Thursday, November 12, 2015

Credentialing and Privileging, part 9: Temporary privileges

keywords:  credentialing, privileging, temporary privileges, telemedicine

So far, what I am understanding from these resources is that temporary privileges are commonly granted in the following cases:
disaster relief scenarios
telemedicine and telehealth consultations
any time medical facility has an "urgent need" to deliver "necessary care" to the patient.

Temporary privileging, more reading: 
Joint Commission reference p. 6
A 2010 article from HC-Pro explains "expedited credentialing" vs. granting temporary privileges.

2015 article on pros and cons of temporary privileges.  Temporary privileges most common in disaster relief conditions and for telemedicine consultation. The author looks at TJC guidelines and CMS interpretation of guidelines and refers you back to your state hospital organization for direction.  

Credentialing and Privileging part 8: Joint Commission references

Joint Commission References on Credentialing and Privileging
original post 2015.11.12, revised 2016.08.29

Keywords:  credentialing, privileging, Joint Commission, licensed independent provider (LIP)

Joint Commission standards on independent providers, credentialing, and privileging:
The Joint Commission (TJC) is the authority on credentialing and privileging guidelines for all U.S. hospital and healthcare systems:   
“An ‘LIP’ is a licensed independent practitioner, defined as an individual, as permitted by law and regulation, and also by the organization, to provide care and services without direction or supervision within the scope of the individual’s license and consistent with the privileges granted by the organization” [TJC’s The Who, What, When, and Where’s of Credentialing and Privileging]

The Joint Commission's Guideline:  Who/What/When/Where of Credentialing 
**great resource**
This resource quoted above, its full title is The Joint Commission Ambulatory Care Program:  The Who, What, When, and Where's of Credentialing and Privileging.  It reviews the basic guidelines for credentialing and privileging health care providers.

Credentialing and Privileging, implementing a process.  Joint Commission blogpost March 12th, 2012, Virginia McCollum, "Credentialing and Privileging-Implementing a process", Ambulatory Buzz.  This blogpost outlines the basics for understanding the credentialing process for an LIP from a TJC leader's perspective.

"Getting to the Heart of Credentialing and Privileging", an April 23rd, 2014, Ambulatory Buzz blogpost written by TJC ambulatory surveyors, Susan Herrold, MN, RN and Mary Pat Hall, MSN, RN, sharing their viewpoint and advice on the process.

More reading:
HH Blogpost that discusses OPPE and FPPE more
Here is a link to the Joint Commission blog
HH blogpost on temporary privileges

Monday, November 9, 2015

Research Journals, literacy, levels to consider when publishing or perusing

Research Journals for publication or perusing
Keywords:  research literacy, publishing, research journals, peer-reviewing research, reading research, research review

Topic:  Acupuncture/EAM and choosing a research journal for publication

author/editor:  Megan Kingsley Gale
Contributing authors/ideas:  Dr. Fuji McPherson, Dr. Chris Kleronomos

So, you've done your research and are finishing up the main part of the work and writing up your results.  Have you starting your list of ideal journals to submit your work to?  

Choosing a journal for publication of your work is a learned skill.  I asked a couple colleagues whom I admire for their research study designs about their advice to other EAMPs looking to publish their work.  
The Highest Standard
The highest standard for research journals are those that have or are the following:
1.  Peer-reviewed journals
2.  The journal’s articles/publications are indexed on PubMed/Medline[i].

3.  The journal is well-read or well-known.  And/or journal has a good reputation.

The peer-reviewed journals Science and Nature are the highest level journals to be published in for the above reasons.  The only accept original work.  They do not accept literature reviews.  However, being accepted for publication in either of those two journals is, by virtue of their reputations, challenging due to sheer competition.

Next Level
Next level of journals to publish in.  ie:  not Science or Nature
Still peer-reviewed journals
Still indexed on PubMed/NCBI.
Consider those journals that have widest distribution and are relevant to your fields (subject matter).

Pain Practitioner
Alternative Therapies in Health and Medicine (ATHM)
Integrative Medicine:  A Clinician’s Journal (IMCJ)
Journal of Nurse Practitioners

Your other area of specialty, some examples:
Journal of Clinical Sleep Medicine
Journal of Nurse Practitioners
Journal of Pain Medicine
American Journal of Public Health
Family and Community Health

For example, if your work is in pediatrics, go to the main journal for pediatrics.  If you work is in sleep, go to the main journals about sleep medicine/insomnia/pulmonology/brain science.

