Choosing the Right Professional Liability Carrier for Your Integrated Practice

By Paul Weber, JD, and Jillian Brandt, CIC

Administrative Eyecare, Winter 1997

Some ophthalmology practices are currently being sought after by payers, hospitals, networks, practice management companies (PPMs), and other managed care organizations. Solo practitioners and small groups are forming larger groups. The dilemma for ophthalmic practices is easy to state but hard to resolve: Which prospective partner should they integrate with to effect economies of scale and face the uncertainties of a dramatically changing health care marketplace?

Prudent decision making about the professional liability insurance needs of any prospective partnership is a critical first step for a practice to take in the initial stages of any consolidation. It is important to carefully evaluate a prospective insurance carrier to make sure it is knowledgeable of and comfortable with the eyecare industry can write policies in all states (if the group will operate in more than one state) is financially strong with an excellent reputation for service desires a long-term relationship with the new venture.

In the rush to form a new group or join a new entity, don’t ignore these basic characteristics. They reveal whether or not the new group understands the importance of selecting the best insurance carrier or program for the individual physician and the entity.

After you have confirmed the general characteristics of a prospective insurance provider, ask the following:

• What kind of coverage will be provided (claims made or occurrence) and who will pay for it?
• What provisions will be made for tail coverage and who is going to pay for it?
• Will there be 24-hour coverage for physician services?
• Which activities are excluded from coverage?
• Who will handle the investigation and defense of claims? Will the physician have the right to withhold consent to a settlement?
• If managed care duties are delegated to the physician practice, will managed care errors and omissions (E/O) and directors and officers (D/O) liability coverage be purchased?
• Does the purchase agreement contain fair indemnification, insurance, and limitation of liability provisions?

You should also review past, present, and planned activities and past and current insurance policies in light of the new venture to determine specific insurance coverage needs. Your present professional liability insurance carrier or insurance agent should be able to assist you at this juncture.

The Current Liability Insurance Market

At present, the competition is fierce among professional liability insurance companies to provide coverage to new ventures being formed by ophthalmology and other specialties. Not only are the physician-owned professional liability insurance companies competing for this new business, commercial companies, which are owned by shareholders, are also bidding to provide insurance to the new enterprises. Thus, malpractice premium prices are dropping for large accounts because of aggressive bidding by carriers to a level that in some cases borders on predatory pricing, which can best described as buying the business for short-term profits.

For the immediate future, physicians and new ventures will benefit from the stiff competition among insurance carriers. In fact, some practices affiliated with PPMs report having reduced their malpractice insurance costs by 30% to 50%. However, selecting a malpractice carrier based solely on price without considering the carrier’s long-term commitment to underwriting the practice can be risky. For instance, if an insurance company has underpriced the coverage (premiums charged do not cover future claims) to get an account, it will eventually have to increase rates to counter the years in which the pricing was too low. It is not uncommon for carriers to try to increase rates by 30% to 50%, as recently happened in the Texas market. Some carriers will opt for simply abandoning their insureds.

Look for a company that already has competitive rates. These companies do not need to drop rates to get the business, allowing them to focus on providing long-term, affordable coverage with an emphasis on risk management and personalized service. They are also less likely to sacrifice their smaller clients (e.g., solo practices, small groups) to provide coverage for large accounts.

The Impact of PPMs

The formation of PPMs presents a number of opportunities and challenges to professional liability insurance companies that want to provide insurance to PPM-affiliated practices. Depending on the agreement a practice has with the PPM, the physician may not actively participate in or have input into the negotiations with prospective professional liability insurance carriers. The PPM, or an insurance broker bargaining on behalf of the PPM, may do all the negotiating with the prospective insurance carrier. Also, the PPM may not only be seeking professional liability and general liability coverage for the physicians affiliated with the PPM but also D/O and E/O coverage and property coverage for the PPM itself. The broker is charged with putting together the best overall insurance package for the PPM and affiliated practices and is commonly paid a commission by the insurance carrier to do so.

Because physicians usually do not sell their practices to the PPM, they are still responsible for the malpractice coverage of their practice, its associated physicians, and the technical staff. The advantage of being affiliated with a PPM is that it can lower the practice’s malpractice insurance costs by requiring volume discounts from the insurance carriers. However, even though an insurance carrier negotiating with the PPM or broker will review the affiliated practices as a whole to determine the overall premium, each practice is underwritten on an individual basis. Therefore, an affiliated practice should be aware that it could be subject to additional surcharges, deductibles, and underwriting restrictions.

