Significant technological advancements, such as videoconferencing, computer and communications technologies, now allow physicians and other providers to treat patients not located anywhere near them and nearly anywhere in the world. Telemedicine – essentially care at a distance – can take the place of face-to-face encounters for consultations, office visits and other health care services, and allows many patients access to care they otherwise would not receive. In this way, telemedicine is truly the new frontier in medicine.

Regulatory and reimbursement obstacles limit the number of patients that can avail themselves of telehealth services. While telehealth treatment is held to the same standard of care as traditional face-to-face interactions between patients and physicians, issues such as credentialing present critical challenges to the full realization of telehealth’s potential.

Hospitals have a legal duty to evaluate the competence of physicians who administer health care services to their patients.1 Credentialing is founded on the principle that hospitals are responsible for ensuring the highest quality of care possible for patients. Medical care facilities take steps to verify their health care provider’s proficiency through the collection, verification and evaluation of data relevant to the practitioner’s professional performance. Once the practitioner is credentialed, the hospital will take further steps to assess the practitioner’s competence in a specific area of patient care, through a process known as privileging.2

Telehealth practitioners, unlike their “brick and mortar” counterparts, do not reside at one specific hospital or institution. A practitioner can be located in what is referred to as a “hub” facility, or main practicing location, and administer health care services to patients anywhere in the country in multiple “spoke” hospitals in just one day. This hub-and-spoke structure creates the issue: which hospital is responsible for credentialing the practitioner – the distance site receiving the telemedicine consult or the originating site giving the assistance?

The structure has created an administrative and legal conundrum: duly credentialed practitioners at one provider may not be able to provide service to a patient at a remote location because that provider is not properly credentialed at the site in which the patient is physically located. One potential solution is to have a separate entity that approves credentials of telehealth care providers. In 2001, the Joint Commission (JC), formerly known as the Joint Commission on Accreditation of Healthcare Organizations, introduced standards for institutional credentialing of telehealth providers. Under these standards, a physician credentialed in any JC facility would be permitted to provide telehealth services in another JC facility. JC allows the facility where the patient is being treated to credential the treating physician in two ways: (1) the treating facility could fully credential the physician based on their own facility’s standards, or (2) the treating facility could accept the credentials of the treating physician based on the fact that the remote institution is JC-certified. JC standards for credentialing are based on patient care, medical/clinical knowledge, practicebased learning and improvement, interpersonal and communication skills, professionalism and systems-based practice.3

While this may seem like a practicable solution, the Centers for Medicare and Medicaid Services (CMS) has weighed in, concluding that a telehealth physician’s compliance with JC credentialing rules is not sufficient to ensure compliance with the Medicare Conditions of Participation providers must meet in order to be Medicare participants. CMS has stated that any physician who provides a “medical level of care” should be credentialed by the facility providing the care. The result is that telehealth providers might be forced to be credentialed by multiple hospitals nationwide – an administrative nightmare for hospitals and providers.

Many in the telehealth field have expressed concern that CMS’s decision may effectively chill the advancement of telemedicine, a prospect that could lead to significantly decreased quality of care in rural and underserved areas, among others. In response to this concern, the Center for Telehealth and e-Health Law (CTeL), a nonprofit research institute, has compiled an assessment to gauge the impact of the CMS policy. The findings of this informational assessment will be published at www.telehealthlawcenter.org.4 In the meantime, physicians and hospitals interested in providing telehealth services must continue dealing with the administrative stumbling blocks that make it difficult to provide these services, potentially depriving many patients – especially those in rural and underserved areas – of critical care. HLB