Survey of doctor disciplinary information on state medical board web sites. (HRG Publication #1506)
Survey of Doctor Disciplinary Information on State Medical Board Web Sites
Sidney M. Wolfe, M.D.
Peter Lurie, M.D., MPH
State medical boards are responsible for taking action against physician misconduct and making information about those disciplinary actions available to the public. The Internet offers boards the opportunity to greatly enhance public availability of that information. Public Citizen's Health Research Group (HRG) recently conducted a survey of the 51 boards regulating medical doctors to determine the current state of Internet-accessible disciplinary information. The survey employed phone interviews, using a structured questionnaire, and examinations of the web sites. It revealed that:
Disciplining physicians at a higher rate does not excuse a state from getting this important information out in a complete and user-friendly manner. Conversely, having a complete, user-friendly web site does not compensate for the failure to achieve a higher rate of serious disciplinary actions. Both are needed. All states should adopt minimum, uniform standards that ensure that sufficient information on a given action is provided; that all of the information is presented in a user-friendly format; and that the information is comprehensive, current, and retroactive for 10 years.
Consumers use the Internet to fill their prescriptions, seek medical advice, and learn about medical research. Hospitals, health maintenance organizations, doctors, and pharmaceutical companies advertise on the web. And the Internet presence of the state medical boards -- those entities charged with licensing and regulating medical doctors -- is also on the rise.
The boards serve patients by ensuring that, in order to be licensed, physicians meet minimum standards of training and competence. They are also required to discipline physicians who commit offenses such as negligence, incompetence, sexual misconduct, and violations of criminal laws. However, most boards have not assumed an active role in disseminating adequate information about these disciplinary actions to patients, preferring all too often to shield physicians from adverse publicity. For years, patients have had to call or write the boards to learn whether their physician has been disciplined and, if so, why, how, and when.
But given the Internet's power to rapidly disseminate vast amounts of information to many people, it is logical that the boards provide disciplinary information on the web. If the data are sufficiently detailed, complete, and easily accessible, providing the information on the Internet would not only benefit patients, but also the boards, which would receive fewer time-consuming phone and mail queries from patients and might then be able to devote more time and resources to their vital enforcement duties.
To determine the current state of disciplinary action information on the Internet, HRG recently surveyed the state medical boards. This report presents the findings of that survey.
Between August 27 and October 28, 1999, HRG surveyed the 51 boards that regulate medical doctors in the United States. The structured questionnaire sought to answer the following questions: What types of information are available on the Internet? In what format is it presented? How complete and current is it? How does it compare to the disciplinary information a consumer can get by calling the board? For those boards without disciplinary action information available on the Internet, we asked whether they planned to get on the web and, if so, when.
Before contacting the boards by telephone, we examined their web sites directly and, when possible, answered survey questions directly from the sites. (In order to see if changes in web sites had occurred since the original survey, all sites were again reviewed during the first week of January, 2000.) Examining the sites usually provided data about the specific kinds of information available and the formats in which the data were presented. The information's completeness, currentness, and how it differs from that found in actual board orders was usually not apparent from examination of the web sites. For this information, we contacted the boards by telephone and interviewed staff directly. Typically, the interviewee was someone who designed and/or maintained the web site or who created the documents containing disciplinary data that were posted on the site.
We created a grading scale to assess the content of disciplinary information each web site provides. An adequate amount of information on a given action was defined as: 1) the doctor's name; 2) the disciplinary action taken by the board; 3) the offense committed by the doctor; 4) a concise summary narrative of the physician's misconduct; and 5) the full text of the actual board order. States that provided all five types of data earned a content grade of "A"; states that provided four of the five types of data earned a "B"; states that provided three of the five types of information received a "C"; states that reported two of the five types of information received a "D"; and states that named disciplined physicians but provided no details about the discipline received an "F." States that had no web sites or reported no doctor-specific disciplinary information on their web site earned an "X."
We also categorized the web sites as either user-friendly or not based on the format in which disciplinary data were presented. A user-friendly format was defined as either a) a database from which physician information can be retrieved by entering a doctor's name in a search engine; or b) a single listing of all licensed physicians that includes disciplinary information; or c) a single listing of all physicians disciplined by the board. Examples of formats that are not user-friendly include multiple reports, newsletters, or press releases. Each of these items must each be searched individually, a time-consuming, hit-or-miss process for patients.
Some board web sites provide disciplinary information in more than one format. For example, a site might have both a searchable database of physician data and newsletters that report board actions. With such sites, it was often the case that the different formats provided different types of information. We categorized board web sites as user-friendly if at least some disciplinary information was presented in an acceptable format.
HRG created a database in Microsoft Access 97 to record the responses. The relationship between the boards' 1998 rates of serious disciplinary actions, determined in an April 1999 HRG study,(1) and their web site content grades was examined using Kruskal-Wallis One Way Analysis in SigmaStat version 1.0. Each board was assigned to one of four geographic regions, based on classifications used by the U.S. Bureau of the Census,(2) and the relationships between region and all survey questions were examined using chi-square analyses in Epi Info version 5.01b. For both types of analysis, a p-value of 0.05 (2-sided) was considered statistically significant.
