The possibility of a patient having a medical emergency (such as a cardiopulmonary arrest) in a clinician’s office exists in all areas of medical practice. Procedures for handling an emergency should be developed and periodically reviewed with all staff. Appropriate equipment should be available for early intervention. Basic life support equipment (including oxygen, oxygen mask, bag resuscitator, oral airways, IV epinephrine and diphenhydramine) should be available, well-maintained and not locked away. Appropriate equipment for pediatric patients should also be on hand. Since an emergency can occur at any time, several, if not all members of the office staff should be trained (and periodically retrained) in using this equipment. Advanced life support equipment may be appropriate for certain patient populations in practices where staff is trained in its use.

Clinicians practicing in a hospital setting are best served by calling a code. Those with offices outside the hospital can call 911. But all offices should be able to start interventions with crash carts, bag resuscitators and masks, etc. onsite.

An inadequate response to a medical emergency may be difficult to defend regardless of the practice specialty or setting. Patients may assume a physician’s office is prepared for medical crises, and may well perceive any delay in emergency treatment as negligence.

Health care providers need to provide reasonable assistive services and auxiliary aids to patients with disabilities. Blindness and deafness are disabilities covered by the Americans with Disabilities Act (ADA). Providers who cannot demonstrate that the required aids and services impose an “undue burden” could be subject to potential liability for violation of the provisions of the ADA. The nature of the assistive actions needed, the costs to be borne by your medical practice, and your financial resources are considered in any determination by a court of what is reasonable or an undue burden. The failure of a medical practice to make reasonable modifications to ensure that a person known to be disabled is not denied its services is also considered discrimination under the federal law.

At least one court case has ruled in favor of the plaintiff over the issue of provision of an interpreter for a hearing-impaired patient in a primary care physician’s office. Many office settings have evaluated their facilities relative to physical access for the disabled; an assessment of the needs of the practice’s patient population to meet any sensory disabilities identified should also be considered.

Interpreter services are required by the Joint Commission on the Accreditation of Healthcare Organizations, the National Committee for Quality Assurance, and by the Office of Civil Rights. A medical practice that fails to accommodate hearing-impaired and non-English speaking patients could also be at risk under the ADA. Providers covered by the above organizations are required to provide professional services. If clinicians with interpreter skills are not part of your practice or department, professional medical interpreters can be hired on a daily basis through an interpreter service pool. Interpreter services for telephone conversations are also available through phone companies and private groups. Patients have the right to refuse and to use an interpreter of their own choosing.

• Get documentation in the patient's language of the refusal of professional interpreter services.

• Patients should be provided with informed consent that explains the treatment or procedure in their own language. Documentation should be included to substantiate the discussion in the patient’s language, signed by the patient, and noting whether or not the interpreter was a professional or provided by the patient.

• Include the signature and contact information for the interpreter.

Yes.

Reviewing prior medical records as part of a current office visit is good patient care. The patient should be asked to describe not only the current complaint (i.e., what brings you to the office today? or this is your follow-up visit after...) but any concerns that may have led up to the current visit. With one or two skillful questions, you can ascertain what is troubling the patient. With an opportunity to talk (uninterrupted) for several minutes, the patient can relate a significant amount of useful information, and feel that you are listening.

However, relying only on the patient’s memory is risky. For example, a patient may have presented over a period of time, with a series of symptoms that—taken one at a time—have been managed appropriately, but all together may indicate a much more severe condition. Review of the past records is necessary to put those pieces together. In addition, a review of the record can refresh your memory about pending test results, the need for routine screening, results of referrals to specialists, or other matters that should be addressed.

Make a reasonable effort to contact patients who miss scheduled appointments or tests. A reasonable effort depends on the clinical importance of the test or visit, the severity of the patient’s medical condition, and the risk associated with the missed appointment. For patients at minimal risk, a single phone call or postcard following the missed appointment may suffice. For patients who need ongoing monitoring or treatment, a more concerted effort (e.g., certified mail) should be made to inform them about the specific risks of missing appointments. Document your attempts to obtain follow-up, as well as missed appointments, failure to follow up, failure to follow care instructions, and any other examples of patient non-compliance, along with the patient’s stated reason for missing the appointment.

Send a letter to all current patients approximately 90 days or so before the last date of active practice. Include:

1. the date the practice will close,

2. the importance of seeking continued health care,

3. and notification that the patient’s records will be sent to a physician of the patient’s choice with the patient’s authorization.

If appropriate, enclose a release form with instructions about its return. The letter should clearly explain that medical records are confidential and cannot be given to anyone without the patient's written authorization. You may wish to send the letter return receipt requested to document notification. Include in the letter several well-chosen physicians in the appropriate specialty or refer the patient to the local medical society.

If you are leaving a group practice, you might refer the patient to an appropriate group member. Patients who are currently ill or hospitalized may need more personal notification. Seeing them in an office visit or on rounds in the hospital may be more appropriate, followed by an official notification letter.

