Retina Informed Consent Video Collection by the American Academy of Ophthalmology
Your patient education materials often play a critical role in defending against allegations of malpractice. Even in cases where the standard of care was met, a poor patient consent process could render a claim indefensible in court. Provide a consistent and thorough informed consent process for your patients with the aid of the Academy’s new downloadable Retina Informed Consent Video Collection developed in collaboration with OMIC. A sample video is included below:
This collection includes 21 short videos in English and Spanish, each about five minutes long, on common retinal conditions, the risks and benefits of procedures and treatment options. See AAO Resource: Video as an Informed Consent Tool: Save Time, Mitigate Risk or visit the Academy Store for more information.
“These are professionally produced videos that explain clearly a variety of retinal in office and surgical procedures. I use these extensively on a daily basis for my patients. For surgical patients, I have found these videos so valuable that I have instituted a separate pre op clinic visit, to ensure that patients watch the relevant video in an unhurried manner. This is one of the most valuable products that AAO has produced.” – Dr. Hardeep Dhindsa
Buy Now >> Retina Informed Consent Video Collection
OMIC’s Retina Risk Management Page provides free resources, recommendations, and several consent form templates.
Let us know what you think. We love suggestions!
Surcharge Eliminated for Cosmetic Procedures
Digest, Spring 2013
At its May meeting, the OMIC Board of Directors voted to eliminate the premium surcharge for ophthalmologists who perform facelift, rhinoplasty, and full body liposuction for policies effective on or after May 1, 2013. The decision was based upon favorable underwriting and claims data tracked by OMIC since the company first approved coverage for these procedures over 15 years ago.
During a recent retrospective review of OMIC-specific and industry-wide claims data, it became evident that the risk exposure for these cosmetic procedures was lower than expected and that OMIC’s experience outperformed that of the industry. Only one claim and two incidents involving facelift procedures have been reported to OMIC since 1997. All three were resolved without indemnity and total expenses paid were $698. Two claims involving liposuction were reported against OMIC-insured physicians. One closed without indemnity and the other settled for $150,000. Expenses for the two claims totaled $24,715. A third claim involving liposuction was brought against an OMIC-insured surgery center for a procedure performed by an open-access member. No rhinoplasty claims have been reported to OMIC to date.
Cosmetic surgery has become safer in the past decade thanks to new “minimally-invasive,” “non-invasive,” or “non-surgical” techniques that carry significantly less risk than more traditional techniques. Continuing medical education courses have given ophthalmologists desiring to add these procedures to their practice the skills and training necessary to do so successfully.
Elimination of the surcharge means that ophthalmologists who perform facelift, rhinoplasty, and total body liposuction will now pay the same rate for professional liability coverage through OMIC as their colleagues who limit their surgery to traditional ophthalmic procedures. This rate is far below what a plastic surgeon, otolaryngologist, or other specialist must pay for similar coverage.
Message from the Chairman addresses elimination of surcharge for facelift, rhinoplasty, and full body liposuction
Digest, Spring 2013
The story of how OMIC arrived at the decision to eliminate the surcharge for ophthalmologists who perform facelift, rhinoplasty, and full body liposuction (see Eye on OMIC) tells us much about how the company balances the risk of providing coverage for procedures ophthalmologists perform with rates the company must charge to cover that risk. The assessment is difficult for many reasons, the primary one being the need to determine the risk of a given procedure or group of procedures. In assessing risk, one must take into account underwriting guidelines the company uses to determine for whom it will provide coverage. If untrained or poorly trained physicians are allowed coverage, the risk—and therefore the rates—will be high. If the company underwrites physicians who are well trained and who meet acceptable standards of practice, the rates may be lower as long as claims remain at an acceptable level.
Fifteen years have passed since the OMIC Board responded to requests by ophthalmologists to provide coverage for total body liposuction and full facelifts for cosmetic reasons. Initially, OMIC had difficulty setting rates for these procedures because claims data was lacking, and there were no proven underwriting criteria that allowed staff to determine who should be insured. Accordingly, premiums were based on average rates charged by other carriers for cosmetic procedures. OMIC selected a 200% surcharge for coverage of full facelifts and a 160% surcharge for coverage of liposuction. Staff immediately developed underwriting criteria and simultaneously began monitoring claims and tracking incident reports for these procedures. This information was reviewed periodically. Over time, the data confirmed that OMIC’s experience was sufficiently favorable that a rate reduction to 150% of basic premium (i.e., a 50% surcharge) could be adopted. This rate went into effect in 2006. Coverage for rhinoplasty, subject to review and approval of a supplemental questionnaire, adherence to underwriting requirements, and payment of the 50% cosmetic surcharge, was added in late 2008.
