Removal of Online Malpractice Data Sparks Outcry

September 17, 2011 — Journalists and consumer groups are calling on a federal agency to reverse its decision to remove a public data file on payments in medical malpractice cases and clinician disciplinary actions from the National Practitioner Data Bank (NPDB)Web site.

The Health Resources and Services Administration (HRSA), which operates the NPDB, removed the file from the Web site on September 1 after news organizations such as the Kansas City Star managed to use it to identify physicians frequently accused of malpractice who went undisciplined by state medical boards. The NPDB data does not include physician names or addresses, but journalists have traced the data to individuals by piecing it together with other data sources.

"Federal law mandates that information about individual physicians remains confidential," HRSA spokesperson Martin Kramer told Medscape Medical News. "We have a responsibility to make sure federal law is being followed."

Individual researchers can still access the malpractice data by contacting the NPDB, and HRSA may post it online again after the agency figures out how to prevent clinicians, patients, and healthcare organizations from being outed. That deliberation will take at least 6 months, according to HRSA.

In the meantime, a group called Investigative Reporters & Editors has posted a copy of the file — downloaded from the NPDB Web site in August — on its own Web site.

The IRE along with the Society of Professional Journalists and the Association of Health Care Journalists sent a letter to HRSA Administrator Mary Wakefield on September 15 asking her to repost the so-called Public Use Data File on the NPDB Web site.

"The Public Use (Data) File...provided invaluable information about the functioning of state medical boards and hospital disciplinary systems," the letter stated. "Reporters for years have used the data to identify flaws in their states' regulatory systems that have led to patient harm. As a result of these stories, states have enacted new legislation and medical boards have taken steps to investigate problem doctors."

The journalism associations also said they disapproved of an intimidating letter that HRSA sent to Kansas City Star reporter Alan Bavley about a story that he was researching with the help of NPDB information about a much-sued neurosurgeon. That news story was published on September 3.

AMA Applauds Removal of Online Malpractice Data

Other groups that have demanded the reposting of the malpractice data include Consumer Union, the publisher ofConsumer Reports; and the watchdog group Public Citizen. The groups wrote in separate letters to HRSA that its decision to take the information off the NPDB Web site runs counter to a push for more transparency within the Department of Health and Human Services and other government agencies.

One group that applauded HRSA's action is the American Medical Association (AMA), which considers the NPDB an unreliable source of information about the overall qualifications of physicians.

"The AMA has long opposed public access to the National Practitioner Data Bank and welcomes the decision to stop posting its public data file online to prevent breaches of physician confidentiality in the future," AMA President Peter Carmel said in a written statement. "Duplicate entries, inaccurate data, and inappropriate information in the NPDB provide, at best, an incomplete and haphazard indicator of a physician's competence or quality."

Congress created the NPDB in 1986 to give hospitals, insurers, state medical boards, and other government entities a way to check up on physicians, dentists, and other licensed healthcare professionals. The Public Use Data File contains information reported to the NPDB on such matters as:

• Payments in medical malpractice cases (settlements as well as jury awards)


• Adverse actions on licensure, clinical privileges, and membership in professional societies


• Adverse actions taken by the Drug Enforcement Administration


• Exclusion from Medicare and Medicaid


• Criminal convictions

In the past, the online file had been updated quarterly, but Public Citizen complained in its letter to HRSA that, earlier this year, updates "have not been posted in a timely fashion."

Physician Offices Nearly as Malpractice-Prone as Hospitals

June 14, 2011 — Most efforts to improve patient safety center on inpatient care, but almost as many malpractice claims paid on behalf of physicians arise from outpatient settings as they do from hospitals, according to a study published June 15 in the Journal of the American Medical Association (JAMA).

"Patient safety initiatives should focus on the outpatient setting, not just on inpatient care," the researchers, with lead author Tara Bishop, MD, MPH, an assistant professor in the Department of Public Health at Weill Cornell Medical College, write.

