business of Medicine
Onboarding Medical Assistants and Office Staff Toolkit
Communication in the Medical Office
The telephone, while an essential tool of communication, can also be a dangerous one. Often, staff members are pressured by patients to answer questions such as, “Can’t you tell me how to reduce the swelling in my arm by myself?” when the patient does not want to schedule an appointment. Staff should be instructed not to give medical advice or information that could be construed as medical advice over the telephone. An appropriate response would be, “I am not a doctor and cannot give you medical advice. For the physician to make an accurate diagnosis and prescribe the appropriate treatment, it would be best for you to come into the office to be seen.”
Written guidelines detailing what type of advice staff members can give over the telephone should be developed.
These guidelines should be placed in the policy and procedure manual as a resource for staff and updated as necessary.
Providing interpreters for hearing impaired and limited english proficient patients
Physicians treating patients who have hearing impairments or who are limited in their Proficiency with the English language may be responsible for providing interpreters for such patients in the medical office at no cost to the patients. These requirements often surprise physicians who note that the cost of an interpreter may exceed the amount billed to the patient for the office visit. Whether a patient is entitled to an interpreter under these requirements, or whether other means of communication will be appropriate, is heavily fact dependent.
This article will briefly analyze communication requirements that apply to physicians treating deaf or hearing impaired and Limited English Proficient ("LEP") persons.
Deaf or Hearing Impaired Patients
Section 504 of The Rehabilitation Act of 1973, implemented by the Department of Health and Human Services ("HHS"), applies to all physicians who receive federal financial assistance and have 15 or more employees. Section 504 requires physicians to provide free auxiliary aids and services, including interpreters, notes, other written materials, and telecommunication devices if necessary for effective communication with their deaf or hearing impaired patients (and their companions). The requirements of Section 504 are more onerous than the ADA's requirements. Unlike the ADA, Section 504 has no "undue burden" exception. Therefore, physicians are required to provide the appropriate free auxiliary aid or service to patients and their companions even if the cost of the aid or service exceeds the payment the physician will receive for treatment.
If physicians or employees recognize or have any reason to believe a patient, relative, or companion of a patient is deaf or hearing impaired, the physician must inform the patient that appropriate auxiliary aids and services will be provided, free of charge, when necessary for effective communication. The physician must inform the deaf or hearing impaired patient that free auxiliary aids and services are available even if the patient does not request any aid.
When a patient is not deaf or hearing impaired, auxiliary aids and services still have to be provided, when necessary for effective communication, if the patient's companion is deaf or hearing impaired. HHS defines a companion as: 1) a person whom the patient indicates should communicate with the physician about the patient, participate in any treatment decision, play a role in communicating the patient's needs, condition, history or symptoms to the physician, or help the patient act on the information, advice, or instructions provided by the physician; 2) a person legally authorized to make health care decisions on behalf of the patient; or 3) another person the physician would ordinarily and regularly communicate with concerning the patient's medical condition. The physician must consult with the patient to determine the most appropriate auxiliary aid or service to use. This communication assessment should be done during the first appointment or when the physician becomes aware that the patient or companion is deaf or hearing impaired. HHS guidelines state that the following should be considered when determining the appropriate auxiliary aid or service, if any: 1) the nature, length and importance of the communication at issue; 2) the individual's communication skills and knowledge; 3) the patient's health status or changes thereto; 4) the patient's and/or companion's preference or stated need for an interpreter; and 5) the reasonably foreseeable health care activities of the patient. With routine office matters, a pen and notepad may suffice. With more complex matters, use of a qualified interpreter may be required.
Physicians may contract with interpreters from outside interpreter services, hire staff members capable of interpreting for deaf or hearing impaired patients and companions, or utilize friends and family of the patient. However, a family member or friend may provide interpretive assistance only if the patient or companion agrees in writing to the use of that person and use of that person is appropriate under the circumstances, giving consideration to the patient's privacy issues. HHS regulations do allow for interpreting by family members and friends in time-sensitive, life-threatening or medically urgent situations.
It is very important to document all discussions with patients or companions regarding auxiliary aids and services. If an auxiliary aid or service is provided, make a note in the patient's chart. Most importantly, if, after a communication assessment is performed, the physician determines that auxiliary aids and services are not needed for effective communication, document in the patient's chart the reasons why the auxiliary aid or service is being denied.
It is clear that engaging in communication with deaf or hearing impaired patients can be accomplished in more than one way. The challenge is finding the most effective method of communicating with the patient considering all circumstances involved. HHS requires a lot from physicians who treat deaf or hearing impaired patients. However, physicians can comply more easily with the law by having set policy and procedures that they use consistently with each deaf or hearing impaired patient.
Limited English Proficient (LEP) Patients
In August 2003, HHS issued to physicians and other recipients of HHS funding revised Guidance regarding Title VI of the Civil Rights Act of 1964 and the prohibition against national origin discrimination affecting LEP persons. HHS intended the Guidance to be an analytical framework for physicians and other recipients of HHS funding to use when determining how best to comply with statutory and regulatory obligations to provide language services to LEP persons.
The first question most physicians ask is whether the requirements set forth in this HHS Guidance apply to them. The requirements apply to any person receiving funds from HHS, including physicians who participate in Medicare Part A, those who participate in federally funded clinical trials and certain other patient categories.
Physicians enrolled only in Medicare Part B and who do not otherwise receive federal funds would not be subject to these LEP requirements.
The Guidance notes that persons who do not speak English as their primary language and who have a limited ability to read, write, speak or understand English may be LEP persons and may be eligible to receive language assistance with respect to a medical office visit.
How do physicians determine the extent of their responsibilities to LEP persons? HHS suggests physicians conduct an LEP assessment of their practice, to determine: (1) How many LEP patients they are likely to see; (2) How often they are likely to see LEP patients; (3) The importance and urgency of the medical care that is typically provided to their patients; and (4) The resources available to the medical office to pay for various language assistance programs.
Some physicians may see so few LEP patients in a year that a language assistance program would not be required. There is apparently no magic number of LEP patients that triggers the obligation to provide language assistance, but generally speaking, the more LEP patients a physician is likely to see, the greater the physician’s obligation in this regard. If application of the four-factor test indicates that the physician must provide interpretation services, then the physician should advise the LEP patient that he or she has the option of having an interpreter provided at no charge, or of using his or her own interpreter. According to HHS, the physician would be obligated to pay for interpretation services even if the bill for those services exceeds the amount the physician will receive for rendering medical services to the LEP patient. Physicians may meet their obligations by employing bilingual staff, by contracting with interpreters to perform services either live or by telephone, by using community volunteers and by having certain vital documents (e.g., consent forms) translated into other languages. Reliance on family members or friends as interpreters at the patient’s request is permitted, but generally discouraged by HHS except in cases of emergency, because it can be difficult to determine the informal interpreter’s competence and the factual circumstances at issue may make it inappropriate for someone close to the patient to be involved (e.g., child abuse or sexual assault). Physicians generally cannot require LEP persons to use family or friends as interpreters. Translation of written documents (e.g., consent forms) from English to another language may be appropriate in certain cases as well.
With regard to LEP compliance, the first thing a physician should do is to complete the four-factor test discussed above. If the answers to that test suggest the physician would be required to develop a language-assistance plan, the next task would be for the physician to develop a workable plan that includes the following five steps recommended by HHS: (1) Set forth procedures to identify LEP persons who need language assistance; (2) Have a mechanism for identifying possible language assistance measures for an LEP patient, i.e., how staff can obtain services or respond to LEP callers; (3) Train staff; (4) Notify LEP persons of available LEP services, e.g., posting signs in the office; and (5) Monitor and update the LEP plan as necessary.
