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Method and Medium
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Original Release Date: November 15, 2017
Expiration Date: December 1, 2019
Learning Objectives
By reviewing medical professional liability claims and/or emerging topics in healthcare risk management, this enduring material series will support your ability to:
Assess your practice for risk exposures.
Apply risk management best practices that increase patient safety and reduce medical professional liability claims.
Target Audience
All primary care clinicians, healthcare staff and administrators.
Credit Designation Statement
NORCAL Mutual Insurance Company designates this enduring material for a maximum of 1 AMA PRA Category 1 CreditTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Disclosure Policy
As an ACCME accredited provider, NORCAL Mutual Insurance Company requires planners, reviewers or authors who influence or control the content of a CME activity to disclose financial relationships (of any amount) they have had with commercial interests associated with this CME activity during the year preceding publication of the content.
Any identified conflicts of interest are resolved prior to the commencement of the activity.
Disclosures
Individuals involved in the planning, reviewing or execution of this activity have indicated they have no relevant financial relationships to disclose.
Primary care physicians are named as defendants in the majority of NORCAL closed claims involving patients with diabetes.
According to the Centers for Disease Control and Prevention (CDC), in 2015, 23.1 million Americans had a diabetes diagnosis.1 That was 7.2% of the population, and the percentage keeps increasing. In 1958, the percentage of the population with diagnosed diabetes was just under 1%; by 1980, it was 2.5% and by 2000, it was 4.4%.2 Projections for the future are grim. For example, a recent study estimated the prevalence of diabetes will increase by 54% to more than 54.9 million Americans between 2015 and 2030.3 As the number of patients with diabetes increases, the number of professional liability claims will most likely increase proportionally.
These numbers should be particularly alarming to primary care physicians, who will most likely be responsible for treating and coordinating the care of diabetic patients.4 Their central role in diabetes treatment most likely explains why primary care physicians are named as defendants in the majority of NORCAL closed claims involving patients with diabetes.
This article provides strategies for primary care practices to assess their office systems, treatment protocols and communication methodologies, with the goal of making changes to improve quality of care for diabetic patients and decreasing liability exposure for the physicians who treat them.
Increasing Patient Adherence to Treatment Recommendations
Failure to adhere to treatment recommendations plays a role in many NORCAL claims involving patients with diabetes. It can be frustrating for physicians when nonadherence is a component of the patient's injury that has prompted a lawsuit. Policyholders often ask NORCAL risk management specialists about the degree to which patients are responsible for their care. How much "hand-holding" is necessary? It varies from patient to patient, depending on the complexity of their situation and their ability to comply. For example, health literacy, inability to pay for treatment and low patient engagement may all contribute to a patient's failure to adhere to diabetes treatment recommendations. In a malpractice suit, patient nonadherence often becomes an aspect of damages calculation. For example, the damages award may be reduced by the percentage of the injury caused by the patient's nonadherence. But a key to risk management and patient safety is to keep things from getting that far. One way to reduce the risk of diabetes-related injury and to keep patients from filing lawsuits against their primary care physicians is to get patients engaged and activated so they can do a better job of taking care of themselves.
Patient Engagement and Activation
Engaged patients are more likely to have better outcomes5 and greater satisfaction with their healthcare experience.6 Satisfied patients are less likely to file malpractice lawsuits.7 Patient engagement is defined broadly. It can generally be summarized as a combination of a patient's sense of confidence or empowerment along with a healthcare provider's interventions designed to promote desired patient behavior.8 Patient activation is the patient's motivation, knowledge, skill and confidence to consistently maintain and improve his or her health and healthcare.9 The most commonly used measure of patient activation level is the Patient Activation Measure® ® (PAM® ®), a tool that requires licensing for a fee.6 (PAM® has been identified as a Merit-based Incentive Payment System (MIPS) measure within the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA.). Increased patient activation indicates improvements in care quality, which can be used to earn performance-based positive payment adjustment.10) There are limited alternatives to the PAM® for measuring a patient's knowledge, skill and confidence to manage their health and healthcare, for example, the Self-efficacy to Manage Chronic Disease Scale, which is available for no fee at: www.selfmanagementresource.com/... (accessed 9/29/2017). Measuring a diabetic patient's activation level using tools such as these provides a physician with a sense of how much help the patient needs to achieve sufficient activation and engagement, and allows for the adjustment of work flow accordingly.
