The Hawaiian Medical Service Association, a state program partnered with Blue Cross-Blue Shield, is breaking new ground by making making house calls available to everyone in the Aloha state — via the internet. American Well, the company offering Web-Calls, will begin providing this service in Hawii on January 15, 2009.

Those who want a faster, easier, less expensive way to visit with a physician will be the first to use the service. The uninsured and those living in more remote or rural areas within Hawaii are amongst the target markets, but others may find the Web-Call more convenient, especially for interactions which don’t really require the doctor to examine them closely.

Some examination is possible via the webcam, but a camera is not required for the visit. Text chatting with the doctor can also be used. While the program is generally well-received, some physicians have expressed concern that it can be difficult to determine the cause of a disease via webcam. Others point out that while it’s a good tool, it cannot replace a personal exam, because over the Internet the physician doesn’t have the opportunity to notice hints of disorders that patients aren’t specifically complaining about. Though it may not substitute for an in-person exam, it can allow doctors the opportunity to do triage, to recommend being seen in person at an E.R., if the concern is grave, or to schedule an appointment, if necessary.

American Well appears to have gained Washington’s attention. Legislators whowant to expand access to health care are giving American Well’s service due consideration. Other states are expected to be offering American Well’s Web-Call service soon.

Within Hawaii, the plan is that the 700,000 members of the Hawaiian healthcare system will pay $10 for their initial ten minute Web-Call with the doctor. (The visit can be extended for additional fees.) During the call the physician can file prescriptions and view patients’ medical histories. American Well is working with HealthVault, (Microsoft’s electronic medical records service,) and
Aetna’s ActiveHealth Management, which scans patients’ medical history for gaps in their previous care and alerts doctors to those gaps during their American Well appointment.

Uninsured Hawaiian patients will also have access to Web-Calls, but they will pay $45 instead of $10 per visit. American Well gets a fee per member and a transaction fee of about $2 for each Web-Call visit.

Concerns that the uninsured might not have internet access have been diminished since Forrester Consulting’s study was released in November, 2008, indicating that about two-thirds of California’s uninsured patients used broadband at home.

The most obvious uses of a Web-Call are for patients who need medication refills or follow-up consultations, and for the elderly and homebound. It is not expected that a Web-Call will ever replace office visits, but is seen as a welcome and useful tool, and an affordable option. Using Web-Call visits to resolve basic needs and concerns could go far towards reducing the cost of healthcare for both the insured and uninsured patients.

What affect this may have upon Professional Liability for those physicians remains to be seen. Neither the insurance industry nor the nation’s healthcare providers have checked in on this novel method, nor have patients fully expressed their views. it is expected that patients will welcome the convenient and affordable access to healthcare providers. Feel free to Comment your thoughts or opinions here!

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Tags: American Well, doctor, Hawaii, Internet house call, Web Call

This case is gaining a lot of attention and, surprisingly, many of the people who hear only part of the story are sympathetic to the doctor. Those people suggest that since the mother and child are well there is no real case, so they should be quiet and let it go. Some are saying that their pursuit of this case will simply raise malpractice rates. If the accounting of events in the allegations are accurate, though, malpractice did occur, and the doctor’s abuse was both physical and verbal/emotional. But can a doctor be sued for poor bedside manner?

The case centers around verbal and physical abuse of Catherine Skol, a former Chicago police officer and mother of five. The situation began when she went into labor at about 4 am on March 1, 2008, while her regular OB was out of town, and Scott Pierce, MD, filled in for her primary OB, Dr. Weitzner. As one reads the details of the allegations, it becomes clear that, if the accounting is accurate, Dr. Pierce should be Mister Pierce from now on. Through a series of blatantly sadistic, belittling and demeaning remarks, through insensitive conversations on the cell phone while the mother was delivering, and by not even bothering to come by to check on mother or child after delivery, behavior of this nature would earn anyone a special place in the books. But that’s not where the allegations end. According to Mr. and Mrs. Skol, Pierce refused the mother’s requests for anesthesia, demanded that she push at inappropriate times (itself a risk to both mother and baby, inserted a catheter during a contraction, demanded use of a 25 gauge needle to suture a tear in the vulva (without anesthesia) … there’s a lot more in the alleged accounting. Through the entirety of the allegations, we see a combination of both verbal and physical abuses. In the final analysis, the mother and child are both healthy, though. Can a healthcare provider be held accountable for being rude?

