15 minute read
Medical/Legal
Sue Boisvert, BSN, MHSA, Patient Safety Risk Manager II, The Doctors Company
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As efforts to connect patients and providers through telehealth have accelerated, enabling technology systems to communicate and exchange information has become increasingly important.
National Goals for Obtaining Interoperable Electronic Systems
In 2015, the Office of the National Coordinator for Health Information Technology (ONC) released a roadmap for advancing health information exchange and the interoperability of electronic systems. ONC’s interoperability roadmap includes three main goals:
1. 2015–2017: Send, receive, find and use priority data domains to improve health care quality and outcomes.
2. 2018–2020: Expand data sources and users in the interoperable health IT ecosystem to improve health and lower costs.
3. 2021–2024: Achieve nationwide interoperability to enable a learning health system, with the person at the center of a system that can continuously improve care, public health, and science through real-time data access.
Although these goals have not yet been definitively achieved, much progress has been made toward the first goal—the ability by providers and patients to view, download, and transmit health information. Given the challenges experienced in 2020, we are still working on the second goal’s expansion of the interoperable health IT ecosystem and now the third goal’s nationwide learning health system.
Telehealth’s Expansion
Telehealth is a perfect example of expanding data sources and users, but it adds several layers of complexity to the already difficult challenges of interoperability—getting computer devices to share information. The first important component would be interoperability between the provider’s computer and the patient’s, a connection that is usually accomplished through the use of a software application.
Before the pandemic, a single-source tool was most often used for enterprisewide telehealth due to strict privacy and security regulations. These regulations were relaxed during the 2020 pandemic, which led to the use of a patchwork of video communication applications, such as Skype, Zoom, and Facetime. The selection of the application was largely based on what practices and patients could manage.
It rapidly became clear that a singlesource solution for telehealth that would be interoperable with the electronic health record (EHR)—and perhaps even embedded in it—would be necessary to maintain telehealth visits on a large scale.
The benefits of an interoperable singlesource telehealth solution may include patient relationship management features such as scheduling, a private “waiting room,” and the ability for the provider to share screens with the patient while discussing diagnostic results and delivering education. Many of the major EHR vendors have the option of integrating a telehealth platform. Enterprise solutions often include technical support, an option or feature that can be very helpful when systems do not function as expected. When surveyed, providers reported that having the ability to easily view the EHR during a telehealth visit facilitates better care and rapport with the patient. In addition, the provider can easily create a visit summary and transmit it to the patient with any orders for diagnostic tests or referrals.
Some practices may not have the ability to integrate the telehealth solution into the EHR. The lack of interoperability may be on the side of the EHR or on the audio/video application used for telehealth. It may be possible to achieve an integrated system with an interface. Practices that are at this stage of decision making will want to consider the risks and benefits of all available options carefully by using a consultant or a structured decision-making process such as failure modes and effects analysis (FMEA).
Additional Considerations
In addition to interoperability of the telehealth solution with the EHR, we are faced with several other considerations.
Imaging files: In some cases, telehealth visits are recorded. The EHR may not be capable of storing large video files, and a physician practice that does not
already provide imaging services may not have access to a picture archive and communication system (PACS). The video file problem is not insurmountable, but it adds data storage and another security endpoint to manage.
Remote patient monitoring: Remote patient monitoring (RPM) has proved to be a valuable adjunct to telemedicine. RPM collects clinical information that is useful to the provider for managing remote care. RPM works well for patients with chronic disease, those who are being managed immediately after hospital discharge, and patients in a hospital-at-home environment. Interoperability of the RPM device with the telehealth or EHR system is a requirement for Medicare reimbursement. Workflow management: In the interim, workflows become even more important. If a disconnect exists between the patient visit and the record, providers may need more time to process the visit after the video interaction is complete. Documenting the visit in the record can be achieved by the provider in several different ways that include entering it directly, creating a separate telehealth note and incorporating it into the record, using speech recognition software for dictation, or using a scribe during the visit.
Care model: Regardless of whether your system is fully interoperable, the model of care delivery is important. During the pandemic, providers may have gotten used to working from home and may want to continue to do so, at least part time. Allocating a block of time for telehealth visits may facilitate a smoother experience for both providers and patients. Some providers may prefer not to practice telehealth and some providers may prefer to specialize in it. Flexibility is key.
For additional guidance, see our other telehealth resources and our on-demand education, Telemedicine to Telehealth: Trends and Emerging Risks, or contact the Department of Patient Safety and Risk Management at (800) 421-2368 or by email at www.thedoctors.com/contactUs/ patient-safety-risk-management-assistance/.
