Nursing Leadership

Nursing Leadership 33(2) June 2020 : 67-79.doi:10.12927/cjnl.2020.26236
Nursing Research

Nurse Practitioner Activities in Ontario Family Health Teams: Comparing Three Different Data Sources

Jennifer Rayner, Faith Donald, Ruth Martin-Misener, Rick Glazier and Alex Kopp

Abstract

Background: Despite the increase in nurse practitioners (NPs) working in primary healthcare, little standardized data are available to understand NP activities at the system level. The Nurse Practitioner Access Reporting system (NPAR), a pilot project underway at 40 family health teams in Ontario, involves NPs recording and submitting standardized codes. The codes are intended to reflect NPs' clinical activities, using an existing physician claim system. The study compared how well data collected through NPAR reflect NPs' activities.

Methods: The mixed-methods approach was used involving NPAR data, focus groups and time and motion data.

Results: All data sources indicated that NPs spent the majority of their time on direct patient care. Qualitative data and time and motion data revealed gaps in NPAR data, for example, codes that fail to capture activities unique to the NP role.

Conclusion: Analysis of NPAR, time and motion and qualitative data provided a distinctive opportunity to examine NP-reported activities and patient characteristics; however, NPAR data did not adequately describe the scope or breadth of activities of NPs practising in primary healthcare.

Introduction and Background

Provinces in Canada have different regulations for nurse practitioner (NP) practice. In Ontario, NP legislation was passed in 1998; however, there was limited opportunity for employment (Blythe et al. 2006) until early 2000 when a wave of primary care reform promoted the development of interprofessional team models (Hutchison et al. 2011). New models that included NPs such as family health teams (FHTs) were developed. There are currently 2,940 primary healthcare NPs working in Ontario, and the majority of Ontario NPs (75.9%) are employed in community settings (CNO 2019). Approximately 500 NPs are employed at FHTs (NPAO 2019).

Researchers have examined the outcomes associated with various primary healthcare models, and a striking finding has been the difficulty in quantifying primary healthcare services (Hutchison et al. 2013). This finding is largely a result of the complexity inherent in the process of standardizing measurement across a changing system using variable data collection techniques and different information management systems and electronic medical records. Consequently, researchers and planners often resort to the use of physician billing data to understand activities and outcomes in primary healthcare.

The Nurse Practitioner Access Reporting system (NPAR) is a reporting mechanism developed by the Ontario Ministry of Health and Long-Term Care (MOHLTC) to establish an accountability system for NP practice (MOHLTC 2007). The NPAR is based on assumptions regarding accurate reporting for planning and evaluation purposes. It was created to replace a reporting system based on Excel spreadsheets (Strickland et al. 2014). In 2011, the NPAR initiative was piloted at 40 FHTs (MOHLTC 2011). A set of NPAR service codes was initially adapted from the Ontario Schedule of Benefits for Physician Services and further adapted to include NP-specific service encounter codes (Q codes). Only direct patient activities were recorded using an NPAR service code and a diagnostic code (if applicable). Several service codes did not require a diagnostic code (e.g., wound care). The pilot site personnel, including NP participants, underwent an initial orientation and were trained on how to record and determine levels of assessment and how to use Q codes. The Q codes were submitted to the MOHLTC electronically through the existing claims system used for physician billing (Strickland et al. 2014), which enabled access to these data through the existing Ontario Health Insurance Program database.

Strickland et al.'s (2014) evaluation results suggested that the NPAR was implemented as an effective and efficient reporting system that could be used to record and evaluate NP clinical activities, but the authors recommended modifications to demonstrate the full scope of NP practice. The authors concluded that it was unclear whether NPAR data contributed to demonstrating the value and unique role of the NP (MOHLTC 2011). Heale et al. (2018) conducted a cross-sectional study examining NPAR data and provided a snapshot of NP practice FHTs between 2012 and 2015. This study indicated that NPs saw patients across all age groups and addressed acute and episodic care and chronic disease management issues. An outstanding issue raised by the authors was that NPAR data only reflect direct clinical care versus other work such as evaluation, planning or teaching activities (Heale et al. 2018).

The purpose of this current study was to examine the usefulness of NPAR data in describing the work done by NPs in FHTs by using two comparison data sources: time and motion data and qualitative data.

Main Objective

The study's main objective was to compare NP activities, documented using NPAR data, with time and motion data and qualitative focus group data, collected by NPs in the NPAR pilot organizations.

