Ten Steps to Ensure that On-Call Coverage Doesn’t Put Your Patient on Hold

By B. Thomas Hutchinson, MD

Argus, September 1997

Medical call coverage, the transference of patient care responsibility from the “attending/treating” physician to a “covering” physician, is a necessary and integral part of contemporary ophthalmic practice. However, when patient care responsibility is transferred, there is greater risk exposure because of real or perceived undue delays in addressing the medical problem and lack of an established relationship between the patient and covering physician. If not carefully planned, effected and monitored, call coverage may be detrimental to the patient and result in a malpractice lawsuit, not only pitting patient against physician but, at times, physician against physician.

Establishing guidelines for coverage that ensures quality care for the patient will satisfy the risk management aspects of shared responsibility and enhance the image of the practice with patients. The following concepts are important to consider when evaluating existing or new call coverage.

Although most state licenses allow a physician to practice medicine and surgery in the broadest sense, a prudent course is to arrange coverage with an ophthalmologist who has similar training and experience, whenever possible. Practice patterns in call coverage must meet the standard of the community, which may vary between geographic areas of concentrated subspecialty care and areas of sparse medical coverage. In areas of concentrated subspecialty care, sharing coverage between different ophthalmic subspecialists and between comprehensive ophthalmologists and subspecialists may be appropriate only if each has maintained skills and practice patterns commensurate with the spectrum of care in the medical call coverage. Optometric and ophthalmological cross-coverage and that of different disciplines of medicine is an inappropriate policy and opens one to substantial legal risk.

Both the treating/attending and covering ophthalmologist should acknowledge the time the coverage starts and ends. The treating/attending ophthalmologist should advise the hospital, office and answering service of the name and telephone numbers of the covering physician. The covering ophthalmologist should advise the hospital, office and answering service of his/her availability and how to be reached.

The treating/attending ophthalmologist should provide covering physicians with information on patients with acute or anticipated problems; this should be documented in the patient’s medical record. The treating/attending ophthalmologist also should give these patients the covering ophthalmologist’s phone numbers and arrange for scheduled visits if the interval of coverage warrants it.

Instructions to the patient from the answering service or other facility must be clear and complete. If possible, an alternative referral source should be provided in case the ophthalmologist on call is unexpectedly unavailable. Access to the physician on call or the responsible facility must be given on the initial inquiry of the patient.

The medical records of the practice being covered should be available if needed.

Documentation

Recording the name, telephone number, identifying address, time of call, reason for call, disposition of the inquiry and follow-up arrangements is absolutely necessary. When returning the call coverage to the treating/attending ophthalmologist, the record of calls and care given will provide continuity of the patient’s care and establish for the written record the events of the on-call care provided.

If a patient’s concerns are not completely addressed during a telephone inquiry, the patient should be seen by the covering ophthalmologist, even if the patient is known to the covering ophthalmologist.

The treating/attending ophthalmologist should partner only with fellow ophthalmologists who share his/her own philosophy regarding prompt, high quality and ethical service to the patient.

Follow-up communication with both patients and any covering ophthalmologist should be a priority when the treating/attending ophthalmologist returns to cover the practice.

Although coverage arrangements are especially important for solo practitioners, it is also important for ophthalmologists in group practices to have clear policies defining coverage arrangements with their associates.

A timely response to a real or perceived emergency benefits not only the patient, but also the practice of both the attending and covering ophthalmologist. In summary, an effective, medically correct and responsive call coverage program is a necessity for every practicing ophthalmologist.

Risk Management Concerns of Satellite Offices

By E. Randy Craven, MD, and Kirk H. Packo, MD, Digest, Fall 1997

Ophthalmology is in a period of transition. With reimbursements steadily declining and competition steadily increasing, ophthalmologists are looking for ways to better position themselves in the market place. Satellite offices present an opportunity to increase patient access and volume, often with a minimal increase in overhead since staff and equipment may already be in place. Unfortunately, the physician working in a satellite office may be unfamiliar, and thus uncomfortable, with the equipment or staff and feel that the satellite office does not offer the same therapeutic and diagnostic capabilities as the main office. A “carpetbagger” mentality may evolve if the physician attempts to reap the benefits of a satellite patient volume with only a minimal outlay of overhead or time.

