Risk Management

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.