Abstract
Background:
Medical staff credentialing is the time-intensive process of verifying a provider's qualifications before granting privileges within a hospital. This process creates a large administrative barrier for telehealth services, as a large number of providers must be credentialed at each participating originating site within a telehealth network.
Introduction:
Despite the availability of a streamlined telehealth credentialing method called Credentialing by Proxy (CBP), a significant number of hospitals still opt for traditional credentialing. This project seeks to better understand the barriers and benefits to CBP.
Materials and Methods:
This study utilized stratified sampling to recruit nine participants who manage telehealth credentialing. Researchers conducted qualitative interviews using a semistructured interview guide and analysis through the constant comparative method. Length of the credentialing time for providers was also tracked over an 18-month period for 20 originating sites.
Results:
The majority of participants experienced uncertainty due to a loss of control over the process with CBP but also acknowledged the benefits of this method. Hospitals utilizing CBP had a significantly shortened credentialing period of 36 days, compared with 103 days with traditional credentialing.
Discussion:
A lack of clarity and a fear of ultimate responsibility or liability were the largest contributors to uncertainty. Factors that decreased uncertainty among originating site hospitals included awareness of regulatory standards for CBP, continuing to check certain credentialing requirements themselves, and adopting a “wait-and-see approach.”
Conclusions:
This study provided valuable insights into the barriers and benefits of CBP and can be utilized to better address these barriers and increase efficiency within telehealth networks.
Introduction
Telehealth has rapidly revolutionized the possibilities for healthcare, increasing access by providing new, efficient paths to high-quality medical services and education. 1,2 Although the utilization of telehealth continues to experience rapid growth, it is often slowed by key administrative barriers that are unable to evolve as quickly as the technology. 3,4 Adjusting regulatory and legal requirements to better apply to telehealth will be of increasing importance in the coming years as telehealth continues to expand exponentially. As substantial cost savings and patient value associated with telehealth become clear, healthcare organizations are quickly jumping on board. 5
In a 2014 survey of healthcare executives, 90% reported that their organizations “have already begun developing or implementing a telehealth program.” 6 In addition, the number of patients utilizing telehealth is expected to increase from 350,000 in 2013 to 7 million by 2018. 7 As common barriers like reimbursement and interstate licensure begin to resolve, the expansion and integration of telehealth will face fewer restrictions. A majority of states now have parity laws, which require reimbursement for services provided through telehealth, and many other states are actively working toward telehealth parity. 8 Many other factors will contribute to the exponential growth of telehealth, including the prevalence of chronic diseases, limited access to care, and increased comfort with remote solutions. 7,9
One of the current administrative barriers to widespread telehealth implementation is credentialing telehealth providers at the originating site hospitals. This valuable but time-intensive process helps to ensure the quality of healthcare providers at both the distant site hospital, where the provider is located, and the originating site hospital, where the patient is located. 3,4 Provider credentialing, governed by the bylaws and specific policies of each individual hospital, involves the verification and review of all the relevant credentials, certifications, and licenses of a healthcare provider. The demands of this process quickly become excessive when credentialing every telehealth provider at each site in a large telehealth network. Since both the originating and distant site are held to the same accreditation standards, the traditional credentialing process creates an unnecessary repetition of effort at telehealth sites as each originating hospital verifies the physicians' education, employment, licensure, and more. In addition, hospitals that can benefit most from telehealth services are often small, with a limited number of administrative staff to complete these verifications and paperwork, creating a barrier to the expansion of telehealth services and their efficient implementation. The credentialing requirements can quickly become a burden to physicians, their references, and their former employers and training facilities.
