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PubMedDate not supplied

Access control based on attribute certificates for medical intranet applications.

BACKGROUND: Clinical information systems frequently use intranet and Internet technologies. However these technologies have emphasized sharing and not security, despite the sensitive and private nature of much health information. Digital certificates (electronic documents which recognize an entity or its attributes) can be used to control access in clinical intranet applications. OBJECTIVES: To outline the need for access control in distributed clinical database systems, to describe the use of digital certificates and security policies, and to propose the architecture for a system using digital certificates, cryptography and security policy to control access to clinical intranet applications. METHODS: We have previously developed a security policy, DIMEDAC (Distributed Medical Database Access Control), which is compatible with emerging public key and privilege management infrastructure. In our implementation approach we propose the use of digital certificates, to be used in conjunction with DIMEDAC. RESULTS: Our proposed access control system consists of two phases: the ways users gain their security credentials; and how these credentials are used to access medical data. Three types of digital certificates are used: identity certificates for authentication; attribute certificates for authorization; and access-rule certificates for propagation of access control policy. Once a user is identified and authenticated, subsequent access decisions are based on a combination of identity and attribute certificates, with access-rule certificates providing the policy framework. CONCLUSIONS: Access control in clinical intranet applications can be successfully and securely managed through the use of digital certificates and the DIMEDAC security policy.

Certification↗
PubMed1998

Counseling students' attribution of diagnostic credibility to clinical supervisors.

Research on factors influencing diagnostic credibility has not been widespread. In this study, agreement ratings for a clinical diagnosis were compared for two groups of students receiving supervision from differently credentialed hypothetical supervisors. Implications of these findings are discussed relative to preparation practices and improving clinical practice. As 190 students who had completed either less than one-half (n = 112) or more than one-half (n = 78) of their programs in 9 institutions gave mean ratings of about 5 on a 10-point scale, they did not differentially rate diagnostic credibility of the hypothetical supervisors having credentials as psychiatrists, doctorate-holding counselor education faculty, doctorate-holding psychologists, and doctoral students holding master's degrees in counselor education.

Adult↗
PubMed1993

Athletic trainer utilization in sports medicine clinics.

Increased use of athletic trainers in sports medicine clinics has created a need for information related to actual and ideal use of these professionals in these settings. The purposes of this study were to 1) describe the characteristics of sports medicine clinics and their personnel, 2) determine whether there were differences between opinions of certified athletic trainers (ATCs), physical therapists (PTs), and professionals with dual credentials (PT/ATCs) about the ideal role of the ATC in sports medicine clinics, and 3) determine whether there were differences in actual usage of ATCs between states with and without athletic training laws. Subjects included 46 PTs, 43 PT/ATCs, and 73 ATCs from six different states. A questionnaire ascertained opinions about ideal ATC utilization and about current practice of ATCs with respect to 28 different clinical procedures. For 27 of the 28 procedures, there were significant differences of opinion about ideal ATC utilization between individuals with the three credentials. No significant differences in actual athletic trainer use in sports medicine clinics were found between states with and without athletic training laws.

Adult↗
PubMed2005

Risk determination for patients with direct access to physical therapy in military health care facilities.

STUDY DESIGN: Nonexperimental, retrospective, descriptive design. OBJECTIVES: This study was designed to ascertain whether direct access to physical therapy placed military health care beneficiaries at risk for adverse events related to their management. BACKGROUND: Military health care beneficiaries have the option at most US military hospitals and clinics to first enter the health care system through physical therapy by direct access, without referral from another privileged health care provider. This level of autonomous practice incurs broad responsibilities and raises concern regarding the delivery of safe, competent, and appropriate patient care administered by physical therapists (PTs) when patients are not first examined and then referred by a physician or other privileged health care provider. While military PTs practice autonomously in a variety of health care settings, they do not work independently within any facility. Military PTs and physicians rely on one another for sharing and collaboration of information regarding patient care and clinical research as warranted. Additionally, military PTs are indirectly supervised by physicians. METHODS AND MEASURES: To reduce provider bias, a retrospective analysis was performed at 25 military health care sites (6 Army, 11 Navy, and 8 Air Force) on patients seen in physical therapy from October 1999 through January 2003. During this 40-month period, 95 PTs (88 military and 7 civilian) were credentialed to provide care throughout the various medical sites. Descriptive statistics were analyzed for total workload, number of new patients seen with and without referral, documented patient adverse events reported to each facility's Risk Management Office, and any disciplinary or legal action against a physical therapist. RESULTS: During the 40-month observation period, 472 013 patient visits were recorded. Of these, 112 653 (23.9%) were new patients, with 50 799 (45.1%) of the new patients seen through direct access without physician referral. Throughout the 40-month data collection period, there were no reported adverse events resulting from the PTs' diagnoses or management, regardless of how patients accessed physical therapy services. Additionally, none of the PTs had their credentials or state licenses modified or revoked for disciplinary action. There also had been no litigation cases filed against the US Government involving PTs during the same period. CONCLUSIONS: The findings from this preliminary study clearly demonstrate that patients seen in military health care facilities are at minimal risk for gross negligent care when evaluated and managed by PTs, with or without physician referral. The significance of these findings with respect to direct access is important for not only our beneficiaries but also our profession and the facilities in which we practice.

