Risk Management

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.)