ECMS Bulletin Nov/Dec 2011

ESCAMBIA COUNTY MEDICAL SOCIETY

President’s Message

NOVEMBER/DECEMBER2011 Volume 41, No. 6

ECMS is My Patient Centered Medical Home

by Michelle Brandhorst, MD

Upcoming Events December 1, 2011

General Membership Meeting 5:30 PM

CME / Medical Errors Sponsors: ECMS, MECOP, Hancock Bank Location: Hancock Bank

January 14, 2012

2012 Inaugural Ball Location: Pensacola Country Club

RSVP: 478-0706

ECMSinfo@bellsouth.net Founded in 1873

This is my final newsletter of the year as President of the ECMS. It seems that it took forever going through the usual offices leading up to this year and then it goes by in what seems to be a heartbeat.

But, I would also do it again in a heartbeat. Preparing for the Bulletin articles forced me to read and learn more about the changes that are occurring and affecting our profession. It also forced me to be more sensitive to the day to day struggle that we all face when trying to allocate our time to maximize the attention we offer to our patients. The latest article I read, written by Dr. Sam J.W. Romeo was on the five principles of Patient Centered Medical Homes which I outline below. As the author points out these are principles and are consistent with medial ethics. It is because I can focus on these principles while working with and attending meetings of the ECMS, that I consider the ECMS my Patient Centered Medical Home.

1. Focus on the Physician/Patient Relationship.

I ended each of my previous articles emphasizing this essential relationship. We are too often forced to abbreviate the time necessary in building this relationship. As a result there can be mistrust of what we recommend or we are seen as someone who only orders what the patient feels that they need. As this relationship builds, physicians become aware of and respect the patient’s needs and preferences and the patient is more likely to follow and be satisfied with the physician’s recommendation.

2. Make the patient the center of care.

The patient, not the payer, should be our focus.

Quality care and value can only occur however when the patient is a vested and committed participant in his or her care.

3. Provide care that is accessible, comprehensive and continuous.

Talking with patients, examining patients, trying to solve their problems, and receiving a reimbursement that is agreeable to both of us. It seems old fashioned and idealistic but this is what we do in every other facet of our lives.

4. Emphasize data that is meaningful and understood by the patient.

Patients are not interDr. Michelle Brandhorst ested in how quickly we sign our orders or if their office note is generated on a computer or if 72% of your diabetic patients have Hgba1c’s less that 7. However, these are metrics by which we are judged. Rather than this top down approach, patients care about what we do for their individual medical problems at individual visits in the context of them as individuals. Implementing and following requirements to facilitate reimbursement, when one does not feel that the requirements truly benefit the patient is not, in my opinion, ethical.

5. Give it time.

These are fundamental principles that have been slowly subjugated for years. Refocusing on these principles and resurrecting them will not happen quickly. Most all of us who become physicians are very independent and willingly take responsibility for our actions and the resulting patient outcomes.

We want to fix things and quickly. This will take patience but cannot start until we as physicians focus on these principles. My hope is our medical society as well as others remember one of the founding principles of the American Medial Association which is our duty to seek changes in law and requirements that are contrary to the best interests of the patient.

In closing, thanks to all the past presidents of our medical society for their hard work in growing this important organization. Also to our new incoming President, Dr. George Smith as well as our new Executive Director, Erica Laxson, best wishes for an exciting new year. And finally and most importantly, thank you members for allowing me to lead the Escambia County Medical Society for the past year.

What a great ride!!

ECMS Bulletin The Bulletin is a publication for and by the members of the Escambia County Medical Society. The Bulletin publishes six times a year: Jan/ Feb, Mar/Apr, May/Jun, Jul/Aug, Sept/Oct, Nov/Dec. We will consider for publication articles relating to medical science, photos, book reviews, memorials, medical/legal articles, and practice management.

Editors Norman Vickers, MD Erica Laxson, Executive Director

AD PLACEMENT Contact Erica Laxson at 478-0706 Ad Rates Full page: $600 • ½ page: $300 • ¼ page: $150

IN A MEDICAL MALPRACTICE CLAIM: Be ready for anything and everything.