Lowest level of professional journals to publish in:
Not indexed in PubMed, but professional enough that it may one day be indexed.
Has a wide distribution among your peers.

Journal of TCM (British, about 20 years of publication)
Military Medicine—publication of AMSUS, the society of federal health care practitioners.  Specific audience.  Wide distribution among that audience.
More advice in choosing a journal to submit your work:
Do a PubMed search under your subject area.  Is your type of work over-published or unique?  If it is unique, you have a greater probability of being published by more variety of journals.  If your work is more of what is already currently very common, you will have more competition in getting published.

Related posts

[i] PubMed/NCBI is the online medical research journal search engine.  If a person is researching a topic, he/she would go to PubMed and search there.  If you work is submitted to a journal that is not indexed on PubMed, the researcher (professional or amateur or average clinician) would not find it.

Friday, October 9, 2015

Dual License L.Ac.s and Hospital Practice

10.9.2015 draft
keywords:  credentialing, privileging, hospital sponsor, PCM, KSAs, biomedical training, hospital culture

Related topics:  Hospital Sponsor

Author/Editor:  Megan Kingsley Gale
Contributing authors:  Fujio McPherson, DAOM, ARNP 
If you are a dual-licensee reading this, please chime in on the comments section.  Would love to hear form you!

Dual-licensed L.Ac.s and strength brought to EAM Hospital Work

A dual-licensed L.Ac. brings great strength to his/her work in the hospital.  Because she also has a Western medical health care license (MD, DO, DC, ARNP), she has a foot in both worlds.  She understands hospital culture and can be a wonderful advocate for single-licensed L.Ac.s into hospital setting.  These dual-licensees, in practice have often been the first L.Ac.s into hospitals.  They have been hired under their non-L.Ac. health care license.  Some have slowly incorporated more EAM work into their clinical practice (when hospital culture was right, they added acupuncture and EAM procedures to their “delineation of clinical privileges”).  Some, in the case of some VA/VHA L.Ac.s, were hired under their non-L.Ac. license for the job of an L.Ac.  i.e. an RN-L.Ac. hired to do full-time L.Ac. work, but no current occupational code existed in hospital system for hiring L.Ac., so hired and credentialed under RN licensed, but position description is entirely L.Ac., not RN and practice work is all L.Ac.  Same example for PA and DC.

Dual-licensees make great primaries on hospital Integrative Medicine research projects.

Negatives to dual-license L.Ac.s in hospital practice

When push comes to shove, these L.Ac.s often find themselves doing more of the non-L.Ac. healthcare work because that is (area of need) where hospital needs them first.  This is less common with RN-L.Ac.s.  Very common with MD-L.Ac.s and ARNP-L.Ac.s.  Non-dual licensees do not have this pull toward two-jobs-in-one.  An L.Ac.-only can not have his time divided into other health care duties.  So, an L.Ac.-only is time and cost-efficient.  Less education expenses to pay back.  Can be counted on to provide only EAM services (not also injections, PAP smears, surgery, etc) to a dedicated clinic.  Having a dedicated L.Ac. clinic is essential to consistent patient care and outcomes.

Dual-licensee distinctions

PCM-L.Ac. and non-PCM-L.Ac.

Non-PCM dual-license L.Ac.
Ex:  MD-L.Ac., ARNP-L.Ac., DO-L.Ac,
These are occasionally PCM, depending on state law:
D.C.-L.Ac, ND-L.Ac, PA-L.Ac.
Definite non-PCM dual-modern medicine licenses that seem to help in L.Ac. hospital practice:
RN-L.Ac.—RNs are not providers
PsyD-L.Ac.—clinical psychologist who is also an L.Ac.
MPH-L.Ac.—one of most common dual-licenses for L.Ac.s.  Master of Science in Public Health is a nice fit for EAM providers.  In hospital setting you are likely to work in admin positions or in positions where you are creating community health programs.  Not always clinical work.
PCMs are clearly providers, based on their non-L.Ac. license (MD, DO).
The non-L.Ac. license seems to help these “duall-ees” understand hospital culture and navigate the system.  Sometimes the non-PCM first license has caused confusion when these duallees want to work clinically as L.Ac.s.  The clinical work of an L.Ac., while not PCM, is provider level 2 work.  If the non-L.Ac. license is not in provider work, it may be counter to duallees first position description to do L.Ac. clinical work.  (example:  RNs do not have acupuncture in their scope of practice.  The RN-L.Ac., to do acupuncture, must be hired under L.Ac. PD to be clearly able to do so.  Trouble arising when their PD does not give credit for their L.Ac. background.
A PCM-L.Ac. is usually hired under the PCM license and gets the L.Ac. scope added/granted as part of his/her clinical privileges, sometimes called "extended privileges"

Recommendation to L.Ac. education leaders—making Dual-licensees more common!!