Delivery of Health Care↗
PubMed2005

Clinical diagnostic accuracy and magnetic resonance imaging of patients referred by physical therapists, orthopaedic surgeons, and nonorthopaedic providers.

STUDY DESIGN: Nonexperimental, retrospective design. OBJECTIVES: This study was designed to compare clinical diagnostic accuracy (CDA) between physical therapists (PTs), orthopaedic surgeons (OSs), and nonorthopaedic providers (NOPs) at Keller Army Community Hospital on patients with musculoskeletal injuries (MSI) referred for magnetic resonance imaging (MRI). BACKGROUND: US Army PTs are frequently the first credentialed providers privileged to examine and diagnose patients with musculoskeletal injuries. Physical therapists assigned at Keller Army Community Hospital have also been credentialed with privileges to order MRI studies for several years. METHODS AND MEASURES: To reduce provider bias, a retrospective analysis was performed on 560 patients referred for MRI over an 18-month period. An electronic review of each patient's radiological profile was performed to assess agreement between clinical diagnosis and MRI findings. Data analyses were performed through descriptive statistics and contingency tables. RESULTS: Analysis on agreement between clinical diagnosis and MRI findings produced a CDA of 74.5% (108/145) for PTs, 80.8% (139/172) for OSs, and 35.4% (86/243) for NOPs. There was a significant difference in CDA between PTs and NOPs (P<.001), and between OSs and NOPs (P<.001). There was no difference in CDA between PTs and OSs (P>.05). CONCLUSIONS: Clinical diagnostic accuracy by PTs and OSs on patients with musculoskeletal injuries was significantly greater than for NOPs, with no difference noted between PTs and OSs.

Adult↗
PubMed1994

Cost-effectiveness and quality of care provided by clinical nurse specialists.

Clinical nurse specialists in psychiatric-mental health nursing provide primary mental health services to prevent and treat minor mental illnesses and collaborate with physicians to provide mental health services to those with complex mental and/or physical illnesses. CNSs practice in a wide range of settings and in rural and urban areas. Eliminating bureaucratic, attitudinal, legal, and insurance barriers to the services of CNSs in psychiatric mental health nursing can improve access, lower costs, and enhance the quality of mental health delivery systems. Nurses can eliminate some of these barriers. Within bureaucratic organizations, such as hospitals and clinics, nurses can document problems and experiment with collaborative models of practice that make full use of their skills. Nurses must be active participants, including taking on leadership roles, in committees that address changes in patient and health care policies in their organizations. Changing attitudes by educating the public--as well as other health care providers and politicians--about the roles and credentials of nurses is instrumental to removing barriers. Brochures about the roles and credentials of nurses can be prepared and disseminated to patients, civic organizations, other health care providers, and politicians. Nurses should never miss an opportunity to address one of these groups! Demonstrating excellence in nursing practice leaves a lasting impression on patients and other health team members. Implementing innovative approaches to care based on current literature in nursing and related areas is an advanced practice expectation. Further documentation of the impact on cost and quality of care by nurse providers is necessary. Legal and insurance barriers are the most resistant to change.(ABSTRACT TRUNCATED AT 250 WORDS)

Cost-Benefit Analysis↗
PubMed1982

Quality assurance: a Tri-Level model.

