Access to enforcement and disciplinary data: information practices of state health professional regulatory boards of dentistry, medicine and nursing.
Abstract: This article describes a study of public access to enforcement and disciplinary information provided by the websites of health professional regulatory boards. The study explored the current state of transparency by specifically examining the availability of disciplinary data on the websites of state boards of medicine, nursing and dentistry. Web sites were reviewed regarding availability of enforcement and disciplinary data on the aforementioned state boards in each of the 50 states and the District of Columbia. The study found that there is more information about individual practitioners available from the boards than ever before. On the other hand, there has not been a comparable increase in information about the administrative practices and the work of the boards. Increased availability of this information would allow public administration and policy researchers to develop performance indicators of state boards and assist in improving policy decisions and allocation of resources.
Subject: Web sites (Usage)
Medical personnel (Practice)
Medicine (Practice)
Medicine (Analysis)
Medicine (Laws, regulations and rules)
Author: Strong, Denise E.
Pub Date: 03/22/2011
Publication: Name: Journal of Health and Human Services Administration Publisher: Southern Public Administration Education Foundation, Inc. Audience: Academic Format: Magazine/Journal Subject: Government; Health Copyright: COPYRIGHT 2011 Southern Public Administration Education Foundation, Inc. ISSN: 1079-3739
Issue: Date: Spring, 2011 Source Volume: 33 Source Issue: 4
Topic: Event Code: 930 Government regulation; 940 Government regulation (cont); 980 Legal issues & crime; 200 Management dynamics Advertising Code: 94 Legal/Government Regulation Computer Subject: Company Web site/Web page; Government regulation
Product: Product Code: 8010000 Medical Personnel NAICS Code: 62 Health Care and Social Assistance
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 250033488
Full Text: INTRODUCTION

This article reports on a study of public access to enforcement and disciplinary information on the websites of health professional regulatory boards. The major purpose of the study was to determine the extent to which enforcement and disciplinary information is available and accessible to the public. A secondary purpose was to determine the extent to which available information can be readily analyzed for policy research and evaluation. The study examined the websites of boards of dentistry, medicine and nursing to determine the types of disciplinary data that could be accessed and analyzed by the public. The findings confirm the trend toward transparency among the boards of dentistry, medicine and nursing. Nevertheless, these boards could significantly increase transparency by providing more detailed information about disciplinary matters.

The study grew out of an unsuccessful effort to obtain current disciplinary data from Virginia's Department of Health Professions, the administrative home of health professional boards, as a first step in conducting a longitudinal study of disciplinary decisions, updating earlier studies. In 1990 and in 1997 the Department of Health Professions conducted studies of its enforcement and discipline activities (Virginia Department of Health Professions, June 1990, January 1997). At that time, Strong was able to obtain and analyze a broad range of disciplinary data, stripped of all identifiers such name, address and license number (Strong, 2005). It was decided to conduct a similar 20-year longitudinal analysis of disciplinary decisions through 2008.

BACKGROUND AND NEED

In attempting to obtain a data set on disciplinary decisions from the Virginia Department of Health Professions, the researcher learned of two developments that, on the surface, apparently resulted in contradictory outcomes: disciplinary data has become simultaneously, more available to the public and less available. The first development is that the Virginia Department of Health Profession has moved in the direction of greater transparency. The amount of information and the ease of accessing that information increased exponentially since the 1980s. The Department's website makes considerable data available that can be easily downloaded in an Excel spreadsheet. This information includes details such as whether a complaint was substantiated, the number and types of violations sanctioned, the types of sanctions imposed, and compliance with department complaint processing performance standards. The quarterly reports contain summary data and date back five years.

At the same time, state policy changes placed new limitations on access to certain types of enforcement and disciplinary data (Communication with Department of Health Professions' staff, Richmond, Virginia, November 13, 2009; Boodman, 2001). Under the new policy, the Department does not release information such as severity of an offense, or source of a complaint (e.g. consumer, law enforcement, practitioners, inspection, etc.).

Given that Virginia has been a leader in strengthening the enforcement and disciplinary functions of regulatory boards, the researcher began to wonder about trends in other states. Where are health professional boards in 2009 with respect to making information available to the public? What has transpired over the last twenty years with state health professional regulatory boards, given the broad trends in public administration and management (such as reinventing government, expansion of citizen participation mandates, and performance management)?

These questions are rooted not only in the developments in Virginia, but also in the literature and practical needs of several constituencies. A frequent criticism of state regulatory boards has been the lack of transparency, accountability and responsiveness to patients and the broader public (Public Citizen Health Research Group, 1993, 2002; Yeon, 2006). In response to consumer advocacy and media scrutiny, in the 1990s state boards began to publicize enforcement policies, such as how to file a complaint against a practitioner, as enforcement and disciplinary actions. Massachusetts was one of the first states to mandate internet disclosure of disciplinary information about physicians (Larson et al, 2009). By 2001, approximately 50% of professional boards posted information about physicians on the Internet (Goldstein, 2001).

RESEARCH QUESTIONS

The Federation of State Medical Boards regularly publishes and updates the Essentials of a Modern Medical Practice Act (Brooks, 2008). The Act strongly encourages medical boards to adopt national standards in making information on final disciplinary actions available to the public (Federation of State Medical Boards, 2009).

However, the question remains: what has transpired regarding transparency since the urging of medical boards to adopt national standards? Further, how have other types of health professional regulatory boards responded to the challenge to be more transparent?

