Members Only | 02.28.19
Telemedicine: A Challenge With Great Rewards
By Maureen Kozlowski, CPCS, CPMSM
Technology is rapidly changing healthcare, allowing clinicians to find new ways to care for patients. As MSPs, we must find a way to make telemedicine happen in our facilities while maintaining quality and safety.
What is telemedicine? Many use the term interchangeably with telehealth, and others distinguish telehealth as a broader term that includes care via telephone, online chats, asynchronous communication, and electronic patient and provider education. Recently, some have begun to use the term “virtual care” as the broader definition.
For an MSP, however, the definition we follow is from the Centers for Medicare & Medicaid Services (CMS): “…the provision of clinical services to patients by physicians and practitioners from a distance via electronic communications. The Distant Site (DS) telemedicine physician or practitioner provides clinical services to the hospital or CAH patient either simultaneously, for example, as in teleICU services, or non‑simultaneously, as is the case with many teleradiology services.”
Whatever definition you accept, I believe that telemedicine is a challenge with great rewards for MSPs.
The MSP’s Telemedicine Connection
The month before I started at Mercy, the CMS began allowing “credentialing by proxy” for telemedicine providers at Originating Site (OS) hospitals, and the race was on! How quickly could our facility, and yours, develop a new process and begin to use it? What began as a recognition by CMS for “the removal of unnecessary barriers to the use of telemedicine” became the MSP’s next challenge.
Mercy knew the CMS change allowing credentialing and privileging by proxy was necessary to help build our telemedicine programs. At the time, we had about 14 hospitals that were receiving our telemedicine services, and we started having bi‑monthly calls to figure out how to implement this in our hospitals. I’d like to say it was easy, but developing a process that satisfied 14 independent medical staff offices and 14 separate medical executive committees (MECs) was not easy. It took us about 12 months to actually credential by proxy. However, after many calls, meetings, and emails, the reward was a new process which decreased the burden on our providers and our MSPs and has grown our telemedicine services to more than 40 hospitals. We did it!
Lesson learned: If your hospital has not yet accepted credentialing by proxy for your telemedicine providers, why don’t you be the positive influence to initiate this change in your hospital? In addition, although many hospitals have established processes for credentialing by proxy, I believe there are opportunities to improve the process and minimize the additional paperwork that many of our processes include. CMS outlined the minimal paperwork required in Pub 100-07, transmittal 78 on December 22, 2011, and I encourage all MSPs to familiarize themselves with this document.
Challenges to Credentialing by Proxy
Credentialing by proxy has created challenges for both the Distant Site (DS) and the OS, but understanding both sides will help all of us be more efficient. We can figure this out together! DS facilities (where the provider is located) meet the same Conditions of Participation (CoP), The Joint Commission (TJC) standards, or other credentialing standards as OS facilities (where the patient is) do. Some of the telemedicine‑specific challenges for a DS may be:
- Verification of Identification: Many DS facilities use contracted providers that never step foot in their building.
» Our verification of identification process includes either in‑person verification, or we allow the contract company employer to witness the provider in person and sign an attestation.
- DS providers are asked to sign numerous OS‑specific access forms, attestations, etc.
» We diligently work with our OS facilities to minimize these forms. Also, we have a single point of contact for our providers to funnel all requests through and ask our OS partners to communicate with our MSPs instead of reaching out to the providers. We realize if we overburden the providers, they will resist telemedicine opportunities and the patients will be the ones to lose out.
- FPPE/OPPE: Although a DS completes peer evaluations on all its providers, the challenge can be setting up a process to share information with OS facilities.
» Some services, such as radiology or neurology, have normal criteria to report while other services, such as teleICUs, only provide cross coverage type service and have minimal reportable data. We share volumes as applicable per service and, if any, the number of complaints.
- The CoP requires OS to share information with the DS at a minimum on adverse outcomes or events.
» As a DS, we solicit this information every six months to ensure our OS facilities are meeting this requirement. We recommend they keep the communications as proof of meeting this requirement.
OS facilities have different challenges specific to their telemedicine providers. Some of these are:
- Does using a telemedicine service provider mean there are larger pools of providers to credential?
» Credentialing by proxy allows the OS to get these providers working quickly while minimizing the work.
- Should we enter them in our credentialing software, and if so, should we complete all the fields?