Obstetricians should be particularly careful to provide care for patients in their last trimester, or for those at high-risk for complications. Personal communication with these patients is essential so that individual treatment plans can be discussed and documented. Make certain that the patient has another physician and the records have been sent.

Because telephone advice must be prompt, accurate, and executed without the benefit of actual observation, the following suggestions may help reduce the related risks:

• Document every telephone exchange. Include the name, date, time, specific complaints, assessment, advice, final disposition of the call, and referrals to other providers or facilities.
• Provide protocols, education, and guidance for nurses and other staff who give telephone advice and information. Nurses giving advice over the phone are accountable for that advice and need to be certain it is within the scope of their state's nursing practice act. The American College of Emergency Physicians and the Emergency Nurses Association advises against any substantial diagnoses or treatment recommendations by telephone.
• If you establish a formal physician-patient relationship during a telephone consult, document and follow up as with a face-to-face patient encounter.

One option is to decide not to provide advice over the phone, especially to unknown or unfamiliar patients. However, if phone advice is provided to known patients, the key areas of concern are the degree of medical advice offered and documentation of the exchange.

Mechanisms should be in place to respond to and record what was discussed during those calls from patients seeking treatment information. If not, the potential for patient dissatisfaction, missed diagnoses, delay in treatment, and possible serious medical consequences exists.

Staff should be supported with protocols including the questions they should ask and when a patient should be referred to a physician. The threshold for obtaining a physician's response should be relatively low. Staff training, telephone procedures, and protocols should be periodically reviewed to ensure that inquiries are being appropriately managed.

Documentation of all phone calls in which medical information is discussed is extremely important. The date and time of the call, patient’s complaints, and advice given should all be recorded. The advice given should include the point at which the patient should seek medical attention. The few minutes taken to record this information will be valuable for ongoing patient care. In the event a patient challenges the quality of medical care they received by phone, or claims he or she made multiple calls and received no or inadequate advice, such documentation will prove worthwhile.

The decision about whether to prescribe over the phone depends upon the physician's relationship with the patient, the type of medication, and the circumstances of the call.

Prescribing new medications to known patients over the phone without a recent clinical evaluation is not recommended, especially when a drug’s appropriateness cannot be readily assessed. If such prescriptions are made by phone, the physician should document that the patient's clinical status and other medications have been assessed, that possible side effects were discussed, and that the patient was told under what circumstances to call again.

For prescription renewals by phone, an assessment of clinical status to check for side effects and the appropriateness of continuing the medication is important and should be documented in the patient's record. When prescribing controlled substances over a long period of time to a patient whose disease process is stable, the BRM recommends that the physician see the patient at least once every six months. For patients who are using Schedule II substances, the Board recommends that the physician see these patients as often as possible and clinically re-evaluate the patient at least every four months.

Out-of-state

The circumstances of an out-of-state call is an important consideration. For the patient “caught” without his or her current medication, prescribing an amount to cover the limited time period may be appropriate. When the symptoms description suggests the need for a new medication, referral to a local emergency room or clinic for assessment is advised.

Special circumstances may develop where patients are being followed out-of-state because of the nature of their illnesses and the expertise of the physician. However, the involvement of a local physician who can monitor the patient and prescribe the needed medications as well, would still be important in these cases.

New or Lapsed Patients

Extreme caution should be exercised in prescribing medications over the phone to new patients or those who have not been clinically evaluated for some time. When suspicions of drug abuse are aroused, careful questioning, prescribing only alternative drugs, suggesting the patient be seen in a clinic or emergency room, and/or prescribing the smallest possible quantity are ways to deter inappropriate use.

Cellular phones raise the same issues as phone advice in general, plus a few based on their technology. The security issues, such as inappropriate eavesdropping, combined with models that include message storage and retrieval that can potentially be accessed by outsiders, should limit the use of these phones for relaying patient information. If patient information is to be discussed, consider acquiring the type of phone that includes a scrambling device.

Yes, but only leave your name (without “Dr.”) and ask for a call back.

Since they may be accessible to individuals other than your patient, take care in leaving messages on answering machines or voice mail.

Provide callback information only: never clinical data, advice, or results. Document the fact that you have left a message.