2011 ECMS Officers President Michelle Brandhorst, MD President-Elect George Smith, MD Vice President Wendy Osban, DO Secretary /Treasurer Susan Laenger, MD

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Pages 4-5 Pain Management Regulations Affect More Than Pain Management Specialists Page 6 How Should Yor Disclose a Medical Error?

YOU SAVE LIVES. WE SAVE LIVELIHOODS.

Page 7-8 Hot Topics in Risk Management: What Physicians Need to Know Page 9 Case Study: Liability Attributed to Physician Extender Vision for the Bulletin: -Appeal to the family of medicine in Escambia and Santa Rosa County and to the world beyond.

- Collaborate with the Alliance to bring together Escambia and Santa Rosa County medical families. To know the needs of the community and promote the healthcare needs.

- A powerful instrument to attract and induct members to organized medicine.

Views and opinions expressed in the Bulletin are those of the authors and are not necessarily those of the directors, staff or advertisers.

www.firstprofessionals.com For more information, contact Shelly Hakes, Director of Society Relations at (800) 741-3742, Ext. 3294.

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Membership Join the Escambia County Medical Society for the Initiation of the 2012 Officers 2012 President: George Smith, MD 2012 President-Elect: Wendy Osban, DO 2012 Vice President: Susan Laenger, MD 2012 Secretary/Treasurer: Christopher Burton, MD Members at Large: Thomas Westbrook, MD Suzanne Bush, MD Brent Videau, MD Andres Candela, MD

January 14th, 2012 | Pensacola Country Club

For more information or to purchase tickets please call Erica Laxson, Executive Director at 850-478-0706 ext 2, or email ecmsinfo@bellsouth.net

Reminder

Membership Updates

ECMS will be publishing the 2012 Pictorial Directory soon.

If you have information that has changed please call or email us at: 850-478-0706 or ecmsinfo@bellsouth.net

It’s time to renew your membership for 2012!

Membership dues can be paid at escambiacms.org via PayPal or by check.

Please contact Erica Laxson, Executive Director with any questions: ecmsexec@bellsouth.net or 850-478-0706.

Benefits of Membership 2012 9 Dinner Meetings in 2012: Opportunities to receive Free Florida Mandated Courses.

Representation in Legislature: ECMS has members actively participating in the FMA and AMA. Such topics include: Managed care legislation, PRN sovereign Immunity, Mandatory malpractice, tort reform, and grass roots efforts. ECMS gives our physicians’ updates through our newsletters, email, and faxes.

Malpractice Insurance Discount: FPIC gives ECMS members a 5% discount. In addition, FPIC’s claims-free program currently allows for the following discounts: 25% discount if claims-free for 15 years; 20% discount if claims-free for 10-14 years; 10% discount if claims-free for 5-9 years.

20% Discount on Pensacola Opera Tickets DocBookMD: ECMS providers are now listed on the ECMS iPhone and Android application.

Workers’ Compensation Insurance: Members can receive up to 24.8% return on insurance premiums with OptaComp.

CME: ECMS offers free CMEs to our members at many of our meetings.

Directory and Website: ECMS website and Member directory, which includes your office information and picture, as well as allows you to control the information and register for ECMS events. We also work with physicians to create and manage their own internet site.

Patient Referral: ECMS refers patients to our physicians daily.

Physician Information Service: ECMS has connections in Pensacola. The Society is pleased to research, ask, and retrieve information for you or your office personnel.

Vested Vendor Resource Guide: This is a guide offered to all members.

These vendors are financially and personally invested in the success of the practice of medicine. They support our CME events, dinners, special events and our Bulletin newsletter. Please make sure to call a supporter of ECMS. The Florida Healthcare Law Firm: At no charge members of the Escambia County Medical Society may call the hotline 561-306-5699 with questions regarding specific legal issues.

Crown Plaza: Mention “Medical Society” for a yearly discounted rate on you or your guest next stay.