Dr. Bishop and her coauthors view the number of malpractice cases that conclude with an award for the plaintiff — along with their dollar amounts — as a "crude indicator of the prevalence and seriousness of adverse medical events."

To compare medical malpractice in the hospital and the physician's office, the investigators dug into the National Practitioner Data Bank (NPDB). Any party paying a malpractice claim on behalf of a physician or some other clinician must report those payments to the NPDB.

From 2005 to 2009, the number of paid claims involving physicians declined 23.3%, from 14,006 to 10,739, according to Dr. Bishop, who provided Medscape Medical News claims data not published in the JAMA article. However, in both years, a small proportion of claims did not identify a location where medical malpractice allegedly occurred. For claims that identified a practice setting, the decrease from 2005 to 2009 was 21.8%.

During that period, paid claims for outpatient events decreased at a slower rate: 19.3%. The rate of decrease in hospitals was considerably higher at 24.6%. Paid claims that spanned both settings declined 18.3%.

At the same time, the proportion of paid claims involving outpatient settings rose from 41.7% to 43.1%, while the inpatient proportion declined from 49.3% to 47.6%.

Diagnostic Errors Leading Source of Outpatient Paid Claims

The near equality in paid inpatient and outpatient claims should come as no surprise, the authors suggest. After all, there are 30 times more outpatient visits than hospital discharges each year. And surgical procedures are increasingly performed in physician offices and ambulatory surgery centers "that may not have the same safety controls as hospitals."

The researchers point out that the outcomes of outpatient events that led to paid claims were not trivial. Roughly 70% involved death, a grave permanent injury such as brain damage, or a major injury, compared with 81% for inpatient outcomes. The average payment for outpatient malpractice claims — $290,000 — was nothing to sneeze at either, although it was considerably less than the $363,000 for their inpatient counterparts.

The paid-claims record in physician offices, the investigators write, is a call for patient safety advocates to pay attention to more than just hospitals. They note that over the past 5 years, the federal Agency for Healthcare Research and Quality has funded almost 10 times as many studies of inpatient safety as those of outpatient safety.

Another research area given short shrift, the authors point out, is diagnostic errors, the leading source of paid malpractice claims in physician offices (in hospitals, surgical mishaps topped the list). They note the conditions in physician offices that invite diagnostic errors: A patient's signs and symptoms "may be subtle or not adequately noted" by physicians seeing a constant stream of patients, and follow-up is harder than in the hospital.

"Communication and coordination of care are problems," Dr. Bishop told Medscape Medical News. "A doctor who orders a test or refers to a specialist won't be 100% sure that they happen until he gets back a report."

Bearing down on patient safety in this environment is especially challenging, according to the authors, because there are many more physician offices than hospitals. In addition, small medical practices may come up short in terms of well-trained staffers who can devote significant time and energy to patient safety projects. "However, the high volume of outpatient malpractice claims and the serious nature of many...suggest that the relative neglect of outpatients safety should not persist," the authors write.

They discuss several limitations to their study, including the use of NPDB data that critiques of other malpractice studies have called problematic.

The problem lies in the "corporate shield" loophole that exempts hospitals from having to report malpractice claims paid on their behalf. The loophole comes into play when someone sues both a hospital and a physician for malpractice and then reaches a settlement that drops the physician from the case. Such a paid claim never makes it to the NPDB.

This scenario — more and more common as physicians increasingly become hospital employees — results in the NPBD's underestimating total malpractice claims by roughly 20%, according to one estimate. However, Dr. Bishop and coauthors write that it is unclear how this underreporting affects the relative proportion of inpatient and outpatient malpractice claims, noting that hospitals employ physicians who work both inside and outside their walls.

Dr. Bishop is supported in part by funds provided to her as a Nanette Laitman Clinical Scholar in Public Health at Weill Cornell Medical College. Coauthor Dr. Andrew Ryan is supported by grant K01 HS018546-01 from the Agency for Healthcare Research and Quality. The authors have disclosed no relevant financial relationships.

JAMA. 2011;305:2427-2431. Abstract