This study explored the current state of transparency by specifically examining the availability of disciplinary data on the websites of state boards of medicine, nursing and dentistry. This is an important public policy area for three major reasons discussed in this section. First, without access to disciplinary data, policy makers and public administration, scholars cannot adequately evaluate regulatory policies and board decisionmaking. Systematic analysis and evaluation is necessary given the regulatory scope of health professional boards.

Second, health professional discipline is an important component of health care quality. Decisions that boards make determine who is able to practice and with what credentials and experience. Third, the extent to which decisions and data are available to the public influences the extent to which health professional boards can be held accountable by legislators and citizens.

CONTEXT AND THEORETICAL FRAMEWORK

This section discusses the context and theoretical perspectives that provide critical background to inform this article's discussion. Among these are a range of administrative and policy issues across the following areas: the scope of the health professional workforce, health care quality, information policy and public access to information, legal framework governing information access, expanded versus restricted access, transparency and regulatory capture.

The final discussion in this section synthesizes these and other observations to provide a view of expanding research on health professional discipline. Since the regulation of health professional boards is a changing field, it is important to document the essential areas, which provide a vital understanding of the context and framework for this study's development and implementation.

Scope of Health Professional Workforce

According to the U.S. Bureau of Labor Statistics, health care is the largest industry in the U.S. The health care industry provides 14 million jobs and is projected to generate the largest number of new jobs between 2006 and 2016 (U.S. Department of Labor, Bureau of Labor Statistics, 2009). There are 2.5 million registered nurses, 633,000 active physicians and 161,000 dentists. Health professional boards regulate a significant number of these practitioners. Virtually any physician, nurse, pharmacist, dentist or optometrist, whether practicing in the private or public sector, has had to come before a state board to obtain a license to practice.

Health Care Quality

The disciplinary function of health professional boards is related to health care quality in several ways. The first relationship is to the education and training of health care practitioners. State boards are authorized to establish credentials and examine people who wish to practice in health care fields. Boards are also empowered to establish, monitor and enforce continuing education requirements that enable practitioners to stay current with new research and best professional practices.

The enforcement and disciplinary functions of boards play a critical role in identifying practitioners engaged in sub-standard or unsafe practices. State statutes and regulations incorporate minimum standards for acceptable professional practice. For example, a state statute empowers the Tennessee Board of Dental Examiners to suspend, revoke or deny a license on the following grounds:

Gross malpractice, or a pattern of continued or repeated malpractice, ignorance, negligence or incompetence in the course of professional practice; (Tennessee Code Annotated, 63-5-124 (a) (1))

Habitual intoxication or personal misuse of any drugs or the use of intoxicating liquors, narcotics, controlled substances, or other drugs or stimulants, such as, but not limited to, nitrous oxide sedation, in such manner as to adversely affect the person's ability to practice dentistry, dental hygiene or as a registered dental assistant;(Tennessee Code Annotated, 63-5-124 (a) (5))

The Board of Dental Examiners can thus prohibit practitioners who endanger the health or safety of the public from practicing dentistry.

Information Policy and Public Access to Information

Questions about access to disciplinary information are rooted in broader questions about government's control of information in the exercise of and constraint on administrative power. These questions are central to the theory and practice of public administration (Feinberg, 1986). A perennial question for government is what information should be kept secret and what should be released or made available to the public. The appropriate balance between government secrecy and government openness has been debated for many years (Cleveland, 1986; Commission on Protecting and Reducing Government Secrecy, 1997; Rosenbloom, 2003). This question pervades all levels of government including state health professional regulatory boards.

Policies governing access to government held information reflect the tension between the impetus toward more open access and the impetus to restrain access. Both the proponents of open access and the proponents of limited access support their positions with compelling arguments that reflect the range of values and theoretical perspectives underlying U.S. governance. We should consider this broader context as we examine the extent to which health professional regulatory boards allow public access to disciplinary data.

Legal Framework Governing Information Access

Constitutional, statutory and case law shape regulatory board practices regarding public access to information. Federal statutes such as the Administrative Procedures Act of 1946 and subsequent amendments (such as the Freedom of Information Act of 1966 and Electronic Freedom of Information Act of 1996) were major milestones in establishing the public's right to access government information. The comparable Model State Administrative Procedure Acts were developed by the National Conference of Commissioners on Uniform State Laws and adopted by most states by 1980 (Bonfield & Asimow,1989).

The effect of these statutes was to change the heretofore default policy on government control of information. Citizens would not have to establish a legitimate need to obtain access to government information. Instead, government information is now accessible unless there is a specific policy rationale (e.g. a statutory exemption) for limiting access (Feinberg, 1986). This step established the federal policy that information collected and/or generated by government agencies belongs to the public. Parallel developments occurred in the states through open records and open meetings laws, confirming the belief that citizens are not supplicants in seeking information collected by state administrative entities:

A broad right of public access to governmental information confirms the idea that the people are sovereign and facilitates control by the principals (the people) over their agent (the government). (Bonfield & Asimow, 1989, p. 537)

Expanded versus Restricted Access

Advocates of expended access to government information argue that openness is essential for democratic governance (Fairbanks, Plowman & Rawlins, 2007). First, it minimizes the dangers of secrecy such as fraud and selfdealing on the part of government officials. Secrecy inhibits the development of independent corrective mechanisms needed to minimize errors in judgment or in the factual bases of government decisions. The assumptions, framework and accuracy of the factors that went into a decision cannot be scrutinized or challenged if secrecy prevails (Fairbanks, Plowman & Rawlins, 2007; U.S. Senate Commission on Reducing and Protecting Government Secrecy, 1997). Claims of democratic governance are not credible if government does not conduct its affairs openly.