We know dual-license L.Ac.s are door-openers for our field of EAM in:


More jobs

Federal work

Hospital work

Integrative medicine clinics

Specialty clinics

Inpatient work

So, what can we, as a profession, especially at our education institutions, do to make dual-licensees more common?

The discussion continues in comments section, email list, and in our social media groups.  

If you found this information helpful or interesting, please considering donating to or sponsoring the project and joining the email list.

EAM--East Asian Medicine.  I current favor this term over the following to describe our modern practice:  TAM (traditional Asian Medicine), AOM (Acupuncture and Oriental Medicine).  In May 2016, President Obama signed a bill to eliminate the term "oriental" from all federal documents because the term is derogatory.
VA/VHA--veteran's administration or veteran's health administration
IM--integrative medicine
PCM--primary care manager
L.Ac./EAMP--state license titles for Acupuncturists.  "Licensed Acupuncturist (L.Ac.)" and "East Asian Medicine Practitioner (EAMP)".  L.Ac. is the most common state title.
PCMH--patient-centered medical homes


Monday, October 5, 2015

Credentialing and Privileging Process part 3, FPPE, OPPE, and Peer Review

Credentialing, Privileging, and Professional Practice Evaluation (FPPE and OPPE)

updated 8.26.2016
Keywords:  credentialing, privileging, FPPE, OPPE, quality assurance, peer review, LIP
Related posts:  Credentialing and Privileging section
For updates in practice and/or a consultation, contact us via the website.

In credentialing and privileging Licensed Independent Practitioners (LIP), The Joint Commission (TJC) established the following quality assurance processes, “Focused Professional Practice Evaluation (FPPE)” and “Ongoing Professional Practice Evaluation (OPPE)”[i].  FPPE is the process a new hospital hire goes through the first year or so of practice.  This is commonly a more detailed and thorough vetting and review process than OPPE.  After the FPPE is complete and the practitioner is no longer “new”, commonly OPPE is used as a professional review and quality assurance measure. [Note that FPPE is always used for a new hospital hire.  It may also be used again (on an established hire) if a practitioner is flagged as performing substandard care.]  

FPPE and OPPE basic guidelines are set by TJC.  Every hospital has specific institution-specific versions of FPPE and OPPE for any provider that falls into the Licensed Independent Practitioner (LIP) category of provider-type.  These institution-specific guidelines follow TJC standards.  [TJC Standards Search page[ii]]  OPPE may include any of the following, as determined by the institution:  periodic chart review, direct observation, monitoring of diagnostic treatment and techniques, possible discussions with consulting providers, nursing personnel, and administrative personnel[iii]

Peer Record Review (periodic chart review by a peer or peers) is a common practice for quality assurance and falls under the requirements that fulfill both FPPE (new hospital hire) and OPPE (established hospital employee).

If you are interested in commenting on a TJC standard: 
“The Joint Commission provides a Standards Online Submission Form as one of the means of soliciting questions about the standards.”  TJC invites providers to use the form and send them your questions and thoughts about the standards in their “how to comment on a standard” webpage: and directed to the TJC Standards Interpretation Group through the online standards question form.

Remember, when TJC looks at creating a standard, they judge it by the following criteria:

  • Does it have a strong evidence-base?
  • Does it have a strong relationship to patient outcomes/clinical care?
  • Does it support a health care organization’s goal of patient safety and quality of care?
  • Does it have benefits that outweigh the costs?
  • Does it support a health care priority which impacts quality and safety?


[i] In 2004 The Joint Commission (TJC) renamed “Peer Review” as “Focused Review of Practitioner Performance” and since 2007, it has been known as “Focused Professional Practice Evaluation (FPPE)” and “Ongoing Professional Practice Evaluation (OPPE)”. 
[ii] From Standards page, search keyword “OPPE”.  Under “Hospital and Hospital Clinics” category, then OPPE-Intent.  “The intent of OPPE allows the Hospital/Critical Access Hospital to identify professional practice trends that impact the quality of care and patient safety as it relates to privileges granted to the Licensed Independent Practitioners.”
[iii] From Standards page, keyword “OPPE”.  Under the “Hospital and Hospital Clinics” category, then OPPE-data collection guides
[iv] From Standards page, keyword “FPPE”.  Under the “Hospital and Hospital Clinics” category, note the following links for FPPE:
Components of Design Process
Monitoring Timeline
New Privileges
Pre-defined Process
*4 Required Components*
Peer Review