In 2012, the Centers for Medicare and Medicaid Services (CMS) released their final ruling regarding credentialing and privileging of telehealth providers, permitting a streamlined version of credentialing called Credentialing by Proxy (CBP). 10 CBP allows the originating site hospital to delegate the credentialing process for telehealth providers to the distant site hospital and accept its privileging decision, instead of repeating this demanding process themselves for providers whose scope is limited to telehealth within their hospital. When both the distant and originating sites are Joint Commission accredited entities and held to the same standards, repeating the full credentialing process at each telehealth site is redundant and unnecessary to ensure the quality of telehealth providers. This process allows telehealth networks to expand without adding exponential administrative work, thereby improving program efficiency and implementation times.
Despite the benefits of CBP, a significant number of hospitals have declined participation in the new expedited process. Credentialing is regularly listed as a barrier for telehealth, but there has been little research done on the perceptions of CBP as a solution, especially with organizations who opt out of this method. In addition, few resources are available to aid telehealth programs in encouraging this streamlined credentialing method and enabling higher efficiency in their programs. Increased understanding of the perceptions of key credentialing personnel could greatly reduce barriers to this method and support the expansion of telehealth as whole. The purpose of this study is to explore the benefits and barriers to CBP as a credentialing method for a large telehealth network, focusing on implementation times and method satisfaction. In addition, we examine the differences in average days to credentialing approval between the traditional and CBP methods.
Materials and Methods
Study Sites
This study was conducted at a large academic medical center in the Southeastern United States, which connects with 22 site hospitals for a wide array of telehealth services. Telehealth activities are organized under a centralized telehealth office, which supports >100 clinical telehealth providers and >100 sites at which services are offered. This program includes >50 different services extended to remote locations throughout the state.
At the time of this study, the Center for Telehealth was operating nine telehealth programs that involved provider credentialing. Participating in these programs were 86 providers, holding a total of 628 medical staff appointments across 22 originating sites. The majority of these medical staff appointments were obtained through CBP, with 15 out of 22 sites utilizing this method.
Data Collection
Respondents were purposefully sampled to recruit individuals who managed telehealth credentialing at a diverse group of community hospitals in South Carolina. The primary source of data was nine semistructured key informant interviews conducted individually through telephone in September 2015. Interviews were recorded and lasted ∼45 min. A semistructured interview guide was utilized by one researcher to conduct the interviews. Question topics included satisfaction with current credentialing method, perceived barriers to CBP, credentialing workload for telehealth providers, and the perceived risks and benefits of utilizing CBP. Data analysis was continuous, and interviews were conducted until a saturation of themes was evident by obtaining redundant information across interviews. 11 All interviews were transcribed verbatim from audio recordings. The study was granted exemption by the Institutional Review Board at the Medical University of South Carolina. In addition, the telehealth credentialing coordinator at the academic medical center collected secondary data on the credentialing process. These quantitative data included tracking of the time in days for each provider credentialed between May 2015 and November 2016 across 18 originating site hospitals.
Analysis Approach
Qualitative data were analyzed using an inductive approach. 12,13 Transcripts were read independently by two researchers to develop high-level codes reflecting the concepts found in the data. The two researchers met frequently to compare and refine the codes. Discrepancies were resolved by discussion and joint review of the data. A third coder was available to resolve disagreements but was not required. This process was repeated until no new themes emerged during the coding. The final code structure was applied to all transcripts by one researcher, with the second researcher reviewing the coded transcripts for quality assurance purposes. Codes were compared across respondents to identify themes related to the benefits and barriers of credentialing telehealth providers. In addition, t tests with unequal variances were conducted to compare the average number of days to credential in the two groups, using Stata 14 analysis software.
Results
Data Analysis
Respondents were employed at nine telehealth site hospitals within a telehealth network served by a large academic medical center in the Southeastern United States. This network includes >20 hospitals where telehealth services are offered. Seven of these site hospitals utilized CBP, and as a comparison, two interviews were conducted with traditionally credentialing hospitals. Table 1 gives the characteristics of respondents' organizations.