Using a voice-mail system or answering machine rather than an answering service creates a different risk for your practice because the communication is indirect and potentially delayed or prevented. If these methods are used instead of backup physician coverage, or as a way to go “off-call,” special considerations are necessary:

• Some practices, such as obstetrical and pediatric, are not appropriate for indirect answering systems because those practices involve too many foreseeable, urgent, off-hour patient care needs. Around-the-clock on-call coverage, supported by an operator-attended answering service, is appropriate.
• For practices where using an answering system is considered feasible, the following steps may be taken to minimize liability and patient anxiety or frustration:
  • let patients know that you use an answering device during off-hours
  • direct callers with urgent problems to an emergency department, giving them the phone number and location (and make sure the ED knows you are doing this)
  • if your answering device takes messages, let callers know when to expect a return call
  • pick up messages regularly, and follow through on callbacks
  • save messages, and document calls in the patient record
  • anticipate some patient dissatisfaction with using your system

E-mail should be treated as formally as medical record documentation. The speed and convenience make e-mail a valuable tool for clinicians. However, its use raises some special areas of concern:

• Consider e-mail containing patient information official correspondence. Before sending, check messages for accuracy and appropriate language. Flippant or humorous messages may look disrespectful when viewed later, out of context.
• Assume that e-mail messages (even deleted ones) are discoverable
• (i.e., can be requested by an opposing attorney during a legal investigation) unless they were between the physician and a risk manager, attorney, or insurance company representative. Messages sent to friends and colleagues are not protected.
• Safeguarding the confidentiality of e-mail messages exchanged with patients is difficult. Confidentiality can be breached by outsiders (hackers) or by patients and physicians themselves who Reply to or Forward messages to individuals outside the patient/physician relationship.
• Answering e-mail questions from unknown or misidentified individuals may unwittingly create physician/patient relationships.
• Messages can be delayed by hours, or even days, and should not be relied on to convey urgent or important information.
• Emotions do not translate well through the computer. Your messages, however well-intended, may seem cold or impersonal to your patients. In addition, you may have difficulty discerning how your patients are feeling.

To reduce these risks, physicians may consider the following suggestions:

• Follow up serious or ambiguous e-mail queries with a phone call.
• Remind patients that they are welcome to call and have questions answered directly. Be sure to recommend that patients seek appropriate additional care as needed.
• Check e-mail at least twice a day, or have an assistant check it, and respond promptly.
• Print e-mail messages sent and received and add them to your medical records as an additional means of documenting patient/physician interactions.

While Internet medicine is relatively new, the delivery of health care services via remote telecommunications, or telemedicine, offers potential benefits, such as increased access to care and specialized expertise for those in remote areas, some features may prove to be problematic, such as:

• The licensing and regulation of physicians (and other health care providers) who practice across state lines
• Reimbursement methods for telemedicine applications
• Potential liability exposure—for a failure to use, as well as for the use of—a telemedicine hook-up
• Potential violations of self-referral statutes where physicians are investors in telemedicine projects, or where health care centers provide telecommunication equipment to smaller facilities (which may have the appearance of inducing referrals)
• Confidentiality and integrity of electronically transmitted patient information
• Application of state laws when the clinician and patient are in different states
• The possibility that a clinician-patient relationship is established by such an encounter
• Creation, maintenance, archiving, and ownership of the records of a telemedicine consultation
• Requests for subsequent access to the information
• Documenting patient consent for a telemedicine consultation
• Contingency plans to handle the potential for equipment, weather, or other problems that may adversely impact the transmission of information

At this stage, the effect of telemedicine practice on the standard of care and malpractice litigation is unclear. However, as the technology of telemedicine continues its advancement, risk management principles and guidelines will also evolve to incorporate these new technologies.

While the Internet offers potential benefits, such as increased access to care and specialized expertise for those in remote areas, some features may prove to be problematic, such as:

• The possibility that a clinician patient relationship is unintentionally established by such an encounter
• The licensing and regulation of physicians (and other health care providers) who practice across state lines
• Application of state laws when the clinician and patient are in different states
• Confidentiality and integrity of electronically transmitted patient information
• Creation, maintenance, archiving, and ownership of the records of an Internet consultation
• Potential violations of self referral statutes where physicians are investors in Internet projects
• Contingency plans to handle the potential for equipment or service problems that may adversely impact the transmission of information

At this stage, the effect of Internet practice on the standard of care and malpractice litigation is unclear. However, as the technology of the Internet continues its advancement, risk management principles and guidelines will also evolve to incorporate these new technologies.

Generally, patient-local licensure is required for both new and established patients. However, your site may decide that, for certain scenarios, limited out-of-state visits without a license may be conducted.

Given the layers of risk involved, such decisions should be addressed with your practice leadership who themselves may need compliance and legal input to guide you. Your compliance team also should advise on how to safely prescribe over state lines. For instance, some Massachusetts-based organizations only allow controlled substances to be prescribed for established patients in Massachusetts.

As health systems strive to reduce disparities in all types of care, it is clear that virtual care poses additional challenges for certain patient populations (e.g., those who have difficulty accessing virtual care due to language barriers, hearing or vision impairment, or cognitive impairment). Strategies that may help level the playing field include:

• Enable closed captioning if available in the video platform
• Encourage family members and caregivers to join the visit to assist
• Use the chat function when available
• Incorporate translators when applicable (e.g., ASL)

Maintaining phone-based and in-person (i.e., office-based) care are also key tools for these populations. This requires robust triage to help make sure patients are scheduled with the right kind of visit based on their unique needs, access to technology, etc.