Method

Design

A mixed-methods design was used to explore and describe NPAR data reported by NPs and to compare these data to time and motion data and qualitative data collected through focus groups. Ethics approval was granted by the Ryerson University Research Ethics Board.

Data Sources

Data sources included the following: (1) the NPAR data set held at the Institute for Clinical Evaluative Sciences (ICES), (2) qualitative data from focus groups held with NPs and administrators employed at the FHTs piloting NPAR exploring perceptions of the utility and accuracy of NPAR and (3) time and motion observation data of NPs in FHTs collected in a recent study (Donald et al. 2016).

NPAR Data

Participants

In total, 34 FHTs and 101 NPs have submitted data as part of the NPAR pilot project. These data are housed at the ICES. The remaining six pilot sites did not have data available.

NPAR data analysis

Secondary data analyses of the NPAR data were conducted at the ICES, using the Ontario Health Insurance database and SAS (version 9.3) software. The FHT name was encrypted to ensure confidentiality. Data from April 1, 2012, to March 31, 2015, were included. All data were stratified by rurality using the Rurality Index of Ontario (Kralj 2009). Descriptive statistics were calculated to describe the NPAR data.

Focus Group Data

Recruitment and participants

The executive directors of all NPAR sites were informed about the study through an e-mail sent by the Association of Family Health Teams in Ontario. The executive directors were invited to participate in a focus group. They were asked to share an invitation to participate in a focus group with all NPs in the organization.

All 34 NPAR pilot sites were invited to participate in the focus groups. In total, 21 participants from 15 FHTs participated. Two focus groups were with NPs (16 participants), and one focus group was with executive directors who were responsible for NPs (five participants).

Focus groups

Three focus groups were conducted. All focus groups were conducted on the telephone and were one hour in duration. The telephone was used to ensure that geographically diverse and busy participants could attend (Hurworth 2004). The focus group was held over lunch and scheduled at the convenience of the participants. A semi-structured interview guide was developed by the research team, using pre-existing knowledge as well as input from a stakeholder meeting. The interview guide was tested with members of the research team. This guide was used during each focus group interview. Two members of the research team took part in each focus group. Probes were included to overcome participation limitations of telephone focus groups (Allen 2013). The same person conducted each focus group, and the other person took notes throughout. All focus groups were recorded and transcribed verbatim.

A thematic analysis was conducted by two members of the research team, using the six steps described by Braun and Clark (2006), to find patterns, identify themes and gather examples from the transcripts. Analysis included becoming familiar with the interviews, generating initial codes, searching for additional themes, reviewing and defining the themes and, finally, producing a report that illustrated the themes with examples.

Time and Motion

Participants

Four NPs, from two different FHTs, were included in the time and motion study.

Time and motion data

A time and motion tool was used to record observed NP activities in one-minute increments over a five-day typical week. The tool was validated for primary healthcare in Quebec (Kilpatrick 2011). The research team was trained to use the tool and intra-and interrater reliability were assessed. This tool was used to record activities of NPs (n = 18) in eight Ontario primary healthcare practice settings, of which two were FHTs, as a component of the main study (Donald et al. 2016). Time and motion data included in the analysis reported in this paper were from the participating two FHTs, that included four NPs. Time and motion data were compared to NPAR and focus group data.

Analysis Strategy for Comparison of Data Sources

Descriptive statistics were calculated to describe the NPAR data and to examine the time and motion data from the two FHT settings. Frequencies for the time and motion data were run using SPSS version 15. These results were then compared to the focus group results for areas of consistency, parallels and divergence.

Results

NPAR

NPAR data were collected over three years and stratified to examine differences between urban and rural sites (Table 1). In total, 34 FHTs and 101 NPs were included in the NPAR analyses. On average, 23 NPs worked in rural FHTs compared to 56 NPs in urban FHTs. In general, rural NPs provided care to a slightly smaller group of patients with a higher number of visits per patient compared to those seen at urban sites.