Large commercial carriers can underwrite broad coverage for a variety of risks and offer a package to PPMs in which malpractice coverage is only one item. The commercial carrier’s profit is not based on one line of coverage (e.g., professional liability) but rather several lines of coverage. For instance, any future losses from professional liability claims may be offset by good loss experience for general liability, property, D/O, E/O, and other coverage. In effect, the large commercial carrier is spreading its risk over a large number of products.

Physician-owned companies also offer a number of insurance products (e.g., D/O and E/O, employment practices liability) and will associate with commercial carriers to put together a similar package with reasonable volume discounts for the PPM. There are advantages and disadvantages for the PPM in entering into a package with one large carrier rather than a partnership of carriers bidding on an account. From the standpoint of the PPM or its broker, it may be easier to administrate a package through one large commercial carrier rather than a number of different carriers acting together. However, a partnership of carriers may offer better service on the specific products they are providing.

Some large commercial carriers may offer a variety of insurance coverage, but that does not necessarily mean they offer service on each product. When carriers form a partnership, they combine their strengths and products.

Use Your Experience

Physician practice management companies are not the only path to practice integration and mergers. Ophthalmologists have a wide range of options to achieve greater operating efficiencies and access to patients. Before entering into any agreement, whether with a newly formed IPA or a publicly traded PPM, consider the ramifications it will have on your relationship with your current professional liability insurance carrier.

Those who have been in the eyecare profession for some time have seen how volatile the professional liability market can be and know that professional liability carriers can and do precipitously increase their rates. When entering into a new venture, realize you may have more experience than those responsible for forming the new venture. Trust your instincts, and use this experience to your advantage.

The Expansion Team

By E. Randy Craven, MD

Ophthalmology Management, February 1998

You’ll face a myriad of new challenges after purchasing your satellite office. Here’s some advice to help you cover all your bases. Once you buy ophthalmic practices, they need to become satellites with a consistent approach to patient and practice management. Otherwise, you’ll expose yourself to the risk of failure and possibly even legal trouble.

To be successful, you’ll need to effectively plan for telephone coverage, medical records and a host of other unique new responsibilities. Follow along as I review key considerations you need to keep in mind. You’ll find these strategies helpful in any satellite arrangement you enter, even outside offices you practice in but don’t own.

Get Your Staff Involved

Satellite practices can fragment and strain a practice. Because of the strain and legal concerns, you need strong leadership and frequent meetings between physicians and staff. Rotating the staff among offices prevents isolation and keeps them up-to-date on happenings throughout your expanded practice. Many practice administrators want to visit locations weekly to make sure everyone understands and follows set office management protocols. This also is a good time to discuss if the satellite is adhering to the image standards of the practice.

Make Sure the Phone Keeps Ringing

Of course, the traditional office used one phone number, had all the records at one location and operated under one schedule. Now, the practice using satellite offices may have several phone numbers, house records at several locations, and have multiple schedules.

A primary number. Avoiding any missed coverage for schedules, telephone calls, or patient needs is crucial. Many practices use a common phone number for all practice locations. For those offices that require long distance telephone calls, a toll-free number lets patients easily touch base with you.

Unlisted numbers. Each practice location may have a phone line, but keep the number unpublished if you won’t be staffing it full time or forwarding the calls to your main number. That prevents patients and referring doctors from getting lost in the process.

Be available. If the office has enough staffing for full-time scheduling and emergencies, then visiting doctors should be accessible to provide coverage. If that’s not possible, adequate coverage should be available from other doctors. Providing satellite offices with your office number, cellular telephone number, and beeper number is crucial for when problems arise. And if the staff is different in each location, work at keeping them acquainted. This will help with the joint effort of finding solutions and providing the best patient care.

Call forwarding. If a call-forwarding arrangement is made, a system that transfers after a power outage is important. This type of forwarding is probably best done through your local telephone carrier. The telephone is quite a problem if you do use call forwarding and your main office has more telephone lines than your satellite office. This creates an increased demand on the incoming lines.