Medical/Legal Pain Management Regulations Affect More Than Pain Management Specialists

by Linda A. Keen, MSN, JD, LHCRM

The recently passed House Bill 7095 affects more than just pain management specialists. Practitioners who prescribe controlled substances for individuals with “chronic nonmalignant pain” also are required to comply with new state regulations, including designation “as a controlled substance prescribing practitioner on the physician’s practitioner profile with the state Board of Medicine by January 1, 2012. What follows is a bulleted summary of the new regulations.

Prescriptions for controlled substances must be either written or electronic. Telephone prescriptions no longer are allowed.

Written Prescriptions for Controlled Substances

• Must have quantity in textual and numerical format

• Must be dated with the abbreviated month written out

• Must be written on a standardized counterfeit-proof prescription pad produced by a DOH approved vendor

Physicians who prescribe any controlled substance for the treatment of “chronic nonmalignant pain” must designate him or herself as a controlled substance prescribing physician on the physician’s practitioner profile and must comply with statutory requirements and applicable board rules.

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• “Chronic nonmalignant pain” is defined as pain unrelated to cancer or rheumatoid arthritis which persists beyond the usual course of disease or the injury that is the cause of the pain or more than 90 days after surgery.

A complete medical history and physical exam must be documented in the medical record.

The exact nature of the examination is not dictated, but it must be proportionate to the diagnosis that justifies treatment and must minimally document: m The pain’s nature and intensity

m Current and past treatment for pain

m Underlying or coexisting diseases or conditions

m The effect of the pain on physical and psychological functions

m A review of previous medical records and previous diagnostic

studies m History of alcohol and substance abuse

• Notably, patients with such a history require referral to, or consultation with, a phsyiatrist or addictionologist m The presence of one or more recognized indications for the use of

a controlled substance

A written individualized treatment plan must be documented and include at a minimum: m Objectives to determine treatment success, such as pain relief

and improved physical and psychosocial function

m Indication of further planned diagnostic evaluations or other treatments m After treatment begins, adjustment of drug therapy to the

individual’s medical needs

m Consideration of other treatment modalities, including rehabilitation, depending on the etiology and extent to which pain is associated with physical and psychosocial impairment

m Use of an interdisciplinary approach to the pain

Risks and benefits of the uses of controlled substances must be discussed with the patient, persons designated by the patient, or the patient’s surrogate or guardian, if the patient is incompetent and must include:

m Risks of abuse and addiction

m Physical dependence and its consequences

m Although not specifically required by law, a written and signed consent should be obtained

The physician must enter into a written controlled substance agreement outlining the patient’s responsibilities and include at least the following: m Number and frequency of controlled substance prescriptions and

refills m Patient compliance expectations

m Reasons why drug therapy may be discontinued

m Controlled substances for the treatment of the patient’s chronic Continued on next page

Medical/Legal nonmalignant pain will be prescribed by a single treating physician unless the treating physician authorizes otherwise and documents it in the medical record

The patient must be seen at regular intervals, at least every 3 months to: m Assess the efficacy of treatment

m Ensure the controlled substance therapy remains indicated

m Evaluate the patient’s progress toward treatment objectives

m Consider adverse drug effects

m Review pain etiology

m Determine whether to continue or modify the therapy, based on the

evaluation and progress

m Reevaluate the appropriateness of continued treatment if treatment goals are not being achieved

m Monitor compliance in medication usage, related treatment plans, controlled substance agreements, and indication of substance abuse or diversion at a minimum of 3 month intervals

m Although not required by law, a notation that the treatment plan was reviewed and updated as necessary is recommended

m Before writing a prescription for a controlled substance, a physician should ask the patient whether he or she is being prescribed controlled substances by another practitioner and it should be documented in the medical record

• If the physician doesn’t, and prescribes as well, the physician could be held complicit in prescribing medically unnecessary medication, in violation of Florida law

In order to achieve treatment objectives, the physician shall refer a patient as necessary for additional evaluation and treatment to achieve treatment objectives. m Special attention must be given to those at risk for misusing

medication or those with living arrangements that pose a risk for misuse or diversion

Patients with a history of substance abuse or a comorbid psychiatric disorder require referral to, or consultation with, a physiatrist or addictionologist.