A Tri-Level Quality Assurance Model consisting of state, local, and national levels of organization is described. Quality assurance is defined as a broad concept integrating traditional quality assurance activities with professional education and credentialing. The Iowa Occupational Therapy Association Professional Standards Review System is described as an example of the Tri-Level Model. Components of the Tri-Level model include professional education, professional credentialing, development of standards of practice, liaison activities with the Professional Standards Review Organizations and the Joint Commission on Accreditation of Hospitals, continuing education, external review, and internal review. It is recommended that, with the growth in quality assurance activities, state associations consider the Tri-Level Quality Assurance Model as a valuable tool for professional development.

Humans↗
PubMed1992

Training internists in procedural skills.

The procedural skills of internists have been scrutinized recently because of concern for quality of care and because of economic and liability issues. The findings of recent surveys of program directors and practicing internists about procedural skills are reviewed. The results of these surveys in relation to the American Board of Internal Medicine's (ABIM) new training requirements and New York State's new policy requiring credentialing of residents in training are also discussed. Surveys show that internists do a large number and variety of procedures, that the number of procedures varies with the nature and location of practice, and that internists who more recently completed training do more procedures. Many graduates do not master the procedures their program directors think they should, and many learn procedures, often without supervision, after they have entered practice. The ABIM has recently ruled that residents must have documented experience and competence in specific core procedures to become eligible for certification. Also, New York State, in the wake of the Libby Zion case, now requires that all residents be credentialed in the procedures they do during training. Programs in internal medicine need to decide which procedures their residents will master and assure that their residents receive the training and testing necessary for competency and for formal certification of mastery in each procedure. Programs may restructure rotations to assure adequate experience. In the new era of accountability, certification of training and of competence in procedural skills will be an important function of training programs.

Certification↗
PubMed1993

Risk issues in claims reported by 85 small hospitals.

According to one business adage, 20 percent of one's activity reflects 80 percent of one's success. Although few managers in small hospitals spend more than 20 percent of their time on credentialing and peer review, those activities are likely to have the most impact on preventing claims in small hospitals. Other strategies that may enhance these activities include redefining the types of services offered when professional staff, resources for new services, and staff education are scarce. Help with developing sound peer review and credentialing practices can be found through networking within professional organizations, in documents published by national organizations, and by using professional risk management services available through liability carriers. Devoting time to improving providers' documentation skills, monitoring key technical skills of health care providers, and analyzing patient flows from provider to provider and service to service are also likely to have an impact on losses in small hospitals.

Data Collection↗
PubMedDate not supplied

Reporting quality of health care to the board.

The reporting of quality of health care to the governing board has long been an enigma. Now we are in the midst of a revolution in health care, as we shift our focus from solely the clinical performance of individuals to a broader scope of assessing and improving all activities around patient services and patient care--i.e., management outcomes integrated with clinical outcomes to help identify opportunities to improve patient care. In addition, apprised of corporate liability for the quality of care provided in health care organizations, governing boards are raising questions and demanding more information. To maintain this high degree of interest in quality of health care, information should be restricted to what the board needs to know. This article will be confined to the hospital's organizationwide quality system of monitoring and evaluating. While medical staff credentialing and privileging are also board responsibilities and quality management activities should be used in the privileging and credentialing process, they will not be addressed in this article.

Georgia↗
PubMed1993

Achieving empowerment through information.

Despite the problems we encountered, which are not uncommon with the development and implementation of any data system, we are confident that our success in achieving our goals is due to the following: establishing a reliable information database connecting several related departments; interfacing with registration and billing systems to avoid duplication of data and chance for error; appointing a qualified Systems Manager devoted to the project; developing superusers to include intensive training in the operating system (UNIX), parameters of the information system, and the report writer. We achieved what we set out to accomplish: the development of a reliable database and reports on which to base a variety of hospital decisions; improved hospital utilization; reliable clinical data for reimbursement, quality management, and credentialing; enhanced communication and collaboration among departments; and an increased profile of the departments and staff. Data quality specialists, Utilization Management and Quality Management coordinators, and the Medical Staff Credentialing Supervisor and their managers are relied upon by physicians and administrators to provide timely information. The staff are recognized for their knowledge and expertise in their department-specific information. The most significant reward is the potential for innovation. Users are no longer restricted to narrow information corridors. UNIX programming encourages creativity without demanding a degree in computer science. The capability to reach and use diverse hospital database information is no longer a dream.