You’ve got mail. And don’t forget to have a staffer check the voice mail. The voice mail system at the main office may be overlooked when you’re at a satellite.

Keep Patients Informed

Communication about your satellite offices is helpful to prevent patient needs from falling through the cracks. Patients may be unaware you’re in a different location on a given day. Using the central phone number saves patients from the strain of having to know where you are on a given day. Let them know that if an emergency occurs, they may need to travel to another location.

Also, have a system in place to handle drug refills. These can be difficult with the satellite because patients may not be sure who wrote or should write the prescription. Drug refills should be done by the office of a remote satellite or through the main phone number.

Track Medical Records

Medical record management is perhaps the biggest consideration for the satellite office. Handling medical records electronically is the best way for practices with two main offices or for those practices where significant time is spent at satellite offices.

When a patient presents on an emergent basis, you can easily access a record electronically. If you use standard paper charts, then a concerted effort must be made to check and double check that all records are packed before you leave the main office.

Medical information – and the ownership of responsibility for it – needs to be thought through when setting up a satellite and should be revisited from time to time for existing satellites. Using a code review committee to help with the appropriate methods for charting would help with this. This is especially true regarding comanagement of patients. Comanaged patients may be seen in another facility. Using your billing/code review committee to review for appropriate records should help you with this.

And in case of a patient add-on, make sure there’s someone at the main office to fax the needed medical record information. If there’s not someone at the main office, then add-on patients are probably best looked at as new patients so a problem area won’t be missed. For instance, imagine if you noted that a patient had an early afferent pupillary defect during her last visit and you wanted to get visual fields as soon as possible. If she came to the office for some other complaint, without the medical record, and you did a focused exam with a diagnosis of blepharitis, you may be inclined to tell her to come back in a year and not follow up on the visual field.

Another consideration: If records are shared among several specialties, it may be impossible to transport the full record, and a duplicate record system (a “skin” chart) may be needed for your patients to keep adequate information.

Keeping your transcriptions in an organized manner – so patients may be recalled via standard word processing – is another way to keep informed about key information. You can take this one step further by giving patients a copy of your correspondences and mentioning to them what needs to be done at the next visit. Then, for instance, if they move to a location closer to another of your satellite offices, and they know that a fundus photograph is needed at their next visit, they can help you with checks and balances by being involved in the process.

If a patient keeps a file with a copy of his own tests and records, it can be helpful for the more involved ocular diagnoses. When the records in the satellite office belong to another eyecare provider, they may be different from your own records. Use a form similar to your main office’s to help keep you on track in caring for the patient. Dictating letters in a standard format also helps when looking for your thoughts and plans at the time of the patient’s last visit.

Copies of visit forms and records in your main office may help you answer questions when the doctor, patient or staff from the satellite calls with questions. The satellite office can also fax copies of the record to help you keep records accurate.

Comanaging Patients Effectively

The comanagement arrangement is very important to your success with satellite offices. At times, it may be difficult to know all the personalities and qualities of people with whom you associate at satellite offices. As a rule, it’s a good idea to enter into your satellite comanagement situations with a definite arms-length arrangement. This is an agreement made with care to avoid taking unfair advantage over another party. This allows you to keep your objectivity and not be forced into financial arrangements or patient care arrangements that don’t meet your approval.

Once you’ve selected someone to work with, find other doctors who’ve had similar arrangements in the past and find out if there were any problems with comanagement, etc. While checking if someone has had significant malpractice claims may sound excessive, it’s reasonable to find out about this to protect your own liability. At the very least, you should confirm that a comanaging doctor’s professional liability policy limits match yours, so that you’re not the “deep pocket” should a claim arise.

When providing satellite surgical coverage with comanaging doctors, you need to make sure that the patients and doctors involved understand who is doing what. Forms such as the one available through OMIC can help out in such arrangements. (See Appendix.)

Cover All Bases

When a patient is sent to you from a comanaging doctor, make it a priority to find out what the patient expects. Sometimes patients expect you to deliver much more than you’re able to, and an initial discussion is important to prevent problems. Additionally, as the visiting doctor at an office, you need to let the patient know what to expect during and after the surgery, including where he needs to travel in the event of a complication. Teaching the patient about possible complications and how to report them will help him feel linked to you after the surgery. Some doctors see patients postoperatively at intervals, even if there is no comanagement fee billed by the referring MD or OD. This is primarily a risk management technique for those patients who may develop a late complication or who’ve had a problem at the time of surgery.

