Medical Staff Briefing

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1 training resource for medical staff leaders and professionals Medical Staff Briefing Volume 24 Issue No. 9 SEPTEMBER 2014 P4 P6 P8 P11 The path to core privileges conversion to core privileging is underway at MaineHealth, and the effort has spurred a standard application for privileges among the eight hospitals in the system, says the head of the system s CVO. Is your autopsy policy current? In the first installment of a two-part series, columnists Patricia. Furci, RN, MB, Esq., and Samuel J. Furci, MP, take a look at the procedure s place in modern healthcare and reasons it should not be considered a dying art. Telemedicine is picking up static Regulatory obstacles are preventing the telemedicine industry from reaching its full potential, while raising legal questions for both hospitals and physicians. Late practice physicians The best time to create your position on the aging physician is before you have an 80-year-old surgeon requesting new privileges in bariatric surgery, writes William K. Cors, MD, MMM, FCPE. Physician education The long view: What to expect from a single O-CGME accreditation system The merican Osteopathic ssociation (O), the ccreditation Council for Graduate Medical Education (CGME), and the merican ssociation of Colleges of Osteopathic Medicine (COM) have begun the process of creating a single accreditation system for all U.S. graduate medical education (GME). The final result could be a simplified verification process for MSPs and CVOs, but a lot must happen before the system is fully implemented and the target date for completion is June The new system will allow graduates of U.S. DO and MD medical schools to complete their residency/ fellowship education in CGME-accredited programs and demonstrate achievement of common milestones and competencies. ll DO or MD school graduates will be eligible for board certification to become practicing physicians. When it s complete and operational, the single accreditation system might expedite the credentialing process for MSPs because they will have only one accrediting body to check when verifying residency training from recent trainees, says Stephen C. Shannon, DO, president of COM. The association represents the 30 accredited colleges of osteopathic medicine in the United States. The net effect will depend on how credentialing, privileging, and primary source verification are done in your medical staff services department. You re still going to want graduate medical education, board certification, that kind of basic information, but it will be one set of standards, if you will, Shannon says. Everybody will have met CGME standards coming out. Some DOs as well as some MDs will also have osteopathic recognition included in their specialty training, too. But they still will have met all CGME standards coming out of their specialty program. pproximately 20% of U.S. medical students more than 23,000 are receiving osteopathic instruction

2 Medical Staff Briefing September 2014 at 42 teaching locations in 28 states in the academic year. Six of the colleges are public and 24 are private institutions, according to the COM. Changes ahead The single system won t be an entirely new entity: The CGME s system will continue to exist, and osteopathic program recognition will also continue. However, there will be substantial modifications to the CGME system to allow unification of the two, says Shannon. These significant structural changes include the addition of two new committees within the CGME. One of these is the Residency Review Committee (RRC) for neuromusculoskeletal medicine, an accredited specialty that exists within the osteopathic professional association but not in the CGME. That RRC should be up and running in about a year, according to Shannon. The CGME will also form an Osteopathic Principles Committee (OPC), which will establish and evaluate programs for osteopathic recognition within the CGME. Specialties that wish to receive osteopathic recognition would not only be approved by the individual specialty RRC, but would also have to meet additional standards established by the OPC. This will enable the osteopathic residency programs to exist within the CGME, while still preserving some of the curriculum and osteopathic practices and principles that exist within the O system, even after the systems combine. In addition, MDs will be able to apply for and gain access to the osteopathic recognized residency programs within the CGME as well as the new neuromusculoskeletal specialty that the CGME will establish. There will be a way for MDs to apply for and gain admission to those other training programs as well. Joining the board The combined system includes other important changes, Shannon says. The COM and O will become member organizations of the CGME with full board representation, joining the merican Board of Medical Specialties, the merican Hospital ssociation, the M, the ssociation of merican Medical Colleges, and the Council of Medical Specialty Societies. Each will nominate four DOs to serve on This document contains privileged, copyrighted information. If you have not purchased it or are not otherwise entitled to it by agreement with HCPro, a division of BLR, any use, disclosure, forwarding, copying, or other communication of the contents is prohibited without permission. EDITORIL DVISORY BORD Product Manager, Digital Services drienne Trivers Follow Us Managing Editor Mary Stevens Follow and chat with us about all things healthcare compliance, management, and lpesh N. min, MD, MB, FCP Executive Director Hospitalist Program Vice Chair for Clinical ffairs & uality Dept. of Medicine University of California, Irvine Michael Callahan, Esq. Katten Muchin Rosenman, LLP Chicago, Illinois William K. Cors, MD, MMM, FCPE Chief Medical uality Officer Pocono Health System East Stroudsburg, Pennsylvania Jack Cox, MD, MMM Senior Vice President / Chief uality Officer Hoag Hospital Newport Beach, California Sandra Di Varco McDermott Will & Emery, LLP Chicago, Illinois Roger. Heroux, MH, PhD, CHE Founding Partner Hospitalist Management Resources, LLC HMR ED Call Panel Solutions Pensacola Beach, Florida Jonathan Lovins, MD, SFHM Hospitalist and ssistant Clinical Professor of Medicine Duke University Health System Durham, North Carolina Sally Pelletier, CPMSM, CPCS Senior Consultant and Chief Credentialing Officer The Greeley Company Danvers, Massachusetts Richard E. Rohr, MD, MMM, FCP, FHM Director of Hospitalist Programs Guthrie Healthcare System Sayre, Pennsylvania Jodi. Schirling, CPMSM lfred I. dupont Institute Wilmington, Delaware Richard. Sheff, MD Principal and Chief Medical Officer The Greeley Company Danvers, Massachusetts Raymond E. Sullivan, MD, FCS Waterbury Hospital Health Center Waterbury, Connecticut Medical Staff Briefing (ISSN: [print]; [online]) is published monthly by HCPro, 75 Sylvan St., Suite -101, Danvers, M Subscription rate: $389/year or $700/two years; back issues are available at $25 each. MSB, P.O. Box 3049, Peabody, M Copyright 2014 HCPro, a division of BLR. ll rights reserved. Printed in the US. Except where specifically encouraged, no part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro, Inc., or the Copyright Clearance Center at Please notify us immediately if you have received an unauthorized copy. For editorial comments or questions, call or fax For renewal or subscription information, call customer service at , fax , or customerservice@hcpro.com. 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3 September 2014 Medical Staff Briefing the CGME board of directors over a phased-in period, according to the O. In addition, osteopathic physicians will be on the RRCs within the CGME. Under the new system, the CGME family practice program will be overseen by an RRC that includes DO committee members. It is anticipated that current O-accredited osteopathic family practice programs as well as some CGME-accredited programs will seek the additional designation of osteopathic recognition, indicating that graduates will also achieve the competencies required for that recognition, Shannon says. That will be the core family practice training plus standards [for] ongoing training in osteopathic principles and practices that have to do with such competencies as the use of manipulative medicine for diagnosis and treatment, he says. Standards review meetings between RRCs and Specialty Committees started in 2013 and will continue through the transition, according to the O. Institutions may apply for pre-application status beginning in pril 2015, and programs will be able to apply for pre-accreditation status in July From July 1, 2015, to June 30, 2020, O-approved and accredited training programs can register for CGME pre-accreditation status and begin the application process for CGME accreditation. O programs are expected to complete the transition to CGME accreditation before July 1, The O will cease providing GME accreditation in July 2020, according to COM. There have been discussions about combining GME systems for several years, but they intensified in the last two years. There s a lot of work to do even before July 2015 comes along. In the end, it will be a seven-, eight-, or nine-year process of implementing all this, Shannon predicts. System drivers The changing healthcare landscape is one of the drivers behind the combined accreditation, Shannon says. The changes in healthcare really refocused everybody s mind on systems-based approaches, use of data, implementation of quality and performance evaluations, and the ability to implement competencybased education and evaluation. ll of these things drive organizations to look for ways to collaborate both in terms of ensuring quality outcomes to the public as well as looking for efficiencies in processes. nother important factor is the emergence of GME as a policy issue, with the nation facing physician shortages and scarce GME spots. Unifying the system in this way provides all of us involved in the policy arena with a clearer message to policymakers around what graduate medical education is like and what our system is like, he says. Even without these forces, a single accreditation system is likely an idea whose time has come. The trend is toward innovation and changes in medical and health professions education in general, especially during the last decade. This is happening both for MD and DO medical education, as well training in other health professions. There s more focus on the new and transforming healthcare system and training the types of physicians needed for that system, says Shannon. Osteopathic training programs were on a parallel path in terms of developing mechanisms by which they could evaluate competencies within the various specialties. In some way, that provided us even further impetus to come together. We are all evaluating and working on improving education of medical students. We re looking at competency evaluation and training for the new healthcare system, increased uses of information technology, and all those things, anyway. The new system likely won t blur the distinctions between MDs and DOs. Many DO graduates about 60% go into CGME-accredited residency programs, says Shannon, so potential crossover between MD and DO GME training wouldn t be a big issue for osteopathic students. The bigger issue might be for MD students interested in GME programs with osteopathic recognition, because they might not have the background that osteopathic students learn during four years of osteopathic medical school. That might be a bigger change in terms of MD education than in DO education, but that all remains to be seen, Shannon says. One characteristic of osteopathic medical education that s much less prevalent in the CGME system is a consortium arrangement for education. ll osteopathic residency programs and medical schools have to be involved in such a consortium. These consortia enable education to occur in community-based and smaller institutions, so I think 2014 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or HCPRO.COM 3

