practice of Medicine
Orthopedic Surgery Toolkit
Communication and the doctor-patient relationship
As reimbursement models shift away from fee-for-service, physicians and hospitals are being faced with the need to increase patient engagement and patient satisfaction. Patients want to become more active participants in their healthcare, but often there is no clear plan on how to engage them. Many physicians may be unsure of how to proceed. At MagMutual we know that improved communication between the physician and patient will help to eliminate the possibility of future claims. The MagMutual Patient Safety Institute’s analysis of five year closed claims data revealed 20% of our claims can be directly tied to a breakdown in communication.
In 2010 a national initiative began that allowed patients to access the doctor notes in their medical records began. 100 primary care doctors from three diverse medical institutions participated by sharing the medical records with the patient. The study, formally known as the “OpenNotes Project”, which took place over a 12-month period of time, demonstrated that patient care became more effective, communication was improved, and patients were more actively involved in their healthcare, despite concerns about making notes on challenging topics such as obesity, mental health, cancer, or substance abuse available.
The basis for this study comes from the idea that transparency can help promote better communication between patients and doctors. Sharing your notes with patients, whether during the appointment or afterwards, allows the patient to check the accuracy of the information you’ve collected, and gives patients the opportunity to understand your treatment rationale. Having access to your notes may also provide patients with clarification about their treatment plan, prescriptions, and health conditions.
Similar to the “OpenNotes Project”, patient portals in medical practices and hospitals can also increase communication between doctors and their patients. The patient portal may be particularly helpful to patients with chronic conditions, patients undergoing significant testing, self-monitoring and self reporting, patients receiving ongoing complicated treatment and/ or for those patients recovering from significant trauma.
In a study of over 5,000 patients who used the patient portal to read notes from their doctors, an overwhelming 77% to 87% reported feeling more in control of their healthcare. With the patient portal, patients can send messages to their doctors, request a service or book an appointment, obtain their health information, or submit information or data.
Some medical practices and hospitals find that there has been slow adoption of this resource. Making it easier for the patient to make appointments, review test results, message the staff, or access notes will be great incentives for the patients to come on board. Additionally, if the portal becomes an integral part of the medical practice’s or hospital’s workflow, the portal will be a valuable asset for both patients and staff members.
By opening the lines of communication, patients may feel more comfortable discussing certain issues with their doctor and will become more active in their own health management. The goal is to provide safer and more informed care.
Levy, MA, Gail. October 1, 2014 5 steps to maximize your patient portal and boost practice efficiency. http://medicaleconomics.modernmedicine.com/medical-economics/content/tag...
Peck, Andrea Downing. August 29, 2014. How to optimize your patient portal. http://medicaleconomics.modernmedicine.com/medical-economics/content/tag...
 Wen, Leana. August 17, 2014. When Patients Read What Their Doctors Write. http://www.npr.org/blogs/health/2014/08/14/340351393/when-patients-read-what-their-doctors-write; see alsowww.myopennotes.org.
 Ellis Jr., MD, FACP, George G. December 25, 2012. Patient portals help improve communication. http://medicaleconomics.modernmedicine.com/medical-economics/news/user-defined-tags/ehr/patient-portals-help-improve-communication ; citing Delbanco, T, et al. Inviting Patients to Read Their Doctors’ Notes: A Quasi-experimental Study and a Look Ahead. Annals of Internal Medicine 2012 October 4; 157(7): 461-470.
The importance of patient follow-up
Doctors are busy. They don’t have time to chase after patients and ensure they are taking their medications, getting the prescribed tests, and proceeding with the discussed treatment plan. With no show rates falling anywhere between 5 and 55 percent, doctors are struggling to get their patients in for appointments. When it comes to patient adherence and follow-up, who is responsible?
According to an article in the American Medical News, medical liability experts believe missed appointments and failures to follow up are a great legal risk for physicians. While experts work on systems to make follow-up more streamlined, we wanted to provide some actionable advice you could implement now.
- Make reminder calls – Patients are busy too, sometimes they need to be reminded about an appointment they made a few weeks back.