Of the 51 boards regulating medical doctors, 41 have web sites providing doctor-specific disciplinary information (that is, the disciplined physicians are named). Although most of these boards have their own sites, a few states provide the data on the site of another regulatory body, such as the Department of Health. Of the 10 boards that do not provide doctor-specific disciplinary data on the web (Alaska, Arkansas, Delaware, Hawaii, Louisiana, Montana, New Mexico, North Dakota, South Dakota and Wyoming), seven have no site at all, while three (Alaska, Montana and South Dakota) have sites that provide no disciplinary data. These sites typically provide basic information like board addresses, phone and fax numbers, the names of board members, and the roles and duties of the boards. Of the 10, five (Arkansas, Delaware, Louisiana, New Mexico and North Dakota) said that they planned to have sites with disciplinary information in the near future, and four of those five said this would occur in the first half of 2000.
Seventeen boards began providing disciplinary data on the web in 1996 or 1997. Twenty-four boards began in 1998, 1999 or 2000.
Only one of the 50 states and the District of Columbia (2%) earned an "A" for content: Maryland. Twenty-four (47%) received "B's"; five (10%) received "C's"; eight (16%) earned "D's"; three (6%) earned "F's" and the 10 states (19%) that provided no doctor-specific disciplinary information on their web sites, or had no web sites, earned "X's" for content (see Methods, page 4, and Table 1).
The formats in which data are presented vary among the states. Of the 41 boards that provide doctor-specific disciplinary information on the Internet, 28 provide at least some of these data in a user-friendly format, as defined in the methods section. Twenty-two web sites feature a database from which physician information can be retrieved by entering a doctor's name in a search engine; three sites post data in a single listing of disciplined physicians; and three sites post data in a listing of all licensed physicians that clearly indicates if a doctor has been disciplined. Thirteen boards provide disciplinary data exclusively in a format that is not user-friendly. Their data are presented in periodically released documents that are posted on the web site. These documents include reports, newsletters and/or press releases, each of which must be reviewed individually.
Some board web sites present additional information on physicians and the disciplinary actions against them (see Summary Table). Sixteen boards report the physician's date of birth, 23 provide an address (business, home or unspecified), and five include a telephone number. Thirty-five boards provide the physician's license number. Twenty-two report the license issue date and 20 report the license expiration date. Fifteen boards report a doctor's specialty. Thirty-five boards provide the date that a disciplinary action was taken. Fifteen indicate if the action was terminated -- that is, if the action was lifted by the board. Twenty boards report the physician's current licensing status. Fifteen report criminal convictions against the physician and ten indicate if the board mandated a treatment program for a physician with a substance abuse problem.
Twenty-seven boards make it their policy to update their disciplinary action information every month or more frequently. In the worst case, the South Carolina Board of Medical Examiners updates the disciplinary information on its web site approximately once per year. When the interview dates were compared with the last reported "update" dates, it was found that 33 of the 41 boards had entered disciplinary data onto their web site within 30 days of being surveyed.
Twelve boards reported that they delete disciplinary data from their web sites under certain circumstances. Of these boards, five delete data as soon as a physician's license expires, is revoked, or is suspended. Three retain the information for a specific period after the license expires, is revoked, is suspended, or the physician dies, before deleting it. The other 29 either do not delete data from their web sites or have not established protocols to remove such data.
If an action was overruled, vacated, or remanded by a court, 12 boards said they would update the originally reported data without providing any indication that it had been changed. Another 12 boards said they would report the action of the court, but would also include information on the original board action. The other 17 boards with doctor-specific disciplinary information on the Internet reported a variety of policies, including six who said it would depend on what the court ordered. Two boards would correct the reported information but also include an indicator that the board had taken some action against the physician.
All 41 boards providing disciplinary information on the Internet will also furnish hard copies of board orders to consumers upon request. However, only two states provide the full-text of the board orders on-line: Maryland and Wisconsin.
When the survey variables were cross-tabulated against the states' geographic regions, no statistically significant results were found. There was similarly no relationship between the states' web site content grades and their respective rates of serious disciplinary actions. Maryland, with a moderately low 1998 disciplinary rate of 2.98 serious actions per 1,000 doctors, had the only "A" in our grading system and states such as Illinois, Minnesota, Wisconsin, and Massachusetts, which all earned "B's" for their web site content, ranked among the 11 lowest states in rates of serious disciplinary actions. Conversely, states such as Oklahoma, Arkansas, Mississippi, Alaska, and Wyoming, all states with among the 10 highest rates of serious disciplinary actions, earned a "D," "F," or "X" for their web site content.
Although 80 percent of the state medical boards provide some doctor-specific disciplinary information on the Internet, 14 million patients(3) live in the 10 states where no such data are available on-line. Clearly, these states need to act to expand their presence on the Internet. However, even among the state medical boards that do provide disciplinary action information on the Internet, the content, format, and timeliness of that information varies greatly is often inadequate.
