September 11th

1
Introducing ESAR - VHP
2
EmergencySystem forAdvance Registration
ofVolunteerHealth Professionals
3
September 11 St. Vincent Hospital

• Many physicians were in New York for a convention
• The hospital was unable to verify volunteer
  physicians identity, basic licensing and
  credentialing information, including training,
  skills, competencies and employment

4
Licensed Health Care Workers (HCW)

• The same credentialing concerns apply to other
  licensed HCWs such as
• Registered Nurses
• Behavioral Health Care Specialists
• Respiratory Therapists
• And so many more...

5
Non-Licensed HCWs

• This process only gets more difficult when trying
  to verify the skills and competencies of
  non-licensed health care workers
• The focus of this credentialing project is on
  credentialing of physicians, allied health
  professionals and other licensed HCWs

6
Credentialing Today

• Inconsistent Disaster Credentialing Policies
  across all Wisconsin hospitals
• Volunteer Physicians and other HCWs may present
  only with Drivers License or Hospital Badge as
  their ID
• Credentialing then depends upon the individual
  efforts and policies of hospitals

7
HRSA Purpose of ESAR-VHP

• To assist medical professionals in volunteering
  for disasters
• by providing verifiable, up-to-date information
  regarding the volunteers identity and licensing,
  credentialing, privileging and certification
• to hospitals and other medical facilities that
  request their services

8
Definitions

• Licensing verification of state professional
  license and identification of any restrictions,
  limitations or stipulations
• Credentialing verification of education,
  training, work experience and hospital
  affiliations

9
Definitions

• Privileging verification of scope of practice as
  defined by the organization in which the
  clinician practices
• Certification verification that the HCW meets
  the special qualifications as established by
  nationally recognized professional organizations

10
Disclaimer

• Hospitals may choose which certifications,
  certifying or privileging organizations they will
  choose to honor

11
Purpose of This Presentation

• To describe the process for the REGISTRATION of
  volunteer HCWs in Wisconsin
• This registration process has been operational
  since November 2003
• Over 700 HCWs are already registered

12
Purpose of This Presentation

• To describe the process for the CREDENTIALING of
  volunteer HCWs in Wisconsin
• To obtain your feedback on this credentialing
  process so that corrections and enhancements can
  be made

13
Value of ESAR-VHP

• relatively inexpensive not labor intensive
• consistent with the Mission of hospitals to
  provide quality care to patients
• reduce liability by assuring that only qualified
  HCWs volunteer (existing legal protections in
  disasters are no substitute for due diligence)

14
State of Wisconsin

• One of 10 pilot states tasked with establishing
  national guidelines and Best Practices by
  January 31, 2005
• 200,000 in Supplemental Funding to enhance our
  Registry and Credentialing systems

15
How Will ESAR-VHP Work?

• The best way to understand how ESAR-VHP works is
  to see how it operates in a disaster scenario

16
Disaster Scenario

• At the Sunday evening Demolition Derby at the
  County Fair, the grandstands collapse. There is
  the initial report of approximately 300 persons
  in need of treatment
• several multiple organ trauma victims
• many victims with fractures
• many victims with lacerations and bruises
• many victims in need of medical evaluation

17
Disaster Scenario

• The more seriously injured victims are being
  transported to Level I and II trauma centers.
• St George Hospital, a CAH, has activated its
  inpatient surge capacity plan and has opened its
  Triage Center and can accommodate all the
  victims, if it can obtain volunteer HCWs

18
Disaster Scenario

• The hospital Medical Director states that he
  needs 10 orthopedists (for fracture reduction)
  and 15 general practitioners (for laceration
  repair and general patient evaluation and
  treatment).
• The The Request for Volunteer HCWs is sent to
  the EOC

19
Emergency Operations Center

• The EOC is a county disaster operations center
  that coordinates the resources necessary to
  manage the disaster
• It operates under the Incident Command System
  (ICS)

20
Base Hospital

• If there is no EOC activated, the hospital
  nearest the incident serves as the Base Hospital,
  coordinating the medical resources necessary to
  manage the disaster

21
Disaster Scenario

• The call goes out through the media, WEAVR and
  the EOC recruitment center for orthopedists and
  general practitioners

22
WEAVR

• In Wisconsin, the volunteer registration portion
  of ESAR - VHP is referred to as WEAVR
• Wisconsin Emergency Assistance Volunteer Registry

23
WEAVR

• a secure, password-protected, electronic
  database, residing within the Wisconsin Health
  Alert Network (HAN)
• WEAVR is owned and managed by the Wisconsin
  Division of Public Health (DPH)