Proponents of restricted access, on the other hand, argue that too much openness can be problematic.

Proponents of restricted access argue that public safety and individual rights can be compromised if too much government information is made available to the public.

One example is Rebecca Schaeffer, an actor killed by an obsessed fan who used a private detective to get her address, then a public record, from the California Department of Motor Vehicles (Layton, 2002). The emergence of safety issues such as identity theft, stalking and domestic violence have contributed to concerns about privacy and the need to restrict public access to government held information (Layton, 2002). Furthermore, values such as individual rights, due process and privacy suggest a need for caution in making available health and medical information available to the public. Much disciplinary information is necessarily private in that complaints and investigations may involve confidential information such as medical histories or conditions. Some patients may therefore hesitate to file a complaint without assurances that the board will protect their privacy.

Practitioners may also have legitimate privacy concerns given that complaints may not be substantiated. A practitioner's right to due process may be a factor in restricting public access to disciplinary information. Boards may avoid disclosing allegations of wrongdoing until those charges are substantiated. One of the challenges for public policy is how to protect the rights of consumers and practitioners while providing sufficient information to the public to facilitate transparency of the disciplinary process.

Transparency and Regulatory Capture

Another dynamic relates to professional selfregulation: transparency and regulatory capture. This question escalated in political importance in 2001 with the collapse of the Enron Corporation, which raised critical questions about the role of auditors in ensuring safe management of the company's finances. How should accountants be regulated? Should the accounting profession police itself (Waddock, 2005)? Similar questions have long been raised about health--should physicians, nurses, doctors and others police themselves? Should we rely on self-regulation to ensure competent and safe practitioners?

How do we determine whether self-regulation is sufficient?

In order to answer these questions, we need to understand the self-policing or regulating functions of state boards.

What do we know about what decisions health professionals are making? We can begin to answer this critical question only if we have access to information about boards' decisions. The question of the availability of information is thus a critical aspect of the broader public policy question of professional self-regulation.

Availability and Access

The exponential growth in information technology has greatly affected the communication strategies and information dissemination in the public sector.

E-governance is evolving as an important theme in public administration and management (Dawes, 2008, Moon, 2005). This exponential increase in the use of technology has enabled state licensing boards to make information on enforcement and discipline more readily accessible.

Consequently, the availability of data on disciplinary actions has increased considerably in the last 20 years.

The federal government also makes some disciplinary information available through the National Practitioner Data Bank (NPDB) and the Healthcare Integrity and Protection Data Bank (HIPDB) created by the Health Care Quality Improvement Act of 1986 to strengthen the reporting and coordination of disciplinary information on health care professionals (http://www.npdbhipdb.hrsa.gov). However, disciplinary information that identifies individual professionals or organizations is available only to regulators, law enforcement and health care institutions such as hospitals. The public may access disciplinary data but is limited to aggregated data that do not identify individuals or organizations. State licensing boards offer considerably more access, as indicated by a review of studies of disciplinary data availability (Citizen Advocacy Center, 1992; Larson et. al., 2009; U.S.

Department of Health and Human Services, 1999).

The Citizen Advocacy Center (CAC) conducted one such study on the release of information to the public by boards of medicine and nursing (Citizen Advocacy Center, 1992). Thirty-one medical boards and 32 nursing boards responded to a questionnaire on the processes and availability of information during and after a complaint investigation. The questionnaire asked about different types of information, depending on whether they were for patients, government agencies, insurers or hospitals. . The questionnaire also asked who was required to report violations or alleged violations to the boards. The major findings of this study are that the majority of boards do not release information when they received a complaint and all states, except the state of Washington, keep information entirely confidential unless the investigation determines probable cause. Many boards will release information once a hearing has been completed, but all will release by the time a probable cause has been found. The study raises the question of due process rights of the practitioner during the process versus the public's right to know, a question all states have had to address but have responded differently.

The Office of Inspector General (OIG), U.S.

Department of Health and Human Services studied annual reports issued by state medical boards (U.S. Department of Health and Human Services, 1999 OEI-01-89-00563). The OIG was interested in determining data available that could be used in developing performance indicators of board enforcement. The study used the Federation of State Medical Boards' indicators of model state medical boards as a reference point in determining the research questions.

Annual reports were reviewed to determine the data categories available in three phases of the disciplinary process: detection of complaints, review of complaints and resolution of complaints. Typical questions were: how many complaints did the board process; how long does it take to process complaints; what percentage of complaints are substantiated; from what sources do boards receive complaints? The OIG study found that the annual reports answered few of the study questions. Most of the medical board reports provided little enforcement and disciplinary data. Consequently, the study concluded, state mandates would be needed to ensure that medical boards provided fuller reporting on professional discipline (U.S. Department of Health and Human Services, 1999, p. 28).

A more recent review of disciplinary performance data analyzed state medical and osteopathy board websites (Larson et al., 2009). This study ranked the boards by state, using six types of disciplinary information on the websites and two indicators of user-friendliness of board websites. It concluded that information on health professional boards is inadequate for informed consumer decision making.

