Don’t rely too much on data bank as major source for credentialing info

Latest assessment shows NPDB incomplete, not reliable enough

The National Practitioner Data Bank (NPDB) may be a good tool for peer review professionals, but it can be a trap if you rely on it too much. The research shows that the NPDB is incomplete at best, and health care providers who depend on it may find that they aren’t getting the whole story. Peer review standards require that you query the NPDB when credentialing physicians, so it’s not a question of whether to use the data bank. The question is what else you use.

Health care providers should be careful to use the NPDB as only one of several sources of information when credentialing physicians, says Janet Brown, RN, CPHQ, head of JB Quality Solutions consulting in Pasadena, CA. "We can assume that it’s less than 100% accurate from the beginning," Brown says. "You have to assume that it’s considered to be incomplete and inaccurate, so you have to cover your bases. That means looking to other resources and doing some of your own leg work."

Brown says the most recent report from the federal government confirms what many peer review professionals have suspected for a while. According to the report, the data bank is alarmingly incomplete, and managed care companies, in particular, seem lax about reporting information.

Most managed care plans have never reported

The Health and Human Services Office of Inspector General (OIG) recently released a report that said, among other criticisms, that 84% of managed care organizations have never reported an adverse action against a health care practitioner to the data bank.

The report went on to conclude that the low rate of reporting may adversely affect patient safety. The OIG urges hospitals, physician groups, and state licensure boards to report doctors who pose a threat to patients, but it says many health plans rarely report to the data bank because they devote little attention to clinical oversight. The health plans’ heavy use of contracted panels of physicians, rather than salaried doctors, is blamed for much of the problem.

The OIG noted that health plans also depend on hospitals, physician group practices, and state licensure boards to monitor and report questionable physicians, a practice that the OIG says may be ineffective.

Federal law requires hospitals and health plans to inform the government of any disciplinary action taken against a physician for incompetence or misconduct. The OIG report, however, revealed that over the past 10 years, 84% of health plans and 60% of hospitals have never reported even a single adverse action.

The OIG noted that this finding is particularly surprising in the wake of the recent furor over medical errors, in which research suggested that tens of thousands of people die each year from errors, and at least some of those deaths are attributable to a doctor’s mistake.

The OIG report is the result of an 18-month study. Between 1990 and 1999, health plans reported only 715 adverse actions, even though they became the dominant form of health care during that period, covering 100 million people. Physician groups reported 60 adverse events.

The American Association of Health Plans in Washington, DC, responded to the OIG report by saying that health plans do identify quality problems and take action, but that action does not always result in a report to the NPDB. Many situations require further review by medical groups, hospitals, and medical boards, so the health plan does not report the physician and expects those other groups to do so if warranted.

Other studies also have raised questions about the reliability of the NPDB. (For more on research about the data bank, see "Previous research casts doubt on value of NPDB," in this issue.) In addition, physicians’ groups have criticized the NPDB for being incomplete and inaccurate.

The latest research brought disapproval. "The OIG report confirmed what we’ve been saying all along about the NPDB — that it’s flawed, incomplete, and not reliable," says Robert Mills, a spokesman for the American Medical Association (AMA) in Chicago. He says the group has opposed the NPDB for years because it provides an incomplete picture of disciplinary action and other incidents.

An earlier report from the General Accounting Office (GAO) reached a conclusion similar to that of the OIG. The Nov. 17, 2000, report stated, "While the [NPDB] is presently the nation’s only central source of medical malpractice payment information, it is not clear that all such data are being properly reported.

"While GAO sampled one month’s submissions, its review suggests that NPDB information may not be as accurate, complete, or as timely as it should be. Inaccuracies in the way reported information was coded could confuse or mislead querying organizations about the severity of actions taken against practitioners. Additionally, duplicate reports overstate the amount of information the NPDB has on a particular practitioner," the report added.

Thomas R. Reardon, MD, immediate past president of the AMA, says the government reports confirm the AMA’s view that the NPDB is "seriously flawed." He says the data bank is "riddled with duplicate entries, inaccurate data, and incomplete and inappropriate information. In addition, many of the medical malpractice citations name the patient as well as the practitioner — raising a serious red flag regarding patient privacy." According to Reardon, the NPDB "is clearly struggling to fulfill its mandate."