Links for OPPE:
Low volume practitioners—data use from another organization
Medical/cognitive specialties
*data collection guides*

Pioneer Perspectives--Learning from Hospital Practice EAM Pioneers

Starting Acupuncture and East Asian Medicine (EAM) in a Hospital:  Perspectives from Pioneers

Contributing authors, interviews with subject matter experts (SMEs) aka the pioneers:
related topics:  Community Outreach, Pioneer Perspectives

Pioneer Perspectives is a chapter of the Hospital Handbook project that
interviews pioneers in hospital practice East Asian Medicine/Acupuncture.

Goals:  Highlight a Pioneer and his or her work and contribution to our field
How does that work tie in to hospital practice?
How and why is this important and relevant to the current hospital EAM/Acupuncturist practitioner?
What wisdom would this this Pioneer share?

Topics will likely include (not an exhaustive list):
starting up a clinic, SOPs, etc
internships, externships
Patient Centered Outcomes
Creating an EHR to capture data from EAM provider notes

Wednesday, September 30, 2015

L.Ac. Occupational Code Comparison Chart, demonstrating most similar to privileged provider professions

keywords:  privileging, credentialing, LIP status, occupational codes
related blogposts:
LIP status and Acupuncturists and related Meridians article
Acupuncturist Occupational Code
Credentialing, privileging, and professional practice evaluation (FPPE, OPPE)

Provider type status (when credentialing and granting privileges) for 
East Asian Medicine Practitioners/Licensed Acupuncturists (L.Ac.s):
U.S. Department of Labor Occupational Codes Comparison Chart
2015 revision

This chart compares the following professions:
Physician (MD, DO), Advanced Registered Nurse Practitioner (ARNP), Licensed Acupuncturist (LAc), Physical Therapist (PT), Chiropractor (DC), Clinical pharmacist (PharmD), Physician Assistant (PA), Ultrasound technician, and Physical Therapy assistant.

The chart compares the following factors:
minimum degree required to practice
duration of training
federal occupational code:  delineation, job zone, core tasks
Licensed Independent Provider (LIP) status:  has NPI?  need supervision?
Note:  Chart does not fit well on blogpost at this time.  Contact this blog's editor for a copy.

Source:  O*Net, the Bureau of Labor and Statistics’ tracking system for new professions in the U.S. and
The Bureau of Labor and Statistics’ Occupational Code Handbook

Foot note 1 = “Level 1” vs. “Level 2” privileged provider exists within the U.S. military (DoD) medical system, when credentialing providers.  “Level 1 privileged provider status” in CHCS and AHLTA is allowed only for MDs and DOs.  All other privileged providers fall under “Level 2 privileged providers” in the U.S. military medical system.  In the civilian system, there is no “level” distinction among privileged providers.  In the civilian system, providers are “privileged” if they practice independently or not privileged.  Technicians are not privileged providers.

Friday, September 25, 2015

Explaining Credentialing and Privileging Process in the Hospital part 1

keywords:  credentialing, privileging, Joint Commission, LIP

related blogposts:  recognition of L.Ac.s as LIP, traditions of credentialing and privileging, the tradition of “medical staff” designation

Please see previous post: 
Semantics: Explaining Credentialing, Privileging, and the Licensed Independent Practitioner from May 2015

covers the following topics:
Basic credentialing and privileging terminology
Fictional example of the credentialing process and privileging process

The Sponsor Issue--Acupuncturists and their Hospital Sponsor

The Hospital Sponsor issue
revised and updated 12.08.2015

keywords: credentialing, privileging, hospital admin, PCMs, peer record review, supervision, licensed independent practitioner (LIP), ACAOM-accredited programs

related topics:  dual-licensees, professional practice evaluation (FPPE, OPPE, peer record review), recognition as an LIP

The Ideal Hospital Sponsor Relationship for an L.Ac.

To get started in a hospital, it has been the experience of successful hospital-practice L.Ac.s to date that they need a Sponsor.

A sponsor is a hospital physician, already established at your medical center, who is willing to support you to be hired.  This person advocates for you through the credentialing process.  This may even be the same person who writes your position description (job duties).  The Sponsor takes on responsibility for you and your potential for better or worse. 

The sponsor understands hospital culture, navigates it easily, and protects you from the political intricacies while mentoring you to work within it.