Table 1. Number of patients seen by NPs and number of NPAR claims from 2012 to 2015
  2012–2013 2013–2014 2014–2015
Rural Urban Rural Urban Rural Urban
Number of patients 15,781 48,556 14,043 52,770 16,105 49,094
Number of NPs 22 56 26 58 26 55
Number of NP claims 67,426 165,036 59,045 173,872 65,592 159,698
Number of patient visits* 37,772 90,553 33,054 96,489 36,589 85,135
Average number of claims per patient 4.3 3.4 4.2 3.3 4.1 3.3
Average number of visits per patient 2.4 1.9 2.4 1.8 2.3 1.7
Average number of patients/NP 717.3 867.1 540.1 909.8 619.4 892.6
*One visit per person/NP/dayNP = nurse practitioner; NPAR = Nurse Practitioner Access Reporting

 

The top diagnosis recorded was "no diagnosis" (Table 2). The NPAR system does not require a diagnosis to be entered for diagnostic and therapeutic procedures (e.g., wound care, tests, venipuncture). Other diagnostic information was consistent among rural and urban NPs, indicating that a range of issues were being addressed by NPs, including chronic diseases, mental health, episodic care and wellness/preventive care. In years one and two of the data included, hypertension was the most commonly identified condition in rural FHTs (4.8%), whereas diabetes was the most commonly identified condition in urban centres. However, by year three, diabetes was identified similarly across the 34 FHTs.


Table 2. Top 10 issues addressed in NPAR (percentage of total issues) from 2012 to 2015
Diagnostic code 2012–2013 2013–2014 2014–2015
Rural Urban Rural Urban Rural Urban
No diagnosis 17.8 23.3 20.4 18.2 19.6 18.2
Other ill-defined conditions 2.1 4.5 4.0 4.9 4.6 7.5
Diabetes mellitus 2.6 4.5 3.0 4.3 3.5 3.6
Common cold 2.2 2.7 1.7 3.5 1.9 3.4
Hypertension 5.3 3.1 5.3 2.9 4.8 3.0
Anxiety 2.0 2.4 2.0 2.7 2.2 2.7
Annual health examination 3.4 2.0 1.5 2.1 1.9 2.4
Family planning 1.8 2.1 1.6 2.3 1.5 2.4
Well-baby care 2.4 1.9 2.9 2.3 2.9 2.3
Warts 1.6 1.4 1.4 1.9 1.2 2.2

 

The NPAR-reported activities were similar for NPs practising in both rural and urban sites and over time (Table 3). Generally, assessment and counselling accounted for the greatest amount of NP time. In rural FHTs, three codes accounted for 41% of rural NP service codes and 51% of urban NP service codes: (1) minor assessment (brief history or exam), (2) intermediate assessment (more extensive than the minor one) and (3) counselling (dialogue about diagnosis, health maintenance and prevention). Individual counselling was higher in the urban FHTs compared to rural FHTs. The NPs in the rural FHTs recorded more chronic disease management service codes compared to the NPs in the urban FHTs. This may explain the slightly higher number of visits per patient for NPs in rural sites.


Table 3. NPAR data: Top 10 annual activities in NPAR by proportion of overall events from 2012 to 2015
Q code Rural Q code Urban
2012–2013 2013–2014 2014–2015 2012–2013 2013–2014 2014–2015
Minor assessment 15.5 16.2 16.2 Intermediate assessment 27.1 25.8 26.4
Intermediate assessment 15.2 14.3 15.4 Individual counselling 17.8 15.0 16.1
Individual counselling 9.0 8.5 9.4 Minor assessment 14.6 10.2 8.8
Telephone advice/counselling 6.3 4.8 4.9 Telephone advice/counselling 8.2 6.1 5.8
Referral to specialist 4.3 4.6 4.7 Referral to specialist 4.4 3.7 3.6
Delegated activity* 3.2 4.8 4.0 Gynecology (pap smear) 4.2 2.4 3.2
CDM (specific to CHF, cardiovascular) 0.2 3.0 3.1 Referral to provider 3.0 2.8 2.8
CDM (general) 7.1 3.4 2.9 Immunization 2.7 2.4 2.2
Immunization 2.4 2.7 2.5 Annual health exam (adolescent) 0.57 2.2 2.0
CDM (endocrine) 0.14 1.9 2.4 Screening – cardiovascular 0.10 1.4 2.0
Note: CDM = chronic disease management; CHF = congestive heart failure; NPAR = Nurse Practitioner Access Reporting.
*Any procedure ordered by the NP and carried out by a registered nurse or registered practical nurse.

 

Focus Group Results

All NP and administrator participants were female. They represented organizations from rural and urban areas as well as academic/teaching centres and nonteaching FHTs. The three themes identified from the focus group analysis indicated that NPAR data did not reflect the full scope of NP activities, were not being used for planning or improvement and did not reflect the unique role of NPs.

