R. Austin Wallace, MD
Chairman
David L. Rader
President
WV Mutual Insurance Company

Tips and Tactics

Our Tips and Tactics are a compilation of questions we receive and observations that are made during our office visits.

HIPAA Issues With Mobile Devices

The use of mobile technology (like PDAs and laptops) have many benefits. But with each benefit, new risks arise.The physician’s office should establish and document policies that address the use of mobile devices and the users' responsibilities, according to the National Institute of Standards and Technology (NIST), at www.nist.gov. The policy should cover:

  • approved uses,
  • software programs users can install,
  • proper storage for devices and associated modules,
  • proper password selection and use,
  • procedures for reporting a lost or stolen device, and
  • disciplinary actions that may result from misuse.

According to the NIST's recommendations about wireless security, organizations should also perform random audits to track whether devices have been lost or stolen.

Answers About Answering Machines

The HIPAA Privacy Rule does not prohibit covered entities from leaving messages for patients on their answering machines or with a family member. However, there are measures that will safeguard your patient's privacy. Some recommendations include:

  • Obtain written permission from the patient to leave messages on their answering machines, voice mails, or with a family member when they are not at home, and maintain this documentation as part of the patient’s record. See our Tools section for a sample communications consent form.
  • The patient’s medical record should document those persons, identified by the patient, who can receive information.
  • Never disclose patient information (including whether a patient has visited the office) to anyone who is not actively involved in the patient’s treatment.

The Phone: Friend or Foe?

The telephone is the most important communication tool in office practice and can be the most dangerous for causing communication failures. Many times a communication failure occurs simply because patients have expectations that aren't met. The following are recommendations that can help minimize communication failures.

  • There should be enough phone lines to accommodate the number of incoming phone calls.
  • The phone should be answered by the third ring.
  • If using choices in an automatic call distribution system, include as few as possible. A quick way to speak to someone in case of an emergency should be offered first in the call distribution sequence.
  • Give callers the option to speak to a person.
  • Greet the caller in a pleasant, friendly tone. Identify yourself and the name of your practice.
  • Speak to the person with the symptoms whenever possible.
  • Provide a timeframe for when follow up calls are made and ask the patient for their time preference.
  • Overall, try to avoid putting a patient on hold. Check on-hold calls every 30 seconds.
  • Remain pleasant, professional and neutral at all times.
  • Learn telephone techniques on how to diffuse an angry caller.
  • Test your system ... talk the talk.
  • Document telephone calls during and after hours when prescribing or changing a medication, directing treatment, or directing the patient to another provider or facility.
  • If your phone system allows patients to leave a message, be sure your patients know how often and when your staff retrieves the messages.

Creating a Credible Record

Juries who decide medical malpractice cases rarely include persons who have a medical background. Despite that fact, they often must decide cases that involve complex medical issues. The medical record can serve to establish or destroy credibility—a significant factor in deciding complex malpractice cases.

  • Never alter a medical record. Altered records immediately raise suspicion. Whatever your intentions are, this may look like a cover up.
  • Never remove documents from a medical record. Missing or incomplete medical records may suggest that you have something to hide.
  • The act of altering medical records may be considered evidence tampering and as such may remove the case from West Virginia Medical Professional Liability Act (MPLA) protections.
  • Work with medical and nursing staff to facilitate complete documentation in accordance with your practice guidelines for medical record keeping. Gaps in documentation often translate to neglect.
  • Avoid personal or judgmental comments. State the facts in a professional and respectful manner using appropriate medical terms. Unflattering terms used to describe the patient may be perceived as prejudicial. Unprofessional language or tone suggests less than professional care may have been rendered.
  • Write legibly! Illegible handwriting may suggest that care was hurried and/or sloppy. Further, illegible records may not be admissible in court.
  • Never use the medical record to document disputes between the professional staff regarding patient care.
  • Use only practice-approved forms to record medical information. Each page should include the patient’s name, birth date, and the patient record number, if used.
  • Observations, assessments and progress notes should be written or dictated as soon as possible after each patient encounter.
  • Ensure that charts are free of any alterations such as use of white out, black markers and erasures. Any text that requires editing can be made as long as the new text is initialed and dated.
  • If information in the chart needs to be corrected or supplemented, make the correction in a manner that allows the reader to see what information has been deleted or added, when, and by whom.

