Risk Management

Access to an EHR System While On-Call

Anne M. Menke, RN, PhD, OMIC Risk Manager

Digest, Winter 2012

A policyholder called today to get input on a difference of opinion in his group. The group has implemented an EHR system. One of the partners, who is an early and enthusiastic adaptor of technology, feels that ophthalmologists must access the EHR when handling after-hour calls for the group. Another physician, less technologically-inclined, is reluctant to carry a computer at all times and take on additional work if it is not necessary.

Q  Am I legally required to access the EHR when speaking to a patient after-hours? Does OMIC require this?

A  No. OMIC is not aware of any laws or regulations that make such access mandatory, and we have no underwriting requirements related to electronic records.

Q  Do all members of the call group have to agree on whether or not to access the records?

A  Patient safety studies have shown the value of a standardized approach in reducing the incidence of errors and improving communication. As in other areas of practice administration, such as appointment scheduling, prescription refills, noncompliance and billing, it is easier for staff if all physicians in a group handle issues in a similar fashion. Once the group reaches consensus, it would be helpful to develop a written protocol and train staff members in it. Policies need to be realistic and reflect goals that can be consistently reached. Such written protocols protect physicians from inadvertent criticism from their colleagues and staff if there are unexpected patient outcomes.

Q  What are the risks if I don’t access records?

A  During telephone conversations, the health care team does not have access to the wealth of information obtained from face-to-face communication and a physical examination of the patient.  Moreover, the patient may be a poor historian who does not know how to communicate what the problem is, or may not want to inconvenience the physician or appear to be whining or complaining. This situation is even more problematic after-hours, when the patient may be unknown to the ophthalmologist and medical records may not be available at the time of the telephone encounter. Making medical decisions on the basis of the limited information obtained over the telephone is, therefore, a risky—albeit necessary—aspect of ophthalmic practice. Indeed, OMIC claims experience confirms that inadequate telephone screening, improper decision-making, and lack of documentation all play a significant role in ophthalmic malpractice claims. Negligent telephone screening and treatment of postoperative patients is especially likely to result in malpractice claims. By reviewing the record, you may find information key to the diagnosis or management of the patient, such as a patient’s allergy, test results, medication record, or history of recent surgeries. Without such information, you may inadvertently prescribe a contraindicated medication, or determine that urgent care is not needed. If the patient is harmed and sues, he or she may allege that failure to consult the record was negligent. As more and more physicians implement EHR systems, pressure may grow to access records after-hours, even though this care is generally not reimbursed by insurance companies.

Q  What else can I do to reduce the risk of telephone care?

A  First and foremost, exercise the same care when treating a patient by phone as you would during an office visit. To promote both continuity and defensibility of care: (1) gather the information necessary to assess the situation and determine the treatment plan, (2) communicate the assessment and plan to the patient, and (3) document the encounter and your decision-making process in the medical record as soon as possible after the conversation, by the next business day at least.

Q  Can’t I just get the information from the patient?

A  You may be able to if you ask enough questions and have a patient who can reliably answer them. At other times, you may have to make a decision with limited or inaccurate information. In the absence of records, OMIC recommends using an after-hours contact log that prompts you to ask detailed questions about the current complaint and prior care. The form also serves to document the conversation and can be faxed to the patient’s regular physician to promote continuity of care.

Q  If I do access the record, how thoroughly do I need to review it?

A  There is no easy answer. You face a similar situation when you take over care from another physician, or see a partner’s patients in the office. The standard to which you will be held is that of a reasonably prudent physician. Obviously, you will not have time to review the entire record. At a minimum, you would want to check allergies, medication history, and recent procedures. Reading notes from the latest visits or phone calls might help you determine if the patient’s condition is changing or worsening. Document which records you reviewed in order to assess the patient. To facilitate after-hours call, it would help if the record contained a front sheet with key information.