THE PATH TO PAPERLESS

The legal perils of telephone triage

How we removed a litigation risk

By Peter J. Polack, MD, FACS

Peter J. Polack, MD, FACS, is co-managing partner for Ocala Eye, a multisubspecialty ophthalmology practice located in Ocala, Fla. He is also founder of Emedikon, an online practice resource for physicians and administrators. He can be reached via e-mail at ppolack@ocalaeye.com

Telephone triage can be a major area of liability risk for medical practices. Medical malpractice insurance carriers have paid out millions in claims for cases related to phone triage.

Triage, as risk management experts define it, differs from the “triage” of assessing a patient’s injuries, such as on the battlefield. Medico-legally, triage can only be performed by a licensed professional such as a nurse or a physician. If your medical assistant asks a patient questions to assess the problem, she is technically just screening the patient. She may then follow prescribed protocols, which may include passing on the information to a professional who can perform the triage. Even if calls are not documented, having written protocols can offer a practice some defense should a bad, phone-related outcome arise – if the practice can show that employees are trained to follow them.

We often receive about 1,000 calls on a busy Monday: urgent, non-urgent, prescription refills, contact lens issues, billing questions. Our fear was urgent problems slipping through the cracks, patients not getting called back until the following day, or triages not resolved promptly.

CHAIN OF CUSTODY

We had used the same “system” that most practices use: telephone sticky-note pads. But this often results in missed or lost messages, lacks accountability and has no audit trail. This type of process resulted in a million-dollar malpractice settlement against a colleague in solo practice due to a missed phone call. The main reason that sticky-notes or paper messages fail is that they lack a “chain of custody.”

Chain of custody states that every transfer [of evidence] from person to person be documented and that it be provable that nobody else could have accessed that evidence. In addition, the number of transfers should be minimized.

EMR systems do one better than sticky-notes in that there is a digital audit trail for messages between staff members. But EMRs fall short when their messaging modules also lack a chain of custody. Messages and tasks sent from one person to another end up in the ‘black hole’ of in boxes and red flags. Thus, the sender is oblivious to the fact that the triage loop was left open. Because EMRs are “chartcentric” they cannot be used to document calls with new patients who have not been seen yet, after-hours calls on consults, or communications between physician and staff outside the patient record.

FINDING THE ANSWER

What we really needed was a simple-to-use, single-purpose, process-based application that would conform to our current workflow processes. So we tasked our IT person to come up with that solution: a Web-based, standalone program that could eventually interface with our practice management and EMR systems.

Our phone triage management system provides an audit trail of all patient-related phone calls, improves customer satisfaction and enhances our workforce training. After almost 10 years of use, several colleagues have encouraged us to help make this tool available to other practices.

If you would like to find out if your phone triage process can be improved, you can contact our software developer Chris Johnson at chris@untangledsolutions.com about becoming one of our beta sites. OM