Dealing With Delays

Scheduling delays can be a significant factor impacting patient satisfaction, as well as a risk factor. Extended waiting times may be perceived by the patient that the physician places a low value on them, and a lawsuit may be more likely should treatment result in a bad outcome. Tips to reduce this risk exposure include:

  • When delays occur, inform patients how long they can expect to wait. Give them an opportunity to reschedule a routine visit.
  • If possible, call patients in advance if a long delay can be expected.
  • Keep a record of missed, rescheduled, or canceled appointments initiated by the physician or patient. This documentation can be helpful later.
  • Try not to overbook. If appointments run chronically late, cut down on the number of appointments scheduled.
  • Let patients know beforehand that the doctor could be called away on an emergency. Include this information in your practice brochure.
  • Establish procedures for unexpected visits or urgent problems. Never turn away a patient with an urgent problem because of scheduling difficulties without offering an alternative means of obtaining care (e.g., going to the Emergency Department).

Consider Collections Carefully

Billing and collection practices, whether handled by the physician’s office, corporate entity, or an outside contractor, must be carefully monitored. Aggressive pursuit of an unpaid bill may be appropriate in many instances. On the other hand, upsetting an already dissatisfied patient could provoke a lawsuit that will likely incur far greater costs in the long run.

  • The office manager and/or doctor should be notified upon receipt of any angry letters, phone calls, legal documents, or other indications that a patient is unhappy with a bill or services received.
  • Discuss high out-of-pocket expenses with the patient before treatment, and document these discussions. Do not send patients unexpectedly high bills.
  • Billing for treatment after an adverse event should be decided on an individual basis. The decision to bill or not to bill should be coordinated with any consulting physicians involved in the care of the patient.
  • Ensure that all collection letters are polite, and invite the patient to call to arrange a favorable payment schedule.
  • Require a chart review and physician approval before sending any bill to a collection agency or suing any patient.
  • Before initiating aggressive collection efforts, have the practice manager call the patient to ascertain the reason for an unpaid bill.
  • Monitor the activity of an outside collection agency. Never use an agency whose practices are too harsh or could be construed as abusive or threatening.
  • Never refuse to release a patient’s record or test results to another doctor because of an unpaid bill.
  • Never refuse to examine or treat a patient because of an unpaid bill. If you choose to discharge a patient from your practice based on unpaid bills, a specific procedure must be followed including sending the patient a termination letter. Please see our Tools section for a sample termination letter.

The Lessons of Listening

Communication, listening, and interpersonal skills of physicians are the catalysts for transforming ordinary patient care into effective patient care. Although listening to and communicating with patients are essential ingredients of effective patient care, patients do not always believe their physician exhibits these important skills. Most patients take for granted the technical expertise of their physician; however, what they tend to evaluate is the art of caring, or the human side of how care is delivered. Communication improvement techniques will not only improve rapport with patients, but will assist the physician in assessing, diagnosing, and treating the patient.

  • Spend a few extra minutes with each patient encounter. Studies have shown that the time spent with your patient can reduce communication failures leading to adverse outcomes that lead to claims.
  • Give the patient time to talk without interruption.
  • Offer facilitating remarks, such as, “What do you mean?” Ask for a description of what is happening.
  • Be reflective. “You said you have had this pain for two weeks now?”
  • Determine the patient’s expectations. Does the patient want a referral, a test or just reassurance?
  • Maintain good eye contact.
  • Probe the hint the patient drops. “Tell me more about this pain that is keeping you awake at night.”
  • Ask open-ended questions. “The pain is where?"
  • Check for accuracy. For example, review specific pertinent information such as the date of onset of pain, history, medications, weight, etc. with the patient.
  • And lastly before the patient leaves the exam room ask, “Is there anything else on your mind?”

Our Tips and Tactics for managing risk are offered as reference information only and are not intended to establish practice standards or serve as legal advice. West Virginia Mutual Insurance Company recommends you obtain a legal opinion from an attorney for any specific application to your practice.