Furthermore, elected officials and the public are not able to judge the effectiveness of boards' performance. The study did acknowledge that some progress had been made in the last 10 years, but there is still considerable room for improvement.

Expanding the Research on Health Professional Discipline

The study discussed in this article advances the research begun with the OIG's study 10 years ago (U.S. Department of Health and Human Services, 1999). This study examined more categories of information than prior studies have. The Citizen Advocacy Center (1992) study examined about half as many and the OIG report examined annual reports because it was before information was available in online formats. Moreover, both of these studies were interested in the administrative processing, as is this current study, which provides an analysis of the state of information availability on boards' web sites in 2009.

In comparing this study to the 2006 web site study (Larson et al, 2009), several similarities and differences can be identified. First, the studies had a few similar categories and those will be the basis for our first comments. The similar categories included: the offense committed, the board action, the date of board action. The additional categories from Larson et. al, were "How accessible were the data (PDF or Excel)", "Was there a narrative/summary describing the offense and action", "Was the full board order (final order of the board) posted", "Does board post multiple state license", and "Does board post information about those currently under investigation." Another dimension of data they captured was board performance such as emergency actions taken and events in between board meetings.

Research Method and Procedures

The research undertaken herein is a case study which examined the websites of all boards of dentistry, medicine and nursing in the United States (Stake, 1995). Case studies are beneficial modes of research when specific trends might be identified which can inform the field for further study (Yin, 2008). In this case, boards of health, nursing, medicine and dentistry, were chosen for several reasons. First, each of these types of boards can be found in every state. The role and scope of their respective roles in health care system were a composite second factor in looking at these three boards. Boards of medicine regulate the dominant health care occupation. Physicians are at the center of organized health care in the United States. Boards of nursing regulate another key health care occupation.

Further, altogether these boards represent a significant percentage of the entire health care workforce. Finally the relative neglect of the study of boards other than medicine was a factor in including boards of dentistry.

Data Sources and Procedures

In this study, web sites were reviewed regarding availability of enforcement and disciplinary data of state boards of dentistry, medicine, and nursing in each of the 50 states and the District of Columbia. The review determined specifically whether the following types of enforcement and disciplinary data were available

* Name

* Date of allegation/complaint

* Type of violation alleged or nature of complaint

* Seriousness of violation alleged

* Source of report

* Mandatory report

* Board findings and disposition

* Nature of sanction(s) imposed

* Whether an investigation was conducted or whether a complaint was dismissed prior to investigation

* Disposition other than sanction

* Length of complaint processing

* Whether data are downloadable

* Other comments from the researcher based on what was seen

* Other data and variables which were available

* URL from which information had been gathered

These elements were selected based on the effort to examine and focused on the availability of enforcement and disciplinary data for purposes of policy research. In addition, prior studies were examined to determine which characteristics had been tracked previously and many of these were included in order to be able to make accurate comparisons (CAC, 1992, Larson et. al., 2009; U.S. Department of Health and Human Services, 1999).

Researchers visited each of the websites and found the boards for each discipline. In order to do so, they needed to search for information regarding each of 12 categories of information which were included in the data sheets for each entity. A master grid was created which was completed with "yes" or "no" based on information found. It was known from the start that training to orient the research assistants to the project would be needed and careful searching of the websites needed to be conducted in order to find the data being sought. This effort was necessary given the lack of a uniform reporting protocol for disciplinary data across states and boards at this time.

In this study, the concept "available" was interpreted broadly in terms of deciding whether a category of information was posted. If any detail of information at all was found in a category, that category was then listed as "available". Complete information was identified as "yes," while no data was clearly a "no." It is important to note that researchers sometimes had to excavate through the websites by following links down through several (five or six) levels to find information; however this complexity was not captured in the recording. Further studies need to evaluate the user friendliness and accessibility of each critical category for public access.

Limitations of Study

Even with our precautions and uniform practices in place, several limitations of this study are identified. These data are not weighted based on relevance to public policy issues. It is a first level analysis that only indicates availability of data. More critical information, such as the seriousness of an allegation, is treated the same as less critical information such as the date of an allegation.

In addition, this study only considered data and information readily available to any member of the public in 2009. It did not pursue freedom of information requests which may provide a broader range of data. Furthermore, the study does not reflect information that may be available if the cost of compiling data is paid by the requesting party.

A final limitation is that this research does not consider the legal framework in which each state board decides on information availability. Boards are constrained by state and federal statutes in terms of information that may be released. Boards are also compelled to release information mandated by state statutes.

DATA ANALYSIS

Analysis Process

Prior to performing data analyses, the data were examined and recoded to a variable format compliant with the selected software (Excel). A binary code of "1" for yes and "0" for no was used based on whether a category of information was found or not. Moreover, additional comments and notations were preserved. Some initial omissions were detected in the first round of data checking. Therefore, a second round of data retrieval was conducted to increase reliability. These efforts included all of the following processes: crosscheck questionable data, supply missing data, and verify random samples of data. All statistical calculations were performed using Excel.

In order to identify the patterns and trends across states, boards and information categories, the following descriptive analyses were calculated on the final data set: category frequencies, percentages, mean, median, mode, standard deviation, variance, and skewness (Ku).

The purpose of these analyses was to determine whether different elements of enforcement and disciplinary data are more or less prevalent in particular states, geographic regions, or disciplines. Other analyses were conducted as needed with a preliminary review of emergent themes, patterns, data results, and findings.