Accurate, current, and complete medical records that are accessible and readily available must comply with law, and the physician’s applicable practice act and board rules. The record should include, at a minimum: o Medical history and physical, including history of drug abuse or dependence m Diagnostic, therapeutic, and laboratory results

m Evaluations and consultations

m Treatment objectives

m Discussion of risks and benefits

m Treatments

m Medications, including date, type, dosage, and quantity

prescribed. Instructions and agreements m Periodic reviews

m Results of any drug testing

m A photocopy of the patient’s government-issued photo ID

m If a written prescription of a controlled substance is given to a

patient, a duplicate of the prescription

m The physician’s LEGIBLE full name

m Although not required by law, the treatment plan, controlled substance agreement, and informed consent for treatment

document signed by the patient should be included in the medical record

Patients with signs or symptoms of substance abuse must be referred immediately to a board-certified pain management physician, an addiction medicine specialist, or a mental health addiction facility.

m While waiting for the consultant’s report, a prescribing physician must clearly and completely document justification for continued use of controlled substances and steps taken to ensure medically appropriate use of the medication

m On receipt of the consultant’s report, the consultant’s recommendations for controlled substance therapy should be incorporated into the treatment plan, documenting resulting changes in therapy

If a physician identifies evidence or behavioral indications of diversion, the controlled substance therapy must be discontinued and the patient must be discharged from care.

m Results of testing and all actions taken must be documented in the medical record

Physicians who dispense medications from their office may not dispense Schedule II or Schedule III controlled substances, unless:

m The drugs are complimentary and labeled as a drug sample or complimentary drug and are provided to the practitioner’s own patients in the regular course of medical practice without any kind of fee or remuneration m The controlled substance is dispensed in association with the

performance of a surgical procedure

• No greater than a 14 day supply can be dispensed, and only one 14 day supply per surgical procedure

• If a physician’s practice requires this to occur, the physician should research and follow applicable law and rules, as they are too involved to discuss here

The Department of Health has established an electronic database for those who dispense controlled substances and will provide advisory reports upon practitioner request.

m Prescribers will have access to database information relating to their patients if they want to review a patient’s controlled substance prescription history

The new law also affects pain management clinics, various pain management specialists, pharmacies, pharmacists and drug distributors.

This is a general overview of compliance requirements for general practice practitioners. Continued interpretation of the law and rule development is expected. Practitioners are encouraged to pay close attention to their licensure boards and medical society information as further interpretation and refinement occurs. Practitioners who must comply with the law should consult an attorney for guidance. A link to House Bill 2095 is attached. The reader is encouraged to read it in its entirety to assure compliance. http://www.flsenate.gov/Session/Bill/2011/7095/BillText/er/PDF Editors Note: Linda Keen is available to assist practitioners comply with the new pain management regulations. She also is interested in obtaining feedback from practitioners implementing the new regulations. Your feedback is welcome. Linda can be reached at lkeen850@ embarqmail.com

Medical/Legal How Should You Disclose a Medical Error? by the Risk Management Experts at First Professionals Insurance Company

Although most states require that a physician inform their patient in the event an adverse incident results in injury or serious harm, virtually all physicians consider it a moral and ethical duty. The legal requirements to disclose a medical error are often set forth by statutes and administrative codes governing professional licensing. Generally, such disclosure is a non-delegable duty and should be done, in person, by the physician. In many instances, the same statutes that require disclosure of medical error or outcomes of care that result in harm to a patient also serve to protect the disclosing physician to the extent that the disclosure itself may not later be used against the physician as an acknowledgment of an admission of liability, or introduced as evidence. Regardless, the manner in which an adverse event or medical error is disclosed is tantamount to claim avoidance.

