Note: The Q&A transcription has been paraphrased to be more succinct.
The recorded presentation may be viewed here.
Presentation: Digital Credentials: Hahnemann University Hospital and Beyond
Speakers:
- Cyndi Streun, MS, Vice President of Information Services, Federation of State Medical Boards
- Michael Dugan, MBA, Chief Operating Officer, Federation of State Medical Boards
Q: (Johmarx Patton)
Thinking of the 6,000 records, how long does it take to convert paper records to digital?
A: (Cyndi Streun)
This was the first time we received data in electronic form, but it wasn’t really received. We had a two-week window of access to their software, which we didn’t know anything about. We then went in and mined the data out. I cannot give a metric per page, but we had a very specific amount of time to get it and get out. Then we took that data and mapped it to our DocuSign. It was a very different experience than we ever had before. Generally, a box (or boxes) show up.
A: (Mike Dugan)
Hanhemann is one situation where we quickly learned they were not folks we could deal with. But, in other closed programs we have two methods that we could use. 1) They provide the data. We line it up. Then, the registrar will sign the documents, and we just keep them. 2) In other cases, there is a type of authorization form that states we are now the custodian. In many cases, we are just a custodian and don’t have signature authority. So, if the organization can sign and we combine that with the custodial signature, then those two things go together.
With Hahnemann, in some cases, we may have to sign the documents; we actually become the signatory. We do the DocuSign process, so signing 6,000 is very onerous. The way that standards work, you’re not allowed to bulk sign; you need to sign one at a time. In a preferred situation, these would be signed as they are issued. For example, a graduating class at a time - those tend to be smaller.
Q: (Johmarx Patton)
My follow-up question: As we look at migrating universally to entirely digital credentials, however long that may take us to get to, should we look at only capturing data prospectively or should we go back and pull in data retrospectively. For example, someone who has been practicing since the 1970’s or 1980’s will have their entire record available digitally. What are your thoughts on that?
A: (Mike Dugan)
We went back to 1980, which is really long when you think about it. I think there’s a practical number there. In looking back, I think perhaps there’s a limit in how far you go back. If the people are still around and available, you could do it on an as-needed basis, which would probably be more efficient. You could still do a degree of digitization on the records, but going back and digitally signing every single document from the past is probably not practical.
A: (Cyndi Streun)
That is a really good question. I once attended a meeting with NAMSS (National Association Medical Staff Services) and that question came up. Separating out fresh graduates who now have electronic records, there are two different pathways you can get to a solution. Trying to find a way for everybody to have electronic records gets difficult very quickly. Our credentialing department deals with that situation. For a physician straight out of training it’s much quicker and easier to get credentials versus a late career physician who is retiring to a different state and has to retrieve his or her credentials in order to get licensed in another state.
Q: (Peter Ludlow)
How do you deal with standardized signed PDFs versus customized data fields and questions that credentialing institutions require?
A: (Mike Dugan)
This wasn’t mentioned in the presentation but in the world of GME there is a standardized form, which made this something we could really commit to and run with. We were not involved in creating this form, it’s called VGMET [Verification of Graduate Medical Education Training]. The Joint Commission authorized that form, and that really allowed us to move forward with great strength.
The other part is if a record has unusual circumstances – for example, there’s disciplinary information in it. There could be a path where a record is just messy enough that it does not qualify for this process. Best practices around that are still developing, but that is a possibility.
Being able to point to that standard is very powerful. When talking about adoption and people changing, we can say that form meets all the standards because of who created it. I think a lot of those specialized forms are still out there. I think uptake on that form is still taking place, but it is out there.
Q: (Terence Ma)
These are essentially document-based. Is there a way for a verified, secure data cloud where the specific data are stored can be pulled at need?
A: (Cyndi Streun)
These are document-based, that is correct. With our DocuSign solution we have the data behind every artifact. It’s the way we built the solution, so we have the structured data. PDFs also have metadata you can store within them. The AACRAO (American Association of Collegiate Registrars and Admissions Officers) have some PDF standards about their documents that we wanted to explore and have not because it would prevent us from moving forward; we needed to get our solution out there. But I think that’s a valid question about the data that a lot of people would be looking for. I believe we would probably embed it within the document versus a data cloud. I think that question is interesting and thought-provoking, but I don’t have an answer.