4 Medical Staff Briefing September 2014 there may be some ability for an expanded role for community-based education, especially in the primary care areas and maybe out-of-hospital type of training for everybody as a result of this as well, says Shannon. It will be important for the medical education community to recognize the value of both traditions as the two accreditation systems integrate and emerge as a single system. There will be a lot to do between now and 2020, but I think in the end, almost everybody recognize the value of the unified GME accreditation system, Shannon concludes. H Core privileging step-by-step approach to systemwide change Editor s note: conversion to core privileging is underway at MaineHealth, and the effort has spurred a standard application for privileges among the eight hospitals in the system. MSB recently spoke with Cheryl Schilke, RN, CPMSM, director of Synernet, MaineHealth s partner CVO based in Portland. On the organization s to-do list: develop and implement core privilege forms for eight hospitals in the MaineHealth integrated healthcare delivery network. What was the impetus for this effort? We wanted to make it easier for a practitioner to move from one hospital to another [in the Maine- Health system]. They also want an OPPE and FPPE system that can roll up systemwide, so there s information that can be shared in order to prevent someone from getting appointed at one hospital and not getting appointed at another. Those are our long-term goals. For short-term goals, the first step was to establish common reappointment dates and to provide physicians with one application form for all the facilities, with separate privilege forms at the moment. Our next short-term goal is to develop standardized privileging criteria with some adjustments for Maine Medical Center, which is a tertiary care hospital within the system [with privileges] that are not provided at the community level. But aside from that, we re developing systemwide standards for getting a privilege. So if you get your appendix out at Maine Medical Center or if you get it out at Waldo General Hospital, there are the same privileging criteria for the surgeon. s an outreach of that, we re developing a single privilege form that allows certain privileges to be greyed out if they aren t available at certain facilities. gain, the goal is to make it easier for the practitioners not only will they have one application for all the hospitals, but they will also have one privilege form and will be required to meet the same standard across every hospital in the system. How far along is the single-form project? fter a year of work, we have agreement with the medical staffs of all of the [MaineHealth] hospitals for forms for the first three specialties. Our first three were psychiatry, anesthesiology, and emergency medicine. We re cleaning up the format of those forms now and figuring out how we re going to implement online privilege requesting. The standardized forms are not in general use at the moment, but we re very close. Now we have an established task force of physicians in each specialty representing all the hospitals [to develop single privilege forms] for three more specialties. The process we have adopted to do that is that there is a clinical specialty task force with a physician leader. That task force meets in person once, then they have regular phone meetings. We gave them a template to work from, using all the forms and criteria for all the hospitals, so they have all the criteria laid out in front of them. They make recommendations and hash it out among themselves, then it goes to each individual hospital s credentialing committee and medical executive committee for consent and approval, and an agreement to use the form in a uniform manner. Once all that s done, then we clean up the form and we ll put it out for general use. 4 HCPRO.COM 2014 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or

5 September 2014 Will that expedite the privileging processes? Currently my CVO mails out the privilege forms with the applications, and if we have somebody going to two hospitals at the moment, we send one application and two sets of privilege forms. In the future, we ll send one application and one privilege form, with places to request for multiple facilities. That will make it a lot easier on the provider, and since we synchronized the reappointment dates, they will only hear from us once every two years. Will these forms be used by physicians in hospital-owned practices? The hospital is the organization that sets the privilege form. So every physician who s going to apply to one of the MaineHealth hospitals will be using the same privilege set. ny physician who applies will get the same privilege form they can be community physicians. The people serving on the task force are a mixture of employed and non-employed because obviously, there s a huge mixture now in medicine altogether when it comes to medical staffs. But this effort is not driven by hospital administration; it s being driven by the medical staff. MaineHealth and the hospitals want them to do this, but medical staff members are the ones who are designing the form. Do you have a rough idea of how many practitioners this will affect? Eventually, when we cover all specialties and allied health Ps, PNs, as well as ancillary specialty podiatrists, psychologists, anyone who is eligible for medical staff membership at our hospitals will eventually be covered, and that s slightly over 3,000 people. On the CVO side, our traditional customer has been hospitals because we were created by a hospital, so that s our primary focus, although we do ambulatory surgery as well. We got some nontraditional