The North Carolina Health Professions Data System

1. The North Carolina Health Professions Data System Katie Gaul, Erin Fraher, Thomas C. Ricketts, Jessica Carpenter University of North Carolina at Chapel Hill

2. Overview of Today’s Presentation The North Carolina Health Professions Data System • Mission • Background • Data Collection, Cleaning, Reporting • Organizational Issues • External Data Sources • WHY? Examples and Value of Work • Wrapping Up

3. Our Mission • To provide timely, useful data and analysis to support decision making for health professions policy in North Carolina and the United States • To support research into health workforce issues and problems • To train others in how to develop and maintain data systems in health workforce

4. HPDS: 3 Main Product Lines Maintenance of Licensure Data Files for HPDS Special Projects: Service to the State and the Institution Allied Health Workforce Studies This function is the backbone of our work. It takes substantial time and staff effort to collect, clean, edit, and disseminate licensure data. Sustaining & maintaining this infrastructure is challenging. The HPDS often undertakes special research projects at the request of the NC AHEC, UNC Board of Governors (respond to legislation, make presentations), licensure boards etc. This service has increased the visibility of the Sheps Center to important local sponsors and policymakers. Funded by the Duke Endowment and the NC AHEC, research has focused on quantifying the supply of, and demand for, allied health workers. Findings highlighting the growth of allied health employment have gained the attention of policy makers. Staff in the Governor’s office, the legislature, and other state agencies are working to develop innovative ways to transition unemployed individuals into allied health jobs.

5. North Carolina HPDS • A collaboration between the Cecil G. Sheps Center for Health Services Research at UNC-CH and the health professions licensing boards. • Data are provided voluntarily by the boards—there is no legislation that requires this, there is no appropriation. • Core funding provided by: • NC AHEC Program Office, data request fees, project cross-subsidies, and the UNC-CH Office of the Provost.

6. The System is Unique in the U.S. • 30 years of continuous, complete data • Comprehensive and voluntary collaboration with 12 licensing bodies in North Carolina • Data remain property of licensing board, permission sought for each “new” use • System is independent of government or health care professionals

7. Certified Nurse Midwives (1985) Chiropractors Dental Hygienists Dentists Licensed Practical Nurses Nurse Practitioners Occupational Therapists (2006) Occupational Therapy Assistants (2006) Optometrists Categories of Health Professionals in Data System • Pharmacists • Physical Therapists • Physical Therapist Assistants • Physician Assistants • Physicians (MDs and DOs) • Podiatrists • Psychological Associates • Psychologists • Registered Nurses • Respiratory Therapists (2004)

8. HPDS Data Collected from Boards • “Base” data from initial licensure/approval forms • Updated data from renewals of licensure and approvals to practice • Includes 100% of active professionals because licensure is required by law • We develop a ‘Snapshot’ of files as of October of each year (Orange Book)

9. Data Items Collected Demographic data: Data elements that usually don’t change • Unique identifier • Name • Date and place of birth • Race/ethnicity • Gender • Basic professional degree (degree conferred, name and location of institution attended, practice qualifications)

10. Data Items Updated Data elements that may change: • Home address • Employment address • Type of position • Employment setting • Clinical practice area/specialty • Activity status (retired, active practice, not employed in profession) • Average hours per week/employment status • Highest degree • Foreign language ability (available from select boards)

11. Additional Data Items Collectedfor Physicians and PAs • Primary, Secondary and Other practice location • ZIP Code location • Facility type • Hours in clinical care (by location) • Hours in primary care (by location) • Provide prenatal care? • Deliver babies? • Hospital Privileges (2007) • Licenses ever held in other states/countries (2007)

12. Licensure File Creation and Maintenance (continued) The entire process takes nearly a year from start to finish October August News Release Review for changes Trial Posts to web Data come in Edits, cleaning Formatted initial analysis file Data Book released

13. North Carolina Health Professions Data Book • Annual Health Professions Data Book, produced since 1979, details state and county level health professions data; current issue: October 2007 data • Publications and research widely used by policymakers, educators, researchers, the media and health professionals as the official source of health professions statistics in NC • Supported by the North Carolina Area Health Education Centers Program and the University of North Carolina at Chapel Hill Office of the Provost