It is clear from the Guidance that no one-size-fits-all strategy applies. Whether physicians have an obligation to provide language services to LEP persons and what language services would be required are highly dependent upon the facts. The language services required of a small-town solo physician where virtually none of the population speaks a language other than English would be different from a solo physician in a county that is heavily populated by immigrants who speak little or no English. Similarly, language services required to be employed by a solo family physician in a metropolitan area would likely be different from those required of a large multi-specialty clinic in the same area.
Americans with Disabilities Act
The Americans with Disabilities Act (ADA) was enacted in 1990 and is one of the nation’s most comprehensive civil rights statutes.
The basic requirements of this new law are simple to state. Private practitioners now have legal obligations:
- To accept patients with disabilities for treatment
- To provide “auxiliary aids” when necessary for effective communication with patients with disabilities
- To make medical facilities physically accessible and usable by patients with disabilities if this is readily achievable
The ADA protects individuals with disabilities and those who have recovered from a disability, such as recovered cancer patients or stroke victims. It also protects individuals who are not actually disabled, but who have been discriminated against because they are “regarded as” having a disability, such as persons with facial deformities or persons who are HIV positive but have not developed AIDS symptoms.
Under Title II of the ADA, “A physician may not discriminate in providing services to individuals with disabilities. A physician may not refuse to treat a patient, nor refuse to accept a new patient, because of the patient’s disability.”
“A physician cannot lawfully refuse to treat a patient who is mentally retarded or whose speech impairment makes communication more time-consuming. A physician can, however, refer a patient whose disability itself creates special complications outside the physician’s experience or knowledge.”
The ADA also requires that physicians provide patients with “auxiliary aids and services” to enable a patient with a disability to benefit from the services of the office. This obligation can be as uncomplicated as providing additional assistance to a patient who has difficulty disrobing and dressing. It may also encompass, however, provision of auxiliary aids such as qualified interpreters, note-taking, brailed materials and other aids in order for the patient to communicate effectively with medical personnel at the office.
The information for this article was from the National Center for Law and Deafness. For more information, call the office of the Americans with Disabilities Act, U. S. Department of Justice, 202 514 0301 or (TDD) 202 514 0381; in Georgia call (Voice) 404 657 7313, (TDD) 404 657 9993.
The Joint Commission states that miscommunication is one of the most common root causes of adverse patient events in the physicians' office setting. While telephone encounters are an integral part of managing patients, without protocols and staff training, serious risks exist. Serious incidents have occurred in which non-clinical personnel answered patients' questions, and were alleged to have given medical advice without training or protocol, (i.e., allegedly "practicing medicine without a license"). There are many telephone scenarios that can lead to serious preventable incidents.
We believe that well-developed protocols can guide office personnel to provide efficient work flow, safe patient advice, and appropriately transfer calls to the proper provider. Additionally, we recommend that all clinical practices develop policies for responding to telephone inquiries for information, medical advice, diagnosis, including maintaining a log of all calls, and documenting telephone communications in the medical record.
Some tips for medical practices related to telephone communications:
- Establish parameters for symptoms necessitating a return call by the physician or provider or necessitating the patient to be seen in person.
- Require physicians to sign off on all protocols before they are implemented.
- Periodically review the protocols and maintain copies of any that are revised or discontinued.
- Use a standardized format to facilitate thorough documentation of all telephone calls, to include notation of the advice provided, and disposition of the call and the signature of the person taking the call. Complete documentation should be added to the patient's file.
MagMutual Risk Management and Patient Safety Consultants invite our policyholders’ questions. If you wish to discuss issues related to this article, or have other questions please call us at 1-800-282-4882, and ask for Risk Management.
CME Course ECRI - Administration in the Physician Office, Part 1: Communication-Based Risks available at www.ecri.org
Article ECRI Institute. (September, 2013). Managing Risks in the Physician's Practice: Supplement A: Outpatient Settings 2. Healthcare Risk Control Risk Analysis available at www.ecri.org
Learning Module Telephone Communications: A Risk Management Overview available in the learning center.