customers last year, [including] Maine Community Health Options that s the affordable care exchange for Maine. That was a whole different work product for us, which required a lot of interesting work. What were some of the differences? Medical Staff Briefing For Maine Community Health Options, it s just managed care criteria instead of The Joint Commission and CMS criteria, which means you can shave a little off on the education and don t need to primarysource-verify everything. For example, we only go to the highest level of practitioner education, things like that. It was a different mind-set for us because we re used to primary-source-verifying everything from the start, so we had to get our minds around not needing to do that, because we can do it this other way, according to NC. s your MaineHealth partner facilities plan and develop core privilege sets, are you getting advice or guidance from other systems? The ones that I know tend to be wholly owned. Here in Maine, we made alliances first. There s no directive from MaineHealth to do this it is strongly encouraged, but facilities can opt out from standardized privileges and criteria. [Their use] is not a mandate yet. t wholly owned systems, it s a little different. For example, Central Maine Healthcare has three hospitals, and they are going the wholly owned route. They are also working on systemwide credentialing, but they re not as far along. We ve talked to other CVOs over the years and we have an idea of the goals, but how we re implementing this is slightly different. Given CMS recent changes to its final rule, do you see a unified, integrated medical staff coming to the MaineHealth network in the future? We re still working on developing collaborative projects among hospitals, but I expect that eventually that will be the goal, to have a unified medical staff. In the future, we re looking at systemwide credentialing committee and systemwide quality committee, which will feed into the unified medical staff idea pretty well. But that s down the road a ways. Right now we re looking at standardizing some of the language about membership and privileging in the bylaws of all the hospitals, and looking at privileging criteria. We thought that was a big enough step to take in the beginning. H 2014 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or HCPRO.COM 5

6 Medical Staff Briefing September 2014 The autopsy dilemma and its implications by Patricia. Furci, RN, M, Esq., and Samuel J. Furci, MP, principals at Furci ssociates, LLC, in West Orange, New Jersey The M, regulators, and medical boards acknowledge that autopsies have historically played a critical role in research, education, and medical practice. So why has there been a steady decline in autopsy rates in recent years? Is it a result of changes in regulatory requirements? Is it a cost issue? Do autopsies provide clinical information that is otherwise not available? For those who perform autopsies, what are some current examples of requirements for competencies? How can hospitals ensure competent autopsy services with low volumes? In this two-part series, we ll seek to answer these questions and provide insight for medical staffs regarding policies, privileging, and other considerations regarding autopsies. In Part 1, we ll provide some background and the reasons this procedure should not be considered a dying art. Much of what we know about medicine comes from the autopsy, stated Stephen J. Cina, MD, PC, chairman of the Forensic Pathology Committee for the College of merican Pathologists, in merican Medical ssociation and PBS Both Join Pathology Profession in Publicizing Why Declining utopsy Rates May Hurt uality of Healthcare, published in Dark Daily, March 14, In a February 20 article that same year, titled Declining utopsy Rates ffect Medicine and Public Health and published in amednews.com, the M noted that 9% of deaths were autopsied in 2007, compared with 19% in In the amednews.com article, Gregory J. Davis, MD, a forensic pathologist at the University of Kentucky College of Medicine, stated that autopsy remains the gold standard for confirming or ruling out diagnoses, and plays an integral role in promoting public health. The decline in autopsy rates If autopsy is considered vital and integral to improving patient care, why is it declining? Potential influences on the autopsy rate over the period include changes in hospital accreditation standards, state laws, and regulations regarding which deaths should be investigated; and sudden and unexplained infant death protocols, according to The Changing Profile of utopsied Deaths in the United States, , published in the ugust 2011 Centers for Disease Control and Prevention (CDC) Data Briefs. Improved imaging, including the emergence of CT scans and MRIs, has been a factor contributing to the decline in autopsy rates, according to the amednews. com article. The expanding prevalence and sophistication of these imaging tools has caused some physicians to think autopsies are no longer necessary in some cases. New imaging capabilities can provide a higher degree of accuracy in determining the cause of death. Certainly another contributing factor was the 1971 decision by The Joint Commission to drop its requirement that hospitals have an autopsy rate of 20% to 25% (for community hospitals and teaching hospitals, respectively) for deaths that occur in these facilities, according to the amednews.com article. nd then there is the issue of cost. Hospitals have powerful financial incentives to avoid autopsies. n autopsy costs about $1,275, according to a survey of hospitals in eight states. But Medicare and private insurers don t pay for them directly, typically limiting reimbursement to procedures used to diagnose and treat the living, wrote Marshall llen in Without utopsies, Hospitals Bury Their Mistakes, published by ProPublica in December Medicare bundles payments for autopsies into overall payments to hospitals for quality assurance, according to John H. Sinard, MD, PhD, director of autopsy service for the Yale University School of Medicine. The hospital is going to get the money whether they do the autopsy or not, so the autopsy just becomes an expense, Sinard said in the amednews. com article. Without an autopsy, doctors and hospitals can t say for certain how patients are dying. When PBS posted the December 2011 ProPublica article, it reported the following data: 50 years ago, autopsies were performed about 50% of the time on patients who died in hospitals. 6 HCPRO.COM 2014 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or

