A new platform developed by Cleveland-based, Zivian Health aims to help nurse practitioners and physician assistants expand their scope of practice.

The HIPAA-compliant and HITRUST-secure platform is designed to help healthcare organizations broaden patient access and scale their businesses while streamlining team-based care, say two of its founders.

Compliance conundrum

Those cofounders, Dr. Rafid Fadul, director of pulmonary medicine at Ohio's Blanchard Valley Health System, and Jesse Corn, Zivian's chief product officer, say the technology was designed with states' varying practice rules in mind.

Each state and territory has its version of the Nursing Practice Act, which oversees licensure throughout nurses' careers. 

If a nurse violates a law or NPA rule of a particular state, the state board of nursing may discipline that nurse – which could mean a loss of their license and any multistate license privileges they may have, according to an overview of the law in the National Library of Medicine.

While 27 states and Guam grant nurses full practice authority, the rest reduce or restrict their practice authority, according to NurseJournal's state-by-state guide. 

Many of these states are littered with healthcare deserts – places where NPs could be valuable in expanding much-needed patient access, even in the face of a physician shortage.

"By 2040, the number of NPs will have eclipsed the number of physicians," Fadul told Healthcare IT News.

But for certified NPs in states that restrict their abilities to assess patient conditions, order tests, make diagnoses, prescribe medications and order treatments, they need a licensed physician collaborator and must ensure compliance with all state and federal laws and rules governing their licenses, and those of their collaborators.

First, they must find a licensed physician collaborator who matches their practice areas, and then safely share patient charts. Over the long term, they must monitor all federal and state regulations and licenses.

"If you're in Texas, or if you're in Georgia, or if you're in Pennsylvania, it's different," Corn explained.

Since coming out of stealth in August, Zivian has steadily attracted sole practitioners and independent practices. The company now has such providers in every state, representing 45% of its business at this time, Fadul said.

From tired to empowered

First, the company matches nurses like Kathryn Anderson, APRN, FNP-C, of Cross Roads, Texas to a physician collaborator licensed in their state, Fadul said. 

Matches are made from Zivian's roster of 4,000 physicians based on the services, scope and licenses needed and practice areas.

A board-certified family nurse practitioner with 12 years of experience, Anderson said she was looking for a better work/life balance, and so were many of her fellow NPs. So they formed Elite Healthcare, which opened in November 2021, to gain control over their patient numbers and length of patient visits, she said.

They all were questioning the "safety" of their licenses while trying to see upwards of 60 patients with varying acuity per day working under physicians locally.

"We were just dogged and tired," she said. "Patients weren't getting the best possible care."

Now at their independent practice, which has four NPs, patient appointments are scheduled in 30-minute blocks. 

Though the lakeside community is located in well-populated Denton County, Anderson said brick-and-mortar medical services are in high demand. 

Anderson said she met Fadul when the aspiring nurse entrepreneurs left their previous employers and set up Elite. They were searching for a collaborating physician licensed in Texas, and he responded to the nurses' single national ad – which Anderson said generated an unexpectedly overwhelming response. 

For more nurses to practice in the states that require physician collaborators, a collaboration and compliance platform is "the entrepreneurial opportunity that [nurses] need," Anderson said.

She noted that she also has telehealth patients in medically unserved areas outside of Texas, which requires compact licenses in those states.

"This model works well with anything where you have this mismatching supply and demand, particularly at the physician level," Fadul said.

Cutting out red tape

Anderson explained that when Elite's NP team met Fadul, he was already consulting with other nurse practitioners, and they knew immediately that he was a clear match for their needs. 

However, that was before the Zivian technology was developed – and there was a lot of extra administrative work, she said, including giving Fadul access to the practice's electronic health records.

"Instead of requiring physicians to log into multiple electronic health records, Zivian has EHR-free chart reviews within the platform, so the collaboration is less burdensome and reduces the chances of human error," said Corn.

Because it is also secure and file-agnostic, NPs can share images and other patient information.

"It's SOC 2 backed in the cloud," Fadul noted.

Anderson said the "seamless upload of chart information" and secure chat functionality have streamlined the practice's communications with Fadul, who remains the practice's licensed collaborator.

Providers also get the feedback they need from their licensed collaborators more quickly on the platform, Corn said.

"As we've been working with more providers, it was important for us to create a way for a very targeted feedback loop that's transparent to these providers and have that in the platform."

The HIPAA-compliant chat feature allows NPs and PAs "to drop a note anytime for their provider," he said.

"We wanted to create communication tools or unlock that for them in a way that they can feel protected and be able to talk freely about what they need to talk about, share files, etc."

Improving access to specialty care

The collaborative team approach is also helpful for in-demand specialties like behavioral health and infertility medicine, Fadul said. 

Formerly a labor and delivery nurse, Raleigh-based Charisse Fullwood, a psychiatric NP, now provides maternal-child health and credits Zivian for making it possible to launch her practice, Mind & Body Renew. 

She said that access to a physician collaborator licensed in her state has green-lighted a growing telehealth caseload without worries about licensing compliance.

"It's pretty seamless," Fullwood said.

Fadul noted that since behavioral health "really lends itself to virtual first," the collaboration platform is a great conduit to improve access and "really have some impact."

"Moms are busy," Fullwood said, so her ability to provide all forms of behavioral telehealth under her collaborator's license is essential.

Covering legal bases

Because Zivian monitors physician licensure and licensing laws across the United States and in all territories, if any red flag comes up, it's reflected in the platform within a month, Corn explained.

"They're going to be prescribing," so nurses need assurance that they are compliant as soon as their bespoke agreement is signed. 

Physicians are also covered under the malpractice insurance of the nurse practitioner.

"One of our primary pieces of software is a rules engine where we are constantly analyzing the state regulations and what happens is that gets translated into actions for the providers," he explained.

"Depending on your state and depending on the provider type, certain actions are prompted each month for you to complete and then there's a test that you completed them."

With the specific state regulations, the platform creates attestations, and then monitors to ensure that the collaborators are keeping up to date and completing those tasks.

In addition, outside counsel aids Zivian in evaluating any proposed rule changes, Fadul noted. 

But with artificial intelligence in the back end "scraping new rules and regulations" to maintain their compliance, Anderson said nurses at her practice no longer have to do "a lot of extra work to keep up" and can focus their attention on patient care.

"Having that safeguard instills more confidence," she said.

The company's credentialing committee also discusses collaborators "that might not be a good fit for our platform," Corn noted.

Meeting physician and enterprise needs

Fadul and Corn said that, in about six to nine months, Zivian will roll out additional offerings for workforce management to assist healthcare organizations that outsource compliance and companies looking to scale.

"It's a provider for the providers, it's a home for them to manage everything with their career," including licensing, payer credentialing and more, Corn said.

Such data would also help improve Zivian's compliance surveillance, the founders said.

Decreasing the learning curve "is also desirable for the enterprises," Fadul noted.

"Imagine a world where [clinicians] have the ability to upskill and get what we call 'micro badges,' and demonstrate deeper requisite training within a specialty area," he described.

Andrea Fox is senior editor of Healthcare IT News.
Email: afox@himss.org
Healthcare IT News is a HIMSS Media publication.