FAQs

FAQs About Telephone/Technology

  • How can I reduce my risk related to telephone consultations or assessments?

    Because telephone advice must be prompt, accurate, and executed without the benefit of actual observation, the following suggestions may help reduce the related risks:

    • Document every telephone exchange. Include the name, date, time, specific complaints, assessment, advice, final disposition of the call, and referrals to other providers or facilities.
    • Provide protocols, education, and guidance for nurses and other staff who give telephone advice and information. Nurses giving advice over the phone are accountable for that advice and need to be certain it is within the scope of their state's nursing practice act. The American College of Emergency Physicians and the Emergency Nurses Association advises against any substantial diagnoses or treatment recommendations by telephone.
    • If you establish a formal physician-patient relationship during a telephone consult, document and follow up as with a face-to-face patient encounter.
    Back to Top

  • What are the patient safety issues surrounding medical advice via telephone?

    One option is to decide not to provide advice over the phone, especially to unknown or unfamiliar patients. However, if phone advice is provided to known patients, the key areas of concern are the degree of medical advice offered and documentation of the exchange.

    Mechanisms should be in place to respond to and record what was discussed during those calls from patients seeking treatment information. If not, the potential for patient dissatisfaction, missed diagnoses, delay in treatment, and possible serious medical consequences exists.

    Staff should be supported with protocols including the questions they should ask and when a patient should be referred to a physician. The threshold for obtaining a physician's response should be relatively low. Staff training, telephone procedures, and protocols should be periodically reviewed to ensure that inquiries are being appropriately managed.

    Documentation of all phone calls in which medical information is discussed is extremely important. The date and time of the call, patient's complaints, and advice given should all be recorded. The advice given should include the point at which the patient should seek medical attention. The few minutes taken to record this information will be valuable for ongoing patient care. In the event a patient challenges the quality of medical care they received by phone, or claims he or she made multiple calls and received no or inadequate advice, such documentation will prove worthwhile.

    Back to Top

  • What are the patient safety issues surrounding prescribing over the phone?

    The decision about whether to prescribe over the phone depends upon the physician's relationship with the patient, the type of medication, and the circumstances of the call.

    Prescribing new medications to known patients over the phone without a recent clinical evaluation is not recommended, especially when a drug's appropriateness cannot be readily assessed. If such prescriptions aremade by phone, the physician should document that the patient's clinical status and other medications have been assessed, that possible side effects were discussed, and that the patient was told under what circumstances to call again.

    For prescription renewals by phone, an assessment of clinical status to check for side effects and the appropriateness of continuing the medication is important and should be documented in the patient's record. When prescribing controlled substances over a long period of time to a patient whose disease process is stable, the BRM recommends that the physician see the patient at least once every six months. For patients who are using Schedule II substances, the Board recommends that the physician see these patients as often as possible and clinically re-evaluate the patient at least every four months.

    Out-of-state

    The circumstances of an out-of-state call is an important consideration. For the patient "caught" without his or her current medication, prescribing an amount to cover the limited time period may be appropriate. When the symptoms description suggests the need for a new medication, referral to a local emergency room or clinic for assessment is advised.

    Special circumstances may develop where patients are being followed out-of-state because of the nature of their illnesses and the expertise of the physician. However, the involvement of a local physician who can monitor the patient and prescribe the needed medications as well, would still be important in these cases.

    New or Lapsed Patients

    Extreme caution should be exercised in prescribing medications over the phone to new patients or those who have not been clinically evaluated for some time. When suspicions of drug abuse are aroused, careful questioning, prescribing only alternative drugs, suggesting the patient be seen in a clinic or emergency room, and/or prescribing the smallest possible quantity are ways to deter inappropriate use.

    Back to Top

  • What are the risks in giving out patient information over my cellular phone?

    Cellular phones raise the same issues as phone advice in general, plus a few based on their technology. The security issues, such as inappropriate eavesdropping, combined with models that include message storage and retrieval that can potentially be accessed by outsiders, should limit the use of these phones for relaying patient information. If patient information is to be discussed, consider acquiring the type of phone that includes a scrambling device.

    Back to Top

  • Is it okay to leave messages on a patient's answering machine or voice mail?

    Yes, but only leave your name (without "Dr.") and ask for a call back.

    Since they may be accessible to individuals other than your patient, take care in leaving messages on answering machines or voice mail. Provide callback information only: never clinical data, advice, or results. Document the fact that you have left a message.

    Back to Top

  • How do I minimize the risk when using an electronic answering system after hours?

    Using a voice-mail system or answering machine rather than an answering service creates a different risk for your practice because the communication is indirect and potentially delayed or prevented. If these methods are used instead of backup physician coverage, or as a way to go "off-call," special considerations are necessary:

    • Some practices, such as obstetrical and pediatric, are not appropriate for indirect answering systems because those practices involve too many foreseeable, urgent, off-hour patient care needs. Around-the-clock on-call coverage, supported by an operator-attended answering service, is appropriate.
    • For practices where using an answering system is considered feasible, the following steps may be taken to minimize liability and patient anxiety or frustration:
      • let patients know that you use an answering device during off-hours
      • direct callers with urgent problems to an emergency department, giving them the phone number and location (and make sure the ED knows you are doing this)
      • if your answering device takes messages, let callers know when to expect a return call
      • pick up messages regularly, and follow through on callbacks
      • save messages, and document calls in the patient record
      • anticipate some patient dissatisfaction with using your system
    Back to Top

  • What precautions should I take when faxing information from my office?