Respondent Characteristics
Between May 2015 and November 2016, 11 providers were credentialed across 20 sites. Of those sites, 13 utilized CBP the entire period, 5 utilized traditional credentialing, and 2 switched from traditional credentialing to CBP in April of 2016. Owing to different service line offerings across the institutions, not all providers were credentialed at each originating site hospital. In total, 119 medical staff appointments were approved during the 18 months. The length of the credentialing period for a new provider was significantly different between the two methods. The average credentialing time period for the traditional credentialing of telehealth providers was 103 days, whereas the average time period for credentialing providers by Proxy was 36 days (p = 0.00) (Table 2). We found no statistically significant differences in the average number of days by provider or hospital site. For the two sites that switched from traditional credentialing to CBP partly through our study, both credentialed three telehealth rosters traditionally and four by proxy. Both sites saw significant decreases in the number of days when switching to the Proxy credentialing process. The first site had an average of 72.33 days to credentialing under the traditional method and an average of 27.25 days after switching to CBP (p < 0.01). The second site decreased the average number of days from 117 under the traditional method to 25.74 days with the Proxy credentialing process (p < 0.05).
Mean Credentialing Time by Method (n = 119)
Themes
Qualitative analysis of the nine hospital interviews identified three primary themes as discussed hereunder.
Delegating the credentialing process led to feelings of uncertainty and uneasiness
Many participants in the study felt generally uneasy with the Proxy credentialing process, even when it relieved them of an unnecessary and often time-intensive process. There were a few specific reasons for this uncertainty. First, participants stated that although they felt the delegated institution was trustworthy, they felt uncertain about losing direct control over the process. One participant stated, “I prefer to do things myself, so that I know that they're done (correctly). It's just kind of hard to rely on somebody else to make sure that it's all done.”
A number of participants also feared that the ultimate responsibility and repercussions of mistakes in the credentialing process would fall back on them and their institution. Anxiety increased when participants felt the requirements of the method were unclear, especially regarding quality processes and tracking requirements for providers credentialed by Proxy. A lack of clear understanding of the requirements often leads to the participants doing unnecessary extra work, despite the streamlined process.
The increased workload of traditional telehealth credentialing drives the adoption of CBP
Many sites reported conflicting feelings toward CBP. Although all participants agreed that the process was beneficial, even necessary in some instances, some still struggled with a loss of control over the process. The burden of credentialing telehealth providers traditionally was reported as one of the biggest reasons for implementation, regardless of the comfort level of the credentialing personnel. Some participants even stated that with their current staff size, they could not credential all the participating telehealth providers without it, with one participant explaining that “this eliminated the need for us to have to hire on somebody else to process these applications to get these services up and going.” Many site hospitals also adopted a “wait-and-see approach” where they understood delegated credentialing to be in trial period at their institution, and if anything negative occurred, they would revert back to the traditional method.
Among site hospitals that did not currently participate in the Proxy credentialing process, all were working toward it, citing the burden that telehealth credentialing had become as new providers and new services had been added at an increasing rate. These staff members also felt uncertain about turning over the process to credential telehealth providers but recognized firsthand the necessity of this delegation as telehealth programs continue to grow. The barriers they faced to implementing CBP were often within their hospital's governing bodies, including resistance to adding the credentialing language into hospital bylaws that would permit this method. Similar barriers were also described by hospitals that were currently participating in CBP. All participants from non-Proxy credentialing hospitals hoped to implement the method in the future.
Clear standards and increased transparency facilitate buy-in to the credentialing process
Certain factors were helpful in reducing uncertainty regarding CBP, including the awareness that the Proxy institution is held by the same regulatory standards as the site hospital, which helps to ensure the same quality of providers who become credentialed through this method. One participant explained her acceptance of the method, “I've been fine with it because, like I said, you all, as Joint Commission accredited, you have to do the same work that we do.” Increased transparency regarding the distant site's credentialing process can also increase confidence that providers credentialed by Proxy are still held to rigorous standards. Many of the site hospitals participating in the Proxy credentialing process also mitigated their uncertainty by checking certain requirements themselves, including Drug Enforcement Administration (DEA) licenses and National Practitioner Databank reports. Although checking these credentials increased their workload unnecessarily, it also helped these staff members feel more confident in the qualifications of the providers who were joining their medical staff.
