Education of Health Record/Health Information Management Professionals in the United Kingdom

Lorraine Nicholson, MIHM, MRSH, FHRIM

Historical Background

This history of the formal education of health records professionals in the United Kingdom commences relatively late in history (that is, in the 20 th century) although we know that medical records were kept for hundreds of years prior to this.

In the 1930's, there was recognition that there was a historical inadequacy in the education of medical record practitioners although little was done about this mainly due to the intervention of the Second World War, which lasted from 1939-45. During these difficult years, staff that worked in the field of medical records contended that the purposes and uses of patient's records were not fully appreciated by the medical and administrative professions of the time. These professions made little use of the information contained in the medical record, as they were not assembled in a way that made retrieval and use of information easy or meaningful.

In May 1946, the Institute of Hospital Administrators published a letter in their Journal, "The Hospital," which advocated an overhaul of existing methods of compiling medical records, training for staff working in the field, and the inauguration of a professional body to be responsible for standards of work and workers in the field who were to be qualified by examination. A meeting was subsequently convened, which resulted in the formation of a committee of nine women to lead the work under the chairmanship of Elsie Royle, the Record Registrar at the Christie Hospital in Manchester.

There then followed two years of preparation, which included efforts to change or modify the attitudes of doctors, administrators, and other staff and also the attitudes of the records staff themselves. Eventually attitudes did change and a new "records consciousness" developed. Medical records departments with officers in charge were created and the concept of a new professional association as an educational body was accepted.

During the next two years, much valuable assistance was received from people of influence at the Ministry of Health, the King Edward's Hospital Fund in London, and the University of Oxford. A residential course, organised by the Nuffield Bureau of Health and Sickness Records, was held at Oxford University in September 1947. This was the first event of its kind and it resulted in the publication of one of the addresses given at a conference entitled "The organisation of a Medical Records Department--the responsibilities of a Hospital Records Officer." This address was later published in the journal of the Institute of Hospital Administrators--"The Hospital."   Three years later, there was a further publication "The Role of the Medical Records Officer."   These two articles outlined some general principles, which were acceptable to hospital management at the time; this period being prior to the establishment of the National Health Service (NHS).

Two working parties were established and the objective of the first of these was to stimulate interest. Having done this, the second working party was formed with membership comprising officers of teaching, local authority and specialist hospitals. At a meeting in July 1947, it was resolved that a professional association be established. This was later named in 1948 (coincidentally the same year that the NHS was established) as the Association of Medical Records Officers (AMRO). AMRO was a founding member of IFHRO (International Federation of Health Records Organisations).

Educational Provision over the Years

In 1949, an Education Committee of AMRO was formed. In the same year, two training schools were established at the Royal Free Hospital in London and the Royal Victoria Infirmary in Newcastle. In 1950, the AMRO Examination and Tuition Advisory Board was formed, and this included representation from the medical Royal Colleges, the Royal Statistical Society, and the Institute of Health Services Management.

In 1954, the first correspondence course was introduced to help students prepare for the AMRO examinations. This was provided by the trade union NALGO (National and Local Government Officers). In 1966, a school was started in Glasgow in conjunction with the local Anniesland College.

The educational activities of AMRO at this time ranged from simple lecture courses in the early days to the three-tier system (Certificate, Diploma, and Higher Diploma), first held in 1972, with awards for students who excelled in the examinations. The Higher Diploma was discontinued just a few years later due to limited interest in this qualification.

More Recent Developments

In 1984, the NHS Training Authority held a workshop to examine the issues surrounding medical records management in the NHS. This resulted in a publication "Making Health Records Professional(s)," which in turn resulted in the establishment of an Accelerated Management Development Programme for Health Record Managers at the University of Manchester. This programme continued for three years, but it had to be discontinued when training budgets were devolved from regional level to individual hospital level following a re-organisation of the NHS. The University of Manchester includes Health Record Management as part of the Health Informatics module of the Master of Arts (Health Service Management), and there are other Universities, which offer health informatics courses and degrees but Health Record/Health Information Management is still not offered at an undergraduate level in the UK. Some Universities are now developing workplace-based Foundation Degrees and this includes NHS Health Records Departments.

Current IHRIM Qualifications for Health Record Managers and Staff

The Institute of Health Record, Information and Management IHRIM (formerly AMRO) currently provides the following qualifications for health records practitioners:

• Certificates of Technical Competence (CTCs) at basic and advanced levels. These are work-based assessed qualifications, and they acknowledge skills and knowledge gained by the experiential route where members of staff receive in-house training to a specified syllabus and are then assessed against defined criteria by an external assessor.

• IHRIM Certificate examination comprises six papers to be taken over two days. These papers are as follows:
  • Operational Health Records
  • Health Records Management
  • Human Resources
  • Information and Data
  • Clinical Terminology
  • IT Application and Development

  In 1995, UNISON (the trade union into which NALGO was subsumed) discontinued organising the correspondence course, which had been established in 1954. IHRIM (formerly AMRO) started to produce its own study notes for students to enable them to undertake self-directed learning for the examination. Current educational support for students comes largely from local IHRIM branches or well-motivated Health Record Managers who organise schools, sometimes in conjunction with local colleges of further education. Single subject night-school classes are also organised in some geographic areas. On successful completion a candidate is entitled to use the designatory letters CHRIM

• The Diploma Award Scheme, which requires production of a personal portfolio, the acquisition of 10 credits by undertaking a range of approved activities and a dissertation on a topic approved by the Director of Education. On successful completion a candidate is entitled to use the designatory letters AHRIM.