OMIC’s conservative approach to underwriting and strong claims performance compared to its peer companies has allowed OMIC to provide coverage for members of the American Academy of Ophthalmology at competitive rates and to embrace new procedures as ophthalmologists begin to perform them. PRK, LASIK, refractive lens exchange, Intacs, facelifts, rhinoplasty, and total body liposuction are examples of procedures OMIC covers at standard rates without surcharge. Elimination of the surcharge means a significant rate reduction for ophthalmologists who perform these procedures. This is good news for those now insured by OMIC and those considering a switch to OMIC and demonstrates how OMIC works on behalf of Academy members to provide coverage at reasonable rates for the work ophthalmologists are doing.
John W. Shore, MD, Chairman of the Board
Pseudotumor Cerebri in Young Female
Ryan Bucsi, OMIC Senior Litigation Analyst
Digest, Spring 2013
Allegation
Failure to diagnose and refer patient for treatment of pseudotumor cerebri.
Disposition
Settled for $850,000 split equally among two OMIC insureds and their insured entity.
Case summary
A 23-year-old female presented to the emergency room with blurred vision and was advised to see the OMIC-insured ophthalmologist the following day for examination. She did not keep the appointment, but five days later called the insured’s office to complain of decreased vision and was advised to come in. On initial examination, the patient’s visual acuity was 20/125 OD and 20/50 OS. The pupils were reactive with trace evidence of an afferent papillary defect. A visual field test was not performed. The OMIC insured’s diagnosis was significant bilateral papilledema likely secondary to pseudotumor. Based on the patient’s size (4’11” and 150 pounds), the insured prescribed 1000 mg of Diamox to be taken daily. He also referred the patient to a neurologist for a lumbar puncture. Upon the advice of the neurologist, the patient did not start the Diamox until after the lumbar puncture. The ophthalmologist advised the patient that the pressure was 36 (normal <25) and instructed her to start the Diamox. Approximately three weeks later, the patient returned to the OMIC insured and his partner, another OMIC-insured ophthalmologist, for an examination. Visual acuity was count fingers OU. A positive finding of afferent papillary defect OD was again noted. A constricted visual field based on a confrontational field test revealed a significantly limited visual field OU. The patient was diagnosed with pseudotumor cerebri and Diamox was increased to 1500 mg daily. The OMIC insureds documented that if no improvement was seen in the next week, the patient would be referred to a neuro-ophthalmologist. The patient did not return to the OMIC insureds after this visit. She self-referred to another ophthalmologist, who referred her on to a neuro-ophthalmologist. The neuro-ophthalmologist suspected that the patient had asymptomatic but uncontrolled bilateral disc edema for much longer than six weeks and that for unclear reasons it went into an accelerated phase resulting in significant loss of vision. The patient underwent two bilateral optic nerve sheath fenestrations, but final visual acuity was hand motion at 1.5 feet OD and 6/200 OS.
Analysis
Plaintiff’s experts opined that both OMIC insureds failed to appropriately diagnose and manage the patient’s pseudotumor cerebri and violated the standard of care by failing to refer the patient to a neuro-ophthalmologist for evaluation of pseudotumor cerebri. Several experts were retained by OMIC to review this case and some common opinions emerged. First, all of the defense experts were concerned that a visual field test was not done during the patient’s initial examination by the insureds. They felt a visual field test was warranted in order to determine the degree of central vision loss. The patient could not see the left part of the visual acuity chart so the experts felt that the extent of the patient’s disease was quite evident during the initial examination. Most of the defense experts opined that upon initial presentation, the patient’s condition was an ophthalmic emergency and “cried out for an immediate referral” to a neuro-ophthalmologist. The two OMIC insureds themselves were not entirely confident in the care they provided to the patient and expressed concern that any neuro-ophthalmologist called to testify would be critical of their care and treatment. As a result of the opinions of our retained experts and the OMIC insureds, the case was settled at mediation on behalf of the two OMIC insureds and their insured corporation for $850,000.
