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3 Record Keeping "Information, not data, is critical to the survival of a health care organization." Diedling and Welfeld (1995) Information management is fast becoming the key to effective action in animal care. As wildlife habitat for many threatened and endangered species continues to shrink, a greater responsibility is placed on zoos to function in part as the last refuges for more rather than fewer species (Teare, 1998). Long-term survival of small populations of captive wildlife requires intense management that encompasses information derived from numerous scientific disciplines, including genetics, nutrition, ethology, and veterinary medicine (Teare, 1998). When faced with questions regarding the care and management of wildlife species, literature surveys and reviews of individual medical records are labor intensive and time consuming. Thus, the more information that can be accurately collected and maintained and later effectively retrieved and used, the more successful captive animal management will become (Earnhardt et al., 1995). As with any facility responsible for the care of its residents, modern zoos require effective systems for gathering relevant information from the field, processing it in ways that provide maximum value, and presenting it in a form that is easy for staff to use in implementing appropriate actions to achieve effective animal management and disease control programs (Morris, 1991). Responsibilities of the chief information officer and managers of those systems are equally important in ensuring effectiveness (Greer, 1998). Several published reviews describe objectives for information management systems and criteria for information-gathering activities in animal health that should be met to ensure effectiveness (Morris, 1991; Harris, 1991). Information management systems are the functional coordination of data (records) from input (the data that goes into the system) through processing (what is done with the data) to output (the information that is produced). Ten characteristics are important in any information management system (R. Whitehouse, Associate Hospitals Administrator and Director, Medical Information Services-University of Michigan Hospital and Health Centers, "Clinical Information Systems" presentation to committee, October 2, 2003): 1. Accessibility, 2. Accuracy, 3. Appropriateness, 4. Comprehensibility, 5. Comprehensiveness, 6. Consistency, 7. Relevance, 8. Reliability, 9. Timeliness 10. Usefulness These characteristics apply to systems ranging from simple (paper record) to complex (decision support software) (see Figure 3-1). Two critical aspects of paper systems are tracking and accessibility of the records. 47

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48 ANIMAL CARE AND MANAGEMENT AT THE NATIONAL ZOO: INTERIM REPORT Records should provide an accurate account of situations and practices relating directly to animal management and health. They should permit reconstruction of events in the recent and distant past and provide a rational basis for decision making. Decision support resources applied Provides for multimedia information management Data is digitized, permitting review of data elements across cases Prompts for information Interactive capture of information and work flow processes All information entered into a data repository from which one can select information Paper record available from computer Basic paper record FIGURE 3-1 Range of complexity in information management systems (R. Whitehouse, Associate Hospitals Administrator and Director, Medical Information Services-University of Michigan Hospital and Health Centers, "Clinical Information Systems" presentation to committee, October 2, 2003). ELECTRONIC DATA MANAGEMENT IN ZOOLOGICAL INSTITUTIONS Many software programs used for zoo and aquarium animal information management have been developed by the International Species Information System (ISIS), a small nonprofit membership organization that maintains a data depository for its institutional members. It has, however, not kept pace with advances in information technology, and it does not have the resources to ensure the accuracy of member records. In an effort to supplement animal collection records, several institutions and some zoo and aquarium associations have developed additional software. For example, the Australasian Regional Association of Zoological Parks and Aquaria (ARAZPA) developed REGASP, software for managing institutional and regional collection planning data. REGASP is now used by several regional associations. The Zoological Society of London supported the development of software to manage invertebrate populations. Several individual institutions have developed in-house inventory systems that meet their individual needs but still export data to a central ISIS database (Dubois, et al., 2003). In addition, veterinarians have been searching to find a replacement for the DOS-based Medical Animal Record Keeping System (MedARKS) software program, which has been adopted as the "de facto" standard for computerized medical records in zoos. It was developed in 1986 and later supported by ISIS. MedARKS is the single largest computerized database of medical information on captive wildlife (Teare, 1998); approximately 200 institutions in over a dozen countries maintain health records in these systems. A new Zoological Information Management System (ZIMS) is being developed by the American Zoo and Aquarium Association (AZA) and a consortium of zoological and professional organizations (Cook and DuBois, 2003) and is being coordinated by ISIS. This new system is being designed to create a global animal information system for zoos and aquariums. It will include modules for animal inventory, veterinary