• Licentiateship of IHRIM--Affiliate members who have had two years in continuous membership and who continue to work actively in the fields of health record and information management are upgraded to Licentiateship and are entitled to use the designatory letters LHRIM. Although this is not a "qualification" in the academic sense, it acknowledges skills and knowledge gained through the experiential route over a minimum of two years.

• In 1998, IHRIM was invited by the NHS Information Authority to develop, in partnership, a new National Clinical Coding Qualification for the United Kingdom and to become the examining and awarding body for the qualification. The development work for the qualification was undertaken in partnership with the National Health Service in all the home countries of the United Kingdom (England, Scotland, Wales, and Northern Ireland). The first examinations for this important new qualification were held in May 2000, and successful candidates are entitled to use the designatory letters ACC (Accredited Clinical Coder). There are now around 500 qualified ACCs in the UK.

Health Informatics Standards and Qualifications

National Occupational Standards

Health Informatics as a profession must be underpinned by standards. The development of National Occupational Standards for the NHS Health Informatics function and also for NHS Health Records services by the NHS Information Authority has now been completed, and these standards are to be incorporated into the NHS Knowledge and Skills Framework (KSF). This will, for the first time, recognise Health Informatics as a specialist set of job roles, with an associated learning and qualifications structure.

Professional Awards in IM&T (Health)

The National Occupational Standards will underpin a qualification structure for Health Informatics professionals, and the Professional Awards in IM&T (Health) will have an important part in this framework. The Professional Awards in IM&T (Health) are a set of qualifications, which provide a professional framework across Health Informatics Specialist areas and levels of management. The standards, which underpin the qualifications, were developed through a rigorous process of consultation with NHS staff with advice and support from educational specialists. The Awards are unique in that they encompass all areas of the health informatics function and allow this diversity to be assessed within one professional framework. These awards are offered at a number of approved educational centres in England.

The values upheld throughout the development of the Awards are that the qualification should meet the following criteria:

• Be credible to the needs of the healthcare sector;
• Recognise knowledge and skills gained through formal study and through experience;
• Contribute to the quality of healthcare management.

Professional registration and the requirement to not only gain appropriate knowledge and skills for the job role but to continue to practise appropriately will be managed through the emerging professional body the United Kingdom Council for Health Informatics Professions (UKCHIP).

UKCHIP--Professional Accreditation for Health Informaticians

UKCHIP (UK Council for Health Informatics Professions) is a newly formed body to develop professionalism in Health Informatics Professionals. This includes all those working in ICT, Health Records, Knowledge-based services such as Librarians, Clinical Informaticians, including managers of these staff, and it is applicable to both those working within the NHS and the private sector. Its primary function is to hold a Register of those who have been accredited as Health Informaticians. It will also de-register any Registrants who fail to maintain adequate professional standards. To do this, it will establish standards for professional conduct, qualification, and development for Health Informaticians. It is not intended to replace any existing bodies; it is an umbrella organisation for those practicing in the field.

UKCHIP will assess qualifications, core competencies, and codes of conduct produced by other bodies including academic, employer (the NHS in particular), and professional societies

Initially, registration will be voluntary although it is expected that in the future the NHS will expect anyone working in Health Informatics to have obtained registration. Eventually, it is envisaged that Statutory Registration will be needed to protect the needs of patients.

UKCHIP has been founded with the support of the British Computer Society (BCS), the NHS Information Authority, ASSIST (the Association of ICT professionals in the NHS), and the UK Institute for Health Informatics. It is associated with many other bodies including British Medical Informatics Society, the Institute of Healthcare Management, and IHRIM, which is a founder member of the Council.

A New European Qualification--ECDL (Health)

The effectiveness and quality of health informatics systems' support to healthcare delivery are largely determined by two factors--the suitability of the system installed and the competence of the users. The imminence of the implementation of electronic patient record (EPR) systems generally, specifically the establishment of the National Programme for Information Technology (England) and the associated implementation of the National Care Record Service, which is the largest ever single IT procurement programme in the world, requires a basic, generic level of skill and competence, not only in the use of IT but in the use of IT-based health systems. There is consequently an identified need for a clear and comprehensive generic user qualification at a basic but robust level.

The European Computer Driving Licence (ECDL) has gained wide recognition as a basic generic qualification for users of computer systems, but it is acknowledged that health systems and data have characteristics that set them apart from other systems and data. Work to explore the feasibility of producing a health supplement to the ECDL commenced in 2003 and the NHS Information Authority facilitated this work. Other involved organisations in the work include the International Federation of Health Records Organisations (IFHRO), the British Computer Society, and the NHS University. A set of draft competencies was produced for consultation both in the United Kingdom and in Europe, and in March 2004, representatives of nine European countries reached consensus on the development of a health supplement to the ECDL at a basic level. The countries involved in the consultation were Sweden, The Netherlands, Finland, Norway, Iceland, Germany, Italy, Ireland, and the United Kingdom. In light of this consensus, the ECDL Foundation will be taking the project forward, feeding it into their formal product development processes and involving stakeholders in the development process.

Conclusion

Health Records Managers are an identified health informatics professional group. National and global developments in Health Informatics are raising the professional profile and the attendant educational requirements for practitioners working in the fields of Health Records and Health Information Management in the United Kingdom.