Unless a board web site provides adequate information about actions, patients will be unable to use the site to make an informed choice of a physician. For these patients, contacting the board by phone or mail will still be necessary, and this represents a lost opportunity for the board to enhance consumer access to doctor disciplinary data and reduce their own workload.
Disappointingly, only one state, Maryland (population 5.2 million), earned an "A" for the content of information featured on its web site. Although 260 million patients live in the 41 states that provide some disciplinary information on the Internet, 114 million of them (44%) are in states that provide three or fewer of the five minimum data types and therefore earned content grades of "C" or less.
Some boards report other important information on their licensees that might be of interest to patients. The California, Florida, Idaho, Massachusetts, and Tennessee boards provide data on malpractice claims. The California, Florida, Idaho, and Massachusetts sites also report disciplinary actions taken by hospitals against physicians. We believe that all states should include such data.
The ease with which disciplinary data can be reviewed is determined largely by the format in which is it presented. A database from which physician information can be retrieved by entering a physician's name in a search engine is the most user-friendly format. A single listing of either all licensed physicians, which includes disciplinary information, or a single listing of all disciplined physicians, is not as elegant as a searchable database, but can be reviewed with relative ease. An archive of periodically posted documents, such as newsletters or press releases, is inconvenient because patients must review a number of separate documents individually to check for information on a physician.
On many web sites, some data were presented in a user-friendly format, while other data were not. Often, the user-friendly format only indicated whether or not a physician was disciplined by the board. However, in our lenient classification system, if only one category of information was in a user-friendly format, the entire web site was classified as user-friendly.
Web-based disciplinary information must also be timely, defined by HRG as that which is updated as frequently as the board meets, covers at least the last 10 years of board actions, and is available regardless of the physician's current licensing status. Most states update their information after every board meeting, but some do not.
We did not formally survey the boards on the retroactivity of the disciplinary data they provide, but it is evident that some sites report actions taken in the past 10 years, while many only report those taken in the last year or two. A ten-year limit strikes a reasonable balance between the patient's right to know about their physician's disciplinary history and the doctor's right not to be punished indefinitely for transgressions committed long ago.
Twelve states reported that, under certain circumstances, such as the suspension, revocation, or expiration of a physician's license, they delete the physician's records from the Internet. We believe patients should be able to access disciplinary data regardless of a physician's license status, so if a doctor attempted to practice without an active license, patients could quickly determine that the doctor was practicing illegally.
Our survey results show that policies vary among the boards on how to manage the disciplinary information posted on-line when a court overrules, vacates, or remands an action. HRG believes that when a court overrules or vacates a board action and exonerates the physician, and the court decision is final, the board should remove all information on the action from its web site. This is fair to the physician. But while an appeal is pending, or while the board reconsiders an action after remand, information on the action and the court's ruling should be reported on the web. This is fair to patients.
Finally, it is clear that there is no relationship between the content of medical boards' web sites and their rates of serious disciplinary actions. A relatively high rate of discipline hardly excuses a state from getting this important information out in a complete and user-friendly manner. Conversely, having a complete, user-friendly web site is no substitute for a higher rate of discipline. Both are needed.
HRG recommends that all state medical boards adopt minimum uniform standards for providing disciplinary information on the Internet.
1) Each board should have a web site that links to a database of physician information. For each physician disciplined by the board, the information should include the action taken by the board, the offense committed by the physician, and a summary narrative of the physician's misconduct. The database should also feature links to the full text of board orders and other public documents related to the action.
2) This information should be provided for all disciplinary actions taken in the last 10 years.
3) Public access to disciplinary data should be preserved even when a physician's license is suspended, revoked, or expired.
4) Patients should be able to retrieve data by entering a physician's name and/or license number in a search engine.
5) Disciplinary action information should be updated as frequently as the boards meet to consider actions (usually once a month.)
6) If a court overrules or vacates a board action and exonerates the physician and the court decision is final, then information on that action should be removed from the database. While an appeal is pending, or while a remanded action is being considered, information on the action and the court's decision should be reported in the database.
7) Any changes in a physician's record resulting from a court decision should be made within two weeks of the court ruling.
A state-by-state analysis of the medical board web sites follows, along with recommendations specific to each state for creating a web site that is maximally useful to its residents.
1. Wolfe, Sidney M., M.D., Public Citizen's Health Research Group Ranking of State Medical Boards' Serious Disciplinary Actions in 1998. Public Citizen, Washington, DC, April 1999. URL: http://www.citizen.org/hrg/PUBLICATIONS/1478.htm
2. State Population Estimates and Demographic Components of Population Change: July 1, 1998 to July 1, 1999. (ST-99-1) Population Estimates Program, Population Division, U.S. Bureau of the Census, Washington, DC, December 29, 1999. URL: http://www.census.gov/population/estimates/state/st-99-1.txt
3. State Population Estimates and Demographic Components of Population Change: July 1, 1998 to July 1, 1999. (ST-99-1) Population Estimates Program, Population Division, U.S. Bureau of the Census, Washington, DC, December 29, 1999. URL: http://www.census.gov/population/estimates/state/st-99-1.txt