INDEX:MS3-7

EFFECTIVE:08/01/13

Page 1of 4

SUPERSEDES:02/07/13

SUBJECT: Telemedicine

POLICY STATEMENT: Telemedicine services will be provided at Hendrick Medical Center (HMC)in a manner that seeks a high level of care consistent with the standards of care for other hospital services. This policy outlines credentialing procedures that are different from routine credentialing procedures and that apply only to physicians providing telemedicine services through separate contract or agreement.

POLICY

RULES:

  1. Physicians applying for Medical Staff privileges at HMC must satisfy the minimum qualifications outlined in the CredentialsManual and the Credentials Procedure Manual of the Medical Staff Bylaws of HMC and all applicable policies of the Medical Staff and HMC.
  2. The telemedicine group must be contracted with HMC. Such contract or agreement will only be made with a telemedicine group that is accredited by an organization such as the Joint Commission as an ambulatory care organization.
  3. If HMC enters into a contract or agreement with anaccredited telemedicine group, HMC may rely on the telemedicine group’s credentialing similar to utilizing a credentialing verification organization (CVO) when considering membership and/or privilegesfor physicians in the telemedicine group.
  4. The granting of Medical Staff membership and/or privileges remains the sole authority of the Board of Trustees of HMC. Physicians providing clinical services via telemedicine may be granted privileges but not membership on the Medical Staff.
  5. HMC retains the responsibility for overseeing the safety and quality of services provided to its patients.
  6. The physician requesting telemedicine privileges must concurrently maintain privileges, at a minimum, for the same scope of services at an originating site hospital or ambulatory care organization

PROCEDURE

RULES:

  1. The telemedicine group’s credentialing and/or licensing staff must provide HMC with a copy or electronic copy of the following items:
  2. Completed Texas Standardized Credentialing Application and all attachments;
  3. Completed and signed privilege form and consent and release form provided by HMC;
  4. Copies of current licensure, DEA and DPS certificates;
  5. Declaration page of the physician’s professional liability insurance in the minimum amounts required by HMC;
  6. Completed and signed Addendum to the Texas Standardized Credentialing Application provided by HMC;
  7. Signed acknowledgement form provided by HMC related to completion of medical records;
  8. Criminal history affidavit provided by HMC;
  9. Signed Medicare/Medicaid attestation form provided by HMC;
  10. Documentation that each physician is qualified to provide telemedicine services;
  11. A current, valid identification photograph;
  12. Signed copy of Hendrick Information Network contract to access HMC’s electronic medical record, if applicable; and
  13. A copy of the DD214, if the physician previously served in the military.
  1. The telemedicine group’s credentialing and/or licensing staff must verify directly from the primary source and provide appropriate documentation to HMC of the following:
  2. Verification that the physician holds a valid, active, unrestricted license to practice medicine in the State of Texas;
  3. Verification of all current and previous licensure;
  4. Verification of medical school, internships, residency/residencies and fellowships;
  5. Verification of Board certification;
  6. Two (2) positive peer references from physicians, not partners, who are knowledgeable about the physician's work;
  7. Malpractice/claims history from all current and previous insurance carriers for the past ten (10) years;
  8. Verifications from all current and prior hospital affiliations for the past ten (10) years; and
  9. Verification of certification from the Education Commission for Foreign Medical Graduates (ECFMG), if applicable.
  1. The telemedicine group’s credentialing and/or licensing staff is responsible for providing HMC with evidence of an internal review of the physician's performance and information that is useful to assess the physician's quality of care, treatment and services for use in privileging and performance improvement.
  1. The telemedicine group’s credentialing and/or licensing staff is responsible for providing or causing the physician's originating site hospital to provide HMC with all adverse outcomes related to sentinel events considered reviewable by the Joint Commission that result from the services provided by the physician and complaints about the physician from patients, other licensed independent practitioners and staff at the originating site hospital.
  1. HMC’s Medical Staff Office is responsible for verifying the accreditation status of the telemedicine group.
  1. HMC's Medical Staff Office is responsible for obtaining the following information:
  2. NPDB query;
  3. Criminal history check and FACIS;
  4. Verification that the physician has not been excluded from participation in any federal or state program such as Medicare and Medicaid; and
  5. Verification of any additional information identified in the course of the credentials verification or privileging process.
  1. The new physician interview process, new member orientation program and EMR training will be waived for physicians applying for telemedicine privileges.
  1. After completion of the above process, the physician’s credentials file will be processed according to HMC’s Credentials Manual and Credentials Procedure Manual for processing applications. The telemedicine group and/or the physician are responsible for providing or causing others to provide all information relevant to an evaluation of the physician.Temporary privileges may be granted consistent with the Medical Staff Bylaws.
  1. Telemedicine privileges, if granted, will be for a period of not more than two (2) years. Individuals seeking to renew telemedicine privileges will be required to complete the reappointment process as outlined in HMC’s Credentials Manual. The applicant must provide HMC with evidence of current clinical competence. This information may include, but not be limited to, a copy of the individual's quality profile from his/her primary practice affiliation and evaluation form(s) from qualified supervisor(s). If all requested information is not received by dates established by HMC, the physician’s telemedicine privileges will expire at the end of the current term. Once all the information is received and verified, an application to renew telemedicine privileges will be processed as above.

Recommended by the Medical Executive Committee:07/26/13

Approved by the Board of Trustees:08/01/13

Initially approved:02/07/13

Amended:08/01/13

Reviewed: