Risk Management

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 Each practice location may have a phone line, but keep the number unpublished if you won’t be staffing it full time or forwarding the calls to your main number.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.