Missing millions: territory grapples with non-admitted patient data

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ACT auditor-general Dr Maxine Cooper has taken a look at data integrity in the territory’s Health Directorate, and found errors that could have left $2-3 million in federal health funding unclaimed.

Cooper found the integrity of activity-based funding data reported by ACT Health to the Independent Hospital Pricing Authority for admitted patients and emergency department presentations was “adequate”.

The problems were with the non-admitted patient data, it seems, which the directorate hopes to fix before its next IHPA submission in September, so the ACT gets all the funding it is entitled to. According to the directorate, there are difficulties with accurately capturing it all in other parts of the country, too.

Cooper acknowledges the directorate has made “considerable effort” and improved governance around data integrity since she published a report on emergency department performance in 2012:

“Improvements in areas such as training staff in systems usage, managing user access to the systems, procedural improvements and data integrity routines implemented in the Health Directorate data warehouse environment have contributed to improved data integrity. However, there is more work to be done with respect to training, documentation and allocation of responsibilities, outcome measures, evaluation, corrective actions and assurance.”

To further improve its data integrity, the auditor-general says ACT Health should work on providing “greater clarity in the allocation of roles and responsibilities” across the agency, its performance information branch and the ACT’s two hospitals.

“Further,” she writes, “the lack of outcome measures and Key Performance Indicators (KPIs) by which to manage data integrity, and the lack of assurance activities targeted at managing the key data integrity risks associated with activity based funding (ABF) data submissions, need to be addressed.”

Both hospitals have adequate application controls in the two main systems they use, and appropriate process controls, to ensure integrity in data collection as well as validation, but only in their emergency departments and admitted patient areas. In the non-admitted patient areas, the opposite is true, and Cooper suggests the training and experience of clerical staff is the key factor.

The auditor-general found the directorate’s internal controls around the reporting of the ABF data were also inadequate:

“The informality of procedures adversely affects the integrity of the reporting process and places a heavy reliance on a few key individuals. The lack of analytical review of the ABF six monthly data submission, and limited validation activities for the ABF costing submission, need to be addressed.”

The audit office found a small number of “coding errors largely associated with front-end data entry” in the reasonably reliable data from admitted patient areas and emergency, but the risk of this materially compromising the information sent to the IHPA was low.

The $2-3 million worth of errors in the non-admitted patient ABF data was due, according to Cooper:

“… to the variety of clinics and systems that feed into the Non-admitted Patient data, the lack of standardised methods and systems across the various outpatient facilities in the two hospitals, and the lack of data assurance conducted by the hospitals and the Health Directorate.”

Responses

The directorate says the “material impact” of the issues found by the auditor-general is “relatively minor” as the $2-3 million in lost funding is only, at most, about 1% of the estimated $304 million it expects to have received from the Commonwealth by financial year’s end. ACT Health pledges to improve its data integrity before its next submission for funding in September, and points out:

“The need to establish more robust Non‐admitted data systems and counting is recognised nationally. In terms of the development of nationally consistent classification systems, Non‐admitted data processes are less mature than inpatient and Emergency Department services due to their breadth and the considerable variation in the provision of these services across health services in Australia.”

ACT Health says processes it has already undertaken to improve this particular area of data capture have increased the estimated number of “national weighted activity units” for non‐admitted patients in 2014-15 from 10,000 to 17,000. It claims that “the additional work to capture activity noted in the audit report” will only add another 1000 units — out of a total estimate for the system of more than 133,000.

The directorate lists its relatively new “data credentialing framework” and the establishment of a new branch focused on data management in 2014, as well as forums to discuss data quality issues with staff, as key measures that have got it back on the right track.

The auditor-general made a total of 18 recommendations in her full report, 10 of which were labelled high priority, and also reported on the Health Directorate’s progress in implementing her previous recommendations.

Calvary Health Care, which runs one of Canberra’s two hospitals, agreed with all recommendations that applied to it, except for the suggestion to have a single patient management system for all outpatient clinics — which it said would only be appropriate if “integrated with existing systems that record outpatient data that meet specific clinical requirements”. Calvary also pointed out that:

“… lack of consistent non-admitted patient data capture is common across jurisdictions and it is generally recognised that there is not a fully developed recording system”.