- Reduce wait times – This isn’t always an easy one. We understand that doctors need to spend as much time as necessary with a patient to get to a diagnosis and develop a treatment plan. But reduced wait times, often leave a better impression on the patients mind, making it more likely they will return for follow-up appointments
- Create a welcoming reception area – This may sound superficial, but if a patient has to spend more than 5 minutes waiting for their appointment to begin, it’s better they do so in an aesthetically pleasing environment. Again, this helps leave a better impression on the patient, making it more likely they will return.
Though the aforementioned tips may increase the likelihood that a patient will keep their appointment and come in for their follow-up, they won’t help in the event that patient doesn’t show. While there may not be an absolute solution for eliminating your liability risk in regards to patient follow-up there are a few things that are important to keep in mind.
- Documentation – Keeping thorough documentation of your emphasis on the importance of a follow-up test, or prescription and the patient’s understanding of that importance is something all experts agree can help protect physicians.
- Reasonable attempts to contact – If a patient misses an appointment or skips a recommended test, even if the doctor has documented the importance of said test or appointment, the doctor is not relieved of legal implications. You must make an effort to contact the patient and reschedule or reinforce the importance of the required test. Be sure to document each attempt to contact the patient and any explanation the patient may give.
With few hours in the day, many appointments scheduled, and numerous patients to see, the patient follow-ups may slip through the cracks. It’s important, however, to develop a system that works for you and your organization to ensure that they don’t. You can’t make a patient proceed with a treatment plan, follow up with tests, or take prescribed medication, but you should attempt to contact and thoroughly document those attempts in the interest of your patient and yourself.
Saboo, Alok. 2015, January 8. Best practices for improving care with patient follow-up. http://www.fiercehealthcare.com/node/124161/print
Lerner, M.D., Barron H. 2014, November 2. When Patients Don’t Follow Up. http://well.blogs.nytimes.com/2014/11/13/when-patients-dont-follow-up/?_r=0
Gallegos, Alicia. 2013, July 15. Medical Liability: Missed follow-ups a potent trigger of lawsuits. http://www.amednews.com/article/20130715/profession/130719980/2/
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.
Follow up and tracking
Follow up is the act of making contact with a patient at a later, specified date to check on treatment plan progress, to verify patient follow-through with referrals, and /or to monitor the patient’s health for other reasons. It is advisable that clinicians identify patients that would benefit from follow up and why in order to have a reliable follow up system.
Patients that may benefit from follow up vary according to the practice type. For example, a urology practice might track patients with elevated PSA levels; a gynecology practice would track patients with questionable pap smears. For providers attesting to EHR “Meaningful Use”, there are requirements for follow up care and preventive care. The certification criteria state: “Enable a use to electronically generate a patient reminder list for preventive or follow-up care according to patient preferences based on, at a minimum, the data elements included in: problem list, medication list, medication allergy list, demographics and laboratory test results.”
In order to reduce risks of a delay in diagnosis, consider the type of patients requiring follow up. Providers are advised to inform patients of the need for follow up, and document those discussions in the medical record. Patients have the responsibility to follow the agreed upon treatment plan and to return as advised for ongoing assessments of health, illness and treatment outcomes.
Implement a tracking system, electronic or paper, for patients who have been identified with a need to follow up. The purpose of the tracking system is to alert the provider to the patient who needs to return to the office and by what date. The patient will remain active in the tracking system until one of three potential outcomes occurs: (1) follow-up is complete; (2) informed refusal is documented, or (3) there have been reasonable attempts (usually three) to encourage patient compliance. Document all attempts to contact the patient. We advise the last attempt be in writing, clearly explaining why the follow-up is necessary, and the potential consequences of failure to do so. Mail the letter certified and/or return receipt requested.
Orthopedist breaches the physician-patient relationship by failure to communicate urgent pre-op chest x-ray findings
By Michael J. Bono, MD, FACEP
A woman in her 60’s went to an orthopedic surgeon with complaints of the right hip, right leg, and back pain for a month. The patient’s history included: a 1-2 pack a day smoker; social; drinking, and Hepatitis C. The orthopedic surgeon diagnosed osteoarthritis of the right hip and pelvis, advising the patient she would eventually have to have a total right hip replacement.