Defining Medical Error

There are situations when it is difficult, if not imprudent, to differentiate an adverse event from a medical error and thus determine if the legal threshold to disclose has been met. In such instances it is best to seek legal or risk management guidance before notification is made to the patient. However, in most cases, defining a medical error becomes a legal, rather than medical issue. While some states do not define a medical error, they may have statutes which define a “medical injury”. The following statutory language is an example of one state’s rather expansive definition of what constitutes a medical injury:

“…any adverse consequences arising out of or sustained in the course of the professional services being rendered by a medical care provider, whether resulting from negligence, error, or omission in the performance of such services; or in breach of warranty or in violation of contract; or from failure to diagnose; or from premature abandonment of a patient or of a course of treatment; or from failure to properly maintain equipment or appliances necessary to the rendition of such services; or otherwise arising out of or sustained in the course of such services.”

An unanticipated outcome may be an omission as well as a commission. The most common cause of an unanticipated outcome is the known, but low probability, adverse event.

Failure to Disclose Medical Error

There may, however, be barriers to disclosure. Financial, psychological and cultural barriers are examples of why disclosure of medical error has been withheld. The pre-mature assignment or assumption of blame and risk of a failed response are prevalent root causes for failing to inform or timely disclose an untoward event to patients. Ethical and legal requirements notwithstanding, patients are far more likely to seek legal action following an adverse event or unanticipated outcome when disclosure is not made or made incorrectly.

How to Disclose Medical Error

Disclosure of a medical error or unanticipated outcome is an uncomfortable situation to be sure. To avoid compounding the situation, adhere to the essential components of disclosure: 1. Timely 2. Proper Setting 3. Accurate 4. Factual 5. Responsive 6. Document

An admission of liability is never required as means of disclosure.

Before disclosure is made to the patient or patient’s family members, try to obtain as much factual information pertaining to the error or outcome as possible. Seek legal or risk management guidance. Communicate in a manner that is open, forthright and expresses empathy. Do not seek to lay blame nor make excuses. Make it known should information or details be unknown at the time of disclosure. Indicate what steps will be taken to obtain such information. Invite questions and seek answers. Remain responsive to the emotional needs of the patient or family member.

Documenting Disclosure

Carefully document the disclosure. Chart the time, date and place as well as the individuals present. Note the information conveyed, including the known facts, condition and treatment of the patient. Document your discussion of the immediate and long term effects or prognosis, if known. Delineate the current and future clinical interventions. The records should clearly reflect what questions were posed and what the responses were, offers of assistance, if any, as well as the treatment plan agreed upon including consultations. Document the agreement (or refusal) for subsequent meetings, the reason for any incomplete disclosure and what follow-up is intended.

Any subsequent discussions should also be carefully documented.

The medical record should reflect the efforts that were made to accommodate the patient and family members as well as the information which was known, or unknown, predicating the extent of disclosure made. The motivation behind pursuing a claim or suit following an unanticipated outcome or medical error may ultimately come from someone other than the patient. Depending on the circumstances, the best risk management measure may be to increase your communication with the patient and the patient’s family members.

Risk Management Guidelines: • Comply with applicable legal requirements regarding disclosure • Do not delegate the duty of disclosure • Disclose adverse events and medical error in person to the patient or

family member • Do not assume or assign blame • Adhere to the essential components of disclosure: Timely, Proper

Setting, Accurate, Factual, Responsive, and Document • Ascertain as much factual information as possible before disclosure

is made • Communicate in a manner that is open, forthright and expresses empathy • Invite questions and seek answers • Remain responsive to the emotional needs of the patient or family member • Carefully document the disclosure • Document the measures undertaken to accommodate the patient • Seek legal or risk management guidance, when necessary

For more information regarding this and other medical professional liability insurance risk management issues, please contact the risk management consultants at First Professionals Insurance Company at (800) 741-3742, ext. 3016 or send an e-mail to rm@fpic.com.

Practice Management Hot Topics in Risk Management: What Physicians Need to Know

by Cliff Rapp, LHRM, Vice President Risk Management, First Professionals Insurance Company

Healthcare providers are faced with a paradox that the more medicine advances, the greater the potential for error. While all undesired outcomes cannot be eliminated even by extremely well-qualified providers, today’s legal climate necessitates that physicians are familiar with longstanding, current, and evolving risk management practices.