Various methods ensure proper care when comanaging patients in the post-operative period. For example, some practitioners use forms to be faxed after surgery for the comanaging doctor to send to the surgeon, while others use electronic medical records to download information for the surgeon. Other doctors may frequently visit the satellites so the comanagement patients can be reviewed directly a week or two later. Others frequently contact comanaging doctors to keep in touch regarding those patients who have recently undergone surgery.

Pay Attention to Details

The feasibility of satellite offices presents us with a good opportunity to expand our practices and offer quality care to new patient populations. However, remember first to take the necessary steps to address the unique risk management issues this new system of health care delivery presents. This will help ensure that these new patients receive excellent care no matter where you, your staff and comanaging doctors provide it.

Goals of Managing Satellite Offices

• Streamline medical records
• Arrange for consistent post-operative care
• Provide coverage for emergencies and complications
• Link practice-wide telephone coverage
• Maintain adequate liability coverage
• Unify practice image at all offices
• Ensure security, safety and time-share liability
• Grow new business without stressing existing business

New Office Arrangements

As all eyecare doctors look for ways to better position themselves in the market, questions arise as to how to make this possible: Would someone visiting my practice help with patient care and provide a service not offered in the area? Or, should I travel to another location?

Studies have shown that the average patient in an urban area expects an eyecare provider within 10 minutes of home. The rural patient may travel 40-80 minutes, but not a lot more for most routine care. Therefore, answers to these questions might mean that a general ophthalmologist or subspecialist would visit a hospital in a small town, or visit an optometrist’s or ophthalmologist’s office at a location that would better serve patients who don’t want to travel.

Sometimes, the location visited may have a significant volume and need for more coverage. These types of arrangements usually call for comanagement of patients and generally fall under the category of satellite offices.

LLCs and Entity Liability

Paul Weber, JD, OMIC Risk Manager

Digest, Summer 1998

Lately, a significant number of OMIC insureds have been forming Limited Liability Corporations (LLCs). An LLC is a relatively new form of business entity offering certain income distribution and tax advantages. Some insureds assume that after forming an LLC there is no need to purchase entity coverage for the LLC (entity) since there is “”limited liability.” The following questions address the professional liability exposures and coverage issues of LLCs and why it is still advisable to purchase entity coverage for them.

Q  What is the difference between practicing in a limited liability corporation and practicing in a partnership as it relates to malpractice claims?

A  Physicians practicing in any form of corporation (LLC, S-corporation, etc.), unlike those in partnerships, have limited liability. Like partnerships, the assets of the corporation are subject to all corporate obligations; however, unlike partnerships, physicians in corporations generally cannot be held personally liable for the malpractice of their fellow shareholders. Please note that physicians cannot insulate themselves from personal liability for their own negligence by incorporating.

Q  Are there any “loopholes” (exceptions) to the general rule of limited liability of corporations?

A  Yes. There are at least two exceptions. First, a physician supervising the work of another may be at personal risk if the person being supervised commits malpractice as a result of the physician’s failure to provide adequate supervision. In this scenario, the supervising physician could be held jointly and severally liable along with the physician being supervised. Second, based on a number of considerations, a court can disregard the corporate entity (in legal terms, “pierce the corporate veil”) where recognizing the corporate form would open the door to fraud or promote injustice. The courts have developed a long list of relevant factors to look for in such cases. For instance, are corporate assets treated as if they were individually owned by shareholders? Is there commingling of assets or records of purportedly separate entities?

Q  Do I need entity coverage for my limited liability corporation?

A  Regardless of the form of the business organization, physicians would be well advised to maintain adequate professional and general liability insurance. A corporation (LLC or other) is not a substitute for purchasing a good insurance policy. Entities can be, and frequently are, named in medical malpractice lawsuits. Even though the entity may be ultimately dismissed from a claim, legal expenses can be costly. In addition, entity coverage offers protection to the corporation for its vicarious liability exposure arising from services rendered by physicians and non-physician employees for their direct liability exposure. As with partnerships, the assets of a corporation are subject to all corporate obligations. If there is a serious medical incident resulting in a large judgment against the corporation, it is possible that all assets, including medical equipment and other tangible items, may be attached to pay off or satisfy the judgment.