Managed care may create a carpetbagger mentality by its very nature: An ophthalmologist provides care through an insurance or managed care plan at a distant facility operated by the plan. Under the terms of the plan, procedures and operations must be done at this approved facility. The purchase of equipment, hiring of personnel, and management of medical records are handled by the plan. The arrangement feels “transient” and the ophthalmologist has less control over patient care. Patients, for their part, may feel restricted if all their care must be rendered at one facility.

New Risk Management Concerns

Some basic medical-legal concerns are common to all possible combinations of office locations and affiliations. Medical records, postop or emergency care, telephone coverage, equipment upkeep, and staff scheduling present potential problems in all types of satellite arrangements. Other concerns include business expenses, malpractice insurance costs, liability for employees traveling to satellite offices, office image, security and safety, and time-share liability.

Satellite offices can fragment a practice, resulting in two tiers of care if the practitioner does not work to avoid this pitfall. The ophthalmologist must apply the same standards and expectations to the care of satellite patients that exist in the main office, especially when patients are being comanaged. Strong leadership and frequent meetings between physician and staff are necessary to address problems related to emergency care, record keeping, and telephone coverage and to ensure a consistent level of care among various offices. Practice administrators should visit locations frequently to ensure that set office management protocols are followed even if the satellite staff is not employed by that administrator.

Telephone Coverage

The traditional office used one phone number, housed all records at one location, and followed one schedule. Now, the practice with satellite offices may use several phone numbers, house records at several locations, have numerous doctors visiting numerous locations, follow multiple schedules, and be staffed by personnel employed by multiple entities. A primary issue that arises is telephone coverage.

Many practices use a common phone number for all practice locations, often requiring a dedicated phone operator. Patients calling in have no idea the phone is actually being answered at a site distant to their treatment facility. Offices outside the immediate area provide a toll-free number so patients can easily touch base with their physician. In other instances, each location may have a different phone line but be able to forward calls to a main number.

The satellite patient or doctor should never feel out of touch, even when the office is unstaffed. Certain telephone principles help reduce potential liability. Call forwarding to the main office is an easy solution and gives patients a sense of security provided the staff remembers to activate the system at each day’s end. Sophisticated systems are available through local phone carriers that will transfer calls even after a power outage. Recorded messages and voice mail systems may be less costly but may frustrate patients and foster feelings of abandonment. Long voice prompt menus further frustrate patients and should always be kept to a minimum.

When sharing another practitioner’s office, the satellite physician may choose to use the existing phone line instead of installing a separate line forwarded to a main location. If this is the case, the satellite staff should be educated on how to handle calls for the visiting satellite practitioner, avoiding such responses as:

“Doctor Smith only comes here once a week. Please call back later.” Or, “We don’t know where Doctor Smith is today.”

Providing satellite offices with the physician’s main office number, cellular phone number, beeper number, daily schedule, and specific instructions for handling emergency calls is crucial when problems arise and patients need prompt care. Phone triage by the comanagement staff should be seamless for the visiting practitioner. If there are different staff at each location, acquaint them with each other to foster a single team mentality toward patient care. Turn the phone line into a valuable risk management tool rather than a potential liability.

Patients should be aware that their physician practices in a different location on a given day and that his or her scheduled presence in the satellite office may be limited. If a comanagement system is not in place at the satellite facility, provide patients with the addresses of the other office locations in case they need to travel to a distant location for urgent care. Giving patients pre-printed maps and driving directions helps foster a sense of caring and security.

Medical Records

Medical record management is probably the biggest consideration for the satellite office. Electronic medical record keeping offers the best solution for practices with multiple locations because it allows quick and up-to-date record access when a patient presents on an emergent basis. The electronic medical record is still an expensive solution requiring auxiliary hardware, computer expertise, and additional learning and set up time, but it may be well worth the effort for effective satellite office management.

If standard paper charts are used, a concerted effort must be made to check and double-check that records are coordinated from the various offices. A decision must be made about where to house paper charts for satellite office patients. Typically, charts are kept at the satellite facility when run by a managed care plan or hospital clinic. A duplicate record system (a “skin” chart) may be necessary to keep adequate information, but each chart needs to contain the same information. The duplicate record is then housed at the main facility and transported back and forth to the satellite. This is helpful in handling emergency calls from patients at the main facility when obtaining the original record from the satellite is difficult or impossible.

When charts are housed only at the main facility, special care is needed to make sure all records are packed and completed prior to being transported to the satellite. “Add-on” patients at the satellite create a special records problem. If possible, have someone at the main office available to fax the needed record information. If someone is not available at the main office, add-on patients are best seen as new patients so problem areas are not missed. Notes for each day should be refiled in the original chart in a timely fashion to avoid therapeutic mistakes. Filing loose notes out of chronological order is another potential pitfall and an invitation to mistakes.