The greater a patient's confidence and empowerment to manage their health and healthcare, the more likely he or she is to engage in preventive healthcare and healthy behavior (e.g., eating a healthy diet, getting regular exercise) and avoid unhealthy behavior, such as smoking. Chronically ill patients with higher activation levels are more likely to comply with treatment recommendations and engage in self-care. It should not be surprising that a recent study of diabetic patients found that patients with higher PAM® scores were more likely to perform foot checks, obtain eye examinations and exercise regularly.11 Although patients present to healthcare encounters with various levels of activation, studies have shown that optimal communication and collaboration, and using targeted interventions, can significantly increase activation levels, and thus improve health outcomes.12,13,14,15
In the following case, it is safe to assume that the diabetic patient was not engaged and most likely had a low patient activation level. For this type of patient, it is imperative to provide ongoing self-management education, including weight loss strategies, physical activities, glycemic control strategies and other diabetes-related self-care. Of course, more time must be spent with a low patient activation level patient, but not all patients will have low patient activation levels. Therefore, it is important to identify the patients with low patient activation and devote more attention to them. Consider which strategies could have been used to achieve a better outcome.
Case One
Allegation:
Negligent management of diabetes resulted in renal failure.
A 47-year-old female patient who was taking insulin and metformin to control her diabetes started treating with a family physician (FP) in 2005. Her presenting blood glucose was 220 (her target range was 70-130); therefore, the FP increased the patient's metformin and decreased the insulin dose. The physician provided the patient with home blood sugar testing supplies, referred the patient to a diabetes education program and ordered blood tests. During the next six years, the patient presented only when she had a health complaint. The FP regularly ordered blood tests and made recommendations about diet and exercise, but the patient never followed through. The FP refilled the patient’s diabetes prescriptions on a regular basis.
In 2011, the patient had her blood tested. Her blood glucose was 280 and HbA1C was 9.3 (her target range was <7). The FP did not document discussing the abnormal results and did not make any changes to the patient’s medications. Over the next two years nothing changed in the way the FP managed the patient or in the way the patient managed her diabetes - she took the prescribed medication, but nothing else.,
In August 2013, the patient presented for peripheral numbness in her hands, which the FP attributed to diabetic neuropathy. He prescribed gabapentin and ordered blood tests. Her blood glucose level was 270, BUN was 33 (normal is 7-20 mg/dL) and creatinine was 2.6 (normal is 0.6 to 1.1 mg/dL for women). The FP did not document discussing the abnormal results with the patient.
In May 2014, the patient was taken to the emergency department (ED) by ambulance after she collapsed at work. The ED admitting diagnosis was chronic renal insufficiency due to diabetes, azotemia and renal failure. The patient thereafter required dialysis and was told she would eventually need a kidney transplant. The patient sued the FP, alleging the FP’s failure to monitor her kidney function was below the standard of care and resulted in kidney failure.
Citing the longitudinal follow-up as disorganized and sporadic, experts who reviewed this case could not support the FP's prescription of diabetes medications with no baseline labs or information concerning potential adverse effects on the patient's kidney function. They also believed the medical records were not only sparse but failed to document the FP's thinking and care planning.
In his defense, the FP testified he instructed the patient to make regular appointments and follow up on ordered blood tests, but she failed to do so. The FP also believed he would have talked to the patient about her kidney disease, when her blood tests in 2013 indicated it. However, the patient testified the FP had never suggested a set schedule for appointments. She also denied the FP regularly ordered blood tests and claimed she was never informed of the risks of nephrotoxicity and was never told she had kidney disease. Her responses to questions during deposition indicated her general ignorance about effective diabetes self-care. Unfortunately, the patient's side of the story was consistent with the FP's medical record, which did not indicate efforts to establish regular visits or increase the patient's adherence to a diabetes management regimen. Defense experts conceded the patient shared responsibility for her outcome, but her inability to be engaged in follow-up and better self-care was exacerbated by the FP’s minimalist approach to management.
Defense experts believed the defense of the case would depend heavily on how well the FP could explain the patient's history of nonadherence and his efforts at counseling the patient on diabetes management and risks of nonadherence. Having a well-documented medical record to back up a defendant physician's testimony is preferable to relying on the physician's recall.