Q  What legal questions might arise when a business entity is sued?

A  Legal issues surrounding settlement may arise when a business entity (corporation, partnership, etc.) is sued along with an individual insured. When it is concluded that a case should be settled with a payment to the plaintiff, it may be appropriate that the settlement be made solely on behalf of the corporation and not against the individual insured. Under certain circumstances, a settlement made solely on behalf of the corporation may not need to be reported to the National Practitioner Data Bank (NPDB). A closed OMIC case may serve to illustrate how this works:

A patient sued an insured and his business entity. The individual insured was dismissed from the lawsuit on a motion for summary judgment on the grounds that he had not seen the patient and therefore had no duty to this patient. However, the physician’s business entity (a corporation) was still a defendant in the case because there was evidence that his staff had taken a call from the patient and had delayed scheduling an appointment, which resulted in a loss of vision for the patient. Because a payment was made solely on behalf of the corporation and the doctor was not named in the settlement release, it was not reportable to the NPDB.

Free Vision Screening Exams

Ophthalmologists and their staff often provide free vision screening examinations at health fairs, schools, senior centers, and local malls. These screenings are enormously beneficial for discovering and preventing eye health problems in the general population. They also generate good public relations for the ophthalmologist who is able to give something back to the community that supports his or her practice. OMIC has not had any claims related to vision screening exams in our 25-year history. We feel that the very low risk of liability can be further minimized by taking a few steps discussed in Free Vision Screening Exams.Recommendations and Sample Form.

Surfers, Charlatans and Teleophthalmology

By Joan Hearst, ARM

Ms. Hearst is a risk management consultant in Pasadena, CA, and former risk manager for the Department of Ophthalmology at the University of Southern California. She has lectured at OMIC risk management seminars on office practice issues.

This is the first of a two-part article on risk exposures and risk management strategies related to teleophthalmology. Part I focuses on the Internet and email. Part II will review current teleophthalmology applications and emerging risk management issues.

Digest, Spring, 2000

Surfing the Web for health care information has become a popular pastime. More than 60 million people searched medical and health care-related Web sites during the year ending February 1999, increasing to 100 million a year later. As Americans come to depend on the Internet as a primary source of medical information and on electronic mail (email) as an essential component of communication, the physician-patient relationship faces new challenges and new risk exposures.

In a Winter 1997 OMIC Digest article, Byron H. Demorest, MD, warned ophthalmologists that patients may cruise the Internet to verify information their doctor has provided. He called this the “Internet phenomenon” and advised ophthalmologists to provide complete and accurate information to all patients and accept the challenge to counsel better informed patients. Three years later, Time magazine pointed out that “any fool – or charlatan – with a telephone, modem and computer can create a decent-looking Web site” with disastrous potential for patients such as “$200 ‘second opinions’ with more disclaimers than a sky-diving class, and incompetent ‘diagnoses’ from self-styled ‘professors’ and ‘academicians’ at $50 or so a pop” (“The Web Docs,” April 3, 2000).

Eyecare Web sites proliferate on the Internet and some demonstrate troublesome implications for ophthalmologists and their patients. Little currently exists in the way of consumer safeguards, so there is enormous potential for abuse. The American Telemedicine Association (ATA) has issued an advisory for consumers and health care providers on the appropriate use of the Internet for obtaining health information and medical services. It cautions against government and industry regulation to avoid “overzealous regulation of commerce,” instead encouraging self-regulation by professional and medical societies to ensure the reliability of information posted on the Internet. You may find it useful to provide patients with a copy of the ATA advisory so they understand that there are no guarantees that medical information posted on the Internet is current or accurate http://www.americantelemed.org/i4a/pages/index.cfm?pageid=1

Build It and They Will Come

Reliable Web sites have great potential for restoring the physician’s role as the primary source of health care information. Recognizing this potential, the American Academy of Ophthalmology and six other medical societies, including the AMA, launched Medem, a health care information service to help physicians create personalized Web sites and provide patient access to appropriate sites for current, accurate, and trustworthy medical information. Medem’s Site Builder Wizard makes it easy to plug in information about your practice and come away with a professional-looking Web page www.putyourpracticeonline.com.