The medical record is the single most important risk management document and all responsibility for its completeness falls upon the practitioner, not the housing agency. There is no defense in blaming a medical records department or other practitioner’s staff for lost notes or missing or incomplete charts.The use of a digital dictation system via phone line is one solution to directing notes to the appropriate chart location. Being able to dictate chart notes at night or during off-hours directly to a specific location minimizes the risk of lost or forgotten documentation.

Soliciting satellite patients to participate in their own care by providing them with a copy of their tests and records and mentioning what needs to be done at their next visit may be helpful. If they are then seen at a second facility or at a later time and know that a fundus photograph was needed at the time of their next visit, they can remind the ophthalmologist of this. This can be especially helpful with complicated ocular diagnoses. Still, the ultimate responsibility lies with the treating physician.

Photos and fluorescein angiography present a challenge for satellite record keeping since graphic images cannot be sent by ordinary fax lines. A patient presenting to one office for laser treatment when the needed fluorescein angiogram is in another location invites delays, courier expenses, or the urge to inappropriately treat the patient without the angiographic guidance. Further mistakes are invited if an angiogram ordered in one practice office is read by another practitioner who may not be as familiar with the patient’s clinical exam or history. When angiograms need quick attention such as in acute exudative macular degeneration, the satellite office should have a system in place for timely review or transfer of the film to the reading physician. A digital angiography system using telemedicine techniques is one solution, but its expense may be a deterrent.

Comanagement Arrangement

The comanagement arrangement is critical to the success of a satellite office. As a rule, it is wise to keep an arms-length distance when entering into a satellite comanagment arrangement. This allows you to maintain your objectivity and not be forced into financial arrangements or patient care scenarios that do not meet your approval. Research your comanagement partner’s education and training, malpractice claims history, and understanding of managing postop problems. While checking malpractice claims history may sound excessive, it is wise to protect your own liability. At the very least, you should confirm that your comanagement partner’s professional liability policy limits match your own so you are not the “deep pocket.” When working with providers where you provide satellite surgical coverage, it is very important that everyone involved has a clear understanding of who is responsible for what.

Case Study

A solo practitioner retinal surgeon maintains a satellite office 80 miles from his main office and once a week sees patients in a hospital time-share office. On one such visit, he performed an uncomplicated scleral buckle operation on a 65-year-old male in the early evening hours following completion of a routine patient day. After sleeping over night in the hospital call room, he examined the patient at bedside at 4:30 a.m. and observed the retina to be attached and tactile pressure to be normal. The surgeon then drove to his main facility to begin another scheduled day. The patient was discharged with instructions to follow-up at the satellite office in one week. No comanagement arrangement was set up; the patient was instructed to call if any problems arose. That evening, the patient called complaining of continued severe pain and nausea. Rather than drive back to re-examine the patient, the surgeon prescribed potent oral narcotics by telephone. The patient presented to his original ophthalmologist four days later still complaining of pain and was found to have no light perception with a pressure of 60. The patient filed suit against the retinal surgeon alleging negligent misdiagnosis of postop angle-closure glaucoma. He ultimately received a large settlement.

This case study demonstrates the dangers of a satellite setup in which there are no provisions for handling postop problems. Successful comanagement, particularly in rural or distant satellite situations, is critically important when postop problems arise. It would not have been necessary for the retinal surgeon to drive back to the satellite office if a defined comanagement setup had been in place. Some geographic areas use visiting nurse practitioners for this as a standard of care.

When a patient is referred by the comanaging provider, it is important to discuss the patient’s expectations of surgery. An open and honest discussion before surgery will help avoid problems later. The visiting provider needs to let the patient know what to expect during and after surgery, including where the patient will have to travel in the event of a complication. Some practitioners continue to see patients postoperatively at intervals whether or not a comanagement fee is billed by the referring ophthalmologist or optometrist, primarily as a risk management tool.

Conclusion

The basic principle in caring for patients at a satellite office is to strive at all times to provide a single consistent level of care throughout the entire practice regardless of facility location. Effective use of comanagement, careful record keeping, and phone planning remain powerful tools in the creation of a low liability satellite facility. (A sample form, Confirmation of Postoperative Comanagement Arrangement, is included in the Appendix.)

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.

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.