7 September 2014 Medical Staff Briefing Today that number is about 5%, according to the CDC. In 1972, the autopsy rate for patients who died of diseases such as cancer and cardiovascular disease was 17%. In 2007, that rate had shrunk to 4%. Teaching hospitals perform autopsies around 20% of the time, whereas private and community hospitals autopsy rate is close to zero. CDC data shows that, in 2008, 684,000 patients over the age of 60 died in hospitals. lthough that represented more than 25% of all deaths in the country that year, just 2.3% were autopsied. Experts note the lost opportunity to learn about age-related diseases. One survey found that in a given year, 63% of hospitals in the state of Louisiana performed no autopsies. Benefits of autopsies The M points out that autopsies have historically played a critical role in furthering the study of medicine in three ways: medical education, characterization of new diseases, and advancing the understanding of disease pathogenesis. Furthermore, the association notes that about 50% of autopsies produce medical findings that were unsuspected before the autopsy. The merican Society of Clinical Pathology s autopsy policy statement advocates for a greater role for the procedure. The paper states: The autopsy today has the potential to serve a much broader range of societal and medical concerns. The new uses of the autopsy include (1) quality assurance of medical diagnostics and service, (2) a reservoir of tissues and organs for transplantation and research, (3) public education, (4) the development of accurate mortality statistics, (5) the early identification of environmental, infectious and occupational hazards to health (including bioterrorism), (6) information documentation for future legal, financial, and medical evaluation (7) evaluation of new forms of therapy and new diagnostic modalities, and (8) continuing education of physicians. Teaching hospitals recognize the autopsy s value in research and education and therefore often perform a higher number of autopsies. For example, Massachusetts General Hospital s autopsy service performs approximately 350 cases per year. This constitutes approximately 13% of hospital deaths. The hospital s general and neuropathology autopsy services perform autopsies on patients who have lived 100 years or more as part of a clinicopathologic study on centenarians, according to Massachusetts General Hospital s autopsy service Web page. Daniel M. very, MD, associate professor in the department of obstetrics & gynecology at the University of labama School of Medicine, Tuscaloosa s College of Community Health Services, offers a different reason for the decline in autopsies in his 2010 merican Journal of Clinical Medicine article, Why re Very Few utopsies Performed Today? Today, most autopsy requests are to determine what the physician missed and should have been able to find out. In other words, most hospital autopsies are requested with litigation in mind, very wrote. Most hospital pathologists have no interest in the legal arena and are never encouraged to pursue what the clinician missed or should have known. He concluded that the most common reason for requested autopsies not being performed is cost. The only areas where complete autopsies are performed are forensic autopsies at the coroner or medical examiner s office. Soon, autopsies will be a dying art, very warned. Earlier research offered additional, troubling findings. In 2002, the University of California at San Francisco- Stanford University s Evidence-Based Practice Center prepared an extensive report for the gency for Healthcare Research and uality. That report found that autopsies revealed major errors related to the principal diagnosis or underlying cause of death 25% of the time. In 10% of the cases, the error appeared severe enough to have led to the patient s death. Next month, we ll look at the credentialing and privileging issues that autopsies can present for hospitals and medical staff services departments. H EDITOR S NOTE The authors are principals at Furci ssociates, LLC, in West Orange, New Jersey, specializing in management and personnel assistance in medical staff offices in various settings. Furci ssociates provides an array of management consulting services to healthcare organizations addressing complex regulatory compliance issues, including plans of correction to multiple state and federal agencies as well as The Joint Commission, HC, CMS, OCR, OSH, NC, and URC. They can be reached at info@furciassociates.com HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or HCPRO.COM 7