care, nutrition, husbandry, environmental monitoring, collection planning, and research, and will be designed to accommodate expansion (ZIMS, 2003). ZIMS will support all of the information that is in the current ISIS software (ARKS, MedARKS) and additional information as determined by planners. The recognition that well-designed, standardized electronic medical record-keeping systems are essential to proper animal care is not limited to the zoological community. The U.S. Department of Agriculture's (USDA) Animal and Plant Health Inspection Service (APHIS) recently announced a proposed regulation of medical record keeping for research facilities, dealers, and exhibitors (Docket No. 97-033-1), which includes zoological institutions. Maintenance of medical records is implied in the Animal Welfare Act, but the regulations do not specifically stipulate the maintenance of medical records as one of the elements in a program of adequate veterinary care. The

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RECORD KEEPING 49 proposed rule would amend the Animal Welfare Act (7 U.S.C. 2131 et seq.; 9 CFR 2) to require these entities to maintain medical records as part of adequate veterinary care. The proposed maintenance of medical records "would serve as a basis for reviewing the medical history and planning veterinary care, and provide a mechanism of communication for matters of animal health, behavior, and well-being. Medical records document the animal's illness, veterinary care, and treatment and serve as a basis for review, study, and evaluation of veterinary care rendered by the facility." The lack of a standardized information technology strategy for regulatory veterinary medicine resulted in state and federal information systems evolving separately (Miller et al., 1994). Animal managers ultimately pay the price for deficiencies in regulatory coordination of U.S. animal health and disease information. As seen in the recent identification of the first U.S. case of "mad cow disease," our national system for tracking and coordinating information on animal health and management needs to be improved, and the USDA has expedited its current efforts (USDA, 2004c). The longer the development of information technology strategies is delayed, the more costly it will be to correct the deficiency (Miller et al., 1994). In another example of moving toward record standardization, the Department of Health and Human Services (DHHS) recently announced the development of a new Systematized Nomenclature of Medicine (SNOMED) for veterinarians and physicians, which was originally created for human medicine, but has been expanded to include veterinary terms; SNOMED will allow institutions throughout the country to share information electronically (AVMA, 2003). In addition, the National Academies' Institute of Medicine has been asked by DHHS to design a standardized electronic health record. Information Managers Information managers, or chief information officers, have become increasingly important in recent years, especially in the human and veterinary medicine fields (Greer, 1998). These people typically occupy positions at the executive management level in the human medical field and administrative or management positions in the veterinary medical (zoo) field (Greer, 1998; Zoo Registrars Association, 2003). There are only two formally established regional groups of animal records keepers: the Australasian Animal Records Keeping Specialist Advisory Group and the North American Zoo Registrars Association. The membership of these organizations consists of people with primary responsibility for animal record keeping in zoological institutions, aquariums, and similar organizations (i.e., registrars). A zoo registrar's responsibilities are varied and complex (see Table 3-1). Two AZA scientific advisory groups (the Institutional Data Management Advisory Group and the Small Population Management Advisory Group) have produced official standards for data management in AZA-accredited zoos. The AZA offers professional training in record keeping. TABLE 3-1 General Responsibilities and Qualifications of a Zoo Registrara Responsibilities: Serves as a member of the Animal Management Team, assists in the development and implementation of the zoo's Collection Management Policy, and its resulting collection plans. Monitors all transactions for adherence to policies. Manages animal records and ensures the maintenance and quality of animal records for use in the management and development of husbandry and breeding programs, preparation of scientific publications, and provision of data for cooperative ventures at both the regional and international level. Serves as liaison and information source to other departments and organizations. Provides a complete inventory and record of all animal transactions. Monitors legislation for compliance with wildlife laws. Collaborates with curators. Works under the supervision of the Zoo director. (Specific responsibilities detailed in Appendix E). Qualifications: Four-year college degree in biology or related field plus two years of experience. Knowledge of concepts, principles, and practices of professional museum and zoo registration methods and collection management standards. Knowledge of inventory accession and record-keeping practices; zoological nomenclature; laws regulating animal acquisition, disposition, exhibition, husbandry standards, and transportation within the United States and abroad; and statistics and population management. Experience with computers, animal records, and word processing software. Ability to collect and collate information from a variety of sources into concise and accurate reports. Good communication and organizational skills, and attention to detail. aAdapted from Zoo Registrars Association (2003).