14. North Carolina Health Professions Data Book • Counts of active, licensed health professionals • Population by age group and race • Employment and income data • Vital statistics (births, deaths, pregnancies) • Infant mortality rates • Hospital and facility data Aggregated by state, county and regions (AHEC, DHHS, Perinatal)

15. HPDS: Organizational Issues

16. Hardware High end personal computers which are regularly upgraded (every 2-3 years) Connected to Sheps Center servers allowing file sharing, storage of large files, automatic back-up Label writer for mailing data requests Cleaning and processing of licensure files is done on local desktop computer using SAS® Archive licensure files kept on UNC mainframe Software Microsoft Access - track data requests, do file audits, invoicing, data book pages Microsoft Excel/Powerpoint - graphically present data Macromedia Dreamweaver® - web development Adobe Acrobat® - create PDF documents for website Quark® or Adobe InDesign® - desktop publishing Adobe Illustrator® - format maps and graphics MapInfo® or ArcGIS® - create maps and do spatial analysis SAS® or Stata® - statistical analysis and programming Infrastructure: Hardware/Software

17. Dissemination • State-Level (examples) • State Legislators, Governor’s office, State Policy Makers • Health Professions Schools • All regional AHECs and their libraries • North Carolina State Library • North Carolina DHHS, Commerce • North Carolina Hospital Association and other employers • Professional Associations • Duke Endowment and Kate B. Reynolds Charitable Trust • North Carolina Institute of Medicine • National-Level • AAMC, other workforce centers, AHECs, and researchers • Federal Bureau of Health Professions, HRSA, NAO • Library of Congress • Email listserv: 2,298 members, sign-up available on website

18. Basic Cost Estimates

19. Cost Estimate for Producing the Annual Data Book: Operating Costs This is a general estimate of the costs to produce the Data Book each year; This does not include funds necessary for infrastructure or additional functions. Fiscal Year 2007-2008 *These estimates cover the production of the annual HPDS Data Book and don’t take into account other projects that we design with the NC AHEC Program and others.

20. Examples of Sources of Funding for Workforce Research Maintenance of Licensure Data Files for HPDS Allied Health Workforce Studies Special Projects: Service to the State and the Institution Annual Contract Current Year, $116,849 NC AHEC Program • State, Federal & Foundation Funding • Development of Dental HPSA process (HRSA, $450,000) • Evaluation of the National AHEC Program (BHPR, $239,467) • Physician Workforce Study with NC IOM (Kate B. Reynolds $44,491) • Rural Pharmacist Workforce Study (ORHP, $78,808) • Supply of Psychiatrists in NC (NC AHEC, $30,000) • Need for Assistance (NFA) process (BPHC, $90,000) • SE Regional Center for Health Workforce Studies (HRSA, $1,000,000) Multi Year Contract Total 2001-2007 $262,476 (Duke Endowment and NC AHEC)

21. Data Request Revenue • July 1, 2006 – August 30, 2007 • 253 total data requests • $6,536.29 Encumbered • Average 5-10 contacts regarding requests per week (including all types and follow-ups on requests in process) • Revenue supports publication of the annual Data Book and other publications, helps cover programming and administrative time, and helps purchase miscellaneous supplies & software • This is not typically a self-sustaining method to fund a data system

22. Data Sources

23. Examples ofSecondary Data Sources • Supply and distribution of pharmacists in North Carolina: HPDS data • Number, type and location of pharmacies in NC: NC Board of Pharmacy • Population data: Census, Claritas, State Demographer • Volume and payer type for prescriptions dispensed in NC: IMS Health • Enrollments and graduations from NC pharmacy schools: UNC-CH, Campbell • Informal interviews • Literature and internet searches • National workforce data: BHPr, AMA, APA, AANP

24. HPDS benefits from other data sets at Sheps • Area Resource File (1994-present, intermittent files for previous years) • HPSA/MUA file • Claritas (1998-2000, 2003, 2005) • AMA Masterfile (1981, 1986, 1991, 1996, 2000, 2001, 2004, 2005, 2006) • ADA Data (various) • NC Hospital Discharge Data (1989-2005, except 1995) • NC Ambulatory Surgery Data (1997-2005)

25. Why?Examples and Value of Work

26. The Data System Can Help Answer Questions Like: • How many dentists are there in North Carolina? Where are they practicing? • Are there too few psychiatrists in the state? • Are we retaining health professionals trained in North Carolina? • Will NC’s supply of physicians keep pace with expected population growth? • Does the ethnic and racial distribution of health professionals match the population? • How well do the linguistic capabilities of practitioners match the language needs of North Carolina’s citizens?