    Sending data via the fax machine can raise confidentiality concerns due to the electronic nature of the exchange and the potential for unauthorized reading at both the sending and receiving sites. In general, patient health care information should be faxed only when the data are to be used for an urgent patient care encounter, and reasonable precautions should be taken. As for any mode of transmission, proper patient authorization should be obtained prior to the release of medical record information. Whenever possible, the fax machine should be avoided for routine release of information to insurance companies, attorneys, or other non-health care entities that can be served effectively by regular mail or messenger service.

    The privacy concerns raised by electronic transmission of medical information should not be underestimated. Do not be surprised if the receiving institution has additional verification requirements or limitations in place for patient-related data or orders sent via fax machines. For example, a facility may be willing to accept a faxed order for a routine diagnostic test, but require additional authentication or contact before initiating certain types of medication orders on the basis of a fax communication. The information being transmitted should be accompanied by a cover sheet with the names and addresses of the sending and receiving facilities, the authorized receiver, and a statement regarding redisclosure, destruction, and receipt verification. Faxes should be entered into the correspondence log, and the original cover letter, authorization, and verification of receipt should be filed in the patient's record.

    Back to Top

  • What are the risk management issues surrounding the use of e-mail for patient information?

    E-mail should be treated as formally as medical record documentation. The speed and convenience make e-mail a valuable tool for clinicians. However, its use raises some special areas of concern:

    • Consider e-mail containing patient information official correspondence. Before sending, check messages for accuracy and appropriate language. Flippant or humorous messages may look disrespectful when viewed later, out of context.
    • Assume that e-mail messages (even deleted ones) are discoverable
    • (i.e., can be requested by an opposing attorney during a legal investigation) unless they were between the physician and a risk manager, attorney, or insurance company representative. Messages sent to friends and colleagues are not protected.
    • Safeguarding the confidentiality of e-mail messages exchanged with patients is difficult. Confidentiality can be breached by outsiders (hackers) or by patients and physicians themselves who Reply to or Forward messages to individuals outside the patient/physician relationship.
    • Answering e-mail questions from unknown or misidentified individuals may unwittingly create physician/patient relationships.
    • Messages can be delayed by hours, or even days, and should not be relied on to convey urgent or important information.
    • Emotions do not translate well through the computer. Your messages, however well-intended, may seem cold or impersonal to your patients. In addition, you may have difficulty discerning how your patients are feeling.

    To reduce these risks, physicians may consider the following suggestions:

    • Follow up serious or ambiguous e-mail queries with a phone call.
    • Remind patients that they are welcome to call and have questions answered directly. Be sure to recommend that patients seek appropriate additional care as needed.
    • Check e-mail at least twice a day, or have an assistant check it, and respond promptly.
    • Print e-mail messages sent and received and add them to your medical records as an additional means of documenting patient/physician interactions.
    Back to Top

  • What are the patient safety issues surrounding telemedicine?

    While Internet medicine is relatively new, the delivery of health care services via remote telecommunications, or telemedicine, offers potential benefits, such as increased access to care and specialized expertise for those in remote areas, some features may prove to be problematic, such as:

    • The licensing and regulation of physicians (and other health care providers) who practice across state lines
    • Reimbursement methods for telemedicine applications
    • Potential liability exposure--for a failure to use, as well as for the use of--a telemedicine hook-up
    • Potential violations of self-referral statutes where physicians are investors in telemedicine projects, or where health care centers provide telecommunication equipment to smaller facilities (which may have the appearance of inducing referrals)
    • Confidentiality and integrity of electronically transmitted patient information
    • Application of state laws when the clinician and patient are in different states
    • The possibility that a clinician-patient relationship is established by such an encounter
    • Creation, maintenance, archiving, and ownership of the records of a telemedicine consultation
    • Requests for subsequent access to the information
    • Documenting patient consent for a telemedicine consultation
    • Contingency plans to handle the potential for equipment, weather, or other problems that may adversely impact the transmission of information

    At this stage, the effect of telemedicine practice on the standard of care and malpractice litigation is unclear. However, as the technology of telemedicine continues its advancement, risk management principles and guidelines will also evolve to incorporate these new technologies.

    Back to Top

  • What are the risk management issues surrounding practicing medicine via the Internet?

    While the Internet offers potential benefits, such as increased access to care and specialized expertise for those in remote areas, some features may prove to be problematic, such as:

    • The possibility that a clinician patient relationship is unintentionally established by such an encounter
    • The licensing and regulation of physicians (and other health care providers) who practice across state lines
    • Application of state laws when the clinician and patient are in different states
    • Confidentiality and integrity of electronically transmitted patient information
    • Creation, maintenance, archiving, and ownership of the records of an Internet consultation
    • Potential violations of self referral statutes where physicians are investors in Internet projects
    • Contingency plans to handle the potential for equipment or service problems that may adversely impact the transmission of information

    At this stage, the effect of Internet practice on the standard of care and malpractice litigation is unclear. However, as the technology of the Internet continues its advancement, risk management principles and guidelines will also evolve to incorporate these new technologies.

    Back to Top

View all CRICO/RMF FAQs