Hospitals and health systems will adopt telehealth if the technology enables them to improve care outcomes, reduce waste and improve provider workflows. But do they feel that accreditation is part of the path to success?
With a vast majority of healthcare providers dabbling in connected care in one fashion or another, the time will soon come when consumers – and, more importantly, payers – judge a health system on its telehealth and telemedicine services. With that in mind, two organizations have stepped forward to develop accreditation standards for healthcare providers.
The Washington-based non-profit Utilization Review Accreditation Commission (URAC) bills its program as “the first independent, third-party national program to offer comprehensive oversight of diverse telehealth programs.” The ClearHealth Quality Institute (CHQI), based in Annapolis, Md., launched a partnership with the American Telemedicine Association in 2017 to create a telehealth accreditation framework and is now managing the program, which began accepting applicants in March 2018.
mHealthIntelligence recently sat down (virtually) with CQHI founder Gary Carneal and Deborah Smith, MN, a Product Development Principal with URAC, to discuss why accreditation is important to healthcare providers and how they should be working toward these standards of care.
Q. How does telehealth accreditation benefit a hospital or health system?
Carneal: Accreditation can bring tremendous value to a hospital or health system. It is a differentiator, offering a consumers and stakeholders an easy-to-identify confirmation of quality.
The application process provides organizations with meaningful, constructive feedback to improve operations, helping to identify both deficiencies and best practices that optimize their telemedicine practices going forward. Through this process, applicants should realize:
Smith: Accreditation is a mark of excellence. URAC’s program addresses a wide spectrum of telehealth providers using multiple channels of communication. So, the accreditation process is enabling of practices that range from postoperative and post-discharge follow-up to reaching beyond the hospital’s usual service area. URAC accredited organizations demonstrate a standard of care and consumer safety that is comparable to face-to-face encounters.
Q. How should a health system go about preparing for accreditation? What data or benchmarks would that health system need to collect?
Smith: Preparation for accreditation means demonstrating compliance with the requirements of national standards and elements of performance. Documentation must address such important quality indicators as regulatory compliance; information systems confidentiality and security; consumer empowerment and protection; quality measurement, oversight and improvement; professional practice principles (e.g. patient experience, safe prescribing and evidence-based practice); technology and user competence; and risk assessment and prevention.
URAC’s validation methods include a review of documentation such as policies and procedures, screen shots, a program description, checklists, meeting minutes, workflows, data reports or dashboards and interviews, observations and audits. Applicants for URAC accreditation establish performance benchmarks and goals, continuously monitor indicators of quality performance, and identify areas for improvement. Important topics include access and value of services, safe practices, or consumer empowerment.
Carneal: The best way for an organization to prepare CHQI’s accreditation application is to acquire the Telemedicine Accreditation Program Standards and Guide document via our website (www.chqi.com). This document details all program standards and offers helpful instructions on how to demonstrate compliance via written response and documentation evidence.
The Standards and Guide document contains three sections for each standard: 1) The standard itself; 2) the narrative section; and 3) the documentation section. As a result, the document provides very specific detail about what CHQI is looking for in terms of the data and benchmarks that an applicant would need to collect and upload to CHQI’s online accreditation portal. In addition, the standards include a section on the demonstration phase of the review process, which discusses in detail what CHQI will be looking for as well. Information that is collected during the review process will vary depending on what modules and service lines an organization has applied for.
Q. What specific services or platforms should a health system focus on to receive a favorable accreditation?
Carneal: CHQI is agnostic in terms of the specific services or platforms that an applicant uses. However, the Telemedicine Accreditation Program Standards and Guide does identify key policies and activities that need to be fully embraced by each telemedicine/telehealth organization undergoing a review. For example, telemedicine encounters must be based upon evidenced-based pathways that are supervised by a clinical director, and telemedicine platforms must comply with key operational and risk management requirements which are overseen by a technology director.
By reading the standards, each applicant can gain a full understanding of what is required to optimize its accreditation application, in addition to taking advantage of the feedback loops that help all applicants make improvements.
Smith: URAC’s telehealth standards encompass a broad spectrum of professional practices, including technology-enabled consultations between two providers, provider to facility and provider direct to consumer/patient. This approach embraces practice by physicians and other healthcare professionals in primary care and all specialties.