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50 ANIMAL CARE AND MANAGEMENT AT THE NATIONAL ZOO: INTERIM REPORT RECORD KEEPING PRACTICES AT THE NATIONAL ZOO Within the National Zoo, animals are assigned a "local ID" in the form of an accession number. This accession number uniquely identifies each animal in the National Zoo and is used in each type of record generated at the National Zoo. The National Zoo generates many types of animal management and husbandry records, including Keeper logs generated by the zoo keepers to document daily observations of each animal. Curator reports generated by the curator, usually weekly, to highlight significant events noted in the daily keeper logs of that week. Specimen reports generated by the records keeper within the registrar's office. It is the official history of the animal and documents major events such as birth, death, origin of specimen, medical history, behavioral and husbandry concerns, and location of a specimen (Earnhardt et al., 1998). These reports are generated from information in the curator reports. Nutritionist records generated by the nutritionist to document diet management. Veterinary medical records generated by the veterinary staff to document the medical care received by an animal, including clinical notes, laboratory results, anesthesia records, and parasitology records. Pathology records generated by the Pathology Department to document the examination of tissue or fluid samples as well as the findings of necropsies. The veterinary medical records are generated on MedARKS (ISIS, 2004; AAZV, 1999). The specimen reports are generated using the Animal Record Keeping System (ARKs) software package developed by ISIS. The keeper logs, curatorial reports, and nutritionist records are generated in a variety of ways detailed below. Keeper Logs The keeper log is the only record of normal daily observations of individual animals. In the past these records were generated through the use of a carbon paper form called the zookeeper's daily report. Over the past five years a prototype electronic keeper record system called the Daily Animal Records System (DARS) was developed and implemented. DARS was implemented in only one unit to test the system; that unit still uses the system. A second electronic system is being developed and implemented, using a Web-based form found on the National Zoo's intranet. This initiative was started approximately a year ago. It uses a form similar to the zookeeper's daily report on paper, and currently two units are using the system, though not every keeper within the unit uses it (NZP, Animal Records Procedures: Statement of Practice, 2003; J. Block, Registrar, National Zoo, personal communication). Both the DARS and the new intranet-based system allow for electronic entry of data onto the form; however, there is no electronic archiving of the information. The forms are printed out and the paper copies are to be archived (J. Block, Registrar, National Zoo, personal communication). Curator Reports Curator reports are generated by the curator, usually weekly, and contain the most salient animal management and husbandry information gleaned from the keeper reports. For one unit this report is generated through the DARS system; for all other units it is generated by a version of a curator report form. Paper copies of these reports are forwarded to the registrar's office, where they are archived, and salient information from the curator reports is included in the specimen report (NZP, Animal Records Procedures: Statement of Practice, 2003). Nutritionist Records In the past and currently the development, implementation, recording, and archiving of nutritionist records has been at the discretion of the National Zoo nutritionist. Nutrition files were kept on hard copy, though it was evident that there was a lack of standard documentation on the current diet of each animal and any changes made to