Ideally, you have more than just your Sponsor who advocates for you at your hospital.  It is your job to make your Sponsor’s “advocacy” as easy as possible.

Eventually, the ideal is that the hospital will see what a wonderful asset you and your medicine are and more L.Ac. providers will be hired and incorporated in more departments and areas of patient care and admin and research.  And someday, enough that an Acupuncture/EAM department may be useful, if such is the case that the hospital is large enough to have physical therapy department or a psychology/behavioral health department.

How are Hospital Sponsors/Advocates grown or cultivated?

Unknown.  There is a wide variety of examples.

However, one common thread I hear through all these shared stories and experiences is that they (sponsors) believe in what we do.  Usually through personal experience or from hearing and seeing positive feedback and results from patients who receive care from an East Asian Medicine Practitioner/Acupuncturist.

Some physicians have also taken a medical acupuncture course or auriculotherapy course.  This is not, however, the majority.

A small number of sponsors are also L.Ac.s.  These are our rare MD-L.Ac.s or DO-L.Ac.s or ARNP-L.Ac.s.  For easier terminology, I will call them “dual-licensed L.Ac.s”.

Peer Record Review, LIP, and the Sponsor

L.Ac.s, as licensed independent practitioners (LIP), require only administrative supervision, not practice supervision.  L.Ac.s can, by education and training standards, receive practice supervision from someone of the same level of ACAOM-accredited education, another L.Ac.  This is consistent with being an LIP.  LIPs, in the hospital setting, must participate in peer record review, a professional performance evaluation standard (FPPE/OPPE).  If an L.Ac. is the only L.Ac. at a facility, this is a challenge.  See related posts on Who supervises the work of an AcupuncturistPeer Record ReviewOccupational Code, and the Meridians article.  

The Sponsor, if he is a dual-license L.Ac., could also be the peer reviewer, by virtue of his ACAOM-accredited training and L.Ac. licensing.  This would be a work-around until more L.Ac.s could be hired.  See Dual-licensee post for more information.

Example of Hospital Sponsor relationship

A PCM with a medical staff appointment (usually a physician) at a medical center takes an interest in wanting to hire an L.Ac.   This person will hereon be called the “hospital sponsor”. This usually comes from one (or more) of the following motivators:

  • Interest in non-drug pain management options (possible push from Joint Commission’s standard if med center has a pain management program)
  • Interest in integrative medical therapies
  • Has had patients request Integrative Medicine (IM) therapies, particularly acupuncture, and is interested in bringing related staff on-board as employees to help fill the need and patient requests
  • Is interested in a PCMH model that incorporates IM
  • The state’s interpretation of the Affordable Health Care Act includes insurance coverage of acupuncture as practiced by L.Ac.s  [affordable health care act post/worker’s comp coverage of acupuncture post]  
  • Great need (or interest) in medical center for non-drug treatment option such as acupuncture that decreases ER return rates, inpatient hospital stay length, and surgery recovery statistics [see Allina example of incorporating EAMPs/L.Ac.s in the ER]  

Hospital Sponsor is Innovator and Synergist, more than your average Administrator
The hospital sponsor is usually a physician who has some administrative time allowed in schedule or is incredibly motivated.  The hospital sponsor will next do one of the following:

  1. Request to hire one L.Ac., in her area of hospital.  For example, the hospital sponsor is main provider at a OB clinic and wants to add an L.Ac. to her staff.
  2. Request to hire multiple L.Ac.s as part of a creation of a specific Integrative Medicine (IM) clinic or healthcare system-wide creation of IM clinics, such as for pain management and/or IM rehabilitation clinics

Among other things, the hospital sponsor will have to do the following:
Get idea approved by hospital admin
Create a position description for the L.Ac.
Create a hiring package with HR for the L.Ac.
Create a credentialing package for L.Ac., working with the credentialing department
As part of hiring process, present credentialing packet and drafted delineation of clinical privileges to the hospital credentialing committee on behalf of the soon-to-be hired L.Ac. employee

When working with Credentialing department specialist to create packet, the following is often helpful:
Useful items when working with the credentialing department and credentialing committee:
The state’s scope of practice for practitioner
Position description created for L.Ac.

Once L.Ac. is hired, and if she is the first L.Ac. ever to be hired by this medical center, the hospital sponsor:

Works with the L.Ac. to develop basic SOP (standard operating procedures) based on her industry standards and experience. 

The L.Ac. is able to direct her hospital sponsor to her national standard organizations to find the best and most current standards and regulations that may apply.  Contact your national EAM/AOM standard organizations and see your EAM/L.Ac. Hospital practice group on social media for examples.