This case blows the concept to absurd proportions, and in the magnification it becomes clear that bedside manner is part of healthcare, and that in such extremes as described by the allegations, the physician should be culpable. What of less vulgar and dramatic circumstances, though? Is being short-tempered with a patient a form of malpractice? What about being insensitive to pain or suffering, or being cavalier in discussing another patient? (Best not to discuss other cases in the patient’s presence in any circumstance.)

Anyone can sue anyone for anything. It will be for the courts to decide (if it is allowed to get that far) whether Pierce is liable for civil damages as compensation for his behaviors. Professional credentials are at risk with this case, as well, and that, too, is for others to decide after all of the facts are found out. If this case serves no other purpose, it should remind us that healthcare providers must be on their best and most professional behaviors at all times.

Video: Which types of medical malpractice cases are most common?

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Tags: bedside, insensitive, malpractice, skol, verbal

Beginning in May of 2009, the public will be able to go to a website, search for physicians’ files, and take a very close look at the history of that doctor. This same information is already available for some 1300 Colorado physicians, but is about to include the remaining 2000 doctors, thanks to CO HB 1331 (the Michael Skolnick Medical Transparency Act,) which requires doctors registering in Colorado to make professional disciplinary action public. But the data files won’t stop with that.

If a doctor’s privileges are revoked at a hospital, you’ll know about it. If a license has been suspended in any state in the Union, by the law, the physician must report that fact. If a MD lets a state license lapse, that is known. Hospital affiliations, suspensions of DEA license, whether or not they’re involved in a medi-spa or other treatment center, if they’ve been convicted of a felony or a crime of “moral turpitude,” if they’ve been turned down for malpractice insurance due to past claims, and if they’ve ever paid a final claim on a malpractice suit.

Some of this may be disturbing. It should be. Ambulance chaser lawyers will file a malpractice suit at anyone anywhere near a case who looks like they might have money… and paying them would become part of your public record.

The case that started this all off is perfect proof of how bad an idea this is. The grief-stricken parents of a young man who had brain surgery claim that the surgeon himself is responsible for the death of their son, even though the horrible events leading up to his death occurred months after the procedure was performed. The man’s parents claims that the surgery was not necessary (though their qualifications for that statement are unclear.) His mother says that if she had known the doctor had a (singular) malpractice claim, she would not have allowed her son to have the operation. But colleagues of the surgeon say he is an excellent doctor. One went so far as to say that he’s “the finest neurosurgeon I ever worked with.” It is an unfortunate fact that people will judge these physicians by the small negative which may not even have been their fault, while going unaware of the thousands of patients the same physician heals every year.

With such laws coming up, it’s all the more important that your professional malpractice insurance include a strong defense policy, and that you be allowed to determine whether or not you choose to settle on a claim. Even if the state you’re in now has no such requirements, there’s nothing to say that it won’t become law in the near future.

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Tags: CO, Colorado, history, information, license, medi-spa, public, record

The talk of the healthcare industry these days is Electronic Health Records, (EHR, EPR, etc.) and other electronic communications (such as virtual visits, email communications with patients, online consults, whether with or without video, etc.)   Yes, the Internet and computers have much to offer, potentials we’ve only begun to tap.  A few years ago, there was even a program to make preliminary diagnosis based upon a patient’s symptoms, and computers have been avoiding drug interaction and contraindication problems for years now.  But before we go plunging headfirst into the maze, let’s take a few steps back and look at it all objectively.

A Harvard study proclaimed that physicians who use electronic health records were about 4% less likely to have a malpractice claim against them.  The immediate (and implied) conclusion was that EHRs reduced malpractice claims.  To draw that conclusion based upon that statistic is both bad science and bad journalism.  It’s just as likely that the practice’s progressive perspective towards healthcare is responsible for the lower incidence of claims, and that it would be the same with or without EHRs.  It might even theoretically have been lower without them.  So let’s not jump off presuming that EHRs will reduce incidents and premiums too quickly.