Initially the patient underwent conservative pain management therapy without pain relief. Several months after her initial consult with the orthopedic surgeon, the patient was scheduled for a total right hip replacement. The surgeon obtained informed consent and ordered a pre-operative chest x-ray and EKG. The patient’s primary care physician faxed a medical clearance form to the PCP, where she declared the patient medically cleared with no further work-up. The PCP had not seen the chest x-ray report, the EKG, or realized the patient gave the radiology department technician a history of shortness of breath and hypertension, at the time his chest-x-ray was performed.
In her report the radiologist wrote, “bibasilar pulmonary nodules are present, rule out metastatic disease…chest CT recommended for further evaluation.” The report was faxed to the orthopedic surgeon’s medical assistant (MA) per the radiology department’s policy. The surgeon never reviewed the report, nor did his medical assistant make him aware of the abnormal findings. After the surgery, the patient complained to the hospitalist of chest pain, which was worse with deep breaths. The hospitalist ordered a CT scan to rule out post-op pulmonary embolism (PE). The radiologist’s impression was “a tumoral pattern in the chest and upper abdomen with pulmonary hepatic retroperitoneal spread. No pulmonary arterial contrast filling defect to suggest PE; bilateral dependent pleural effusions with neighboring atelectic change, and background chronic liver disease”. Upon further work-up, the patient was diagnosed with end stage hepatocellular carcinoma and metastatic disease. Two months after her hip surgery, the patient died as a result of this disease.
The plaintiff alleged both the orthopedic surgeon and his medical assistant breached the standard of care by failing to fully inform her of the radiology imaging results, and the radiologist’s recommendations, which would have allowed her to have made a decision about proceeding with the hip surgery.
This case was eventually settled.
Patient Safety Discussion
The damages were limited in this case. In terms of the orthopedic surgeon’s role the delay in diagnosis of metastatic disease was only by a couple of weeks.
It appears the patient had an aggressive, advanced, cancer, and that the short delay in diagnosis did not make a difference in this patient’s outcome. However, case reviewers believed there was merit in the plaintiff’s allegations about the patient’s ability to have made an informed decision about whether or not to proceed with the hip replacement in light of her inoperable, metastatic cancer.
The radiologist and the hospital radiology department did adhere to American College of Radiology communication guidelines in ensuring that the radiology report was faxed to the surgeon’s MA. The radiology clerk stated he made a phone call to the practice prior to faxing the report to ensure the correct ordering physician, the correct fax number, and the name of the ordering physician’s MA. In addition, the clerk stated that per radiology department protocol, he spoke with the MA, advising the report was abnormal.
The radiologist and radiology department were not held liable in this case.
Medical Office Communication Systems
The surgeon admitted his MA did not notify him of the abnormal radiology report. Clearly the communication system involving the tracking, receipt, and review of reports and lab results, in particular pre-operative reports, was lacking in his office. Flawed medical office communication systems, such as illustrated in this case, are one of the root causes of medical malpractice cases. Failed communications are the root cause of many malpractice cases we defend at MagMutual. The failure to report abnormal test results can lead to serious consequences for the patient, and that point is not arguable.
Physician Sign-off on Reports
Physicians have responsibility to ensure appropriate follow-up of test results for tests they ordered. Physicians also have the responsibility to take appropriate action, and follow-up with the patient with appropriate urgency. Evidence that the ordering physician has reviewed lab, imaging, diagnostic report results, or consultative reports, can be demonstrated by a signature on such reports. The ordering physician is expected to review and sign all of these reports prior to filing them in patients’ medical records. With the volume of reports medical offices and physicians receive daily; it is imperative that effective record keeping systems procedures be employed. We recommend physicians follow five routine procedures to keep patients informed about test results:
- Ensure test results are routed to the responsible physician
- Have the responsible physician sign off on the results
- Promptly inform patients of all results, normal and abnormal
- Document the patient was informed
- Advise patients to call the office if they do not receive their test results within a certain time period.
A reliable system of reconciling test results and coordinating care with other health care providers involved in the patient’s care is a fundamental physician responsibility. When these processes fail, the risk of an adverse outcome is significantly increased. Even a simple process failure can have a significant impact.
We invite all of our policyholders to utilize the on-line resources we’ve prepared concerning maintaining medical office clinical tracking systems, such as our newly updated online Learning Module, Maintaining an Effective Clinical Tracking System in Your Medical Office.
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.