8 Medical Staff Briefing September 2014 Government seeks feedback on obstacles within telemedicine as focus turns to state licensing State licensing restrictions have limited the efficiency of telemedicine, prompting new guidelines and input from advocacy groups lthough telemedicine has the potential to make access to care simpler and easier, healthcare experts and telemedicine advocates still have concerns that regulatory obstacles are preventing the industry from reaching its full potential, while raising legal questions for both hospitals and physicians. This issue was brought to light after the House Energy and Commerce Subcommittee on Health announced in May, during a hearing titled Telehealth to Digital Medicine: How 21st Century Technology Can Benefit Patients, that it would be exploring how telemedicine can be used more efficiently to advance U.S. healthcare. press release issued through the Health Subcommittee indicated that legislators will look at which technologies hold promise for advancing the delivery of healthcare and what supporting role exists for the federal government. s part of that effort, the Health Subcommittee asked for input and feedback from those in the healthcare community. We will be looking for specific policy and legislative ideas on how the federal government can support technology adoption in our health care programs for the express and explicit purpose of reducing costs and increasing the overall quality and efficiency of the programs, Subcommittee Chairman Joe Pitts (R-Pa.) said in the press release. We are also looking for ways in which the federal government currently inhibits the use or adoption of such technologies by all players in the health care system be they insurer, provider, or patient. The more specific and targeted the policy, the greater chance it will hold for Congressional support down the line. In addition to various reimbursement challenges that have impeded the growth of telemedicine, one ongoing and central obstacle is state licensure requirements, says Jeffrey Short, a healthcare attorney with Hall, Render, Killian, Heath & Lyman, PC, in Indianapolis. The lack of consistency between states when it comes to physician licensing often requires physicians to fill out multiple applications in order to practice telemedicine across state lines. Hall Render submitted a letter to the Subcommittee on behalf of a healthcare coalition of hospitals and health systems highlighting some of these challenges. lthough new regulations adopted by The Joint Commission and CMS that allow hospitals to utilize privileging by proxy have removed many of the credentialing obstacles with telemedicine, Short says many providers are still uncomfortable with allowing another facility to perform physician credentialing on their behalf. I think it s about getting the laws that were adapted for the bricks-and-mortar approach to medicine straightened out so that we can operate telemedicine programs more efficiently and with less fear of violating some federal law, or having federal laws running so counter with state laws that you can t get a telemedicine program off the ground, he says. In a letter to the House Subcommittee, the merican Telemedicine ssociation echoed some of the same concerns regarding state licensure and advocated for state reciprocity, which would save physicians an estimated $300 million annually in fees and administrative costs. Concurrently, many health policy organizations have released sample guidelines and reports for telemedicine programs, many of which address some of the legal issues surrounding credentialing and state licensure. Short believes that as technology progresses and there is more demand for telemedicine, there will be pressure on regulators to help make telemedicine conducive to a wider patient population. There is now some clinical proof out there that it does help, and when appropriately done, we can get good outcomes, improve care, raise the quality of care, and reduce the cost of care if we wisely implement telemedicine, he says. Recommendations for a nationalized licensure system On May 12, shortly after the House Energy and Commerce Subcommittee on Health announced its intention to look at telemedicine, the Information 8 HCPRO.COM 2014 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or

9 September 2014 Medical Staff Briefing Technology & Innovation Foundation (ITIF) released a report entitled Unlocking the Potential of Physicianto-Patient Telehealth Services. The report highlighted the ever-increasing benefits of telemedicine, but also noted that the regulatory and policy environment has not kept pace with the technology and several barriers must be overcome before patients and doctors in the United States can fully enjoy the benefits of telehealth. Those obstacles include complicated state licensing requirements that have limited the scope of telemedicine. One of the primary recommendations in the report is that if states fail to adopt an interstate agreement within the next 18 months, Congress should adopt a uniform national licensure program for telehealth that would be accepted in all states. The idea that a doctor in Virginia can t practice in Maryland is just very antiquated, says Daniel Castro, senior analyst for the ITIF in Washington, D.C., and lead author of the report. The standards are more or less the same in most of these states, and we re not talking about big differences in the quality of providers. With the technology that we have today, one license in one state, where states can check credentials and have enforcement agreements, there is really no reason this can t take off. The report added that the obstacles surrounding state licensure have created legal challenges for physicians that want to provide telemedicine services outside of their own state. Since state licensure rules vary and healthcare providers cannot practice medicine without a state license, providers would need to obtain a license for every state that their patients live in. There are two simple fixes to this issue, according to the report. One is to allow physicians licensed in one state to obtain a special limited license to practice telehealth in surrounding states. The other option is to allow reciprocal licensing in which states recognize the medical licenses of one another. However, only 12 states (labama, Louisiana, Minnesota, Montana, Nevada, New Mexico, North Dakota, Ohio, Oregon, Tennessee, Texas, and Washington) have provided accommodations for telehealth licensing. Nine other states have adopted limited accommodations, but not enough to allow for large-scale provision of telehealth, according to the