The idea of a computer as a tool is a very good thing.  It can do repetative tasks lightning-quick and avoids humans suffering some of the tediums of record-keeping.   In a perfect world, a well-designed electronic system would be as efficient as restaurants which employ similar systems for communication between the server and the kitchen.  A little touch-screen in each room and everything from health records to billing and calling for a candy-striper and a wheelchair can be accomplished in seconds via that screen.  Access to a PDR, to medical databases, etc. would also aid the physician.  But that’s still just a tool.  The idea of a computerized “virtual” physician is dangerous mojo, something that’s best left in the realm of science-fiction.

Virtual consultations are also something to think long and hard about.  The first question is whether you’d be covered by your malpractice policy in such a circumstance.  The patient isn’t necessarily even on the same continent at the time.  So many small nuances that a healthcare professional might pick up on are not apparent online, and that difference could easily lead to a misdiagnosis.  Here again, using the computers as tools for scheduling appointments, gaining data (such as a glucose record, etc.) and even programming dosage machines (in the future) may be good applications.  Remote surguries, where a full compliment of competent surgical staff is present with the patient, should something go wrong, may also be acceptable, if approved of by one’s malpractice carrier.  But diagnosing, treating, and prescribing via online consultations isn’t wise at this time. 

We all look forward to the progress and improvement that computers and their interfacing promises.  But let’s take things slowly, and make sure that we’re stepping smartly and in the right direction.  To quote Galen, Primum non nocere; First, do no harm.

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Tags: EHR, electronic health records, future medical technologies, internet, liability, malpractice

Nearly all physicians are doing the best they can for their patients.  We all hope you’re never served with a malpractice suit,  but sometimes things happen.  We’re all human beings.  When we make mistakes, we regret them and wish we could take them back.  We feel bad about the error and any consequences the patient may suffer.  But don’t let that allow you to make the mistake of letting your guard down during a deposition.

Your patient may very well only be trying to get fair compensation, but the patient’s attorney is nowhere near so noble.  The attorney is out for your blood, your soul, your home, family, cars, present and future earnings, body parts and your firstborn child.  It’s not personal.  That’s his job — to be coldhearted and ruthless, to do anything and everything he can to win.  If he can trip you up, fracture your confidence, or make you look incompetent, he’s going to do so.  They train for this very thing, and then hone their techniques.

A deposition is supposed to be a fact-finding mission.  In reality, it’s often the prosecuting attorney’s practice round with you.  He’s going to try to set you up, and make statements that he can then bring up in court later.  He’s also feeling you out, finding out what makes you tick and where your buttons are at, if he can get you rattled.  No matter how cheerful you may both be during the deposition, he is the enemy.

One lawyer, in a recent article, outlined fifteen things to do to get you to slip up, to catch you off-guard.  One technique he suggested was to skip over the usual “What’s your name?” and “What are your credentials?” questions and head right to the heart of the matter.  The same attorney suggested asking nonsensical questions to tip you up, such as “Isn’t it true that you removed the wrong half of my client’s brain?”  They’re also advised to try to push your buttons during the deposition, to find out if they can get you flustered and what triggers it, so they can use that in the trial itself.  Any decent lawyer will have Googled you and found any documented skeletons you may possess.

The winning method in handling these questions is to start calm and remain so throughout the deposition.  Listen to each question, remaining cheerful as you respond to that question calmly and precisely.  If the attorney asks you about  a certain detail, answer about that detail, but offer no other information without being asked.  Don’t become argumentative or sarcastic, no matter what you see his question implying.  Stick to the question asked, and answer that specific question politely, regardless of the implication.  Remember, you had no ill intention.  The attorney is trying to find ways to get you to say you that you were negligent or irresponsible.  Don’t give him anything to work with.

Of course. your attorney should be present for any deposition, and you should not speak — on or off the record — to the patient’s attorney in any other circumstance.  If the attorney should contact you, refer him  (or her) to your attorney or insurance company, without giving any statement or reaction about the patient or case whatsoever.

The good part is that you’ve got your own attorney  who is also an experienced professional.  Your attorney will be familiar with these tactics and techniques, perhaps even a step or two ahead of the patient’s attorney.  So relax.   You’re in good hands.   When faced with a deposition, stay calm and stick to the facts, remember that you had no ill intent, follow your attorney’s instructions, and you’ll do just fine.

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Tags: deposition, malpractice