There are a number of risk management issues which require a heightened awareness. These include the use of physician extenders and hospitalists and issues regarding internet defamation, patient identity

patients that are unaware or who do not understand the hospitalist model.

The hospitalist has a responsibility to notify the patient’s PCP of the diagnosis, clinical status, discharge plan and any necessary follow-up. To ensure an adequate exchange of clinical information, the PCP and hospitalist should maintain open dialogue and agree upon a “game plan” of periodic updates.

With a modicum of risk management effort, prevalent liability issues entailing a hospitalist model can be minimized. As is the case with most

theft, and regulatory requirements.

Physician Extenders

The number of physicians who support the use of physician extenders continues to escalate. Physician extenders can provide several benefits, including faster patient access to care, and increased physician time and focus. However, along with the increasing use of physician extenders is the spiraling frequency and severity of medical malpractice claims against physicians who are being exposed to the acts of physician extenders.

Malpractice claims attributed to PEs can often be traced to clinical and administrative factors that are easily identified and remedied. Consequently, there are precautions and assurances that the employing physicians should initiate. Determine that your PEs are not providing services beyond their capabilities or the scope of their licensing. Monitoring enables detection of misdiagnoses, delays in diagnoses, improper orders, or any other issues requiring attention. Physician extenders are the agents of their employers—their acts reflect directly upon the supervising physician.

Although the practical benefits of utilizing PEs are numerous, myriad legal doctrines hold the physician responsible for the acts and omissions of such employees. Implementing effective risk management measures will help ensure that the benefit of using physician extenders in your practice is not at the expense of increased liability exposure and malpractice claim development.

Hospitalists

Hospitalists have evolved into a medical specialty that is growing both in number and sophistication and is a rapidly increasing option for primary care physicians (PCP) and their patients. Hospitalists are beneficial because they specialize in inpatient care and treatment. They are very familiar with the workings of the hospitals and the staff who work there.

From a liability standpoint, inpatient and outpatient care inherent to the hospitalist model presents the greatest challenge, both in terms of continued erosion in the physician-patient relationship and the incidence of medical malpractice claims. While there are many types of hospitalist models, none possess a distinct risk management advantage over another.

The primary cause of claims related to hospitalists result from communication breakdowns and failure to follow up. Discontinuity of care encompasses such risks as abandonment, allegations of negligent referral, and patients lost to follow-up. However, perhaps the greatest risk is that of

loss prevention measures, effective communication remains the chief caveat.

Physician Internet Defamation

There has been explosive growth of anonymous doctor rating sites available on the Internet with “hits” that number in the millions. These sites provide patients with the ability to post false and defamatory statements alleging physician negligence. Negative postings present potential risks to the professional reputations of doctors and their practices.

Currently, libel cases are difficult to resolve. Patient confidentiality laws and federal immunity laws granted to Internet Service Providers (ISP) limit the options for recourse, increasing the difficulty and expense.

On rating sites, patients, or people posing as patients – such as disgruntled employees, ex-spouses, and even competitors can damage a hard-earned reputation. In most instances, a doctor has little recourse. As an arcane nuance of cyberlaw, the websites are immune from accountability (Section 230 of the Communication Decency Act). Some sites have taken the position that they will not monitor or police such content.

As a physician, one of your most valuable assets is your reputation. Anonymous web postings by disgruntled patients can threaten your good name and practice. Most medical practices are built through word of mouth. It only takes one negative Internet posting to impact your livelihood.

Patient Identity Theft

Cases of patient identity theft continue to substantially increase every year. It is critical that all medical professionals acknowledge the emerging risk associated with this dilemma. Physician offices, clinics and hospitals are all prey to the possibility of compromising personal health information (PHI).

The PHI stolen from a medical office can be used to obtain credit cards, drain bank accounts, falsely bill Medicare and make e-transactions – globally. Physicians with sophisticated encrypted electronic files are no less vulnerable.