Before you put your practice online, decide whether it will be a commercial venture or an information-only service. The ATA advisory suggests that clear distinctions be made between Internet-based activities providing information only and those selling medical services and products. State the specific intention of your Web site on the home page. If you are charging a fee to use your site, state so clearly at the top. If your site provides information only, make sure no advice is rendered. Include an appropriate disclaimer that there is no intent to create a physician-patient relationship with patients you have never examined. You may filter entry to your site by requiring unknown users to agree (through checkbox selection) that by visiting your site they are not entering into a patient-physician relationship nor receiving a diagnosis or treatment for any condition. Look for sample disclaimers on the OMIC Web site at www.omic.com. Model website disclaimers are also available here.

Periodically evaluate and update the content of your Web pages and links to other sites. If you sign up for Medem’s Put Your Practice Online service, you may choose to add any medem.com content you want your patients to have, and you won’t have to worry about keeping current because Medem will continuously update its central data bank with the latest health information and automatically put it on your site.

Be extremely careful if you join a chat room discussion about a patient problem or condition not to use patient identifiers. In the event of litigation involving a patient discussed in a chat room, you could possibly be called as a witness or party. Preface any chat room discussions by stating that you are not giving medical advice or opinions for a specific patient or condition.

Be cautious about the use of any advertising on your Web site. If you advertise refractive surgery, for example, make sure all the risks are accurately defined. Some of the laser surgery sites reviewed for this article provided erroneous, incomplete information. Puffery or exaggeration – common in advertising nonprofessional services or goods – is prohibited in the medical arena and may be considered deceptive, subjecting an ophthalmologist to fines or licensing investigations. Offer information only and make no guarantees of any kind. Claims of superiority are self-serving, may be in conflict with the physician’s foremost responsibility to the patient, and may raise the standard of care to a more difficult one to defend in the event of a claim. OMIC insureds are required to submit advertisements to OMIC for approval before placing them in the media or online.

Reach Out and Email Someone

Physician-patient communication is a cornerstone of medical risk management and may be enhanced by the use of email. Email has the potential to be more effective than telephone communications because words can be chosen more carefully, interruptions or playing “phone tag” reduced, advice clarified, and instructions regarding care retained in a written record. There are many applications for email in the ophthalmic practice. Email may be used to instruct patients about aspects of their care, accept requests for prescription refills, and provide test results. Patients can use email to communicate directly with ophthalmologists and their staff, and clinics can forward Internet links on a particular topic in emails to their patients.

There are limitations and risks, however, to communicating with patients by email. Never use email to report abnormal test results to patients. This always must be done in person or by phone by the ophthalmologist to ensure the patient receives the information, understands it, and has a chance to ask questions. Nor should email be used as a substitute for direct patient care. If you use email to provide medical advice, make sure you are licensed in the state in which your patient resides.

Before you begin using email to communicate with patients, sit down with your staff and develop clear guidelines for its use. Will patients submit questions electronically regarding their care and treatment? Will they inform you regarding unusual symptoms? How will messages be handled? How many messages can your office handle on a daily basis? Who will be responsible for monitoring, printing, filing, responding to, and following up on messages? Who will respond to email when you are on vacation?

Give patients a copy of your guidelines so they know what they can and cannot expect from email communications with your practice. Obtain their signed consent to abide by these guidelines and place it in their record. (See Protocols for Email in the Ophthalmic Practice.)

Confidentially Yours

A major concern of patients is the possibility of a breach of confidentiality of their medical information. Define exactly what constitutes private patient information and establish a strict confidentiality policy for communication, retention, and release of all information. Avoid discussing highly sensitive issues via email and ensure that email protocols given to patients contain a disclaimer of responsibility in case the message goes astray or is copied or transferred inadvertently. A brief header at the top of each email message could state:

This message may contain medical information intended only for the personal and confidential use of the designated recipient. Email is not to be used for urgent or emergent problems. Use passwords and screen savers to reduce the possibility of displaying information on a monitor in full view of office personnel and others. Protect your patients’ privacy by using the “blind cc” feature if you use group email to correspond with specific categories of patients; for example, to update your glaucoma patients on the availability of a new drug therapy.

The Internet and email offer significant opportunities to ophthalmologists to enhance patient satisfaction and improve care. Applying caution and sound risk management before the need arises will reduce the risk of claims and allow your practice to reap the benefits of teleophthalmology. The same fundamental risk prevention strategies that have been advocated in the past apply to teleophthalmology: Be available by phone; follow up with other health care practitioners involved in a patient’s care; document carefully; and obtain written informed consent.