Professional practice enabled by technology requires many of the same considerations as face-to-face practice, such as establishment of a provider-patient relationship, attentiveness to the patient experience and documentation of evidence-based practice. The use of a variety of enabling technologies adds emphasis on systems capabilities; technology selection; privacy, security and integrity of data; information exchange issues; and transmission reliability.
Q. What are the most common mistakes that a health system makes that would affect accreditation?
Smith: The changing landscape of state regulation of telehealth is a challenge for all telehealth providers. As acceptance of the relative safety and quality of technology-enabled practice has grown, state laws and regulations have fluctuated. So keeping track and assuring compliance is critical.
For example, practitioner licensure to practice is required in the state where the consumer/patient is located. The Interstate Medical Licensure Compact offers a voluntary pathway to legal medical practice in multiple states. Our most-recent check shows 24 states and 1 territory (Guam) have agreements to participate.
Other practice-related challenges include addressing consumer education, decision-making tools for consumers and consumer empowerment. These expectations extend beyond the capabilities of patient evaluation, treatment recommendations, and intervention.
Carneal: We most often see applications that are incomplete in some way – either by not providing enough detail in the narrative sections or not uploading enough documentation. Each CHQI applicant is assigned an account manager at the onset of the process; applicants are encouraged to use their account manager as resource to answer any questions and provide any clarification on the application or the process.
In addition, each standard, and its supporting narrative and documentation requirements, has been carefully drafted and designed to ensure that applicants are launching, maintaining and updating a “best-in-class” telemedicine/telehealth program. Applicants who fully internalize the process and incorporate the spirit behind the standards will benefit. And those who just do the minimum to get a passing grade are missing out on an important opportunity.
Q. Within the hospital or health system, who would most likely be in charge of handling the accreditation process, and why? Would this be a committee function?
Carneal: Ownership of the accreditation process depends on the size and structure of the applicant organization. For larger organizations, we often see employees in charge of compliance and/or quality take a leadership role in the application process. For smaller organizations, we see a range of roles. Some applicants have created an accreditation committee/task force, but whether this makes sense for an applicant depends on the size and structure of the organization.
Smith: A cross-functional team often is led by an office of quality and accreditation. This is a staff function working across management spans of control. Telehealth may or may not be a discreet service within the hospital or health system structure, but most often is integrated into many of the clinical service lines. The medical staff plays a key role. Some systems (e.g. HCA) do have a designated executive for telehealth.
Q. Would the process be different for a health system that partners with a vendor on a telehealth platform, as opposed to one who handles everything in-house? Why?
Smith: There is a difference between an integrated service within a hospital or health system, where staff conduct the consultations, and those who contract with a service provider and its practitioner network, such as American Well. The difference URAC would see is who credentials the consulting practitioners. That said, it is unlikely that the contracted service would constitute all of the telehealth practice within a hospital or health system of any size. One interesting model of which we are aware is the telehealth organization that contracts to oversee the care of patients in intensive care at various distant locations, such as Mercy Virtual.
Carneal: Not really. At the end of the day, the health system still must actively oversee and work with a vendor providing the telehealth platform. In part, this is done by the applicant entering into the appropriate written agreement with the vendor, which allows ongoing oversight of how IT services are provided back to the health system. Whether the telehealth platform is offered through a vendor or provided in-house, the CHQI Telemedicine Accreditation Program has the same requirements in order to promote quality-based telemedicine services.
Q. Would a rural health system be measured differently, or require different data, than an urban health system? If yes, why?
Carneal: At this time, the CHQI Telemedicine Accreditation Program makes no distinction between an urban and rural health system. That being said, while CHQI has created national standards, the accreditation process is always customized. The CHQI accreditation process is designed to accommodate different telemedicine/telehealth delivery models, so adjustments would be made for each applicant depending on their customized approach to providing telemedicine/telehealth services.
One thing that helps is that all applications are peer reviewed on a de-identified basis by CHQI’s Accreditation Committee, and inter-rater reliability studies are run to ensure the consistency between applications.
Smith: A rural health system is eligible to apply for URAC accreditation if it provides telehealth services. We expect that the same standards would apply to both urban and rural providers. The difference(s) we most likely would see is in scale and complexity. Requirements for practitioner credentialing, professional practice, consumer protections, and performance monitoring and improvement are the same.