All the participants reported that NPs saw between 10 and 15 patients per day. The majority of NP time was spent dedicated to direct patient care. Typical appointments lasted for 30 minutes. Direct patient care activities included chronic disease management, episodic care and health promotion and education. NPs also reported being responsible for quality improvement initiatives (e.g., cancer screening, same-day access), teaching (e.g., students), program development (e.g., health promotion and chronic disease management groups) and evaluation (e.g., program evaluation of activities within the FHT). Most NPs reported spending approximately 80% of their time on direct patient care and 20% on indirect care (e.g., charting, completing forms, care coordination, administrative meetings).

NPs did not use NPAR data in decision making or program planning in their practice setting. Two administrators indicated that they were able to use some NPAR data to help with quarterly reporting to their funders, such as the numbers of patients seen and various activity measures. Despite this potential utility, overall, NPs and administrators perceived that the "data went into a black box" and they had "no concept of how or if it was used" once it was submitted.

All participants reported that the NPAR data elements lacked comprehensiveness and did not adequately describe the work of salaried NPs. They explained that NPAR data did not capture activities related to the social determinants of health, acuity of problems, multiple conditions, initial visits or time spent providing coverage for physicians (e.g., laboratory test results, consults). The participants expressed concern that NPAR data were incomplete and too focussed on overall numbers instead of quality of care. One NP remarked the following:

When I started 4 or 5 years ago, it felt more like shadow billing and that you were billing [coding] like the doctor's bill. In the five years I have been here, our role has changed so much and we have evolved as NPs and we're going into our own profession, so I don't think it captures how we've evolved and how complex our practice has become. We are not doctors, we do not bill like doctors, we cannot bill the same way and I find that is my big frustration with NPAR because I feel forced to bill [code] like a doctor. I am not a doctor and I don't want to bill [code] that way. I don't want to reflect my job that way. It is just a bunch of numbers.

There was widespread agreement with this statement, and most participants added that "the system is based on doctor billing and does not provide any evidence to the unique role of NPs." All participants believed that accountability was important and wanted to demonstrate the unique role of NPs.

Time and Motion Results

The time and motion data indicated that the bulk of NP time was spent on direct and indirect care (Table 4). Direct service included all activities related to patient care, such as physical exams, assessment and health teaching. Indirect activities included documentation in the electronic medical record, administrative meetings and coordination activities within the organization. Ten activity types accounted for 69.2% of the overall time NPs spent working (Table 4). Direct care activities accounted for 53% of the time spent with these 10 activities. Activities that were not commonly recorded reflect the remainder of the time and are not included in this analysis.


Table 4. Time and motion data: Top 10 activities by proportion of overall time observed by two FHTs
Description Percentage of overall time
Documentation (EMR, letters, forms) 14.4
Physical exam* 11.8
Therapeutic relation with patient* 8.2
Order/interpret labs* 7.3
Personal time (e.g., lunch, breaks) 5.8
Teaching education (with the patient)* 4.8
Collaborate/consult with other HCP (oral) 4.7
Monitor/prescribe meds* 4.4
Administrative meetings 4.1
Care coordination within organization 3.7
EMR = electronic medical record; FHT = family health team; HCP = healthcare provider.
* Direct patient care activities

 

Discussion

This study explored NPAR-reported data and sought to determine its usefulness in describing the work of primary healthcare NPs by comparing these data to two additional data sources. Although there were several consistencies across the three data sources, the analyses of time and motion data and qualitative focus group interviews suggest that NPAR data do not describe the full range of activities undertaken by NPs working in FHTs.

The three data sources indicate that varying amounts of NP time are spent on direct patient care. The granular time and motion data revealed that both direct and indirect activities took up a little over 50% of direct care, whereas focus group participants suggested that 80% of NP time was spent on direct client care. The time and motion data included the time spent on documentation in the electronic medical record or consultation with other providers as indirect care. The focus group participants may have considered both of these activities as part of direct care because they are connected directly to patients. Time and motion results indicated that indirect care mainly consisted of patient documentation, including charting, letters and completion of forms. Based on the time and motion data, on average, NPs in FHTs saw nine patients face-to-face each day and provided other care by phone (data not shown). The analysis of NPAR data suggested that NPs provided comprehensive primary healthcare, including chronic disease management, assessment, treatment and preventive care. The average number of patients seen by NPs each year was slightly higher in urban areas. However, NPs in rural areas saw patients slightly more often, and more of the patients in rural areas were living with at least one chronic disease when compared to the patients in urban areas. The NPAR data did not allow the detection of patients with multiple co-morbidities within one visit. The types of services provided by NPs were similar in both rural and urban areas.