Based on the findings and working with the data it was decided to develop a scale which would indicate the completeness and transparency of information available from a board. A scale of 0-12 was used to represent the 12 information categories about which data were collected. The most transparent board would have provided all 12 elements of data, and be assigned a score of 12. The data were then coded by state in this manner according to how many categories were available.

Several unusual situations were encountered in the research process that resulted in having to make decisions about how to code evidence. For instance, for some states when not all data were available in a category, it was originally coded as "in some instances." In these situations that category was re-classified broadly as" available". For instance, on the state of Wyoming's website, the date of an allegation is sometimes available, and other times not. Therefore, it is classified as available in these records.

FINDINGS

Examples of Violations of Practice

The research examples of violations that may be included in the postings of various board websites will be helpful for readers to comprehend the scope of issues noted. To set the tone and context of this extensive and critical topic, a few compelling examples from each discipline are shared as examples.

Examples of egregious violations found on dental board web sites:

* Pulling out teeth without a thorough exam (e.g. no x-rays);

* Sexual harassment and sexual battery;

* Sloppy dental work that resulting in infections, pain, disfigurement, or other medical complications.

Examples of egregious violations found on nursing board web sites:

* Allegations related to stealing drugs which are assigned for administration to patients;

* Using stolen drugs for personal use ;

* Sexual misconduct, or abusive behavior with patients;

* Negligence of patients;

* Reporting to work under the influence of alcohol or other drugs

Examples of egregious violations found on medical board web sites:

* Prescribing dangerous medication in wrong dose which killed the patient;

* Operating on the wrong patient;

* Surgically removing the wrong organ.

These examples illustrate the severe nature of allegations and violations handled by health professional boards, emphasizing the importance of the study of these policies. Contrary to some claims that what appear are mostly trivial claims from disgruntled patients, examples of lethal, harmful violent and criminal activity abound in the reports.

Frequency of Characteristics Availability by State

Tables 1, 2, and 3 display the frequency and percentage of occurrence of each characteristic by which the data were coded, by state. Separate tables are provided for each board type: medicine, dentistry, and nursing, in that order. Review of these data reveal that differences and trends within and across the different health professional boards exist. This section describes these patterns.

The boards of medicine data reveal four tiers of response rating groups. The highest is in the 80% range, then the 50% range, next is the 30% range, and the lowest is the 20% range. Within the 80% range is information on the name of the offender and the nature of any sanction applied, both of which are critical consumer concerns. The 30% range includes information about the severity of the allegation, where one would think the boards would be greatly interested in focusing their work and then the 20% range being primarily information which would support public policy research.

The most frequently available elements of information about violations are the name of the practitioner and the type of sanction imposed. Moreover, the most common downloadable format is PDF. From a patient's point of view this information may be sufficient. However, from a policy research and evaluation perspective, much progress still needs to be made.

Moreover, there are large gaps between available information at 80%, then 40-50% and the next level at 2030%. Further investigation needs to be done to understand what the boards are doing and indicators of what needs to be evaluated.

The boards of dentistry data reveal that they are less open than the boards of medicine. For example, only one category of information is in the 80% range and that is the name of the offender. Only 61% provide the nature of sanction in comparison to the 82% disclosure of the same information by the boards of medicine. Further lack of transparency and accessibility is demonstrated by the 53% availability of downloadable information vs. 84% with the state boards of medicine.

Regarding the state nursing boards, the most frequently available elements of information are the name of the offender and the type of sanction imposed and thus begins the strong similarity to the data as depicted for the boards of medicine. Fifty-seven percent of both nursing and medical boards provide the alleged violation. When one compares Tables 1 and 3, it is apparent that the key element of the severity of the violation state nursing boards' websites is comparable to the boards of medicine.

Accessible Information Categories by State

Table 4 reveals the 0-12 scale score for each state according to the data collected from the websites. This scale was described above as how many of the total 12 characteristics of information identified in this study a state had posted on its website. While Table 4 lists those totals by state, Table 5 provides the descriptive statistics which are helpful in describing the data and accurately analyzing the pattern of its distribution.

Trends evident in the information across boards by state reveal the range of scores among boards for any given state.

Several states stand out in terms of the number of categories of information accessible by the public. Virginia and Wisconsin are on the high end of providing information across the three board types. Virginia's ranking is consistent with its leadership in the professions in the 1980s as when it began scrutinizing its enforcement and disciplinary systems (Virginia Department of Health Professions, 1990, 1997). Hawaii and Rhode Island, on the other hand make available the least information across the three types of boards. In Hawaii, the scales were 0-1-2 in the order of dentistry, medicine and nursing. While in Rhode Island, the same boards were 2-3-2. These four states reveal the wide variability of data and reinforce some of the issues of having a fragmented disciplinary system. Another compelling example is found with North Dakota and in Wyoming. In North Dakota (0-0-7) two boards (dentistry and medicine) provide no information while the Board of Nursing provides moderate to substantial amount of information. In Wyoming (0-7-8) one board (dentistry) provides no information while two boards (medicine and nursing) provide moderate to substantial information. Trying to generalize the variance in the data is difficult because there are many nuances. Expectations that understanding the historical, political and social characteristics of the state alone would reveal answers would be contradicted with these examples. Clearly, additional research has to be done to determine why there are such wide differences among states and their boards.

Nevertheless, the next reasonable questions to ask are how great a variation is there among the data, and how does one characterize the variation of the data? The answers to these questions can be found in Table 5, which displays the descriptive statistic related to the 12 categories of information across 50 states and the District of Columbia.

Table 5 further confirms that boards of medicine have the highest compliance of any of the three health professional regulatory boards in providing all 12 characteristics of data on their websites. However, these data also reveal that the nursing information is most centrally distributed at the mean. This pattern indicates a distribution with high mid range and fewer occurrences of extremely high and low data points.

In comparison across medicine and dentistry, medicine is more consistent and normally distributed with providing information. We can also see from the range there is a greater spread of scores among medicine and dentistry than in the nursing data. The nursing data is more tightly clustered around the midpoint range of five. Finally, the skewness value (ku) clearly identifies the positive skewness of the dentistry data, indicating that rather than equally distributed around the midpoint of data, the bulk of scores are in fact pushed towards the lower data points.

Additional findings. In some instances, available data could be downloaded. Generally, the data could be downloaded into word processing, PDF or Excel spreadsheet formats, although few websites made spreadsheet data available. This research demonstrates a trend that the vast amount of data, which is downloadable from these sites, is not in a format that can be analyzed quantitatively. Qualitative analysis would be possible on text documents such as board minutes, administrative hearings and investigative reports that are posted.

Research on the disciplinary functions of regulatory board's data is hindered when boards do not provide data in a format that allows for analysis and evaluation. In the case of the category "nature of offense available" not all results were equivalent either. In several states, a board may cite specific statutes rather than use descriptive language for the public to readily comprehend. For example, "Dr. John Smith is in violation of Section 520(a) of Statute 634" rather than, "Dr. John Smith prescribed drugs inappropriately." In this case, the nature of the offense is obscured for consumers and researchers who would have to conduct additional research to identify what the codes translate to by finding and reading the original statute. Therefore, access to the nature of offenses in these data does not mean it is necessarily understandable as presented on the website. It only means it is indicated.

DISCUSSION OF FINDINGS

This section discusses the findings in terms of data availability, board resources and the apparent paradox of the effects of increased use of technology by the boards. There is no consensus and no guidelines or standards as to what a board should provide. Thus, states are left on their own to determine the degree of public access. This highlights the complexity of doing policy research among health disciplinary boards because of differences in each state's history, administrative structure and legislative structures. Additionally, economic, political, and social contexts shape boards in different states as well. . Consequently, generalizations, shared policies and collaboration across board states are difficult and slow to develop under these circumstances.

Availability of Disciplinary Data

Tables 1, 2 and 3 portray the current state of information availability. What we do not know is why different categories of information are available or not on the respective websites. In addition, why some boards are more willing to share information than others is not evident. However, from a public policy perspective, understanding the categories of disciplinary information boards receive is important for two reasons. First, we are better able to consider the trends in professional disciplinary issues and whether resources need to be redirected.

For instance, if boards are being overwhelmed with complaints about rudeness or insensitivity, then they might need to hire counselors or social workers to deal with such complaints. On the other hand, if boards receive complaints about practitioners stealing medication to get high or sell, or cutting off the wrong limb, then boards might need more health professionals to evaluate and deal with complaints concerning standards of care. A better understanding of the types of complaints filed with boards would help target resources. The drawback to not doing this is that the boards may be overwhelmed with minor complaints, while the more serious complaints are buried or fail to receive adequate time and resources.

Further use of this information could be made to help support requests for more resources for board to address critical issues. Moreover, when boards do not publish the total number of complaints they receive versus the number substantiated, their workload is grossly underestimated (Virginia Board of Health Professions, 1997). For instance, perhaps they receive and process 3,000 complaints, but only 200 have judgments, then the 200 is all the public sees.

Another reason it is important to identify the types of individuals and institutions who typically file disciplinary complaints was identified in a prior study of Virginia boards (Virginia Department of Health Professions, 1990). The Virginia study found that a majority of consumer complaints were dismissed as not having sufficient evidence to support allegations, whereas two-thirds of practitioners' allegations resulted in a finding of a violation. In addition, the consumer complaints tended to be about less serious violations. Boards need to gather this information in order to be able to see if this trend applies in other states. If it does, then this indicates consideration for strengthening the reporting of practitioners, because that will have the greatest impact on public safety and welfare.

However, regardless of the costs, the complaints of the patients cannot be ignored in a democratic society. This point articulates the issue of democratic values as incorporated in administrative practice within state regulatory boards.

The results of this study reinforce the findings, analysis and trends identified by Larson et al. (2009) although there are differences in the methodology. One difference is that the Larson study weighted the characteristics in their scale and this study did not. While they used two experts to determine the weighting, the limitation of that strategy is the weighting criteria may or may not correspond to policy, administrative practice and consumer advocates' priorities. The research reported in this article took a more conservative approach in order to analyze a broader range of categories that are needed by different constituencies. Furthermore, the focus of the current research is the availability and access of data useful for policy and evaluation research rather than, primarily, consumer access. Together, the results of both studies can be informative to a broad base of people involved in and interested in the quality and safety of health care.