Call coverage guidelines for physicians
Receiving phone calls at all hours of the night covering for several physicians at a time while not being familiar with their patients, not being familiar with the nursing staff, and having to go into the hospital to examine patients, are not only some of the inconveniences of being on call but create liability exposures for all on-call physicians.
Consider the following call coverage guidelines:
- The covering physician should be in your same specialty or competent in your particular area of medicine.
- Backup consultants should be available.
- Hospitalized patients should know about covering physicians, and the length of time they will be covering.
- Verify the covering physician's hospital privileges, the procedures for which he/she has been credentialed and his/her familiarity with hospital routines.
- Use a good “Hand-Off” procedure:
- Review hospitalized patients' current status and any problems with the covering physician.
- Caution the covering physician against prescribing or refilling medication over the telephone. If refills are necessary, request the covering physician prescribe only enough medication to last until your return.
- Provide the covering physician with a list of your office patients who may call and require attention.
- Upon your return, discuss with the covering physician any changes in condition, therapies or special situations, etc.
Other suggestions for decreasing your on-call risks:
- Institute a "Sign-Off" system whereby you can be aware of the status of hospitalized patients or those in the delivery room.
- Ensure that you are able to reach the hospital in a reasonable amount of time.
- Understand the high potential for miscommunication when relying upon phone communications with hospital employees.
- Know the hospital staff and the call system; this is as important as knowing your on-call patients.
- Once you’ve given telephone orders, review them with the nursing staff. Make sure the nurse reads back your orders precisely before hanging up, especially if it is in the middle of the night.
- Review all on-call orders; yours, your partner's, and/or your mid level provider's, when making rounds in the morning.
When you receive a call about a patient with whom you are not familiar, ask multiple questions about the patient, the reason for their hospitalization, their current condition, and any labs before giving an order for that patient. Even aspirin or a stool softener may not always be appropriate. Continue to question the nurse until you are comfortable with your decisions. If there is a potential life threatening condition, or your inner medical voice tells you that the information you are receiving does not make sense, go see the patient. This single effort has saved many an unfortunate outcome. It gives you real time data to make a proper decision. Incidentally, most patients and family recognize the inconvenience and appreciate your efforts to help in the middle of night.
- The on-call physician has a duty to all patients assigned to his/her care during the on-call period.
- Take telephone calls from the nursing staff very seriously; ask extra questions needed to assure you of a patient's stability; take quick notes.
- If there is any doubt in your mind about the information you are receiving by phone, go examine the patient personally.
- Take on-call duty seriously.
A physician, sued for an incident occurring while he was taking call, once stated, “It is better to lose a few hours sleep one night than to lose hundreds of hours over the resolution of a lawsuit caused by not taking care of a potentially avoidable incident while on-call.”
Communicating lab and diagnostic report results to your patients
As a doctor it is your responsibility to communicate effectively with your patients, both during and in between appointments. Communicating lab results or diagnostic test results is crucial for effective patient care. It’s important that your medical practice or hospital has a clear policy for communicating these results in a timely manner.
If you’re having trouble contacting a patient concerning their lab or diagnostic results, MagMutual typically recommends contacting the patient on three separate, and timely occasions; twice with a phone call and message; and once with an e-mail or letter. Take care to document each of your attempts to contact the patient—noting time, date, and method of communication.
While this is a good general rule for practices to follow, each case needs to be considered separately. Depending on the specific circumstances (the patient’s condition, the nature of the test results, and the urgency of the situation, etc.), the contact methods and frequency should be reevaluated and adjusted.
The information provided in this resource does not constitute legal, medical or any other professional advice, nor does it establish a standard of care. This resource has been created as an aid to you in your practice. The ultimate decision on how to use the information provided rests solely with you, the PolicyOwner.