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From the archives: Ensuring data integrity is essential

Anne Roberts, CPMSM, CPCS, is the director of medical affairs at Children's Medical Center of Dallas, where she oversees the medical administration, graduate medical education, continuing medical education, research administration, and medical staff services departments.

Dear credentialing colleague,

As many organizations continue to struggle with the integrity of physician activity data, I wanted to highlight this issue once again. Although I originally wrote this column in March 2008, many of the lessons remain the same. 

In many healthcare organizations, the medical staff services department (MSSD) maintains the majority of physician information. MSSDs are generally looked at as the "source of truth" as it relates to such data. Some examples of where and how an organization may use data maintained by the MSSD include the following:

 - Admitting. To verify the physician's admitting privileges as well as contact information for the admitting and referring physician
 - Clinical staff. To verify that physicians have privileges to perform specific procedures, to confirm the physician's specialty, and to verify the physician's ability to prescribe narcotics through DEA schedules
 - Operators. To verify physicians' contact information, including the preferred method of contact
 - Information systems. To verify the confirmation of physician status in order to issue appropriate logins, deactivate prior logins, and monitor login activity

These are just some examples of how institutions use physician information outside of the MSSD, but still within the organization. This diverse usage highlights the need to ensure that your MSSD carefully and accurately maintains data within the credentialing database. 

The recruitment and planning departments can also use the information maintained by the MSSD to determine if there are enough practitioners to serve patients in specific geographical locations. This information is helpful during the recruitment process as well as for planning future growth of the organization.

Additionally, statistical data from the MSSD may have uses outside of the organization, for example:

 - Tracking professional memberships
 - Participation in national surveys (such as the U.S. News and World Report "Best Hospitals" survey)
 - Market research studies derived from historical medical staff censuses 

One of the most challenging issues regarding data integrity is collecting adequate information to comply with The Joint Commission's ongoing professional practice evaluation (OPPE) standards. Having information that is attributed to the correct physician can be very challenging particularly when the attending physician may change from time to time or, as is the practice in an academic medical center, numerous times throughout the patients’ stay. Identifying who the admitting physician is and then who attended to the patient each day has challenged organizations to develop physician attribution policies or procedures, such as requiring an order whenever the attending physician changes. This ensures that the correct quality data is attributed to the correct provider.

Your organization may store OPPE-related data in many different databases throughout the organization, such as quality, finance, medical records, and pharmacy. Many organizations are relying on MSSDs to gather this information and organize it for OPPE reporting purposes. It is important that organizations invest in databases that meet the needs of the MSSD and other departments for this effort to be effective and successful. 

Remember, clear, effective communication is the key to success!

That's all for this week.

All the best,

Anne Roberts, CPMSM, CPCS