‘-J-he
uses
and
I-
Abuses
HE PROBLEMS that accompany the admittedly marve 1ous capacity we have these days for the collection, analysis, and dissemination of large data sets, has been nagging at me with increasing frequency. Clearly, the computer is the tool that has enabled this fairly new achievement, and as the use of computers has increased, most of us have become quite reliant on the accumulation of the objective measures they provide in order to form some of our opinions and, more importantly, to inform much of our important decision making. A wonderful asset. What is the down side to this proliferation of data, especially as it is used outside of the scientific community? I would suggest that the negative aspects fall into two major categories. The first is represented by those instances in which data are gathered concerning the performance of institutions and agencies. The second involves the collection of data related to the practices of particular individuals. Those of us in health care are becoming increasingly familiar with each of these potential problems. A good example of the first type, the release of corporate data, is best illustrated by the mortality reports that are published annually by the Health Care Financing Administration (HCFA). You will recall that these involve the presentation of mortality rates among patients in selected diagnostic related groups, by hospital, measured against an expected mortality rate. Thus, hospitals are cited as being within, above, or below the expected rate and this information is released to the public with much fanfare. To be sure, a caveat is always included that indicates that these data represent only an overview and should not be interpreted as quality indicators in and of themselves; yet, what other conclusion can a reader form? As a consequence, in my own place of employment we breathe a sigh of relief each year when our outcomes are published as within or below the expected mortality rates. This, in spite of the fact that we know (and HCFA knows) that the methodology is flawed (Green et al., 1990). Obviously, there could be a constructive use made of this study if it were used as a basis for further investigation of those institutions that appear to have significant problems. Only then should these data be released to the public. The HCFA mortality study represents only an example of an approach that is on the increase, both at the state and national level. The second category of problems with large
l_
MARGARET L. MCCLURE, RN, EDD, FAAN Executive Director of Nursing New York University Medid
of
Large
Sets
data sets, involving individual practitioners, is perhaps more worrisome. This year the National Practitioner Data Bank (NPDB) comes on line. It is a most welcome addition to the screening opportunities available to those of us who are employers and it has the potential for adding real safeguards to patients and their care. The NPDB was mandated by the Health Care Quality Improvement Act of 1986 and was created to collect and release information related to the professional competence of certain health care practitioners. Initially, these data will be entered for individual physicians and dentists; registered nurses are the next group scheduled to go on line. The law requires that the following data be reported to the NPDB: (1) any malpractice judgement payments, (2) adverse licensure actions by state boards, (3) adverse privilege actions taken by health care agencies, and adverse membership actions taken by professional societies. The law further requires that an institution employing or credentialing professionals must query the NPDB regarding each applicant before accession and every 2 years thereafter. At present, access to the information in the NPDB is limited to state licensing boards, health care facilities, individual practitioners wishing to view their own records, and attorneys who file professional liability claims against practitioners if, and only if, the health care agency failed to request the mandated information from the data bank. Aside from the inevitable bureaucracy that is required to implement and maintain the NPDB, there does not appear to be grounds for any major concern thus far. One area that will be interesting to watch is the practice of settling out of court those malpractice cases for which the insurers believe their costs in defending a case, even a solid case, are reduced if they negotiate a settlement with the plaintiff. Even before the creation of the NPDB, many practitioners were dismayed by their insurance carriers insistence on such actions, especially when they believed their case was defensible. With the advent of the new data bank, it is clear that these professionals will be much more reluctant to participate in any negotiations that might jeopardize their records. It seems to me that as we herald the opportunity to use the information gleaned from large data bases, we need to be cautious regarding the potential abuses that such an opportunity brings. I believe we have the makings of a big-brother-is-watching-you-environment that could become corrosive and punitive over time, eventually backfiring on the society it purports to serve. As our forefathers taught us, the price of freedom is indeed eternal vigilance. This trend definitely needs watching.
Centw
Reference
560 First Ave New York, NY 10016
Copyright 0 1991 by W.B. Saunders Company 8755-7223/91/0702-0002$03.00/O
72
Data
Green, J., Wintfeld, N., Sharkey, P., & Passman L. J. (1990). The importance of severity of illness in assessing hospital mottality. JAMA,
Jownul of Profkusional Nmsing,
263,
241-246.
Vol 7, No 2 (March-April),
199 1: p 72
uses
and
I-
Abuses
HE PROBLEMS that accompany the admittedly marve 1ous capacity we have these days for the collection, analysis, and dissemination of large data sets, has been nagging at me with increasing frequency. Clearly, the computer is the tool that has enabled this fairly new achievement, and as the use of computers has increased, most of us have become quite reliant on the accumulation of the objective measures they provide in order to form some of our opinions and, more importantly, to inform much of our important decision making. A wonderful asset. What is the down side to this proliferation of data, especially as it is used outside of the scientific community? I would suggest that the negative aspects fall into two major categories. The first is represented by those instances in which data are gathered concerning the performance of institutions and agencies. The second involves the collection of data related to the practices of particular individuals. Those of us in health care are becoming increasingly familiar with each of these potential problems. A good example of the first type, the release of corporate data, is best illustrated by the mortality reports that are published annually by the Health Care Financing Administration (HCFA). You will recall that these involve the presentation of mortality rates among patients in selected diagnostic related groups, by hospital, measured against an expected mortality rate. Thus, hospitals are cited as being within, above, or below the expected rate and this information is released to the public with much fanfare. To be sure, a caveat is always included that indicates that these data represent only an overview and should not be interpreted as quality indicators in and of themselves; yet, what other conclusion can a reader form? As a consequence, in my own place of employment we breathe a sigh of relief each year when our outcomes are published as within or below the expected mortality rates. This, in spite of the fact that we know (and HCFA knows) that the methodology is flawed (Green et al., 1990). Obviously, there could be a constructive use made of this study if it were used as a basis for further investigation of those institutions that appear to have significant problems. Only then should these data be released to the public. The HCFA mortality study represents only an example of an approach that is on the increase, both at the state and national level. The second category of problems with large
l_
MARGARET L. MCCLURE, RN, EDD, FAAN Executive Director of Nursing New York University Medid
of
Large
Sets
data sets, involving individual practitioners, is perhaps more worrisome. This year the National Practitioner Data Bank (NPDB) comes on line. It is a most welcome addition to the screening opportunities available to those of us who are employers and it has the potential for adding real safeguards to patients and their care. The NPDB was mandated by the Health Care Quality Improvement Act of 1986 and was created to collect and release information related to the professional competence of certain health care practitioners. Initially, these data will be entered for individual physicians and dentists; registered nurses are the next group scheduled to go on line. The law requires that the following data be reported to the NPDB: (1) any malpractice judgement payments, (2) adverse licensure actions by state boards, (3) adverse privilege actions taken by health care agencies, and adverse membership actions taken by professional societies. The law further requires that an institution employing or credentialing professionals must query the NPDB regarding each applicant before accession and every 2 years thereafter. At present, access to the information in the NPDB is limited to state licensing boards, health care facilities, individual practitioners wishing to view their own records, and attorneys who file professional liability claims against practitioners if, and only if, the health care agency failed to request the mandated information from the data bank. Aside from the inevitable bureaucracy that is required to implement and maintain the NPDB, there does not appear to be grounds for any major concern thus far. One area that will be interesting to watch is the practice of settling out of court those malpractice cases for which the insurers believe their costs in defending a case, even a solid case, are reduced if they negotiate a settlement with the plaintiff. Even before the creation of the NPDB, many practitioners were dismayed by their insurance carriers insistence on such actions, especially when they believed their case was defensible. With the advent of the new data bank, it is clear that these professionals will be much more reluctant to participate in any negotiations that might jeopardize their records. It seems to me that as we herald the opportunity to use the information gleaned from large data bases, we need to be cautious regarding the potential abuses that such an opportunity brings. I believe we have the makings of a big-brother-is-watching-you-environment that could become corrosive and punitive over time, eventually backfiring on the society it purports to serve. As our forefathers taught us, the price of freedom is indeed eternal vigilance. This trend definitely needs watching.
Centw
Reference
560 First Ave New York, NY 10016
Copyright 0 1991 by W.B. Saunders Company 8755-7223/91/0702-0002$03.00/O
72
Data
Green, J., Wintfeld, N., Sharkey, P., & Passman L. J. (1990). The importance of severity of illness in assessing hospital mottality. JAMA,
Jownul of Profkusional Nmsing,
263,
241-246.
Vol 7, No 2 (March-April),
199 1: p 72