IM = integrative medicine
PCMH = patient-centered medical home
L.Ac./EAMP = state license titles for Acupuncturist.  "Licensed Acupuncturist (L.Ac.)" and "East Asian Medicine Practitioner (EAMP)".  Most common state title is L.Ac. 

Read more about how to Get Your Foot in the Door of Hospital-based Practice: First Steps, a new (2019) publication on the website and its companion resource, The Workbook

related blogposts: 

Peer Record Review
updated 2017
keywords:  peer record review, supervision of an L.Ac., quality assurance measures, licensed independent practitioner (LIP), Joint Commission, credentialing, privileging, focused and ongoing professional practice evaluation (FPPE and OPPE), professional standards, quality assurance, quality improvement (QI)

Peer Record Review and Joint Commission
Peer review process is a usual professional standard required by The Joint Commission (formerly JCAHO or Joint Accreditation Commission of Hospital Organizations). 

Peer Review process and Provider vs. Technician status
Peer Review process is a standard that goes back to quality assurance.  Credentialing is a vetting process and a quality assurance tool.  Maintaining credentialing relates back to quality assurance.  

A provider who is not credentialed is a technician.  A technician does not get credit for the workload he or she generates.  Instead the technician’s supervisor gets the credit.  I believe this goes with the idea that the supervisor takes the responsibility for the work and hence garners the credit for the work.  

Peer Record Review and the East Asian Medicine Practitioner (EAMP)/Acupuncturist (L.Ac.)
In our profession, as East Asian Medicine Practitioners/Licensed Acupuncturists (acupuncturists), we are responsible for our own work (master’s level training, national board certification), and have LIP status (as defined by TJC) in most states, and so, when working in hospitals, we are providers (LIP-type provider), not technicians.  And, as LIPs, are credentialed and granted a delineation of privileges.  As part of being a credentialed provider, we participate in peer record review.  Peer record review is a periodic review of a practitioner's charting, reviewed by a peer in that provider's discipline.  For example, a licensed acupuncturist (LAc) quarterly reviews another licensed acupuncturist's chart records, following the facility's standard form.  This goal of this review, part of FPPE or OPPE, is a quality assurance check for gross lack of charting, improper charting or patient care.  The goal of FPPE and OPPE is to flag providers who are performing below standard.

Peer Review and SOAP Note Standard
Our profession has SOAP note standards.  When we do Peer Record Review, we are able to do so using our standard.  The standard has been general and based on TCM, as per national certification standard guidelines (NCCAOM board exam).  For more specific guidelines and training on proper SOAP noting and how this relates to our modern health care delivery system, see the upcoming Coding and Charting Manual/Handbook Resource and related blog.

Hospital Practice and Standards
Peer record review (which, at its core, follows a general profession-specific standard for charting) is an essential quality assurance measure for hospitals.  This is part of the quality assurance measures that make the facilities eligible to renew their Joint Commission accreditation.

The ability to participate in peer record review, a component of focused professional practice evaluation (FPPE) and ongoing professional practice evaluation (OPPE), is also an essential delineation between providers who must be credentialed and those who practice as technicians.  A professional health care practitioner, such as an EAMP/LAc, participates in peer record review. 

Peer Record Review and need for minimum of  two EAMPs/L.Ac.s per facility
As licensed independent practitioners (LIPs), acupuncturists participate in a peer record review process.  Peer record review process is best accomplished in a timely manner when a minimum of 2 LAcs work within the same medical center (that uses the same electronic charting system, etc). Peer record review is done between two professionals who have the same specialty training (i.e.ACAOM-accredited master's or doctorate level education, passed the NCCAOM board exam).

An acupuncturist (LAc) is an LIP who signs his/her own notes.  An acupuncturist is a provider who refers to and consults with appropriate providers as needed.  An LIP requires only administrative supervision.  No practice supervision required. In a medical system, all providers work as part of a larger team. An acupuncturist, like other professional-level health care practitioners, participates in peer record review, a quality assurance process, with another acupuncturist (LAc), ideally within the same medical center. 

Similar LIP profession types who typically participate in peer record review as part of OPPE in hospital-based practice include physical therapists, health psychologists, and licensed clinical social workers.

