Running head: A CASE FOR CENTRALIZED DATABASE IN TELEMEDICINE 1

A Case for Centralized Database in Telemedicine Credentialing

Paige Gray

Northern Arizona University – Personalized Learning

A CASE FOR CENTRALIZED DATABASE IN TELEMEDICINE 2

A Case for Centralized Database in Telemedicine Credentialing

“The doctor will see you now” are blessed words a parent would love to hear coming

from her phone while attending to her sick child at home. Such a reality is now available using

telemedicine, albeit in limited ways. Through the implementation of a nationalized database

credentialing redundancies would be reduced, there would be an increase in patient safety, and

patients would have access to care in a timelier manner.

Background

Telemedicine is a delivery method where the provider (physician or mid-level) is in one

geographic location and the patient is in a different geographic location and receives medical

care as if the provider was physically located with the patient. Begun as a project for the

National Aeronautical and Space Agency (NASA) to monitor astronauts in space in the late

1960s telemedicine has become a world-wide accepted delivery method for healthcare (LeRouge

& Garfield, 2013). However, in a formal setting such as a hospital, rural health clinics, and

critical access facilities, the Centers for Medicare & Medicaid Services require practitioners to be

credentialed (background information verified) at each facility where a provider holds

membership and/or privileges. Similarly, state licensing boards, malpractice insurance carriers

and health plans require a similar credentialing process causing a duplication of information

shared by the provider and verified by the noted agencies. Patient safety is affected by this

redundancy as information is not shared among entities in real-time or even in a timely manner

for an entity to quickly address which has resulted in an increase in malpractice cases. To reduce

these redundancies blockchain technology is being investigated as a viable solution to this issue.

Blockchain is a new technology where information is stored and authenticated simultaneously in

a ledger across a network which contains shared information via cryptocurrency (Church, 2017).
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Resolution of Credentialing Barriers

A telemedicine provider is required to provide basic demographic information to each

credentialing entity (state licensing agencies, health plans, and distant-site entity) as well as a

listing of all education, employment, affiliation and work history, as well as a listing of

malpractice claims information. Suppose a provider is licensed in at least two states,

credentialed at five facilities and three health plans. Under this scenario the provider would have

had to complete at least 10 applications which contain all the same information and each of the

entities would be required to verify the information provider listed on the application. Each

queried facility would need to respond to 10 queries of the same information. In a large group

telemedicine practice, physicians typically have 20 state licenses and over 200 hospital

affiliations. At an average of 90 days from receipt of a completed application to the approval

process, the redundancy of the current credentialing system is posing a barrier to patient care,

particularly in rural areas. In addition, each provider is required to be reverified at a minimum of

every 24 months, which encompasses a reverification of each of the items identified above.

Stakeholders are investigating blockchain technology to reduce redundancy, improve

efficiency and ensure accuracy of credentialing information. Credentialing with blockchain, if

instituted at a federal level, would allow entities to ensure a provider’s credentialing data is

accurate and has already been validated through multiple entries in the ledger while ensuring

security of information. Instead of completing multiple applications for various entities, a

provider would provide an encryption key to the requesting organization. In this way, a provider

is still in control of his or her information and controls who has access to the information.

Through this method a provider could potentially be credentialed in 30 days or less.

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In July 1998, health plan stakeholders founded the Council for Affordable Quality

Healthcare (CAQH) as a provider repository controlled by the provider and accessed by health

plans and other entities the provider authorized. Utilized by over 170 entities, ranging from

health care facilities to individual health care plans, CAQH has successfully demonstrated the

efficiency of a single, standardized repository of information for health care credentialing. While

the accuracy of the provider’s data within CAQH is validated quarterly by the provider, CAQH

falls short as a universal credentialing solution for telemedicine credentialing as it does not

contain credentialing verification documentation which is the timeliest process in credentialing.

In addition, CAQH is a voluntary participation program for entities, not mandated for usage by

the federal government. The lack of federal mandate allows entities, particularly small rural

facilities, to opt-out of participation and require a provider to complete their facility specific

application. The structure and format of CAQH have demonstrated the cost-savings and

effectiveness of a provider-managed data repository and serves as a precursor to blockchain

credentialing.