report. I ve seen a lot of surveys about how consumers are interacting with health information, and they actually do want to go online and get care, but they re not able to do it right now, Castro says. lthough some legislative bills have been drafted in an attempt to establish a national telemedicine licensing system, many in the medical community aren t as open to this approach, Short says. You get down to federalism how far is the federal government willing to step in to state rights and to date, medical licensure has largely been considered a state right, he says. You re really swimming upstream against some of the state medical boards. t the very least, Castro says states need to adopt a common definition of telemedicine, which currently varies dramatically from state to state. ccording to the ITIF report, some states require phone-based interactions, while others require interactive video. This can cause potential legal problems for physicians who may be treating patients in multiple states and therefore must adhere to inconsistent standards. ccording to the report, 23 states have defined telehealth for both Medicaid and private insurers, whereas nine states have telehealth definitions for Medicaid only or no definition at all. What you want is to say, This is what telehealth is, this is what it includes, and this is how we define it so that doctors understand what is and isn t allowed, Castro says. Then you start writing rules around these common definitions, and hopefully you write rules that are the same. You don t want to have 50 different ways of making doctors do things. Establishing standards of care nother obstacle identified by the ITIF report is the lack of standards of care in telemedicine, which can translate to legal risks for physicians. Current medical residents should have telemedicine education incorporated into their training curriculum so they can understand these potential risks, Castro says. We are a litigious society, and especially when it comes to healthcare, doctors aren t going to go out on a limb if it s not crystal clear what they are allowed to do, and the way state laws are now, it s anything but, he says. lthough specific clinical standards of care need to be developed by professional organizations in each field (dermatology, radiology, psychiatry, etc.), it s important to establish basic, agreed-upon standards for 2014 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or HCPRO.COM 9

10 Medical Staff Briefing September 2014 the practice of telemedicine, says Lisa Robin, chief advocacy officer for the Federation of State Medical Boards in Washington, D.C. For example, all physicians should have a way to authenticate the identity of a patient, and patients should be able to verify the physician s identity and his or her credentials. Healthcare providers should take steps to protect patient information as well as document the encounter and the resulting diagnosis and treatment. It should be an expectation that those standards need to be in place regardless of the medicine or the type of condition being treated, Robin says. The physician would be accountable to the medical board of understanding and knowing what conditions would be appropriate for their specialty and what is the accepted standard of clinical care. H New telemedicine guidelines from FSMB and M Two new sets of telemedicine guidelines from the Federation of State Medical Boards (FSMB) and the M have provided more direction for healthcare providers practicing telemedicine and state boards attempting to manage this new field. In pril, the FSMB released the Model Policy on the ppropriate Use of Telemedicine Technologies in the Practice of Medicine. The guidelines provide a basic road map for state medical boards to help ensure patients are receiving safe and appropriate care. These guidelines are going to be very helpful in looking at how to provide oversight over the practice of medicine using these technologies, and at the same time encouraging access and the potential for improving access to specialty care and services, says Lisa Robin, chief advocacy officer for the FSMB in Washington, D.C. I think they were really developed to look at removing regulatory barriers to widespread adoption of the appropriate use of telemedicine technologies, while also making sure we don t compromise patient safety. Included in the guideline is the requirement that telemedicine providers establish a credible patient-physician relationship. To establish that relationship, physicians should: Fully verify and authenticate the location and identify the requesting patient Disclose and validate the provider s identity and applicable credentials Obtain appropriate consent from patients regarding the delivery models and treatment methods or limitations, including special informed consents regarding the use of telemedicine technologies Concerning state licensure, the FSMB guidelines indicate that a physician must be licensed by, or under the jurisdiction of, the medical board of the state where the patient is located. This drew criticism from the merican Telemedicine ssociation (T), which sent a letter to FSMB prior to the approval of the guidelines. The T stated that this would prohibit a state medical board from entering into a reciprocal relationship with neighboring states or regions regarding state licensure whereby a license to practice medicine in one state is recognized by the other state. However, Robin says the FSMB is in the process of developing an interstate medical licensure compact, which would allow expedited physician licensure in all participating states. In January, a letter signed by 16 U.S. senators expressed support for the compact s development since it will help ensure telemedicine is practiced safely and accountably. The FSMB has been working on the development of interstate compacts since pril 2013; the most recent draft was released in May, and according to its website, the