Every year, physicians across the country have to fill out voluminous forms detailing their education, experience, specialty, training, disciplinary record and other qualifications, for an average of 17 different professional credentialing organizations, according to the Medical Group Management Association.

To Michigan officials, that was 17 times too many.

In 2007, the state decided to tame the paper tiger, not just for altruistic reasons but because they also believe managing provider identities and credentials is a vital missing piece in the effort to grow a nationwide electronic health system.

So the Michigan Public Health Institute (MPHI) applied for and received a $5.2 million Medicaid Transformation Grant to automate and centralize the credentialing and verification process for all providers across the state.

The resulting solution"built by Medversant Technologies, LLC"went live earlier this year. It is initially being used for Medicaid providers but will eventually be expanded to include not just other public and private sector physicians but nurses, physical therapists and other licensed clinicians.

"The credentialing process is something every hospital, large group practice, insurance company, health maintenance organization, government health program and government payor in every state has to do every two or three years for every provider that somehow touches their organization," said Jeffery Allison, manager of interactive solutions for MPHI.

"It's a largely paper-based, repetitive process that's duplicated literally thousands of times across the country," he said. "It's massively redundant and costly to everyone involved."

A centralized credentialing application would not only make life easier for health care providers and credentialing organizations by cutting overhead and smoothing workflow, but it has huge ramifications for patient safety and catching fraud and abuse, says Allison.

Dynamic verification

Michigan's system uses AutoVerifi, a Medversant-developed Web crawler that continuously checks provider information held in thousands of online databanks. When it encounters any sanctions, address changes or other changes pertinent to a providers' professional standing, it sends an auto-alert to credentialing organizations. Most significantly, the technology catches those changes on the fly, Allison said.

If a physician treating and billing Medicaid in Michigan, for example, had their license yanked in Ohio because of malpractice, state officials could be notified on the fly, Allison said. Under the old paper-based system, they were not likely to find out about the license suspension until the next credentialing application got underway sometime within the standard three-year cycle.

"You can get providers who shouldn't be practicing dealt with much faster and off the street," Allison said. "You've also got data and evidence you need which makes it much easier for medical staff to take action as well when there is an issue."

Michigan is not the only state that's applying IT to address the credentialing challenge. Washington state went live this spring with a Web-based universal credentialing system. Other states are also considering similar solutions.

"It's a hot topic within the states right now," said Howard Thomas, president of Thomas and Consultants, an independent consulting firm in Seattle. "It's a problem that states have known about for years, but I think folks are finally getting serious about solving it."

Provider inputs

Washington takes Michigan's solution a step further. The state has AutoVerifi on the back-end, but providers can also log-on to a Web-based system using a secure single sign-on service provided by OneHealthPort and supply their credentialing information electronically. Providers also can update the information on an as-needed basis or verify it the same way.

Thomas points out that any electronic credentialing application only automates the collection of provider demographic data and verifies that it's accurate, up-to-date and tied back to primary sources. Hospitals, health plans and other organizations can access all of the information, but they can apply their own credentialing criteria.

"It's a really important aspect because hospitals and health plans won't sign off on a one-size-fits-all credentialing process and give up their right to say, "˜yes, this physician is qualified to practice here' and meets their very specific, personalized criteria," he said.

One factor driving the adoption of centralized and automated credentialing is the renewed focus on electronic health records and health information exchange. Another is the growing recognition that a centralized repository of clean, accurate provider data is essential to the larger health information technology effort.

To meet those trends, provider information needs to be automated, accurate and accessible electronically "just like patient records and prescriptions"for health IT projects to maximize their cost, efficiency and quality benefits.

"Provider credentials are more than just their demographic data and licensing information and where they went to school," Medversant CEO Matt Haddad. "It's what providers are allowed to practice within facilities, what is their quality of care, what are their metrics. So the whole move to the "˜pay-for-performance' model really depends on gathering and having this type of information readily available."

"And that's because the nexus between provider information and clinical information is quality."

In Michigan, Allison expects the credentialing project will provide the statewide health information exchange with a centralized database repository of information on all physicians that can then double as a master provider index.

"This would tell the HIE: Where are all of these physicians supposed to be practicing and where are they privileged to practice?" Allison said. "For example, the system would be able to inform someone that physician A has recently lost privileges at hospital B, so they shouldn't be asking for information about patients at that facility anymore and shouldn't be granted access to the HIE."

Michigan will also eventually tie the provider database into the Medicaid claims process "to make sure that anyone billing Medicaid is a licensed provider eligible for reimbursement under state laws and doesn't have other issues that would normally prevent payment to them," said Haddad.

Standard snafus

But many problematic credentialing issues are not always complicated or mal-intended.

"It could be that the physician has moved their practice and the insurance company continues to send all notices and sometimes patients to the wrong address," said Sue Merk, vice president of business development and product manager for OneHealthPort. "These are simple, routine changes but they don't always get conveyed and it can cause major problems."

In fact, studies have shown that credential data in paper-based systems is 30 percent to 50 percent inaccurate. According to Thomas, sloppiness starts at the beginning when providers get overwhelmed and complacent about providing so much redundant information, but continues as information grows stale over tim