Every physician needs to be aware of the Federal Trade Commission’s “Red Flags” Rule (Rule) pertaining to patient identity theft protection standards. For purposes of the Rule, a “red flag” is a pattern, practice or specific activity indicating the possibility of identity theft. The Rule requires “financial institutions” and “creditors” holding consumer or other “covered” accounts to develop and implement an identity theft rule. Individual physicians, physician groups, hospitals and other healthcare orgaContinued on next page

Practice Management nizations fall under the FTC’s definition of a creditor because they generally do not collect payment at the time a service is rendered and often hold off billing patients in full.

Implementing a written identity theft prevention program is a requirement of the Rule. The program must detect, prevent and mitigate identity theft.

Noncompliance is subject to monetary penalties and civil litigation.

The FTC identified December 31, 2010 as the starting date for enforcement after several previously announced delays. However, pending the outcome of a U.S. District Court of Appeals case, physicians are currently exempted. First Professionals will provide updates regarding the Rule to our policyholders as they become available.

Florida Practitioner Profiles

Florida physicians are required by the Department of Health to update any change that is made to the following: • education & training

Benefits of Risk Management Protection

Although today’s legal and regulatory climate continues to present additional challenges to doctors, many cases can be prevented or reduced by simply utilizing risk reduction strategies and tools. To reduce the frequency of claims, exceptional risk management services are essential for any medical practice. The risk management benefits provided by FPIC are unmatched in the industry and are available at no additional cost to its policyholders.

For over 35 years, FPIC has maintained a commitment to protect you, your patients, your reputation and the assets you have worked so hard to accumulate. We are confident that the products and services we provide are superior to those offered by other medical professional liability insurance companies.

For more information, please visit the Risk Management link of our website located at www.firstprofessionals.com. You can also discuss any

• • • • • •

of these services directly with a risk management representative via e-mail at rm@fpic.com or by phone at (800) 741-3742, extension 3016.

current practice & mailing addresses staff privileges & faculty appointments financial responsibility legal actions BOM final disciplinary action within previous 10-years liability claims which exceed $100,000 ($5,000 for podiatrists) Physicians who do not comply with this requirement are subject to fines, penalties, and disciplinary action.

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Practice Management Case Study: Liability Attributed to Physician Extender Editor’s Note: This case study analysis reflects an actual FPIC case.

Case Analysis

A 53-year-old female underwent laparoscopic cholecystectomy without incident. The surgeon saw the patient three days post-op, noting she was doing well and without complaints other than the expected incisional pain. The patient was next seen five days post-op by the surgeon’s physician assistant (PA) who noted an infection at the umbilical surgical wound.

A culture was obtained (which later proved to be Klebsiella) and patient was started on the antibiotic Levaquin. The patient returned four days later and was re-evaluated by the surgeon who noted that the wound still looked infected with the presence of drainage. Cellulitis was diagnosed and instructions given to continue the Levaquin and return if needed. A week later the patient returned and was seen by the PA. She complained of nausea, vomiting, diarrhea and a temperature of 103. Although the PA noted that the wound still appeared infected, because the abdomen was non-tender and no masses were felt, he diagnosed “superficial wound infection” and “gastroenteritis”. The PA instructed the patient to continue the Levaquin and prescribed Phenergan for nausea and vomiting. Three days later the patient was admitted through the ER with an acute abdomen. She underwent exploratory surgery, was diagnosed with an intrahepatic abscess and developed disseminated intravascular coagulation (DIC). The patient continued to deteriorate until her expiration several days later.