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Legal Checklist Important Topics to Review With Your Legal Advisor or Attorney Legal Checklist
Power of Attorney: the authority to act for another person in specified or all legal or financial matters. For a power of attorney to become a legally enforceable document, at a Important Topics to Review With Your Legal Advisor or Attorney minimum it must be signed and dated by the principal. Some jurisdictions also require that a power of attorney be witnessed, notarized, or both. Even when not required, having the document reviewed and signed (and often stamped) by a notary public may increase the likelihood of withstanding a legal challenge. A Power of Attorney is only valid during the life Power of Attorney: the authority to act for another person in specified or all legal or of the person giving the authority. financial matters. For a power of attorney to become a legally enforceable document, at a minimum it must be signed and dated by the principal. Some jurisdictions also require that a Living Will: an advanced healthcare directive, also known as a living will, personal directive, advanced directive, medical directive or advanced decision, is a legal document in power of attorney be witnessed, notarized, or both. Even when not required, having the which a person specifies what actions should be taken for their health if they are no longer document reviewed and signed (and often stamped) by a notary public may increase the able to make decisions for themselves because of illness or incapacity. likelihood of withstanding a legal challenge. A Power of Attorney is only valid during the life of the person giving the authority. Healthcare Proxy (HCP): is a document or legal instrument with which an individual appoints someone to legally make healthcare decisions on behalf of the patient, when the patient is incapable of making and executing the healthcare decisions stipulated in the proxy. Once the health care proxy is effective, the agent continues making healthcare decisions as long as the primary individual is legally incompetent to decide.Living Will: an advanced healthcare directive, also known as a living will, personal directive, advanced directive, medical directive or advanced decision, is a legal document in which a person specifies what actions should be taken for their health if they are no longer Guardian(s): a person who looks after and is legally responsible for the property of someone who is unable to manage their own affairs, usually an incompetent or disabled able to make decisions for themselves because of illness or incapacity. person or a minor child whose parents have died. An alternate guardian or successor guardian should be named in case the first appointed guardian is unable or unwilling to serve as guardian. A successor guardian usually has the same duties and powers as the previous guardian. Healthcare Proxy (HCP): is a document or legal instrument with which an individual Executor(s): (of an estate) is an individual appointed to administer the estate of a deceased person. The executor's main duty is to carry out the instructions to manage the affairs and appoints someone to legally make healthcare decisions on behalf of the patient, when the wishes of the deceased person's estate. The executor is appointed either by the testator of the will (the individual who makes the will) or by a court, in cases wherein there was no prior appointment. patient is incapable of making and executing the healthcare decisions stipulated in the proxy. Once the health care proxy is effective, the agent continues making healthcare decisions as long as the primary individual is legally incompetent to decide. Titling of Property: when executing updated and properly drafted wills and trusts you want to coordinate the titling of property so that it correlates with the objectives of your estate planning documents. This would address how real estate, marketable securities, checking/savings accounts and brokerage accounts should be held. If titled incorrectly, it could negate the purpose of the new testamentary documents.Guardian(s): a person who looks after and is legally responsible for the property of
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Credit Shelter Trust (CST): is designed to allow couples to reduce estate taxes when passing assets on to heirs, typically the couple's children. This type of irrevocable trust is structured so that upon the death of the trust's creator (or settler) the assets specified in the trust agreement and the income they generate are transferred to the settlor's spouse. However, a key benefit to this type of trust is that the surviving spouse maintains certain rights to the trust assets during the remainder of his or her lifetime. Under specific circumstances such as the need to fund certain medical or educational expenses, the surviving spouse can tap into the trust's principal and not just the income. Upon the surviving spouse's death, the trust's assets are transferred to the remaining beneficiaries without any estate taxes levied.
Insurance Trust: is either revocable or irrevocable and can be a tool for a family to solve some of their estate planning needs. The trust is both the owner and beneficiary of one or more life insurance policies. Upon the death of the insured, the trustee invests the insurance proceeds and administers the trust for one or more beneficiaries. If the trust is revocable the assets are part of the estate for tax purposes. If it is irrevocable the assets are not part of the estate for tax purposes.
Trustee(s): an individual person or member of a board given control or powers of administration of property in trust with a legal obligation to administer it solely for the purposes specified. A successor trustee is a person who assumes control of the trust after the initial trustee dies or becomes unable to continue with his or her responsibilities.
Portability: applies to the federal estate tax exemption between married couples and comes into play if the first spouse dies and the value of the estate does not require the use of all of the deceased spouse's federal exemption from estate taxes. The amount of the exemption that was not used for the deceased spouse's estate may be transferred to the surviving spouse's exemption so that he or she can use the deceased spouse's unused exemption plus his or her own exemption when the surviving spouse later dies
Special Bequests: a testamentary gift of a specific item of property (e.g., a Picasso painting) that can be easily identified and distinguished from all other property in the testator’s estate.
Common Disaster Clause: a provision in most life insurance policies (and some wills) under which the primary beneficiary of the policy (or will) must survive the insured by a certain number (usually 60 to 90) days to qualify to receive the policy’s (or will’s) benefits.
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•Financially, what are the differences in practicing in a private group vs. hospital Much like medical care, financial planning requires individual attention. To arrange a personal consultation with WealthMD, employee vs. independent contractor?please call 404-926-1312 or email svaron@wealthmd.com. You can be confident in your decision to work with us. •What accounts can I use to reduce my tax liability? Here are some questions to ask yourself: •Are there any tax benefits to incorporating as an independent contractor? •Will my tax filing status impact my student loan payment? We know you probably have plenty of questions for us. We are excited to help you with all of them! There are some questions, •What type of retirement plan should I set up to reduce my taxes? though, that you may not have thought of yet. The following are topics and questions that we regularly hear from our physician clients and are prepared to address with you. •What are the advantages of using a tax professional versus doing it myself?
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