Thursday, September 10, 2015

Physical exam training for Acupuncturists

keywords:  hospital practice, KSAs, physical exam skills, charting, SOAP, electronic health record (EHR), evaluation and management (E&M), practice standards

Physical exam training.  This was required part of schooling and part of the biomedicine board exam.  Both Western physical exam skills (such as Range of Motion) and Eastern physical exam skills (tongue, pulse, palpation, abdominal/Hara diagnosis, etc).  This is an important part of the objective measures section of the SOAP note.  The Objective measures section in the SOAP note will be more thorough during initial evaluations and re-evaluations/re-exams.  Re-evaluation is always done at scheduled discharge.

*only use the physical exams that are appropriate to the patient, as the patient case presents.

Evaluation and Management
Evaluation and Management (E/M) codes and standards are kept by the Center for Medicaid and Medicare.  For more information on current standards expected for evaluation and management as related to E/M codes and modifiers used (which are the codes you use when you do an initial visit and when you do a re-evaluation or re-evaluation/discharge), see this manual from CMS website.  It is a free federal resource, as part of the CMS's "Learning Network (MLN)".

Hospital practice L.Ac.s find that they need to keep their physical exam skills, both Eastern and Western, updated regularly.  

Medicare Learning Network (MLN)

Western Physical Exam resources
 Bates' Guide to Physical Examination and History Taking
Bates Visual Guide to Physical Examination
Hoppenfeld's Physical Examination of the Spine And Extremities

Eastern Physical Exam resources
Well, any of the references listed for the NCCAOM board exam
Barbara Kirshbaum's Atlas of Chinese Tongue Diagnosis
Maclean and Lytteton's series of Clinical Handbook of Internal Medicine:  the Treatment of Disease with Traditional Chinese Medicine
The standard red CAM book:  Chinese Acupuncture and Moxibustion edited by Cheng Xinnong

In the comments section, please list your favorite resources for Western physical exam skills or Eastern physical exam skills.  Please also provide a link to the resource.  Thank you!

Related blogposts
What is CMS?

Prescribing in the Hospital setting: Pharmaceuticals, med review, Neutraceuticals, Self-Care

keywords:  hospital practice, prescribing, medical review, SOAP notes, CHM, self-care, practice standards, documentation standards


Pharmaceuticals.  L.Ac.s do not prescribe or advise on pharmaceutical medications.  However, an L.Ac. must know what medications a patient is taking because it affects the larger TCM diagnostic picture.  Example:  symptoms of fatigue as side effect of medication 

Medication Review.  Medication review must be done at first visit.  Recommend updating this review when patient reports a new med added or removed.  Recommend updating the med review during TCM re-evaluations.

Neutraceuticals and Chinese Herbal Medicine L.Ac.s can prescribe Chinese Herbal Medicine (CHM) when they have

a.  the required training and NCCAOM board certification status (see point #2 on CHM practice in hospitals)

b.  it is in their scope of practice at the hospital.  Can be an add-on to credentialing paperwork.

c.  see related section on CHM practice in hospitals for more details

d.  see related state license for “neutraceuticals”

Self-care.  L.Ac.s can prescribe self-care/home care to patients that may include but is not limited to:  acupressure, tai chi, qi gong, meditation, breathing exercises, TCM nutrition recommendations, reflexology homework, self-care massage, hot/cold therapy, orthotic devices, movement therapy  . . .

Practicing Chinese Herbal Medicine in a Hospital Setting

keywords:  hospital practice, CHM practice, specialty practice

Practice of Chinese Herbal Medicine in a hospital setting by an L.Ac.

Training/Credential Guidelines:

  • Practitioner must have current/active diplomate status from NCCAOM as:
    • Dipl. Oriental Medicine (includes Chinese Herbal Medicine board exam) or
    • Dipl. CHM
      • *however, as of 2015 NCCAOM is making it easy to update from Dipl. C.H. to Dipl. O.M.
  • So, I recommend to keep it at Dipl. O.M. since practitioners can now change their certificates over to O.M.  Sticking with one diplomate certificate (when it is an easy change to make for a practitioner trained and who has passed the herbal board exam) makes explaining a new process to credentialing simpler.
  • Current state license
  • Experience—minimum 2 years experience in 20 hours/week AOM practice at min prescribing CHM to patients.

Recommend the following:

  • Understanding and/or taking CEUs in herb-drug interactions, pharmacodynamics and kinetics
  • Understanding and training, including CEUs beyond the formal schooling, prescribing individualized formulas as well as patents.
  • If working with a specialty population, such as pediatrics, recommended practitioner show he/she has additional training in prescribing CHM to that population with hours in class as well as shadow/internship, no matter how informal.  Letter of verification or recommendation from shadow/internship supervising practitioner.