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RECORD KEEPING 51 the diet (e.g., see Box 2-1). The acting head of the clinical nutrition program, appointed for a two-year term, has begun organizing the nutrition records, and is developing and implementing a new electronic record-keeping system for nutrition records. STRENGTHS AND WEAKNESSES IN RECORD KEEPING AT THE NATIONAL ZOO Failure to Adequately Document Animal Management, Husbandry, and Medical Care With the exception of the Pathology Department, the adequacy of the record keeping varied greatly within the different units and departments of the National Zoo, and often was deficient, as in the case of the Grevy's zebra "Buumba" (see Box 2-1). This resulted in part from a lack of standardized practices for reporting and archiving records. Patterns of inconsistent record keeping and archiving were found in keeper logs, curator reports, nutritionist records, and medical records. The National Zoo has acknowledged errors in record keeping for a number of animals (African lion [Accession # 108413], bobcat [Accession # 103175], East African bush elephant [Accession # 26223], eastern bongo antelope [Accession # 110565], Geoffrey's marmoset [Accession # 113220], Masai giraffe [Accession # 104081], Sumatran orangutan [Accession #100797], tree kangaroo [Accession # 110974], Vietnamese pot-bellied pig [Accession # 109080], zebra [Accession # 113393]; NZP, Letter to Committee, December 31, 2003). Keeper Logs The keeper log is a particularly important record as it is a primary sources for information used for animal management decisions (Earnhardt et al., 1998). There were numerous instances of keeper logs not reflecting important changes in an animal's behavior or management (e.g., see Box 2-1). This may occur for a variety of reasons, including a failure to appropriately train keepers regarding the information that should be recorded in a keeper log and a failure of the curator to provide appropriate quality control. Another keeper log issue that arose was a failure to archive these records (see Boxes 2-1 and 2-2). Currently each unit is responsible for archiving the daily keeper logs, though there is no stated expectation of how long to archive the materials. There is a lack of appreciation at all levels of the importance of these records, and that in various situations it may be essential to be able to review weeks, months, or even years of keeper logs on a particular animal or group of animals. Not only were there numerous failures to archive these records but there was also a failure to manage these records as a whole. In essence, no individual within the National Zoo has responsibility for documenting where the records are archived and how they are organized. This leaves each unit's records vulnerable when staff turnover occurs. When staff leave the National Zoo (particularly curators, who are responsible for overseeing the quality and archiving of keeper logs), knowledge as to where the records are kept and how they are organized is lost. With the large amount of staff turnover resulting from the buyouts, it is particularly important to standardize practices relating to keeper logs, so that these records are accessible regardless of the current staffing situation. Curator Reports Curator reports also failed to provide complete information regarding animal management (e.g., see Box 2- 1). This is partially because curator reports are compiled from keeper logs (which were deficient in many cases) but also because of a failure to appropriately train curators regarding their responsibilities in generating complete and accurate curator reports, and also their responsibilities in overseeing the quality and completeness of the keeper logs. There is no formal training process; rather, the registrar, on a case-by-case-basis, informally discusses record keeping with a curator. In addition, few curators have received training on record keeping through the AZA (2003a). The National Zoological Park Animal Records Procedures, which outline the responsibilities of the curator and the information for which they are responsible, was developed in July 2003, and there has been no organized effort to educate curators of the contents of the document, ensure they are properly trained to carry out its policies, or provide oversight to ensure they are adhering with the policies.