Academic Medical Centers↗
PubMedDate not supplied

Radiologic technologist licensure. An assessment of economic considerations.

This report presents criteria by which states and professions can evaluate certain economic aspects of the credentialing of diagnostic radiologic technologists. Based on the criteria presented, the literature reviewed, and data obtained from state credentialing programs, certain outcomes are suggested. The criteria include shortages in services; availability of supplies, materials, and energy; teaching opportunities; and the effect on competition.

Costs and Cost Analysis↗
PubMed1999

Regulation of health care professionals, Part 2: Validation of continued competence.

Today's demand for professional accountability regarding patient outcomes of care stems from two principle concerns: (1) the risks associated with health care services and their delivery, and (2) health care cost-containment and wanting to get the best care with the best patient outcomes at the best cost. Whereas patient outcomes are a function of multiple factors, health care professionals and their practice are considered key to those outcomes. Today's society and particularly the payers for health care services, have grown skeptical of professions and their willingness to do a good job of self-policing their own members, incompetent performers. In the 1970s, this early skepticism and the concurrent malpractice crisis led professionals and state regulators over time to move beyond the one-time testing for a lifelong credential so long as you didn't get into major problems, to considering alternatives for assuring continued competency in practice. The first efforts focused on voluntary or mandatory requirements for continuing education as a basis of attesting to continuing or recredentialing (licensure or certification). Unfortunately, this continuing education process has never been validated, demonstrating its efficacy in assuring continued professional competence and currency of knowledge as it plays out in practice and patient outcomes. Reasonable assumptions are no longer publicly acceptable; evidence is being demanded. Also, a problem that has plagued private credentialers has been the legal concept of a license or certification as a lifelong property right based on the such conditions when it was awarded. Credentialing bodies have been at legal risk in removing a license or certification for failure to comply with new criteria, particularly if the criteria has not been validated as making a difference. Rather than looking solely at currency of knowledge and competence in its utilization (including the associated technology), it is now being recommended that a multifaceted methodology be used in assessing those professional attributes deemed essential for achieving quality patient outcomes.

Certification↗
PubMed2002

Medical malpractice claims and quality improvement program as viewed by a forensic pathologist.

This is a review article dealing with the half-century evolution of the quality assurance program to improve patient care in the United States. The author attempted to point out some differences in approach to solving the medical error and medical malpractice problems between Japan and the U.S. In the 1970s, an increase in the medical malpractice claims resulted in such high premiums for medical liability insurance that it threatened the healthcare system in the U.S. Urgent legislative remedy, the Medical Injury Compensation Reform Act (MICRA) was put into place in the State of California. This act was the beginning of the definitive quality improvement in our health care system. It was followed by other improvement programs, such as the National Practitioner Data Bank (NPDB) for tracking physicians with malpractice judgments or settlements against them, or who have problems with the medical licensing Board or other impairments. By comparison, in recent years, in Japan, there has been a rash of medical malpractice claims, similar to the situation in the U.S. in the 1970's. The two pronged approach to maintaining and assuring quality health care are: (1) Set standards by inspection and accreditation of hospitals and healthcare facilities and (2) by credentialing and peer review program to assure the competency of the physicians and other healthcare personnel. Clinical medicine has made a major effort in setting up a quality assurance program and so has forensic medicine. Similar approaches have been used in both programs. The current emphasis in forensic medicine is on inspection and accreditation of the medical examiner and coroner's offices by the National Association of Medical Examiners (NAME) and re-certification for the medical license and specialty board and credentialing and peer review activities.

California↗
PubMed2003

The current state of esophagogastroduodenoscopy training in family practice residency programs.