Data bank managers not happy with trends

The NPDB is managed by the Health Resources and Services Administration (HRSA), an agency of the U.S. Department of Health and Human Services (HHS) in Chantilly, VA. HRSA has made it clear that health care providers are not reporting information as they should. "HRSA continues to be concerned about the low level of clinical privileges actions reported by hospitals and other clinical privileges reporters such as health maintenance organizations," the agency said recently in a public statement.

The level of reporting is "unreasonably low. Nationally over the history of the NPDB, there are 3.9 times more licensure reports than clinical privileges reports. Moreover, 52.5% of the hospitals currently in active’ registered status with the NPDB have never submitted a clinical privileges report. Clinical privileges reporting seems to be concentrated in a few facilities, even in states which have comparatively high overall clinical privileging reporting levels," the agency added. That means peer review professionals must turn to other sources, Brown says. Many hospitals already use credential verification organizations (CVOs) — private companies that query the NPDB and make other inquiries on behalf of the hospital.

Those services can save you a lot of work, but Brown cautions that those using that kind of service must be familiar with how the particular CVO works. If the CVO only queries the NPDB and doesn’t do much else, users are not getting enough for their money. Whether hospitals do it themselves or pay a CVO, a good credentialing program must include queries to state medical boards and insurance companies.

"If you’re using CVOs, make sure they’re doing everything you would do if you had the time," Brown says. "They’re supposed to be a convenience, a way to make the process efficient. Don’t just turn it over to them without asking exactly how they’re going to get the job done."

State systems may provide another option

Patti Higginbotham, RN, CPHQ, FNAHQ, vice president of quality management at Arkansas Children’s Hospital in Little Rock, has similar advice. She also is concerned about the reliability of the NPDB. "It’s required that we query the [NPDB] for credentialing, so we absolutely do that for each one. But we look at it more as a compliance issue," she says. "You can’t query too many sources, and if the data bank has information, you want it," she points out. "But it’s one source among many, not necessarily the definitive source."

Higginbotham says she doesn’t expect any one source to be complete and serve all of her needs, so in that sense, she is not critical of the NPDB. But she recommends that health care providers consider the NPDB no more authoritative than other sources, and she worries that not everyone does that. "The data bank only tells you if there has been action again a practitioner," she says. "It doesn’t tell you what is pending, and it doesn’t verify any data for you. We query, and if something turns up, fine. But if nothing comes out of the data bank, we don’t consider that a stamp of approval."

Higginbotham says she is more excited about a program that is unique to Arkansas. The state’s Centralized Credentials Verification Service (CCVS) was created in 1995, apparently the first credentials verification service provided by a state licensing agency. Higginbotham says the system is very reliable, even though it still is in its early stages.

When she queries the CCVS about a physician seeking credentials, the system provides information about disciplinary action similar to what should be in the NPDB, but it also verifies information about the physician’s education, certification for foreign medical schools, and similar matters. (For more on the CCVS, see "Arkansas licensing agency offers verification," in this issue.) "It gives us all the information that we would get if we had to go through and do a primary verification on each item," she says. "And it’s a tremendous value to the physicians because they don’t have to submit verification for each little thing."

NPDB shortcomings put burden on you

Brown notes that, though it has always been a good idea to search beyond the NPDB, the latest research creates more of an obligation. With more evidence mounting to show that the NPDB is incomplete, hospitals risk greater liability if they don’t go the extra mile in credentialing, she adds.

"We have to put the risk management hat on with the quality hat. Patient safety is such a huge issue that when it comes to the competency of our medical staff, we should look at that as the most basic element of patient safety," she says. "This recent study has to raise a red flag and make us realize that, even if we suspected this all along, there’s no denying it now, and that puts the responsibility back on us."

Brown raises other questions about the reliability of the NPDB, suggesting that a full-scale audit is warranted. There are so many variables in the reporting process, she says, that hospitals can’t judge the reliability of the NPDB without delving into exactly how information gets there. How is the data transmitted from a hospital or medical board? Who receives the information at the NPDB? Does someone have to re-enter the data and risk typing mistakes? Are all the physician numbers entered perfectly?

"My laundry list of questions gets pretty long," Brown says. "The impact of these questions can be pretty scary, because people have become so dependent on the data bank as a central source. But I guess that’s the message: You shouldn’t be."