A: (Johmarx Patton)
Adding to that from the MedBiquitous angle, there are some conversations happening with IEEE [Institute of Electrical and Electronics Engineers] and some other standards development organizations around lifelong learner records that adhere to digital credentials. Some of those efforts and conversations highlight exactly what Terence is asking about - having the more granular data available rather than the actual verified document credential and other smaller pieces.
Here are some links to related conversations happening in the world right now:
- Guide for Conceptual Model for Learning Technology Systems (CM4LTS)
- Recommended Practice for Integrated Learner Record (ILR)
Q: (Jeff Kaminski)
With the workflow changes that occurred with your internal team, were there any hurdles or challenges with coordination and adherence to behavior changes and what strategies were used?
A: (Mike Dugan)
It streamlined our workflow a great deal. These programs would close, ship us boxes, and so we had an index. We didn’t pre-fill out all these forms. Depending on which institution was asking for them, you might get a different form. We would get a request, call out to the storage facility, pull back the right box, complete the form, and go from there. Perhaps the rest of the box might get digitized in case you get another request from that box. It was a big drain on resources.
Now, it’s work upfront with the new ones. The data needs to be cultivated and put through the DocuSign process. If we are the signatory, we may cultivate the data to have it ready, and then we’ll generate the form and sign it. For the most part, it can be done in real-time. Part of the reason we wait to generate it is because there is a cost associated with DocuSign. In our case, it may be in the fifty cents to a dollar range. When you’re doing thousands, it adds up. There’s no real need to do it if the document will never be needed. But, overall for that team, it has greatly streamlined that work.
For workflow on the other side we had seminars with boards at the start explaining why they’ll see these documents, why it’s acceptable, and how to ensure it’s from us. We also include a cover sheet instead of just a form. There’s an intro sheet that explains how to use this form. I do not know of any kickback from receiving institutions – and we do know there have been receiving institutions.
A: (Cyndi Streun)
On the internal side, we started with a kickoff meeting with our as-is state and our to-be state, and we had the support from top down. The vision was there with clarity around where the future needs to be or it’s not sustainable. I think everyone was aware of what we needed to do to sustain our closed program initiative. It was very visible and spelled out. That made a difference. It was a little bit hard for some individuals. We all work in organizations where many of us have been there for 20 years. Just having it all very clear, and visually represented was helpful.
Q: (Terence Ma)
What would you envision a standard on digital credentials would look like? Should it be specific to the needs of medical credentialing, all health professions credentialing, or to all sorts of credentialing needs?
A: (Mike Dugan)
We love standards and have been supportive of MedBiquitous for years. I think it’s a pretty quick “yes” that we’d love to see a standard. If it were up to me, I would start with medical credentialing. That alone is a lot to bite off, then you could take it from there.
A: (Cyndi Streun)
When we worked on the paper, “Healthcare and Digital Credentials: Technical, Legal, and Regulatory Considerations,” we were trying to go to a standard like the open badge standard, which has committees like the MedBiquitous standards. We even used the MedBiquitous Professional Profile standard to see what data fields are collected. There are quite a few standards out there and it would be nice to unify them. Because we work with so many state medical boards, medical schools, and GME programs – it’s hard to think they would ever standardize on anything. I guess we can hope.
A: (Johmarx Patton)
Hope is a powerful tool. There are several standards organizations in the space of education and workforce training, such as PESC [Postsecondary Electronics Standards Council], MedBiquitous, A4L [Access 4 Learning], and HR Open Standard. And, we are actively trying to harmonize and unify between our standards and keep each other informed as to what we are working on.
In one to two years, I think we will see a lot more unification and harmonization between standards so that they are easier sells to state medical boards and universities, and to the many other dozens of stakeholders involved in these types of conversations. They will see there is this concerted effort to support them in that transition.
A: (Mike Dugan)
I think this is an evolutionary process. It’s something that we’ll be talking about for time to come.