Q. How does EMR integration fit into the accreditation process? AI tools? Privacy and security?
Smith: URAC standards specifically address Information Systems Confidentiality and Security, including performance elements addressing protection of data and information, and confidentiality of individually identifiable health information (IIHI). An entire focus area is devoted to Information Systems. These requirements include information systems capabilities; technology selection; user competence; risk assessment and reduction; system privacy, security, and integrity; information exchange issues; and transmission reliability.
The existing standards do not specifically address AI. The care delivery model on which the accreditation is built assumes a responsible provider/practitioner and is silent on the use of AI tools to support the practitioner or the consumer/patient.
Carneal: The use of electronic medical records is an important principle embedded in CHQI’s Telemedicine Accreditation Program. Among other goals, it is important that the patient’s information is getting to the right stakeholder at the right time after any telemedicine/telehealth encounter (e.g., when appropriate, getting the information to the patient’s primary care provider). Therefore, EMR integration, along with automated tools and related IT functions, is important.
Of course, not all telemedicine/telehealth programs offer integrated EMR systems. However, CHQI will work with applicants to help identify best practices moving forward. In addition, key requirements such as compliance with HIPAA is mandatory. Applicants must demonstrate IT proficiency has highlighted in the standards.
Q. Is patient engagement measured in accreditation? If so, how is it measured?
Carneal: CHQI’s Core Standards require applicants to provide evidence that assesses the effectiveness of its telemedicine services based on several quality indicators, one of which is patient satisfaction, which can be measured a variety of ways – via consumer surveys, Net Promoter Score (NPS), wait times, cost of services, patient re-engagement levels, grievance/complaint tracking, customer retention, etc.
Smith: Patient engagement is recognized in the Guiding Principles for URAC accreditation and a required element of performance for care coordination services provided via telehealth programs.
As consumer empowerment, it consists of access to services, opportunities for feedback, consent, engagement and health literacy practices that enable consumers to actively participate in their care and practice responsible self-management.
Specifically defined as consumer engagement (also known as “patient engagement”), it includes actions individuals must take to obtain the greatest benefit from the healthcare services available to them. These actions fall within the category of adaptive health behaviors.
Documented proof of compliance is demonstrated by a (written) description of patient engagement strategies pertinent to support health improvement and promote relative wellness that is reviewed via desktop validation methods and is verified via patient records audits during the interactive review session.
Q. Are there new services or technologies on the horizon that might soon figure into the accreditation process?
Smith: Everyone is interested in the potential for AI in healthcare. For telehealth services, as in all healthcare practices, there is a reasonable likelihood of improvement in the quality of care delivered via AI “deep learning” capabilities. Such technology “could be the very thing that catapults American healthcare into the future – helping to clarify the best care approaches, creating new approaches for diagnosing and treating hundreds of medical problems, and measuring doctor adherence without the faulty biases of the human mind.”
Carneal: CHQI has begun work on two new modules that will cover remote patient monitoring (RPM) and telemedicine outcomes based upon the National Quality Forum (NQF) recommendations.
Q. How will, or should, telehealth accreditation evolve?
Carneal: As the practice of telemedicine evolves, telemedicine accreditation should evolve. CHQI and our volunteer-based Telemedicine Standards Committee are committed to regularly fine-tuning and updating the existing Telemedicine Accreditation Program Standards and to adding future accreditation modules as healthcare technology, regulations, and measurement tools evolve.
CHQI is in the process of revising its current standards, which were finalized during the spring of 2018. In addition to adding new modules, we are looking at updating CHQI’s scoring criteria, the application of the standards to international telemedicine providers, allowing for a “provisional” accreditation when applicants do not have enough experience, and much more.
Finally, we recently created a working group focused on how to demonstrate the clinical and financial outcomes associated with telemedicine/telehealth programs. We are in the beginning stages of developing a return on investment (ROI) tool and believe it will be a game-changer for measuring and showcasing the value of a telemedicine program.
Smith: URAC will strive to keep pace with the industry and to maintain the big tent approach to our standards that enables a wide variety of organizations with diverse practice models and multiple types of practitioners to qualify for the accreditation. Our aim will continue to be promotion of quality care and consumer protections.
We review our programs on a cyclic basis. As we gain experience with additional and even more diverse telehealth accreditation clients, we will re-evaluate the need for revisions. URAC is a stakeholder driven organization that seeks comment and participation from a broad range of individuals, consumer groups, practitioners, providers, and regulators.