24
Purpose of WEAVR

• provides healthcare professionals with an easy
  way
• to indicate their interest in volunteer service
  during a disaster
• to update their registration information
• to indicate their expertise by degree, licensure,
  certification and specific skills
• See Attachment A WEAVR Screens

25
Disaster Scenario

• Within less than an hour the first volunteer
  HCWs begin to call the EOC or report directly to
  the hospital to assist the St. George Hospital
  physicians

26
Disaster Scenario

• According to the Wisconsin Hospital Emergency
  Preparedness Plan (WHEPP),
• the EOC will credential volunteers HCWs
• or the hospital may choose to credential
  volunteer HCWs

27
Rationale for Disaster Credentialing

• The rationale for disaster credentialing is the
  fact that all hospitals can rely on one anothers
  protocols for credentialing

28
Rationale

• Modifications to the Medical Staff By-Laws or
  Policies allow hospitals to honor the
  credentialing efforts of other JCAHO or Medicare
  certified hospitals in a disaster situation
• All Wisconsin hospitals must be accredited by
  JCAHO or be Medicare Certified by the State of
  Wisconsin

29
Conditions of Participation

• JCAHO-accredited hospitals meet the Medicare COP
• Non-JCAHO-accredited hospitals (n 30) are
  surveyed by the State to certify that they meet
  the COP to participate in the Medicare program
• JCAHO and COP credentialing and privileging
  standards are essentially the same

30
Important Distinctions

• Emergency Credentialing applies to any
  life-threatening incident, during which the
  hospital can grant privileges to a clinician, who
  is on the Medical Staff, so that he/she can
  provide necessary medical treatment beyond the
  scope of practice of that clinician

31
Important Distinctions

• Disaster Credentialing applies to a local,
  regional, state or national incident that
  overwhelms the resources of any one institution,
  during which the hospital can grant privileges to
  a clinician, who is NOT on the Medical Staff, so
  that he/she can provide necessary medical
  treatment

32
Sample Language

• Disaster Privileges may be granted, in response
  to a disaster, to providers of known competence,
  qualifications and quality, who hold medical
  staff membership and clinical privileges at
  another fully JCAHO accredited or Medicare
  Certified hospital. These Disaster Privileges
  shall be in place as long as the hospital
  determines that it is in need of these providers
  to deal with the disaster.

33
WDC

• In Wisconsin, the credentialing portion of
  ESAR-VHP is referred to as WDC
• Wisconsin Disaster Credentialing

34
Wisconsin Disaster Credentialing

• a secure, password-protected, web-site that
  allows a hospital
• to do immediate primary source verification for a
  physician or allied health professional
  (available to all hospitals) and
• to access the hospital affiliation(s) of a
  physician or allied health professional
  (available to participating hospitals)

35
Back to the Disaster

• Perry White MD, Orthopedist, is the first to call
  in to the EOC
• The EOC begins the credentialing process
• WDC is accessed
• The name Perry White is entered
• The following information appears...

36
Perry White MD

• See Attachment B the Credentialing Profile of
  Perry White MD

37
Perry White MD

• See Attachment C the Affiliations Profile of
  Perry White MD

38
Credentials Verification

• The EOC verifies the credentials of Dr. White on
  the Request for HCWswith information from WDC
• The EOC faxes the Request to the hospital,
  indicating that Dr. Whites credentials have been
  verified
• The hospital can also access WDC and print out
  the Credentials and Affiliations Profiles

39
Hospital Affiliations

• If the hospital of Dr. White is not voluntarily
  sharing its Affiliations Profile, then the
  requesting hospital will need to complete the
  Disaster Privileging for Non-Medical Staff
  Volunteers (Attachment D) and determine the
  hospital affiliation of Dr. White before
  deploying him (unless the hospital has a policy
  to deploy him)

40
Hospital Affiliations

• Hospitals are encouraged to participate in this
  voluntary component of the WDC.
• It will provide necessary hospital affiliation
  and other information that will otherwise need to
  be collected manually by the hospital
• This may result in delay in the deployment of the
  HCW (unless the hospital has a policy to
  immediately deploy the HCW)

41
Affiliations Data Elements

• First, Middle Initial, Last Name, Suffix
• Professional License Number
• Practitioner Type
• Birth Date
• Primary Degree

42
Affiliations Data Elements

• Primary Contact Information
• Street Address 1 and 2
• City, State, Zip Code
• Telephone Number
• FAX Number
• Cell Phone Number
• Pager Number
• Email Address

43
Affiliations Data Elements

• Specialty/Board Information
• ABMS/AOA Specialty or Sub-Specialty
• Board Certification (yes/no)
• Hospital Affiliations
• Staff Category
• Initial Appointment Date
• Primary Specialty
• Admitting Privileges (yes/no or N/A)
• Special Qualifications or Limitations