In broad terms, there is some information available, the boards are moving towards providing more information, but progress is mixed across boards and states. For example, only four boards provide information about federal discipline (Larson, 2006). Federal discipline involves cases where practitioners have been barred from participating in federal financed programs such as Medicare or Medicaid because of fraud or substandard practice. Further, in our research we found that few boards provided information about the source of the complaint. Taken together we realize neither consumers nor researchers can use the currently available data to determine if a complaint was filed by a dissatisfied patient, law enforcement or an agency or program such as the Drug Enforcement Administration (DEA) or Medicare. Each of these sources could be related to entirely different violations in nature and scope. Moreover, having specific information on the source of complaints would also help current boards, policy makers and theorists understand how to use resources more efficiently and effectively, strengthen inter-agency coordination and develop better-informed intergovernmental cooperation protocols.

Limited Resources and Competing Priorities

A constant and significant challenge for the boards is balancing their staffing and budget resources against public demands for disciplinary information. Open access may be an ideal but it costs money, staff time, and technology resources. In a world with limited resources, how important is transparency? The boards may agree that transparency is important but policies and practices that have a direct impact on patients might have a higher priority. Alternatively, perhaps the boards think it a better use of time and money working with dental schools to strengthen professional development and training which might have greater impact on the public's welfare than providing more information on the website. Further research is needed to determine if there is empirical support for these possible perspectives.

More Information, But Less

In many respects there is more information about individual practitioners available now in 2009 from the boards than ever before. However, there has not been a comparable increase in information about the administrative practices and the work of the boards. Availability of this information would allow public administration and policy researchers to develop performance indicators of state boards and assist in improving policy decisions and allocation of resources.

Much of the impetus for providing increased access to health professional discipline has come from advocacy organizations whose primary concern and perspective is of the patient or the consumer. Therefore, it makes sense that those organizations have emphasized increasing access to information that answers "What information can I find about Dr Jones?" Consumers seeking information about a doctor, nurse or dentist are not interested in the administrative functions of a board. Similarly, practitioners are concerned about information on licensing and continuing education requirements and new board regulations. Consumers and practitioners have no compelling reasons to seek information on board performance in the administration of enforcement and discipline.

Even though there have been some advances in transparency and boards' awareness of the need to provide information to the public, it does not appear that the findings are that much different in terms of transparency. In fact, the public might be gaining access to more quantities of information which reveals less detail. Particularly given the availability and increased ease of use and reduced costs of the technology at this time, this seems to be an unexpected trend.

CONCLUSION

This study sought to determine the availability and accessibility of disciplinary data on the websites of boards of dentistry, medicine and nursing and whether such data can be readily analyzed for policy and evaluation research. The evidence produced by this study shows that the record is mixed. Generally, all boards across the states make disciplinary data available on their websites, thus allowing public access. However, the quantity and quality of data available varies considerably.

The study identified variations among the boards that represent different occupational groups. Regarding different professional boards, these findings confirm that medicine and nursing are further along than dentistry in providing information for consumers to review. It is not clear why boards of dentistry are lagging behind medicine and nursing. It may be that medicine and nursing constitute a workforce that is significantly larger than dentistry, thereby playing a broader role in health care. Consequently, boards of medicine and of nursing have been more closely scrutinized so probably began to look at these issues more systematically. Professional socialization may also be a factor. Several studies have noted the greater professional isolation of dentists compared with doctors. Dentists who are mostly solo practitioners may be less attuned to the importance of sharing information than are nurses and doctors who practice more in group and institutional settings (U.S. Department of Health and Human Services, Office of Inspector General, 1988).

Dentistry needs to vastly improve the information it provides to consumers. The next areas to address for these boards would be to begin to address policy related information in the same away medical boards have. This pattern is consistent with the literature related to the percent of discourse and research on boards of other than medicine (Davies, 2004).

When we turn to the question of whether disciplinary data are available for policy research we find that some descriptive data analysis is possible as is qualitative data analysis of complaints, board minutes and board orders. It is also possible to tease out some variables from narratives posted on the websites for correlational or multivariate analysis. However, aggregated disciplinary data, as may be presented in monthly or annual reports, inhibits more in-depth analyses. Furthermore, analysis of administrative processes is also inhibited because of the absence of information on the states' processing of complaints.

Future Research

Much of the research being done on health professional enforcement and discipline is being done in the disciplines themselves (nursing, dentistry, medicine) and to a limited extent in the public administration literature. Health professional discipline certainly warrants more scholarly attention, although public administration has not recognized this research as a priority. Given a workforce of 1.5 million health professionals, disciplinary policies and practices constitute an important component of health professional regulation. With the enactment of the Patient Protection and Affordable Care Act, the major health care reform of 2010, new issues and questions concerning the roles and responsibilities of health professionals will emerge. Finally, none of the following have been given sufficient attention: performance indicators for state licensing boards, information policies on access and privacy, and evaluation of enforcement and discipline. Given the scope of their impact and connections to public policy, these issues are worthy of greater attention, research and discussion.

The broad global trend of government information policies is toward more transparency. The particular details, policies and issues by state may influence data availability, but that does not change the overall national trend. A state court decision, for example, may compel government agencies to restrict the public's access to specific information. Alternatively, the political climate might change and state agencies will not provide information because budget and staff cuts require boards to re-allocate resources. It may simply be that there is not sufficient time to post all the information. Part of the nature of policy evolution is that there may be a retreat and then advance, an ebb and flow of available data. Nonetheless, these findings, along with the prior studies, confirm a persistent trend towards increased public access to disciplinary data and greater transparency of health professional regulatory boards.