A list of source references used in preparing this article can be found here.

Protocols for Email in the Ophthalmic Practice

A comprehensive email policy will help ensure that staff and patients alike understand the benefits and limitations of using email communications. The policy should contain written guidelines delineating the responsibilities of each party and establishing controls over staff with access to electronic patient information. A flow chart may be used to illustrate the proper procedure for documenting, printing, distributing, and filing email messages. Update the policy annually and distribute it to staff and patients.

Instruct patients to identify the subject category of their messages to you: prescription, appointment, billing, education, etc. This can be used to filter and respond to messages in a timely fashion.

Require patients to put their name and medical record number in the body of their message; many email addresses fail to indicate an owner’s true name. Correspond only with known patients. Do not unwittingly create a physician-patient relationship with an unknown or misidentified person.

Notify patients of the hours you will accept email messages and the importance of contacting you by telephone with any unusual symptoms or urgent needs. Identify those medical events that necessitate a phone call. Inform patients that even important or urgent email messages may be delayed by hours or days.

Advise patients that you will not be responsible for messages that are garbled or not received. To minimize problems, use reliable equipment and service providers.

Ask patients to use the autoreply feature to acknowledge reading your message. Configure your system to automatically acknowledge receipt of messages; then send a message informing the patient when a requested action has been completed. If patients expect responses to questions regarding their treatment, messages must be checked regularly, responded to promptly, and documented thoroughly.

Verify that all email sent from your practice is accurate and includes appropriate language. Email is self-documenting and clearly conveys the information that was communicated; email will be discovered in the event of litigation.

Quote the full text of an email sent to you when responding and place copies of all correspondence with replies and confirmation(s) of receipt in the patient’s medical record.

Follow-up any serious or ambiguous email queries by phone, reminding the sender that you (or an appropriate substitute) are always available by phone.

Resources/Websites Used for Article on Internet and Email

Angert, Amy B., JD, Understanding the Basic Rules of Advertising, Argus, December, 1993.

Boughton, Barbara, Enhance Your Patient Relationships With Email, EyeNet, April, 2000, p 43.

Bristow, Joan, Protect Your Practice: Telemedicine, The Doctors’ Advocate, The Doctors’ Company, Third Quarter, 1999. Website: http://www.thedoctors.com/Resources/TDA/archives/index.htm

Conklin, Charles B., M.B.A., Risk Management Ramifications of E-mail in a Hospital. Risk Management in the CyberAge, Forum, Risk Management Foundation of the Harvard Medical Institutions, September, 1998 Volume 19, Number 3. Website: www.rmf.harvard.edu

Cykiert, Robert, MD, FCS, Hanging Your Shingle on the Web, Ophthalmology Management, October, 1998, p 66.

Day, Susan H., MD, Ethical and Risk Management Issues Related to Advertising and Marketing, OMIC Digest, Summer, 1996.

Demorest, Byron H, MD, Medical Information and the Internet, OMIC Digest, Winter 1997.

Hoskins, H. Dunbar Jr., MD, Give Patients What They Want: A Web Site They Can Trust, EyeNet, April, 2000 p 11.

Kane, Beverley, MD and Sands, Daniel Z., MD, Task Force on Guidelines for the Use of Clinic–Patient Electronic Mail: White Paper for the AMIA Internet Working Group: Clinical Use of Electronic Mail with Patients., Journal of the American Medical Informatics Association, Volume 5, Number 1, Jan/Feb 1998. Website:http://www.amia.org/pubs/pospaper/positio2.htm#7

Linkous, Jonathan D., American Telemedicine Association Issues Advisory on Use of Medical Web Sites., American Telemedicine Association, July, 1999. Website:http://www.atmeda.org/news/072899.html

Smith, Loren A, Esq, Legal Issues in Telemedicine, Dateline, The Newsletter of the Medical Liability Mutual Insurance Company, September, 1998.

Stanford Health Services, Stanford University Medical Center. Website:http://www-med.stanford.edu/shs/smg/email.html

Telemedicine: A Medical Liability White Paper, Physician Insurers Association of America (PIAA), 1998.