Suit was filed against the surgeon, the PA and the medical practice alleging failure to diagnose and treat the intrahepatic abscess. Defense experts could not support the PA’s failure to properly assess the patient when she presented with obvious clinical signs of infection. The PA was criticized for failing to consult with the physician. The surgeon, having signed off on the PA’s medical management, was held vicariously liable for the acts of the PA and directly liable for his inadequate supervision of the PA. Settlement of the case was necessitated for the surgeon’s direct negligence and his vicarious liability for the PA, for the practice, for the negligence of the PA, and for the PA. Risk Management Discussion

Frequently, claims involving post-operative complications involve known risks. Early recognition and appropriate case management are key factors in reducing a physician’s exposure in these situations. Consider the following loss prevention measures in order to help reduce errors and deter lawsuits and preserve defenses necessary to defeat the unavoidable claims: • Utilize informed consent • Re-evaluate post-op patients prior to discharge • Obtain all outstanding labs and diagnostic studies prior to discharge • Document the absence of clinical indications of complications • Schedule prompt follow-up appointments • Document no-shows or cancellations • Provide written post-op instructions, outlining the expected side

effects and the unanticipated signs and symptoms that should be reported • Give high priority to post-op patient complaints.

If a complication develops, consider the following steps: • Inform the patient – express empathy • Document your medical rationale • Increase communication • Seek legal or risk management guidance This information does not establish a standard of care, nor is it a substitute for legal advice. The information and suggestions contained here are generalized and may not apply to all practice situations. First Professionals recommends you obtain legal advice from a qualified attorney for a more specific application to your practice. This information should be used as a reference guide only.

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InThe Community Hospital News Sacred Heart News

Baptist Healthcare

Outstanding Pediatric Surgeon Receives Prestigious Award

Baptist Medical Group Welcomes Dr. Edwin Rogers as CMO

Dr. Jimmy Jones, a retired pediatric surgeon with Nemours Children’s

Baptist Medical Group, Baptist Health Care’s employed physician

Clinic and Sacred Heart Children’s Hospital, was recently recognized as

network, announced that Dr. Edwin Rogers, a longtime member of their

an outstanding children’s surgeon in the state of Florida by the Children’s

medical staff, has been named Chief Medical Officer (CMO). For the last

Medical Services (CMS.) Dr. Jones was honored with the Philip O. Licht-

30 years, Dr. Rogers has served the greater Pensacola community as an

bau Award, which is given annually by The Florida Pediatric Society to a

experienced cardiologist with Cardiology Consultants, an affiliate of Bap-

children’s surgeon who has contributed significantly either regionally or

tist Health Care. The CMO position is newly created in response to physi-

statewide to the CMS program.

cian feedback and continued growth of the medical group, now com-

prised of over 100 primary care and specialist physicians. Learn more at

“Dr. Jones has spent the past 45 years as an advocate on behalf of

the children of our region and has committed his time and energy to the

BaptistMedicalGroup.org.

cause of children’s healthcare,” said Laura S. Kaiser, CEO and president of Sacred Heart Health System. “We are so honored and grateful for all of

Comprehensive Care for Arrhythmias Available at the New Baptist

the contributions he has made to Sacred Heart and Northwest Florida.”

Heart Rhythm Center

Dr. Jones was the first pediatric surgeon at Sacred Heart Children’s

BHC and Cardiology Consultants are proud to introduce the Heart

Hospital and served as the only pediatric surgeon in the entire Panhandle

Rhythm Center, the region’s best heart center focused exclusively on the

for 35 years. He is currently the assistant medical director at Nemours

diagnosis and treatment of complex heart rhythm disorders – known as

Children’s Clinic. He is active in civic affairs and currently serves on the

arrhythmias. Led by an expert team of board-certified electrophysiolo-

Board of the Community Maritime Park.

gists, the Heart Rhythm Center offers the most comprehensive, compassionate treatment program in the region. Learn more at eBaptistHealthCare.org/HeartRhythm or call 850.444.1717.

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MECOP Reminder

11th Annual Best Clinical Practice Symposium Saturday, January 14, 2012 Sacred Heart Greenhut Auditorium 7am-4pm Contact: Jenna Coleman 850-477-4956 ext 1 Or email homestudy@mecop.org

Member Benefit: The Health Care Attorney On Call Hotline (561) 306-5699 View and opinions expressed in the Bulletin are those of the authors and are not necessarily those of the board of directors, staff or advertisers. The editorial staff reserves the right to edit or reject any submission.

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