Discussion
To our knowledge, this is the first study to explore the benefits and barriers to credentialing telehealth providers by Proxy. This study identified a significant decrease in the number of days to credential providers and several key causes of uncertainty surrounding CBP that contribute to the resistance to this method. Major contributors to uncertainty among participants included a loss of control over the process, a lack of clarity regarding the requirements of this method, and a fear of where the ultimate responsibility would fall for any credentialing errors or negligence. More importantly, participants were able to identify which factors helped them to feel more confident utilizing this alternative credentialing method. Participants' uncertainty was eased by the knowledge that the distant site hospital was held to the same regulatory standards as they were and, therefore, held providers to the same rigorous standards. Some participants also mitigated their uncertainty through maintaining certain checks and credentials themselves, which, despite creating extra work, allowed them to implement this process at their institution with confidence. Many participants felt ambivalent about this method, feeling uneasy about losing control but also acknowledging the necessity of this method for telehealth services. Participants experiencing ambivalence often viewed CBP as being in a trial period at their institution. All participants who did not yet utilize CBP were working toward it, and many hospitals currently or previously faced barriers to implementation within their hospital's governing bodies or leadership. On average, CBP reduced the administrative processing time by 66 days. Such efficiencies are worth exploring as credentialing is often listed as a significant barrier to implementation of telehealth. 14,15
In addition, administrative barriers are most taxing on sites that have the fewest resources, so not addressing these barriers could delay services and healthcare access in areas that need it the most. Without a streamlined method, it may not be possible for smaller hospitals to provide the administrative resources needed to traditionally credential and privilege all of the providers on a large telehealth roster.
Certain operational recommendations became clear through these findings. Clear communication regarding the process and responsibilities of each party is essential to empowering credentialing personnel to have confidence in this method. Targeted communications should focus on legal responsibility or lack thereof in delegated duties, as well as clear instructions for related regulatory requirements like quality data and reappointment cycles. Transparency regarding the distant site's credentialing process can also reduce uncertainty and help instill confidence in the originating site that these providers are held to similarly rigorous standards. In approaching new sites about implementing CBP, communications should highlight the increased efficiency of this method especially as compared with the burden of credentialing these providers traditionally, and should also emphasize that both the distant site and originating site are held to the same regulatory standards for medical staff credentialing.
Credentialing personnel should be given as many resources as possible regarding CBP, including documents detailing the Joint Commission and CMS guidelines, the specific workflow, and other relevant information. Providing them with an abundance of information up-front will reduce uncertainty about the process and also enable them to be an advocate for CBP with their hospital leadership and governing bodies. The distant site should offer support in terms of presentations or discussions with leadership or governing bodies, and increased communication, information, and availability during accreditation surveys.
Limitations
There are several limitations to this study. First, results are based on one telehealth network in the southeast United States and may not be generalizable. Second, the analysis of the two sites that switched methods has a small n, however, results are promising for quality improvement purposes.
Conclusions
The experiences of one telehealth network utilizing CBP showed significant decreases in the average number of days to credential providers. As services through telehealth become integrated into routine healthcare, organizations will also seek out efficiencies to the related administrative processes. The utilization of CBP has become increasingly essential as the number of telehealth programs, services, and participating providers grow. CBP currently has growing utilization and support, especially from those directly involved with medical staff credentialing. As this credentialing method becomes more common, its novelty will decrease along with the uncertainty toward it. This will enable widespread implementation, and resulting growth and efficiency within telehealth programs. Improved transparency and communication during the credentialing process will facilitate adoption and relieve anxiety of staff members at the remote hospitals.
Footnotes
Disclosure Statement
No competing financial interests exist.