GAO official: VA must improve clinician productivity tracking
In testimony this past week before the House of Representatives' Committee on Veterans Affairs, Randall Williamson, director of healthcare at the U.S. Government Accountability Office, spotlighted the ways VA could improve its metrics around clinical productivity and efficiency.
With no shortage of attention focused on the VA's new partnership with Cerner to replace its VistA electronic health record, it's worth remembering that the EHR is only a means to an end. The real goal is delivering better care, and Williamson said VA could do better ensuring "high levels of productivity among its clinical services and operational efficiency to maximize veterans' access to care and minimize costs."
Back in 2013, VA developed clinical productivity metrics to track the time and effort it took its providers to perform select procedures in 32 clinical specialties, as well as formulating statistical models to measure clinical efficiency at VA medical centers, designed to track utilization and expenditures for high-volume areas such as ED use and urgent care.
A recent report from GAO took a closer look at those tools, hoping to assess whether they give a complete and accurate picture, and look for ways to improve the efforts where they fall short.
The office found four big limitations with the VA's metrics, said Williamson:
Productivity metrics are incomplete since they don't take into consideration all the providers a veteran might see or clinical services they may use. "Due to systems limitations, the metrics do not capture all types of providers who deliver care at VAMCs, including contract physicians and advanced practice providers, such as nurse practitioners, serving as sole providers," he said. "In addition, the metrics do not capture providers’ workload evaluating and managing hospitalized patients because VA’s data systems are not designed to fully capture providers’ workload delivering inpatient services that do not involve procedures – in particular, evaluating and managing patients who are hospitalized."
The metrics don't necessarily reflect the "intensity" of clinicans' workload. Williamson noted that a VA audit from 2016 showed that providers "do not always accurately code the intensity – that is, the amount of effort needed to perform – of clinical procedures or services. As a result, VA’s productivity metrics may not accurately reflect provider productivity, as differences between providers may represent coding inaccuracies rather than true productivity differences."
They may not accurately depict staffing levels. "Officials at five of the six selected VAMCs we visited reported that providers do not always accurately record the amount of time they spend performing clinical duties, as distinct from other duties," said Williamson. "VA’s productivity metrics are calculated for providers’ clinical duties only."
Efficiency models could be skewed by inaccurate workload and staffing data. "To the extent that the intensity and amount of providers’ clinical workload are inaccurately recorded, some of VA’s efficiency models examining VAMC utilization and expenditures may also be inaccurate," he said. "For example, the model that examines administrative efficiency requires accurate data on the amount of time VA providers spend on administrative tasks; if the time providers allocate to clinical, administrative, and other tasks is incorrect, the model may overstate or understate administrative efficiency."
GAO recommends that VA "expand its existing productivity metrics to track the productivity of all providers of care to veterans," said Williamson, such as contract physicians who aren't employees of the agency or advance practice providers acting as sole providers. "VA agreed in principle with our recommendation and stated that it plans to establish productivity performance standards for advanced practice providers, using available productivity data, by October 2017," he said.
Moreover the office suggested VA improve its workload and staffing data by giving training for its providers on proper coding clinical procedures. "VA agreed in principle with our recommendation and reiterated its existing efforts to improve clinical coding accuracy. It also said that the department would reissue existing policy to VAMCs by June 2017 as well as continue to provide need-based, focused coding training to providers, as appropriate," said Williamson.