Risk Management

Telephone care

ANNE M MENKE, RN, Phd, OMIC Patient Safety Manager

Telephone care was the central focus of the case featured in the Closed Claim Study. Our policyholder’s care consisted of just one conversation with a pediatrician who called for advice. This single call determined not only the child’s clinical outcome but also the liability risk for the two physicians who spoke to each other. Telephonic exchanges can occur between the ophthalmologist and other physicians involved in the care, but most physician-to-physician calls come from the Emergency Department (ED). These calls raise a number of concerns.

Q. Do I establish a physician-patient relationship by speaking to another physician about a patient?

A. To many physicians, the only fair and obvious answer is no: one would have to examine or treat a patient to establish a relationship with so many risks and duties. After all, how can you be legally responsible—and potentially liable—if you never even meet or speak to the patient? (Of course, never seeing or speaking to the patient is the norm for specialties such as pathology and still quite common in radiology.) Contrary to this assumption, courts have consistently ruled that telephone advice provided about a specific patient does indeed establish a physician-patient relationship.

Q. Do I have to provide advice on the phone to any physician who calls me?

A. No, there are situations when you may refuse to provide such advice. You may decline the request if the call concerns someone who is not your patient. Before saying no, be sure that you do not have a contractual obligation to accept the call, such as a condition imposed by a health insurance company in order to be on its panel. If you or your group are not accepting any new patients, it might be prudent to tell the caller to contact someone who is available for ongoing care. There are, however, certain times when you do have an obligation to discuss a patient. Other physicians who are part of a current patient’s healthcare team often need to speak to you in order to safely diagnose and treat the patient. You not only receive such calls, but make some yourself and no doubt appreciate the time the other physician takes to answer your questions. You or a physician in your practice must take these calls.

Q. What about calls from the ED?

A. You are required to speak to physicians who call from an ED in two instances. First, whether you are on call for that hospital or not, you are expected to answer questions about your own patients. Be sure to document these conversations and clarify who will provide any needed care. If the patient needs to be examined or treated in the ED, you may—but are not required to—provide that care even if you are not
on call that day for that hospital. Or you could, for example, speak with the ED physician, advise on needed exams, tests, or treatment, and then ask the ED physician to contact the ophthalmologist who is on call to the hospital that day. Document this conversation as well. Second, you must provide telephone advice to an ED physician if you are the on-call ophthalmologist that day for that hospital. And you must examine the patient in person if the ED physician requests it. Review your medical staff bylaws to determine if you are serving on call for just that hospital or any hospital in an affiliated group of hospitals. Remember also that the hospital must accept transfers of patients who need a higher level of care if it has the capacity and capability. By extension, you must respond to calls about these patients. The call may come from the transferring hospital trying to reduce the risks of the transfer as
much as possible. If an ED physician from a hospital that wants to transfer a patient contacts you first, ask the physician to discuss the transfer with an ED physician at your hospital.

Q. How do I know if I can trust that the physician who calls me has made a competent assessment of the
patient?

A. Your ability to safely provide telephone care depends upon your assessment of the other physician’s knowledge, skill, and judgment. Do not assume that the history and physical examination reported to you are adequate. Make that determination only after asking enough questions to ensure that you, as the specialist in eye conditions, have the information you would gather yourself if you were seeing the patient. Document the conversation. Consider using our telephone contact form as a template. It is available at http:/www.omic.com/after-hours-contact-formand-recommendations/.

Q. Can my technician handle calls from patients that come during office hours?

A. Technicians can help by gathering the information you need and relaying your advice to the patient. Consider using our template in http:/www.omic.com/telephone-screening-of-ophthalmicproblems-sample-contact-formsand-screening-guideline/.

Review the information to determine if you need to speak to or examine the patient. Document your decision and instructions.