27. BUT it can’t answer some types of questions for lack of appropriate data: • When do physicians actually retire? • Are fewer physicians delivering babies because of malpractice issues? • Are we facing a psychiatrist shortage because reimbursement rates are too low? • Where should we put the new (dentistry, pharmacy, satellite medical) school? • Goal: to provide data-driven, timely and objective analyses to inform the policy debate.

28. The Basics: Describing the Workforce • For example… • Supply of physicians is growing, but growth has slowed • Average age of physicians is increasing slightly • Gender is converging slowly for new physicians • Newly licensed physicians were more likely to be female, be minority or be younger • Of the physicians that left the file between 2002-2003, 143 retired from practice and the average retirement age was 66 • 27% of active physicians in 2003 completed medical school in NC; 35% completed NC residencies

29. Makes analysis “simple” • Ongoing tracking stimulate attention and policy change • Having the trend data readily available makes it unnecessary to do complex studies • The data speak for themselves, and allows the stakeholders to feel some ownership in the data • Stakeholders can “do their own analysis” by asking us questions of the data which we can answer • Our data help people avoid doing large and complex (time-consuming) studies that cost a lot of money • In some cases, the Medical Board will include “survey” questions on their licensure and renewal forms, making it easier to collect data with broad interest

30. Informing Policy Makers North Carolina General Assembly, 2003-2006 • Planning for potential new schools of: • Dentistry • Pharmacy • Optometry • Plans for expansion of medical, dental schools • Effects of malpractice insurance rate increases • Effects of changes in license rules

31. Trends in the Supply of Dentists in North Carolina, 1996-2005 Policy Issue : Dental access in rural NC Key Findings: • NC lags behind national supply • Between 1996-2005, 33% of counties experienced decline in dentists per 10K pop, 26 of 33 were rural counties • Aging dental workforce, especially in rural counties • 87% of dentists are white Policy Response Legislature appropriated $89.6 million for new dental school at ECU and $96 million For expansion at UNC-CH February 2007

32. The Supply and Distribution of Psychiatrists in North Carolina: Pressing Issues in the Context of Mental Health Reform Policy Issue: State decentralizing mental health services—will there be an adequate supply of psychiatrists? Key Findings: • Overall supply adequate, distribution is a problem • 44 counties qualify as mental health professional shortage areas • Of 19 counties that qualify as primary care HPSAs, 11 have shortage of psychiatrists • 43 counties have no child psychiatrists Policy Response: • Legislature gave $500,000 of recurring funding to AHEC to address maldistribution and supply. Pilot efforts focus on mid-levels, residents and tele-psychiatry, consultation models. January 2006

34. NC AHEC, Sheps, NC IOM: The Primary Care and Specialty Physician Taskforce • HPDS data revealed in 2003 that rate of growth of physicians per10,000 population slowed • At same time, supply of primary care physicians did not keep pace with population in many rural counties • With funding from Kate B. Reynolds, NC IOM convened taskforce to examine issue • Nurse practitioners, physician assistants and certified nurse midwives included

35. The Primary Care and Specialty Physician Taskforce: Supply Projections Key Findings: • Despite rapid growth of NPs and PAs, NC provider supply will not keep pace with population • NC IOM made 32 recommendations to the legislature to address supply, diversity and maldistribution • Final report released June 2007; available at http://www.nciom.org 105% .75 FTE, faster growth 100% 95% Ratio Relative to 2004 Level 90% 85% .5 FTE, slower growth 80% 2004 2006 2008 2010 2012 2014 2016 2018 2020 2022 2024 2026 2028 2030 Year

37. Wrapping Up

38. “Giving Back” to the Boards Health Professions Licensing Boards • Consult on new or modified questions on licensing forms • Language ability (Pharmacy, Nursing, Medicine) • Race (Pharmacy) • Activity status (Physical Therapy) • Help evaluate online registration (Medical Board, Nursing)

39. Lessons Learned • Data driven workforce analyses necessary to: • Monitor longitudinal trends in supply and distribution—establish benchmarks. Are we worse or better off? • Identify emerging workforce issues • Challenge anecdotal evidence • Be perceived as objective in politically charged policy debates • Justify funding requests • Tackle discrete policy-relevant and manageable size projects • Disseminate results in short policy briefs with lots of pictures (maps are good…)