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DENISE E. STRONG

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Table 1
Boards of Medicine Web Site Information: Information
Availability by State

                                        Frequencies

                                        Yes (1)   No (0)   total

Name of offender                        44        7        51
Date of allegation                      6         45       51
Alleged violation                       29        22       51
Severity of offense                     18        33       51
Who submitted complaint                 2         49       51
Was it a mandatory report               5         46       51
Did the dept do an investigation        21        30       51
Bd Finding/Viol./No Viol                24        27       51
Nature of sanction which was applied    42        9        51
Disposition other than sanction         15        36       51
Length of the complaint processing      10        41       51
Is the data downloadable?               44        7        51

                                        Percentages

                                        Yes (1)  No (0)

Name of offender                        86%      14%
Date of allegation                      12%      88%
Alleged violation                       57%      43%
Severity of offense                     35%      65%
Who submitted complaint                 4%       96%
Was it a mandatory report               10%      90%
Did the dept do an investigation        41%      59%
Bd Finding/Viol./No Viol                47%      53%
Nature of sanction which was applied    82%      18%
Disposition other than sanction         29%      71%
Length of the complaint processing      20%      80%
Is the data downloadable?               86%      14%

Table 2
Boards of Dentistry Web Site Information: Information
Availability by State

                                       FREQUENCIES

                                       yes (1)   no (0)   total

Name of offender                       41        10       51
Date of allegation                     12        39       51
Alleged violation                      30        21       51
Severity of offense                    13        38       51
Who submitted complaint                4         47       51
Was it a mandatory submission          1         50       51
Did the dept do an investigation       15        36       51
Bd decision of violation or not        31        20       51
Nature of Sanction which was applied   36        15       51
Disposition other than sanction        1         34       51
Length of the complaint processing     6         45       51
Is the data downloadable?              27        24       51

                                       Percentages

                                       yes (1)   no (0)

Name of offender                       80%       20%
Date of allegation                     24%       76%
Alleged violation                      59%       41%
Severity of offense                    25%       75%
Who submitted complaint                8%        92%
Was it a mandatory submission          2%        98%
Did the dept do an investigation       29%       71%
Bd decision of violation or not        71%       29%
Nature of Sanction which was applied   61%       39%
Disposition other than sanction        33%       67%
Length of the complaint processing     12%       88%
Is the data downloadable?              53%       47%

Table 3
Boards of Nursing Web Site Information: Information Availability
by State

                            Frequencies                Percentages

                            yes (1)   no (0)   total   yes (1)  No (0)

Name of offender            48        3        51      94%      6%
Date of allegation          4         47       51      8%       92%
Alleged violation           29        22       51      57%      43%
Severity of offense         16        35       51      31%      69%
Who submitted complaint     3         48       51      6%       94%
Was it a mandatory report   0         51       51      0%       100%
Did the dept do an          17        34       51      33%      67%
  investigation
Bd Finding/Viol./No Viol    20        31       51      39%      61%
Nature of Sanction which    49        2        51      96%      4%
  was applied
Other disposition than      9         42       51      18%      82%
  sanction
Length of the complaint     5         46       51      10%      90%
  processing
Is the data downloadable?   42        9        51      82%      18%

Table 4
Characteristics Scale by State/DC

State/DC         Dentistry   Medicine   Nursing Scale
                 Scale       Scale

Alabama          1           4          5
Alaska           3           5          4
Arkansas         7           2          5
Arizona          9           4          6
California       7           6          7
Colorado         4           4          5
Connecticut      3           5          5
D.C.             7           5          5
Delaware         7           7          5
Florida          9           4          5
Georgia          8           4          4
Hawaii           0           1          2
Idaho            0           1          4
Illinois         4           1          4
Indiana          4           1          2
Iowa             5           6          4
Kansas           7           4          5
Kentucky         8           4          3
Louisiana        3           4          2
Maine            6           6          3
Maryland         7           1          4
Massachusetts    0           5          3
Michigan         2           4          5
Minnesota        6           6          4
Mississippi      1           6          8
Missouri         4           2          10
Montana          5           5          3
Nebraska         7           7          6
Nevada           3           4          6
New Hampshire    1           7          7
New Jersey       3           10         2
New Mexico       2           4          3
New York         6           6          6
North Carolina   11          5          3
North Dakota     0           0          7
Ohio             2           6          6
Oklahoma         3           6          4
Oregon           11          5          6
Pennsylvania     6           6          6
Rhode Island     2           3          2
South Carolina   4           6          6
South Dakota     3           3          3
Tennessee        5           5          5
Texas            2           9          2
Utah             6           7          8
Vermont          6           12         4
Virginia         9           11         9
Washington       6           9          5
West Virginia    8           7          3
Wisconsin        8           8          8
Wyoming          0           7          8

Table 5
Descriptive Statistics across 50 States and District of
Columbia

Statistical      Dentistry       Medicine        Nursing
calculation      Data by         Data by         Data by
                 state/DC        state/DC        state/DC
                 Scale of 0-12   Scale of 0-12   Scale of 0-12

Mean (M)         4.58824         5.13725         4.705882
Median (Mdn)     5               5               5
Mode (Mo)        3               4               8
Range (R)        11              12              10
SD               3.00442         2.54389         1.88745
Variance (Var)   9.02653         6.47136         3.56248
Skewness (Ku)    0.13802         0.38662         0.63344
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