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Ensuring data integrity is essential

Credentialing Resource Center Connection, March 27, 2008

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

Dear credentialing colleague:

In many healthcare organizations, the medical staff office (MSO) maintains the majority of physician information. MSOs 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 MSO 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 organizations use physician information outside of the MSO, but still within the organization. This diverse usage highlights the need to ensure that your organization carefully and accurately maintains data within the credentialing database.

The recruitment and planning departments can also use the information maintained by the MSO 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 MSO 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 newest challenges regarding data integrity is collecting adequate information to comply with The Joint Commission's (formerly JCAHO) ongoing professional practice evaluation (OPPE) standards. 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 MSOs 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 MSO 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

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