40. Health Workforce Planning: The Future • Workforce issues are not going away • Federal workforce research funds have been cut and there are limited national data • Responsibility falls on individuals states—most policy levers are at state-level

41. Moving Forward • We (HPDS) are starting to shift from “classic” workforce studies (assign physician to place, counts by county, look at distribution, etc.) to more in-depth analyses • Involves merging administrative and other databases onto our licensure files to capture more detailed information • Dr. John Doe is not just a surgeon at ABC Hospital; Dr. Doe does this many of these particular procedures on these types of patients per year, and has shifted from doing general surgery to more specialized surgical procedures

42. Recommendations • Start small and make a big impact • Expand later • Get a good team together - people with different skill sets who work well together and can learn from each other • What you’re looking to do will inform state policy = look for some state money to fund this (don’t depend solely on federal funding sources) • Stay objective and maintain credibility

43. Contact Us Katie Gaul k_gaul@unc.edu (919) 966-6529 Erin Fraher, Director erin_fraher@unc.edu (919) 966-5012 Tom Ricketts tom_ricketts@unc.edu (919) 966-5541 Jessica Carpenter jmcarpen@unc.edu (919) 843-3402 Cecil G. Sheps Center for Health Services Research University of North Carolina at Chapel Hill 725 Martin Luther King Jr. Blvd, CB 7590 Chapel Hill, NC 27599 HPDS Main Line: (919) 966-7112, nchp@unc.edu

44. HPDS Websitehttp://www.shepscenter.unc.edu/hp County- and region-level data Historical health professions trends (1979-2006) Practitioner per 10,000 population ratios and maps Data definitions HPDS publications, press releases Powerpoint presentations Data request instructions General information about the HPDS; frequently asked questions Sign-up for HPDS listserv Links to NC licensing boards, other national and state health workforce sites, other useful statistics sources

45. Extra Slides

46. Overview The North Carolina Health Professions Data System Background Organizational Issues Data Sources Special Reports and Projects Allied Health WHY? Examples and Value of Work Wrapping Up Contact Information

47. The Cecil G. Sheps Centerfor Health Services Research Founded in 1968; is one of the oldest and largest health services research centers in the nation Is an organizational unit of the University of North Carolina at Chapel Hill in the Health Affairs Division $14 million annual budget (2006) Employs or houses 170 staff including senior faculty, research fellows, analytic staff, fellows and graduate students Over 130 research fellows based in other academic departments, state and federal government, private industry and other countries are affiliated with the Sheps Center

48. Data Request Process Receive requests by • Email • Fax • Phone Informational Requests • Non-Sheps Data – refer to appropriate source (if possible) • HPDS Data request procedures • HPDS General Information Requests tracked in contact database (MS Access) • Requestor’s name & contact information • Detailed description of request • Output type • Due date – date sent

49. Data Request Process Two types of data requests: • Off the shelf data and publications • Aggregate statistics found on HPDS website or Data Book (e.g. How many RNs are active in Durham County?) • Requests for Publications (Data Book, fact sheets) • Requests requiring data processing • Aggregate statistics not found in HPDS publications (e.g. How many family practice physicians in the state provide obstetric deliveries?) • Individual level data • Mailing lists (e.g. Regional MS Society sending educational fliers to local physicians; Companies advertising CE programs to psychologists) • Analysis files for research Permission sought from board to release individual level data

50. Data Requests Requiring Processing Requests tracked in contact database (MS Access) • Requestor’s name & contact information • Detailed description of request • Output type • Due date – date sent Fees • Health Professions Data Book • $20.00 per book, plus postage • Mailing lists (name, address, county, specialty) • $4.50 per 100 names for electronic files • $100 minimum, non-profit organizations; $200 minimum, for-profit organizations • $600 maximum • Analysis files (including the above plus additional demographic and practice characteristics) • $7.00 per 100 names for electronic files • $200 minimum, non-profit organizations; $300 minimum, for-profit organizations • $700 maximum, non-profit organizations; $800 maximum, for-profit organizations • Requests requiring programming • $50.00 per hour for substantial requests (else free) Discounts given for AHECs, students, UNC System, North Carolina State Agencies, and at the Director’s discretion