Another example of a pre-cursor program to a centralized blockchain credentialing

system would be the recently formed physician compact State licensing system managed by the

Interstate Medical Licensure Compact (IMLC). Established in April 2013, the Federation of

State Medical Boards (FSMB) recognized the burden placed on physicians licensed in multiple

states and sought to relieve this burden through the creation of a compact license – a license

recognized by other states from the provider’s home state, with little to no additional paperwork

required by the physician. A provider completes a single application, identifies his or her home

state, and if found to qualify, selects additional states where a license is needed (The IMLC,

n.d.). The “home state” is initially responsible for verifying the physician’s information, and
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when requested, to share the provider’s information with the commission for approval of

interstate medical license applications. Like CAQH, the IMLC falls short as participation in the

program is voluntary with participation by only 29 medical and osteopathic medical boards from

22 states.

The final example of efforts to create centralized credentialing information which would

benefit from blockchain credentialing integration is the National Practitioner Data Base (NPDB).

Established by Congress in 1986, to ensure “bad doctors” cannot move to another state and not

reporting poor quality of care in the new state. Unlike the CAQH and IMLC, Congress

mandated all health care entities are required to query the NPDB at time of initial appointment,

reappointment and privilege changes to ensure the facility is aware of malpractice case

settlements or awards and disciplinary actions taken by state medical licensing boards and/or

credentialing entities. Similarly, entities are mandated to report actions taken against a physician

to the NPDB or face serious consequences such as a financial penalty and loss of peer review

protection rights. However, the NPDB is as unsuccessful as the CAQH and IMLC as a timely

means for credentialing telemedicine providers as the NPDB only maintains derogatory quality

of care information.

As telemedicine continues to increase to meet the demands of rural areas and physician

shortages, the creation of a centralized credentialing database is inevitable. Integration of

information from demographic information (CAQH), education and licensure verification

(IMLC), and quality and malpractice information (NPDB) will be necessary to be an effective

solution to a streamlined credentialing process. For a fully successful system, entities will need

to provide their credentialing information to ensure all information available and can be

accurately relied upon. Finally, mandated instead of voluntary participation in the program will
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be necessary to a fully streamlined and efficient credentialing system which will help to ensure

patient safety and reduce inaccuracies of information.

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References

Arizona Health Care Cost Containment System (AHCCCS). (2015, October 01). AHCCCS

Medical Policy Manual, Quality Improvement and Performance Improvement Program -

Credentialing and Recredentialing Process. Retrieved October 02, 2017, from AHCCCS:

https://www.azahcccs.gov/shared/Downloads/MedicalPolicyManual/Chap900.pdf

Bresnick, J. (2017, August 10). Illinois to Use Blockchain for Healthcare Credential

Management. Retrieved October 3, 2017, from HealthIT Analytics:

https://healthitanalytics.com/news/illinois-to-use-blockchain-for-healthcare-credential-

management

Church, Z. (2017, May 25). Blockchain, explained. An MIT expert on why distributed ledgers

and cryptocurrencies have the potential to affect every industry. Retrieved October 02,

2017, from MIT Management Sloan School:

http://mitsloan.mit.edu/newsroom/articles/blockchain-

explained/?utm_source=mitsloantwitter

LeRouge, C., & Garfield, M. (2013, Dec). Crossing the Telemedicine Chasm: Have the U.S.

Barriers to Widespread Adoption of Telemedicine Been Significantly Reduced? Int J

Environ Res Public Health, 10(12), 6472–6484. doi:10.3390/ijerph10126472

Mann, S. (2017, March 14). Association of American Medical Colleges. Retrieved October 3,

2017, from AAMC News - Medical Education: New Research Shows Shortage of More

than 100,000 Doctors by 2030: https://news.aamc.org/medical-education/article/new-

aamc-research-reaffirms-looming-physician-shor/

National Association of Medical Staff Services (NAMSS). (2017). NAMSS Comparison of

Accreditation Standards 2017. Retrieved October 02, 2017, from NAMSS:

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http://www.namss.org/Portals/0/Education/CertPrepResources/namss_comparison_of_ac

creditation_standards.pdf

Overview. (2013, November 6). Retrieved October 02, 2017, from CMS.gov Centers for

Medicare & Medicaid Services: https://www.cms.gov/Regulations-and-

Guidance/Legislation/CFCsAndCoPs/index.html?redirect=%2FCFCsAndCoPs

Rogove, H., McArthur, D., Demaerschalk, B., & Vespa, P. (2012, February 2). Barriers to

Telemedicine: Survey of Current Users in Acute Care Units. Telemedicine and e-Health,

18(1), 48-53. doi:ttps://doi.org/10.1089/tmj.2011.0071

Sotos, J., & Houlding, D. (n.d.). IT Peer Network. Retrieved October 3, 2017, from Healthcare:

Blockchains Everywhere: https://simplecore.intel.com/itpeernetwork/wp-

content/uploads/sites/38/2017/05/Intel_Blockchain_Application_Note2.pdf
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