Focus group participants stressed that NPAR data did not adequately describe the services NPs provided or the patient complexities. For example, NPAR coding allows only one diagnosis per visit. NPs indicated that many patients have more than one reason for seeking care, and NPs do not limit patients to one concern. In addition, NPAR codes fail to capture the broader activities of NPs such as program planning, evaluation/quality improvement, administration and teaching. The time and motion data suggested that patient education and therapeutic relations with patients are important and time-consuming aspects of NP patient care, and these are not captured adequately in the NPAR data entry. The consensus among the focus group participants was that NPAR data did not reflect or demonstrate the unique role of the NP working in primary care. Similarly, a recent study by Katz (2012) suggested that physician billing data did not reflect the scope of clinical practice or the complexity of physician–patient interactions.

Study Limitations

There were several limitations to this study. The NPAR data were based on 101 NPs employed at 34 FHTs; however, the time and motion data were collected at only two FHTs with four NPs, over a five-day period. These two FHTs and/or four NPs may not have been representative of the larger group. During the focus groups, other difficulties with NPAR were identified, such as lack of training for new NPs and the use of clerical staff to enter NPAR codes. This lack of consistent, ongoing training and NPAR code entry may have impacted the accuracy of the data and results. Finally, NPs and administrators who volunteered to participate in both the focus group interviews and the time and motion study may not be reflective of all NPs and administrators employed in FHTs (volunteer bias).

Conclusion

This study examined the utility of NPAR data in describing the work done by NPs at 34 FHTs in Ontario. The NPAR is a form of shadow billing and is similar in structure to administrative physician billing. An important difference between the providers lies in the form of remuneration; as NPs are paid a salary, they are not reliant on these data for payment for their services. However, all participants in this study agreed that NP data are important for accountability and population-based planning. A criticism raised of the NPAR system is that it does not accurately describe the work of NPs. This identified gap in coding presents a unique and timely opportunity to develop indicators to collect meaningful information that captures NP activities that reflect the value add of the NP role (Mundinger 2002; van Soeren 2009) and are linked to "improved" health outcomes (Martin-Misener et al. 2015; Russell et al. 2009) as well as "enhanced" organizational and team outcomes.

NPAR data are currently being recorded by NPs employed within a small number of NPAR-pilot FHTs in Ontario. This study suggests that the data do not capture the full breadth of NP activities. Despite this reality, the NPAR data system provides a potentially unique administrative data source that can be modified to accurately reflect NP work. Policy implications include adapting NPAR to include a broader range of relevant primary care activities that include those that may be unique to NPs and/or to use electronic medical record data extraction to track NP activities. This has been successfully achieved within community health centres in Ontario with standardized data entered into the electronic medical record by all providers (Alliance 2015). These data are extracted and can be linked to other administrative databases, ensuring that the continuum of care can be analyzed. It is clear that standardized data are required to evaluate the full range of NP activities and their relationship to patient, organizational and system outcomes.

About the Author(s)

Jennifer Rayner, PhD Director, Research and Evaluation, Alliance for Healthier Communities Toronto, ON, Adjunct Faculty Member, Centre for Studies in Family Medicine, Schulich School of Medicine and Dentistry Western University, London, ON

Faith Donald, NP-PHC, PhD, Associate Professor, Daphne Cockwell School of Nursing, Ryerson University, Toronto, ON

Ruth Martin-Misener, NP, PhD, FAAN, Professor and Director, School of Nursing, Assistant Dean Research, Faculty of Health, Dalhousie University, Halifax, NS

Rick Glazier, MD, MPH, Senior Scientist, Institute for Clinical Evaluative Sciences, Staff Family Physician, St. Michaels Hospital, Toronto, ON

Alex Kopp, BSc, Senior Methodologist, Institute for Clinical Evaluative Sciences, Toronto, ON

Correspondence may be directed to: Jennifer Rayner, PhD, Alliance for Healthier Communities, 970 Lawrence Ave., Toronto, ON, Canada M6A 3B6. She can be reached by phone at 647-638-8437 or by e-mail at jennifer.rayner@allianceon.org

Acknowledgment

This study was funded by the Ontario Ministry of Health and Long-Term Care (MOHLTC), Health Services Research Fund, Ministry Grant Number 06695. The study was further supported by the Institute for Clinical Evaluative Sciences (ICES), which is funded by an annual grant from the Ontario MOHLTC. The opinions, results and conclusions reported in this paper are those of the authors and are independent from the funding and information sources. No endorsement by the ICES or the Ontario MOHLTC is intended or should be inferred.

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