Galina Roofener, a 2015-2016 member of the NCCAOM Hospital-based Task Force, is a pioneer in this at the Cleveland Clinic.  She also teaches classes on herbal practice safety in the hospital setting. The May 2014 Acupuncture Today article about this clinic by Shellie Rosen, DOM, mentions that requirements also include an "NCCAOM approved course on FDA 'Dispensary and Compounding Guidelines' ".

Who supervises the work of an Acupuncturist?

keywords:  supervision, hospital employment, credentialing and privileging, LIP, Joint Commission, the Hospital Sponsor

Supervision of an L.Ac.  
related topics include:
  • the Hospital Sponsor
  • working as part of a team
  • referring to appropriate providers, red flags, etc.

In hospital practice, the following question, “Who supervises the work of an L.Ac. at our hospital/medical center?” is common.  Here is a good answer and some talking points.

Direct Answer

The supervision of an L.Ac. is limited to administrative review.  Practice review (TCM practice review) can only be done by another L.Ac.  L.Ac.s, therefore, as health care professionals, must participate in the Peer Record Review process.  [Quality Assurance review aka Peer Record Review and the assessment of any scope of practice can only be determined by a supervisor and/or senior clinician with the same license and training (master’s or doctorate degree from ACAOM accredited program and current NCCAOM diplomate status).]

Special case:  L.Ac. Internship or preceptorship:  The supervision of an L.Ac.’s clinical work can be done by another L.Ac. as may be the case during an internship or preceptorship.

L.Ac.s are independently practicing providers with graduate health education* and degree(s).  The state law term is "licensed independent practitioners (LIP)". The Joint Commission uses the term "licensed independent practitioner" (LIP) for this class of provider. **  Acupuncturists should be credentialed as professional health care providers, eligible for a “delineation of clinical privileges”.  L.Ac.s are not primary care providers as primary care physicians or advanced registered nurse practitioners are.  L.Ac.s are LIPs similar to clinical psychologists, physical therapists, pharmacists, and chiropractors. 

Why Peer Record Review vs. practice supervision

Simple answer:  L.Ac.s are health care professionals, not technicians.  Hence, they participate, as other credentialed and privileged professional health care practitioners do, in the peer record review process as well as other professional practice evaluation processes (FPPE, OPPE).

*Graduate health education. Acupuncture education is a graduate master's or doctorate degree program accredited by the ACAOM (which is recognized by the U.S. Department of Education). As of January 2018, the Bureau of Labor and Statistics published the Standard Occupation Code (SOC) for the profession, 29-1291 Acupuncturist, which recognizes acupuncturists as health-diagnosing professionals. [update added 5.21.2019]

**LIP is a state law/scope of practice term. It is not a term that translates well in hospital setting. No professional in the hospital practices "independently". Every professional in the hospital has a chain of command (line of management). 

Review:  Health care professionals (LIPs) vs. technicians

Licensed Independent Practitioners (LIP), a state law term, are health care professionals, not technicians. 
Professional work “requires the exercise of discretion, judgment, and personal responsibility for the application of an organized body of knowledge that is constantly studied to make new discoveries and interpretations, and to improve data, materials, and methods.”[1]

Licensed Independent Practitioners (LIPs), a state law term--Joint Commission recommends these types of providers be credentialed
Can be credentialed. Are NOT privileged.
Has a national provider identifier (NPI)
Does not bill insurance. Does not have an NPI
Able to practice clinically with only administrative supervision
Carries out the treatment plan their supervisor, the provider, creates
Has training and education to evaluate a patient
Cannot sign notes; does not take full responsibility for treatment
Can create a treatment plan
Clinical work is directly or indirectly supervised
Can modify a treatment plan
Does not have ability or authority to evaluate patient
Can re-evaluate patient
Does not have ability or authority to change or modify treatment or procedure
Can adapt treatment procedures

Reads research literature in the field, including evidence-based clinical guidelines and recommendations. Able to discern and incorporate clinically relevant information into current practice

Participates in peer record review, an OPPE process and standard
Does not participate in peer record review
BLS occupational code delineates as “health-diagnosing professional”
Example: 29-1291-Acupuncturists
Group 29-0000 is the major group, “healthcare practitioners”
Group 29-1000 is the minor group, “health diagnosing and treating practitioners”

References for table:

[1] p.7, “Distinguishing Between Professional and Technical Work”, Professional Work in the Medical and Healthcare Group, 0600, Office of Personnel Management (U.S.A.), published September 2017. Retrieved 5.22.2019.

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