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52 ANIMAL CARE AND MANAGEMENT AT THE NATIONAL ZOO: INTERIM REPORT Nutritionist Records In the past there has been a failure to maintain accurate, up-to-date records on the diets and nutritional management of animals at the National Zoo. This situation arose due to several factors, including: a failure on the part of nutritionists to fulfill their responsibility to maintain adequate records, the lack of written expectations as to what would be contained within nutritionist records and how they were to be managed and archived, and the failure of senior management to provide appropriate oversight to ensure that the nutrition department was fulfilling its responsibilities. An acting head of clinical nutrition has been hired for a two-year appointment and the process of organizing the few records that do exist, developing an electronic system to document diet management, and creating a diet management record for each animal in the collection has begun. The original intent was to have a diet management record created for each animal in the collection, and to have these records accessible via the Intranet. However, due to the retirement of the commissary manager, the acting head of clinical program temporarily assumed the responsibilities of the commissary manager, which has delayed completion of the nutrition records. A new commissary manager has been hired. Those nutrition records that have already been created are slated to be assessable via the Intranet in early 2004. Veterinary Medical Records In general the medical records kept by the veterinary staff at the National Zoo were acceptable, however there were multiple instances of medical records being altered weeks and even years later (see Box 2-1). The National Zoo, like many other zoos, uses the MedARKS system as a teaching tool, by allowing veterinary students and residents to create the initial clinical note in an animal's record and then, at a later point, editing these records when errors are made. The MedARKS system documents the initials of the person who creates the clinical note, though the system does not automatically identify the user when edits are made to a record. Recently the veterinary department established a variety of policies regarding the identification of persons who enter or edit a record, including having students use the initials of the case veterinarian and most recently, having students use their own initials as was done previously. When edits are made, case veterinarians should manually enter their own initials. Though editing of clinical notes is a standard practice at the National Zoo, it is an unacceptable practice as currently implemented. The American Animal Hospital Association has established clear standards for medical records, including "the author of medical record entries is permanently and uniquely identified (by a code numbers/letters, initials, or signatures) in a manner that is understood by anyone examining such records." The National Zoo's practice of editing medical records without identifying the changes made or the individual making the changes casts doubt on the credibility of their records, especially when the quality of the veterinary care is called into question. If erroneous entries are made, they should be corrected by addenda, not by altering the original entry. If the National Zoo continues to allow students to make medical record entries, the students need to be carefully supervised to limit inconsistencies and errors that would require the supervising veterinarian to create an addendum; these addendums should be made in a timely fashion. Lack of Records Accessibility There are two main issues regarding accessibility of records. The first was discussed above and involves a failure to consistently and appropriately archive keeper logs and curator records. Each unit and the nutrition department is responsible for archiving the unit's/department's generated records, with no apparent oversight. This has resulted in records being lost or misplaced. When records are not retrievable in a reasonable manner, their value is lost. Second, all pertinent animal information is not archived in one location (be it paper or electronically). Currently at the National Zoo the information management infrastructure is set up so that daily information about an animal is included in the keeper log; the curator summarizes this information into a weekly curator report; medical information is contained within the MedARKS medical records; and nutritional information is contained within the nutritionist records, which are still being developed. Many units within the National Zoo submit all of their keeper logs to the veterinary medical department daily. Some do this by faxing the forms, while others send it by e-mail. Other units submit only their weekly curator reports to the veterinary medical department by fax, while at least one

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RECORD KEEPING 53 unit does not submit any reports to the veterinary medical department (J. Block, Registrar, National Zoo, personal communication). In addition, there is no expectation, nor should there be, that the veterinarians archive these materials for future use. In an emergency, if veterinarians needed access to these records (for example, to determine if medications were administered or behaviors were altered.), they would have to rely on locating a member of the unit staff to find the paper copies of these records and transmit them to the veterinary staff in a timely fashion. According to National Zoo policy (NZP, Animal Records Procedures, July 2003), the registrar is responsible for setting the standards and overseeing the animal records systems, maintaining the transaction files and the core data in the specimen records, and reporting on collection holdings and changes. In reviewing keeper logs, curator records, medical records, pathology records, and specimen records over the last six months, the committee found that the type of information being documented in the keeper and curator records was inconsistent and the keeper and curator records were inappropriately archived if they were retained at all. These deviations from stated policy directly affected the quality of care some animals received (see Box 2-1) and hampered the investigation of the circumstances contributing to animal deaths at the National Zoo. It is clear that there was not adequate oversight of keeper and curator record keeping and archiving by the registrar. It is not apparent whether adequate policies on record keeping and archiving were in place prior to July 2003. The committee was unable to determine whether the registrar had a clear mandate and appropriate authority to ensure adequate record keeping