BACKGROUND AND OBJECTIVES: Esophagogastroduodenoscopy (EGD) is a useful diagnostic procedure to evaluate patients with upper gastrointestinal complaints. Although family physicians have demonstrated that they can competently perform EGD, only a minority of family physicians perform EGD. This study determined the current state of EGD training in US family practice residency programs and how often graduating residents seek EGD privileges. METHODS: We conducted a cross-sectional descriptive study surveying program directors from all Accreditation Council for Graduate Medical Education-approved family practice residency programs regarding EGD training in their program. RESULTS: Of the 471 surveys mailed, 441 (94%) were returned. A total of 143 (32%) program directors reported that their program offered EGD training, but only 58 (13%) actually trained at least one resident. Residents performed a mean of 20 +/- 2.4 EGDs per resident, and residents trained by family physicians performed more EGDs than residents trained by other specialties. In July 2000, .04% of graduating family practice residents sought credentials for EGD, and their training occurred in 32 (7%) residency programs. CONCLUSIONS: Only a minority of family practice residents seek credentialing after residency to perform EGD.

Clinical Competence↗
PubMed2003

Screening for diabetic retinopathy in remote Australia: a program description and evaluation of a devolved model.

OBJECTIVES: To describe the diabetic retinopathy screening program operating in the Kimberley and evaluate recruitment into and the quality and timeliness of, the screening procedure. METHOD: Review of the documents relating to the Kimberley diabetic retinopathy screening program and analysis of Kimberley diabetic retinopathy screening database. RESULTS: The Kimberley Public Health Unit developed and maintains a program of training, credentialing and ongoing professional development for retinal camera practitioners and a Kimberley-wide database of retinal photographs taken for diabetic retinopathy screening. As a result of this program, diabetic retinopathy screening is available in or close to most diabetics' home towns/communities and 58% had undergone retinopathy screening in the preceding 2 years. Over 90% of sets of photographs were of excellent or adequate quality. There was a positive relationship between credentialing and photograph quality and timeliness of photographs being sent away for reporting. CONCLUSIONS: Quality diabetic retinopathy screening, at prevalences comparable to, or higher than, other urban and rural populations, can be achieved in a remote area.

Adolescent↗
PubMed2001

Certification: perspectives on competency assurance.

As registered professional nurses, we have an obligation to our patients to assure we are practicing at a competent level. Nurse managers and administrators must show to the Joint Commission for Accreditation of Healthcare Organization (JCAHO) that the nurses providing care in their facility are competent. Assessing competency is not a simple task, and there is no 1 correct answer or definition of competence or competency assessment. Some of the methods available for competency assessment are self-assessment models, multiple choice examinations used for certification and licensure, oral or essay examinations, and practice or patient simulations. The Certification Board Perioperative Nursing (CBPN) recognizes that learning and competency maintenance is accomplished in a variety of ways, and that learning is achieved through successful participation in various professional activities. Becoming certified and remaining certified, or completion of the Professional Perioperative Portfolio are ways for nurses to continue to show competency in perioperative nursing. Research is vital to validate that certification does indeed show competency. The research committee of CBPN and the Nurse Credentialing Research Coalition (NCRC) are committed to quantify not only the value of the credential but to examine the personal, professional, and practice outcomes of certified nurses across the country. It is hoped that the current research being conducted will eventually allow concerned parties to have assurance that the certified professional registered nurse is indeed a competent registered nurse.

Certification↗
PubMed2004

The current state of colonoscopy training in family medicine residency programs.

BACKGROUND AND OBJECTIVES: The US Preventive Services Task Force has recommended that all adults ages 50 and over be screened for colorectal cancer. Colonoscopy is the most accurate screening procedure, but the feasibility of colonoscopy as a screening tool is limited by the number of physicians trained to perform it. This study determined the current state of colonoscopy training in US family medicine residency programs. METHODS: We surveyed program directors of all Accreditation Council for Graduate Medical Education-approved family medicine residency programs regarding colonoscopy training. RESULTS: The response rate was 94% (426 of 455). Forty-eight percent (n=201) of directors reported that their program offered colonoscopy training, but only 18% (n=75) of all respondents had actually trained one or more residents to do colonoscopies. Nationally, the mean number of colonoscopies performed per resident was 42.6 +/- 3.9. Regional differences were reported; residents trained in the western United States performed a mean of 69.8 +/- 12.8 colonoscopies per resident. Gastroenterologists in hospital-based gastroenterology suites trained approximately 75% of family medicine residents. Fifteen percent (n=64) of directors reported that 133 (4%) of their July 2002 graduates sought credentials to perform colonoscopy. CONCLUSIONS: Only a minority of family medicine graduates seek credentials to perform colonoscopy, and significant regional differences in training exist.

Colonoscopy↗