» I recommend entering minimal demographic information and having a separate identifying field, so you can separate them for reporting. If you don’t have an identifier in your database, work with your software provider to build it.
- Can we use our current Delineation of Privileges (DOP), or should we accept the DS form?
» Using your current form may grant more privileges than the provider has at the DS. I recommend using the DOP from the DS or at least mirror their privileges.
- How will reappointments be handled? Should I put providers on my facility's schedule or stick with a separate schedule?
» You will need to do what works best for your facility, but I recommend reappointing all telemedicine providers at the same time. Develop a very minimal reappointment process with your DS and take care of them at one time.
- How do we handle credentials committees and MECs struggling with the differences in reviewing a credentialing‑by‑proxy file?
» Once you have learned the requirements for telemedicine, share your knowledge with your committees. These files should look different and have fewer documents to review. We include a detailed profile and an attestation letter of primary source credentialing. Also, reach out to your DS to have a spokesperson speak to your MEC if you are not completely comfortable.
Lesson learned: Communication is the key for both DS and OS facilities when using credentialing by proxy. We recommend quarterly calls, but you don’t have to wait for a scheduled call. Work with your telemedicine partners to eliminate barriers, and use your MECs to remove any unnecessary paperwork. These obstacles only add more time and frustration rather than value. Remember, you are both on the same team.
Telemedicine Workflows
The following timelines are examples of how my health system and other hospitals are using telemedicine to care for patients. It can be helpful for MSPs to understand the workflow and how the physicians we credential factor in to the process.
Example A:
» 9 a.m.: The patient arrives at a CAH with acute stroke symptoms.
» 9:10 a.m.: The emergency room nurse pushes a button on the stroke cart that connects to a nurse sitting at the virtual care center in a St. Louis suburb. The virtual care center nurse identifies the patient in a shared EMR and pages the on‑call neurologist located in Springfield, Missouri. The patient is sent for a CT scan.
» 9:25 a.m.: The neurologist reviews the patient EMR and calls the bedside nurse who connects the physician with the patient via audio video technology.
» 9:50 a.m.: The neurologist reviews the CT and orders a tissue plasminogen activator (tPA). An informed consent is documented with a bedside witness present.
» 10 a.m.: The patient is administered a tPA and admitted to the ICU or transferred to a hospital with the appropriate level of care.
» Three days later: The patient leaves the hospital with minimal side effects from an acute stroke.
Example B:
» 2 a.m.: A 2‑year‑old is brought to a rural hospital emergency room in distress.
» 2:10 a.m.: The emergency room nurse practitioner pushes a button on a mobile cart to request a consult with a pediatric emergency medicine physician.
» 2:20 a.m.: The pediatric emergency medicine physician calls in via video and assists with stabilizing the child.
As we know, many specialty physicians are in short supply, so having them available at the touch of a button allows for greater access and better outcomes. Other uses include behavioral health assessments and pediatric and adult specialty consults in emergency departments and in‑patient settings, tele‑ICUs, and hospitalist programs.
Telemedicine is not just being used in hospitals. Chronic‑care management teams are “seeing” patients at home, paramedics on oil rigs are communicating with physicians to administer virtual care, and the military and federal government have used electronic means on mountain tops and in remote locations for decades. Every day, new companies are starting to provide telemedicine services, remote physiologic monitoring (RPM), and artificial intelligence for improving patient care and health. Not all telemedicine would meet our standards for care, but we can’t assume that just because it is new or different that it’s bad. We need to accept the challenge and help our patients receive the best access to care that’s available. Your health or the health of someone you love may depend on it!
Share Your Knowledge
When our NAMSS Immediate Past President Diane Meldi asked if I would write an article for Synergy, my first thought was “I don’t have time.” My second thought was “I don’t have anything to say worth reading.” Then I thought about what I have learned from Diane and other MSPs. I told myself “I can do it.” Challenge accepted and complete.
Thank you to the MSPs who have assisted in my learning over the last seven years. You have made this “job” a challenge with great reward!
This feature appeared in the March/April 2019 issue of Synergy.
Maureen Kozlowski, CPCS, CPMSM, is director of support services for Mercy Virtual. She is responsible for licensing and credentialing and helped lead Mercy Virtual through a successful initial Joint Commission Survey in 2016. When she’s not working, Maureen enjoys spending time with her husband, three children, two daughters-in-law, and two precious grandsons.