Comanagement of Ophthalmic Patients 060107 by 5SxAc56H

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									Comanagement of Ophthalmic Patients
Anne M. Menke, R.N., Ph.D.
OMIC Risk Manager

PURPOSE OF RISK MANAGEMENT RECOMMENDATIONS
OMIC regularly analyzes its claims experience to determine loss prevention measures that our
insured ophthalmologists can take to reduce the likelihood of professional liability lawsuits.
OMIC policyholders are not required to implement these risk management recommendations.
Rather, physicians should use their professional judgment in determining the applicability of a
given recommendation to their particular patients and practice situation. These loss prevention
documents may refer to clinical care guidelines such as the American Academy of
Ophthalmology’s Preferred Practice Patterns, peer-reviewed articles, or to federal or state laws
and regulations. However, our risk management recommendations do not constitute the
standard of care nor do they provide legal advice. If legal advice is desired or needed, an
attorney should be consulted. Information contained here is not intended to be a modification of
the terms and conditions of the OMIC professional and limited office premises liability insurance
policy. Please refer to the OMIC policy for these terms and conditions.
Version 6/1/07


Surgical malpractice lawsuits scrutinize all aspects of the care process, from indications
for surgery (preoperative evaluation and diagnosis), type of procedure planned (choice
of procedure, technique, implant, equipment), candidacy for surgery (coexisting ocular
and medical conditions, contraindications, known risk factors for complications and poor
outcomes), informed consent (disclosure and documentation of risks, benefits,
alternatives), performance of the procedure (technique, and recognition, management,
disclosure of complications), and postoperative care (discharge condition and
instructions, postoperative visits and telephone calls, recognition and management of
complications and poor outcomes).

While the surgeon is usually the main focus of a surgical malpractice case, the plaintiff
attorney often also names as defendants the surgical facility, members of the operative
team, and the surgeon’s staff. Ophthalmologists and optometrists who comanage can
expect to be added to this list. This document identifies the patient safety and liability
risks of the phases of surgical care, and offers risk management recommendations on
how to minimize those risks.

PATIENT SAFETY AND LIABILITY RISKS
 Negligent preoperative evaluation
        o Contraindications to procedure
           o Risk factors for complications or poor outcome
           o Unrealistic expectations
   Negligent performance of procedure
   Delay in diagnosis and treatment of complications
           o Failure to diagnose
           o Failure to refer
   Poor rapport
   Abandonment
   Negligent referral
   Vicarious liability for surgeon’s negligence
   Vicarious liability for comanager’s negligence

REASONS FOR COMANAGEMENT1
 Clinically appropriate and in patient’s best interest
 Surgeon’s unavailability
         o Travel, illness, leave, itinerant surgery in a rural area, surgery performed
              in a designated physician shortage area
 Patient cannot travel
         o Distance, development of another illness
 Not done as a matter of routine policy
 Not done for predominantly economic reasons
 Be prepared to explain your reasons to a jury

LEGAL ISSUES: SEEK LEGAL ADVICE
 Beware of kickback, fee-splitting, and referral prohibitions2
        o Check federal and state laws
        o Payment: ensure that all fees reflect an appropriate fair market value for
           the services performed and are billed separately
 Scope of practice issues1, 2, 3, 4,5
        o Verify state law
 Apparent partnership2,6
        o Appearance of business relationship created by:
                Profit sharing
                Using common letterhead, billing, advertising, business name,
                   office space, personnel, medical records
                Referring to each other as partners
                Seeing each other’s patients on a regular basis

CREDENTIALING OF SURGEON AND COMANAGER
 Licensure
 Education, training, and experience
 Scope of practice
 Current competency
 Professional liability insurance
 Willingness to develop and abide by protocol


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WRITTEN COMANAGEMENT PROTOCOL
 Patients eligible for comanagement
 Training, competency evaluation of comanager
 Indications and contraindications for surgery
 Informed consent for comanagement
         o Lists reason for comanagement
         o Surgeon has duty to obtain
         o Comanager acknowledges availability and agrees to provide reports to
             surgeon and notify of complications
         o Should be documented in record; may also use comanagement consent
             form
                  Informed consent required as condition of coverage for OMIC
                     policyholders. Such consent must be in writing if non-physician will
                     be providing postoperative care.
 Respective roles of comanager and surgeon in preoperative care
 Respective roles of comanager and surgeon in postoperative care
 Surgeon’s availability to patient during postoperative period
 Frequency, scope of postoperative visits
 Content of written reports to surgeon
 Signs and symptoms of complications
 Indications for consultation with/referral to surgeon
 Fees
 Preoperative evaluation7,8
         o Aspects that can be delegated to comanager
                  Data acquisition
                  Assistance in screening for contraindications
                  Education about proposed procedure
         o Aspects that are the exclusive duty of the surgeon
                  Candidacy for surgery
                          Independent evaluation based upon personal examination
                            and review of all pertinent tests
                               o Assessment of physiological, social, emotional and
                                   occupational needs of the patient
                               o Evaluation of clinical status
                  Treatment recommendations: choice of procedure
                  Informed consent
                          For procedure
                          For comanagement
         o Professional liability insurance aspects4,6,8
                  Comply with Underwriting requirements of your carrier
 Postoperative care3,4,5,8
         o Aspects that can be delegated to comanager
                  Follow-up care after surgeon has determined patient is stable1,3



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                        Pursuant to written comanagement protocol
                        Comanager sends report to surgeon of all care
                        Patient has access to surgeon during the postoperative
                         period at no additional cost
                             o Comply with coding and billing requirements of
                                  Medicare and other payers1
         o Aspects that are the duty of the surgeon
               Post-procedure discharge evaluation and instructions
               Postoperative assessment to determine that patient is stable for
                 comanagement
               Evaluation of reports from comanager (date, initial, file)
               Available to see patient at request of patient or comanager
         o Professional liability insurance aspects4,5,6,8
               Comply with Underwriting requirements of your carrier

REFERENCES
1. American Academy of Ophthalmology and American Society of Cataract and
   Refractive Surgeons. Ophthalmic Postoperative Care: A Joint Position Statement.
   February, 2000.
2. C. Gregory Tiemeier, JD, Lowering the Risks of Comanagement.
3. American Academy of Ophthalmology. An Ophthalmologist’s Duties Concerning
   Postoperative Care. Initial policy, September 1987; last revised and approved
   February, 2003.
4. OMIC. Postoperative Care Guidelines.
   http://www.omic.com/products/bus_products/postop_guidelines.rtf
5. OMIC. Postoperative Comanagement Selection.
   http://www.omic.com/products/bus_products/postopcomgmtselection.rtf
6. OMIC. A Guide to Apparent Partnership.
   http://www.omic.com/products/bus_products/announce/printVer.cfm?margin=yes&bo
   dy=_guide_part&pathmod=../../../
7. American Academy of Ophthalmology. Pretreatment Assessment: Responsibilities
   of the Ophthalmologist. Initial policy, February, 1988; last revised and approved
   February, 2003.
8. OMIC. Guide to Refractive Surgery Procedures.
   http://www.omic.com/products/bus_products/ref_guid.cfm#guide


OMIC policyholders who have additional questions or concerns about practice
changes are invited to call OMIC’s Risk Management Hotline for confidential
assistance at (800) 562-6642, extension 641.




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