about the national transition to ICD-10 codes – the catalog numbers for diagnoses and procedures Health Information offices use to bill insurance, Medicare, and Medicaid. The transition is so complex that the official date of transition from ICD-9 to ICD-10 was moved from 2013 to 2014.
Lois wishes her successors good luck with that. She’s been there already.
It’s time to go home.