Risk management principles
The insureds made the correct diagnosis in this case but, sadly, delayed aggressive treatment of the pseudotumor cerebri as they did not appreciate that it was an emergency situation. Not only did this patient have a high-risk condition, but her behavior in delaying follow-up treatment for five days after her ER visit made her a high-risk patient. Patients who risk serious vision loss and do not take their condition seriously should be referred early for subspecialist care. Early referral ensures that patients likely to delay care or not follow treatment recommendations receive the most advanced care from the start.
Test Management System is Key to Prompt Diagnosis
Anne M. Menke, RN, PhD, OMIC Risk Manager
Digest, Spring 2013
The OMIC claims database includes cases where ophthalmologists needed to take prompt, decisive action but failed to do so. At times, physicians did not appreciate the emergent nature of the patient’s condition. Other times, physicians appeared to be on the right track but did not pursue the diagnostic process to completion by obtaining, reviewing, communicating, and following up on the results of diagnostic tests. This article will review the role other members of the health care team can play in helping maintain a robust test management system.
Q What is the best way to ensure that test results on hospitalized patients are reported to me promptly?
A Do not assume that the laboratory technician or nurse knows which tests need to be done urgently or which results you consider to be clinically significant. Give adequate information on the test order to guide the lab or imaging department, and provide ways to reach you both during and after office hours. Inform the nurse caring for the patient of your diagnosis, its consequences, and planned studies. Instruct the nurse to contact you as soon as the results are available. Include in your written order any symptoms that should be reported to you as well. “Mr. Avery has had more bleeding than expected. I am ordering a CT to check for intraocular bleeding. I will be performing surgery on another patient, but please contact me as soon as the results are in, and please watch the patient for any signs of increased bleeding, such as….” If the hospital has an electronic health record, be sure the alert system is on and you respond to any alerts that appear. Ask the circulating nurse in the OR to watch for these alerts if you are performing surgery.
Q I have a small practice and we do not have an electronic health record (EHR). How can my staff help track tests?
A Offices without EHR have created an effective tracking system using a simple Excel spreadsheet. Ask your front office staff to review your exam record or super bill for any tests and to enter each one into the Excel spreadsheet. Assign a staff member to check the tracking sheet daily and weekly and to contact the laboratory or consulting physician if results are not received in the expected time. If the patient did not present for the test or consultation, ask staff to contact the patient to determine why and report back to you for follow-up instructions.
Q May my staff member review the results?
A Your staff member may help by conducting an initial review and sorting the results, but you are expected to review and sign all reports and to arrange for another ophthalmologist to conduct the review when you are out-of-town. Normal results may be placed in a folder for you to sign and review at the end of the day; a copy of the results can be mailed to the patient and the original filed in the medical record with the notation “mailed to patient on [date].” The Excel spreadsheet can be updated to indicate “normal results, patient notified, no follow up.” It is helpful to send a document explaining the reason for the test and the meaning of the results. Abnormal results need careful handling. Staff should receive training and be provided with a written protocol on how to manage them. The protocol should identify test values that need a prompt response, such as those the laboratories have identified as critical or those you have determined to be clinically significant. Thank staff each time you are notified of such results to encourage them to interrupt you for these important messages.
Q How can I be sure that patients are notified of results?
A There are two methods that work well, especially when used together. While busy practices might prefer to only notify patients of abnormal results, patient safety experts agree that it is best to inform them of all results. One method is to inform patients of tests to be completed and ask them to address an envelope to be used to send them their results. Patients then know to watch for the results and have provided their most current contact information. Patients are asked to call the practice if they have not received the self-addressed envelope within a specified period of time. Another method, which ensures that test results are incorporated into the treatment plan, is to instruct staff to schedule a follow-up appointment for any patient referred out for testing or consultation so the results can be shared. Insist that the appointment be scheduled before the patient leaves the office so the patient is part of the appointment tracking system. When pulling records for the next day, ask staff to confirm that results from tests and consultations have been received. If not, have staff call to obtain them.