44
Affiliations Data Elements

• License Type
• State
• Number
• Expiration Date
• ID Type
• Number

45
Affiliations Data Elements

• Liability Insurance Carrier
• Policy Number
• Coverage Type
• Effective Date
• Expiration Date
• Limit Per Occurrence
• Limit Aggregate

46
Affiliations Data Elements

• The Affiliation Data Elements are voluntary.
  However, the following elements are essential for
  participation
• Hospital Name
• Physician or Allied Health Professional Name
• Specialty
• Hospital Medical Staff Status
• Practitioner Type

47
Affiliations Data Elements

• Although Immunization (TB and Rubella) and
  Criminal Background status are not collected, the
  provision of these Affiliation Data Elements
  gives the requesting hospital the assurance that
  these elements have been verified by the hospital

48
Credentials Verification

• The hospital prints a copy of Dr. Whites
  Credentialing and Affiliations (if available)
  profile from WDC
• the photo on the Affiliations Profile can be
  matched to the photo on Dr. Whites Drivers
  License or his Hospital Photo ID
• Dr. White will sign the profile(s), attesting
  that this accurately represents his credentials

49
Primary Source Verification

• Board Certification (ABMS/AOA)
• Hospital Affiliations (voluntary)
• DEA License
• National Practitioner Data Bank
• Criminal Background Check (for future
  consideration)

50
Primary Source Verification

• State Licensure
• Office of the Inspector General (OIG)
• AMA Profile (education and training)

51
Mary Black MD

• Dr. Black is a Family Practice physician, who
  presents to the hospital
• The exact same credentialing process occurs for
  Dr. Black
• Hospital has option
• to use WDC
• ask EOC to credential Dr. Black

52
Geoffrey Gray MD

• Dr. Gray works in a rural clinic and does not
  have Medical Staff membership at any hospital
• He can be deployed only if he completes the
  Disaster Privileging for Non-Medical Staff
  Volunteers

53
WDC Credentialing

• Dr. Gray completes the Disaster Privileging
  form
• The EOC or the hospital then enters both the Date
  of Birth (DOB) and Social Security Number (SSN)
  into WDC
• The Credentials Profile will be available
  immediately for Dr. Gray

54
Susan Blue MD

• Dr. Blue is retired and has Emeritus status at
  St. Christine Hospital
• She can be deployed only if she completes the
  Disaster Privileging for Non-Medical Staff
  Volunteers

55
Henry Brown MD

• Dr. Brown is visiting from out-of-state and
  responds to the call for assistance
• He must complete the Disaster Privileging for
  Non-Medical Staff Volunteers
• The Credentialing Profile for Dr. Brown can be
  obtained, if he is from one of the 17 states
  linked to WDC

56
DMAT and EMAC Professionals

• These healthcare professionals must also complete
  the Disaster Privileging for Non-Medical Staff
  Volunteers
• DMAT Disaster Medical Assistance Team
• EMAC Emergency Management Assistance Compact

57
Disclaimer

• In all cases, the hospital has the right to limit
  the privileges of any volunteer HCW or even not
  allow that volunteer HCW to work at the hospital,
  based on the hospitals own criteria, even though
  the volunteer HCWs credentials and privileges
  can be verified.

58
License Restrictions, Limitations and/or
Stipulations

• It is recommended that a HCW with a license
  restriction, limitation or stipulation not be
  deployed because the reason for these cannot
  easily be verified.
• The hospital may have a policy to dictate
  otherwise so that the HCW may be deployed.

59
Louis Redd MD

• Dr. Redd is from out-of-state
• He must complete the Disaster Privileging for
  Non-Medical Staff Volunteers
• There is some suspicion about whether he truly is
  who and what he says he is.

60
Possible Fraud

• A person that is thought to be falsely portraying
  him/herself as a HCW should be reported to law
  enforcement and assigned only as a lay volunteer
  until the credentials of that person can be
  verified.

61
Attestations

• When the physician arrives at the requesting
  hospital, the following documents will be signed
• The Credentialing and Affiliations Profile
• Agreement to Abide by Medical Staff By-Laws and
  Hospital Policies and Procedures

62
On-Site Activities

• This presentation will not address issues such as
  supervision, medical records, liability and
  malpractice, billing/coding, orientation basics,
  etc.
• Policies and procedures for these issues are
  being addressed in another forum

63
Final Documentation

• After the disaster, the Medical Staff Services
  Office maintains the following records
• Credentialing Profile
• Affiliations Profile (if available)
• Disaster Privileging for Non-Medical Staff
  Volunteers

64
How Do We Credential Nurses?

• WDC will provide the Credentials Profile for a
  RN, once the DOB and SSN is entered
• The RN signs the attestations
• The RN self-reports his/her skills and
  competencies and is assigned accordingly

65
How Do We Credential Other Licensed HCWs?

• WDC will provide the Credentials Profile for a
  licensed HCW, once the DOB and SSN is entered
• The HCW signs the attestations
• The HCW self-reports his/her skills and
  competencies and is assigned accordingly

66
How Do We Credential Non-Licensed HCWs?

• These HCWs are not subject to credentialing
• The criteria for deploying these non-licensed
  HCWs are being addressed in a separate forum.