and archiving by the keeper and curatorial staff. Findings and Immediate Needs As with any zoological park it has often been necessary at the National Zoo to review the history of an animal in the collection to help determine a future medical treatment, a change in diet, or to help identify a cause of illness or death. The National Zoo has been handicapped in its efforts to provide adequate animal care by a nonfunctional information management system (see Box 2-1). Finding 5: The National Zoological Park lacks a comprehensive information management system for animal husbandry and management records, which results in inconsistent record keeping and practices of alteration in medical records weeks or years after events. While some issues are being addressed (e.g., an electronic keeper log system is in development) these are stop-gap measures often having no concrete timeframe for completion or implementation. Immediate Needs: The National Zoo should implement an information management system that ensures complete documentation of animal husbandry and management and reasonable accessibility to the records by all units and departments. This does not necessarily mean that the entire system needs to be computerized immediately but rather that consistent practices be put in place, that a system be developed to make the records reasonably accessible and that an appropriately experienced individual be given responsibility for system oversight. It is essential that the problems outlined within this section be addressed immediately, either through better use of the ARKs system already in place at the National Zoo or through efforts to standardize record keeping and archiving and to make records accessible. Based on the deficiencies in record keeping observed by the committee, when developing and implementing a system, the following performance standards should be established: There should be standardized practices for recording and archiving animal husbandry and management information. These practices should outline the information to be contained in each type of record and how and where these records are to be archived. Employees should be appropriately trained and prove their competence regarding recording and archiving standards. There should be oversight to ensure compliance with recording and archiving standards. A communication system should be developed to ensure that all appropriate individuals are notified about significant changes in animal husbandry or management. A protocol should be developed to allow for pertinent information related to a specific animal or group of animals to be reasonably accessed by an employee, even if that employee is attached to a different department.

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54 ANIMAL CARE AND MANAGEMENT AT THE NATIONAL ZOO: INTERIM REPORT The information management system should be implemented in such a way that record keeping, archiving, and accessing records is unaffected by staff illness, absence, or turnover. Records should provide an accurate account of situations and practices relating directly to animal management and health. They should permit reconstruction of events in the recent and distant past and should provide a rational basis for decision making in the present. Records should indicate who generated them which animals were involved when the observation was made or procedure done what practices were carried out or problems were encountered where events took place why actions were taken There are several ways these performance standards can be achieved. Ideally, a single, comprehensive electronic record-keeping system should be implemented. The National Zoo already uses such a system (the ARKS and MedARKS systems), though it currently uses it only to generate specimen reports for communication with institutions outside the National Zoo. The ARKS system was developed as an electronic information management system to provide a way to organize all information about an animal and make it electronically accessible to keepers, curators, and veterinarians, nutritionists. In addition to the ARKS software, an entire system was developed around this software to describe how a zoo could standardize record keeping and use the ARKS system most efficiently and to the fullest extent. This information is contained in the document "Standards for Data Entry and Maintenance of North American Zoo and Aquarium Animal Records Databases: (Earnhardt et al., 1998). If the National Zoo were to choose the ARKS system to address the most pressing issues relating to information management, the system would have to be accessible to all appropriate staff within the zoo, including keepers. Data entry would have to occur daily, and be derived directly from keeper reports that are quality checked by the curator. To control the security of the system the data entry and data changes should be limited to the registrar's office (Earnhardt et al., 1998). The current staffing level of the registrar's office (a recently retired registrar who has not yet been replaced and an assistant registrar) and the lack of appropriate computer equipment and training might preclude these improvements. The National Zoo would also need to devise a system in which pertinent information originating in the veterinary hospital or nutrition department is sent to the registrar's office for daily data entry. The ZIMS system currently being developed by AZA could be an ideal solution for the National Zoo; however, it will be at least two years before this system is available. It is unacceptable for failures in the current information management system to remain unresolved for two or more years; therefore, the National Zoo may choose to make improvements to its current system (mixed paper and electronic). Resolving the failures in the current mixed paper and electronic information management system will require a quick and thorough evaluation of the current system under the direction of an individual versed in implementing and overseeing a successful information management system. It is essential that a qualified individual be clearly designated to oversee the evaluation of the current system, development and implementation of new practices and standards, and adherence with these new practices and standards. This individual should have the authority and responsibility for achieving these goals. With the recent retirement of the National Zoo's registrar after decades of service to the zoo and significant contributions to the field of animal record keeping (Miller and Block, 1992), the zoo should quickly identify and hire an individual to head the record-keeping functions of the zoo. This person should be qualified in implementing and overseeing a comprehensive information management system.