FSMB anticipates it will be ready for state legislative consideration in I think it would create a much easier administrative process for physicians wanting to license and practice in multiple states, and yet it would not compromise the ability for patients to have a remedy of their state board if there was an adverse outcome, Robin says. The medical board would still have jurisdiction over physicians practicing in their states. During its annual meeting in June, the M approved its own list of guiding telemedicine principles. In the document, it recommended that physicians establish a valid patient-physician relationship, which would include a face-to-face examination, if a face-to-face encounter would otherwise be required in the provision of the same service not delivered via telemedicine. The M also recommended that physicians delivering telemedicine services must be licensed in the state where the patient receives services. We believe that a patient-physician relationship must be established to ensure proper diagnoses and appropriate follow up care, M President Robert M. Wah, MD, said in a press release. This new policy establishes a foundation for physicians to utilize telemedicine to help maintain an ongoing relationship with their patients, and as a means to enhance follow-up care, better coordinate care and manage chronic conditions. 10 HCPRO.COM 2014 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or

11 September 2014 Medical Staff Briefing The aging physician: Some practical tips by William K. Cors, MD, MMM, FCPE, chief medical quality officer at Pocono Health System in East Stroudsburg, Pennsylvania This month we continue with a series on practical tips for medical staff leaders to deal with a host of challenges that they may encounter in their roles. The challenges and solutions are excerpted from The Medical Staff Leader s Survival Guide, which was recently published by HCPro, a division of BLR, in Danvers, Massachusetts. The material is designed to offer medical staff leaders a quick snapshot of various challenges and solutions that can be implemented to address them. This month we address some challenges raised by the aging physician(s) on your medical staff. Physicians are not immune from the effects of aging. They suffer physical, mental, and degenerative disorders in similar proportions to the population as a whole. Many physicians enter their 60s practicing medicine full time and without apparent difficulties. On the other hand, the probability of decreased performance increases with time. In the past, as physicians inched away from 60 and toward 70, many started making significant adjustments to their schedules and scope of practice. In the present time, however, there is a sense that more and more physicians are practicing longer either because they are able to or because they are forced to, given the changing financial climate. Most of us acknowledge the affect that aging has on our cognitive and motor skills, with the help of some not-so-subtle hints from our colleagues and loved ones. For some, it s no big deal there are so many ways to earn a livelihood inside and outside the healthcare profession that it seems fruitless to hold onto things that may no longer fit our professional goals, such as inpatient privileges. These physicians gladly move into the ambulatory setting and are often relieved to enter a different phase of their professional lives. For others, however, this transition is not easy, and it may require the guidance and support of peers. For this reason, it is important for medical staff leaders to understand how to support and respect long-serving colleagues while ensuring that patients are not inadvertently placed in jeopardy. dvocacy is vital n important function of medical staff leadership is to advocate for the needs and preferences of physicians while simultaneously protecting patients and the reputation of physicians and the hospital. dvocacy involves creating policy on difficult issues before they become problematic. No national consensus has developed concerning the best approach to the challenge of aging physicians. Unlike other professions, medicine has no established guidelines. By contrast, commercial pilots must undergo regular health exams starting at age 40 and must retire at age 65. FBI agents have a mandatory retirement age of 57. No such rules exist for physicians (or lawyers, for that matter). The best time to create your position on the aging physician is before you have an 80-year-old surgeon requesting new privileges in bariatric surgery. The medical staff credentialing function is performed carefully to protect patients; however, leaders must also preserve the rights of physicians. It is a very delicate balance to show respect for our senior colleagues, but the definitive obligation is to ensure patient safety. Once again, medical staff leaders need to return to some fundamental principles to work through this dynamic. The first principle is that there is a definitive obligation that the organization and its medical staff assess competency. n essential part of competency is capacity to perform, which includes both cognitive and physical ability. s physicians and other practitioners age, both the natural aging process and specific diseases have the potential to adversely impact these clinicians capacity to perform some or all of their requested privileges. The development of an objective policy that takes this factor into account and is applied equally to all is a first step toward resolution of this often emotionally charged issue. n objective approach to dealing with aging is to develop a policy requiring physicians who hold privileges to proactively demonstrate their cognitive and physical ability to perform beginning at a certain age. This is non-discriminatory in that the policy doesn t single out a particular physician, but 2014 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or HCPRO.COM 11