67
QuestionsAboutWDC
68
Is This Really Necessary?

• Hopefully, we will never need to use WEAVR and
  WDC. But, if we do, the consequences of having an
  unqualified HCW, caring for patients, needs no
  further explanation.

69
How Do Hospitals Access WDC?

• Each hospital will be provided with a User ID and
  Password
• There is no cost to the hospital to access this
  information
• The website will be live 24/7 so that hospitals
  can exercise WDC

70
Who Can Access This Information?

• Users at a particular hospital must be authorized
  by a person such as the Medical Staff Services
  Director
• It is expected that a hospital will designate
  several users so that an authorized person is
  available to access this service in a disaster

71
Are There Restrictions on the Use of This
Information?

• Hospitals must sign a User Agreement the first
  time they use WDC
• Site is monitored for frequency of use
• Illegal/Improper Use results in loss of access to
  WDC

72
How Often Is the Credentialing Profile Verified?

• The Credentialing Profile is verified
  immediately in real-time at the time of the
  query

73
How Often Is the Affiliations Profile Verified?

• This information is not verified, but is up-dated
  monthly or as often as deemed necessary by the
  hospital
• Up-dates are essential, since the assumption
  behind immediate deployment is membership in
  good standing on a hospital Medical /Allied
  Health Professional Staff

74
What If a Physician Has Multiple Medical Staff
Memberships?

• All hospital affiliations will show up under each
  Affiliation Profile
• However, the Affiliation Profile will contain
  only the affiliations listed on any one hospital
  profile

75
Is There a Redundant System?

• The redundant system is paper the Disaster
  Privileging for Non-Medical Staff Volunteers
• A manual deployment system and the accompanying
  policies and protocols for deployment of HCWs
  will be necessary until WDC is back on-line

76
What IT Capabilities Does Our Hospital Need to
Have?

• Each hospital will be asked to complete the
  survey regarding their IT capabilities for
  reporting
• IT assistance, at no cost, will be provided to
  all hospitals requesting help so that they can
  both access WDC and upload the Affiliation
  Profiles (if the hospital chooses to participate)

77
What About Privacy and Confidentiality?

• All information available through WDC, e.g. the
  Affiliations Profile has restricted access and
  users are bound by Confidentiality as per the
  User Agreement

78
What Are the Costs for Participating Hospitals?

• There are no costs for the hospital to access the
  Credentialing Profile through WDC
• There are no costs for the hospital to access the
  Affiliations Profile through WDC
• Only the hospital using WDC for Primary Source
  Verification will be billed

79
How Is WDC Funded?

• The WDC is funded through grants from the Health
  Resources and Services Administration (HRSA) for
  hospital bioterrorism preparedness

80
Who Manages WDC?

• The license is to be held by Shared Health
  Services of LaCrosse, WI, the fiscal agent for
  HRSA Region 4
• The WDC is managed by a Board of Directors,
  chosen by the users of WDC

81
Comments and Suggestions

• Your comments and suggestions to enhance WDC are
  welcome
• Email any comments and suggestions to
• tomczdj_at_dhfs.state.wi.us

82
Presenters

• Dennis Tomczyk
• Director, Hospital Emergency Preparedness
• Wisconsin Division of Public Health
• 608-266-3128
• tomczdj_at_dhfs.state.wi.us

83
Presenters

• Kate Conklin, CPMSM, CPCS
• President, Wisconsin Association Medical Staff
  Services (WAMSS)
• St. Vincent Hospital, Green Bay
• 920-433-8284
• kconklin_at_stvgb.org

84
Presenters

• Ellen Broyles, CPMSM
• (title)
• Columbia/St. Marys Inc., Milwaukee
• 414-961-5355
• ebroyles_at_columbia-stmarys.org

85
Presenters

• Carol McDonough, CPCS
• Credentialing Coordinator
• Board of Directors, WAMSS
• Howard Young Medical Center, Woodruff
• 715--356-8988
• mcdonough_at_hyhc.com

86
Presenters

• Marta Sattergren-Hoch, CPCS
• Medical Staff Coordinator
• Board of Directors, WAMSS
• Aurora Medical Center of Oshkosh
• 920-456-7615
• marta.sattergren-hoch_at_aurora.org