The patient must be an active participant in meeting diabetes management goals. Helping patients play an active role in their healthcare is a key aspect of improving patient engagement. Consider the following recommendations to gauge and increase activation, engagement and adherence among diabetic patients:6,16
Educate patients about diabetes, diet changes, exercise, the risks of nonadherence and other aspects of the disease and its treatment.
Discuss the role that patient behavior plays in diabetes management, including why medication and self-care are necessary.
Confirm comprehension by asking patients to repeat back instructions in their own words (e.g., "We talked a lot about how to measure and record blood sugar. I want to make sure I explained this clearly. When you are at home, how will you measure and record your blood sugar?").
Numerous teach-back resources are available online; for example, the Always Use Teach-Back! Toolkit describes principles of plain language, teach-back, coaching, and system changes necessary to promote consistent use of teach-back and includes videos of clinicians using teach-back. It can be accessed at: teachbacktraining.org (accessed 9/29/2017).
Document education given and patient responses regarding self-help recommendations and improvement strategies.
Help patients identify their own concerns and challenges regarding treatment and self-care.
Use motivational interviewing techniques.
Various motivational interviewing resources are available online, including: www.aafp.org/... (accessed 9/25/2017).
Provide ample opportunities to ask questions.
Before moving to another topic, ask the patient about other concerns and questions about the information you have just covered.
Instead of asking the patient, "Do you have any questions?" Try asking, "What questions do you have?"
Help patients feel comfortable about asking questions.
Use "Ask me 3," a National Patient Safety Foundation educational program intended to help patients better understand their health. Implementation tools are available at: npsf.org/... (accessed 9/25/2017).
If a language barrier exists, offer to provide an interpreter.
Document that an interpreter was offered, as well as the name of the interpreter and his or her relationship to the patient.
Quantify patient motivation and ability to be engaged in diabetes management by using a measurement tool such as PAM® (www.insigniahealth.com/... (accessed 9/25/2017)) or the Self-efficacy to Manage Chronic Disease Scale (www.selfmanagementresource.com/... (accessed 9/25/2017)).
Make adherence with treatment and self-care recommendations as easy as possible, particularly for patients who have low activation levels, low health literacy levels or in other ways struggle with adherence.
Whenever possible, arrange for laboratory tests onsite and on the day of the appointment.
Have staff meet with less activated patients prior to their appointment to help formulate questions for the clinician and after the appointment to discuss and review medications and other treatment recommendations. (The NORCAL Communication Template can be used to facilitate this conversation.)
When discussing self-care, demonstrate the skill (e.g., monitoring blood sugar, administering insulin, or documenting diet and exercise habits), then watch the patient perform the task to ensure comprehension.
Because patients understand and learn in different ways, supplement discussions with diagrams, models, pictures and demonstrations.
After obtaining the patient’s consent to do so, include family members in discussions and education. Ensure these individuals understand firsthand the scope of the patient’s condition and the importance of self-care. Patients may minimize their disease in reporting it at home to family members after the physician appointment.
Propose self-care improvements in small steps — success is an important aspect of increasing activation level.
If patient documentation of diet and exercise habits is part of the treatment plan, ensure the process is not intimidating (e.g., emphasize self-awareness, progress and challenges rather than spelling and grammar, or the need for lengthy documentation).
Supply the patient with resources appropriate to their circumstances (e.g., activation, literacy, financial ability, goals, etc.).
Monitor patient success with treatment and self-care recommendations.
Help patients discover the best option for recording blood glucose monitoring that is easy enough for them to use and also organizes the data in a way that is easy to interpret.
The American Association of Diabetes Educators recently published its "Guide to Blood Glucose Meter Selection and Monitoring for Accuracy and Safety," which is available at: diabeteseducator.org/... (accessed 9/25/2017).
If a patient's report of adherence is not resulting in improvement, try to determine whether the patient is performing the task correctly and provide further training as necessary.
Regularly revisit treatment and self-care recommendations and determine if modifications are necessary.
Help the patient explore why interventions are not working and how to take action.
For example, instead of asking the patient, "Are you exercising?" or "Are you watching your sugar intake?" Ask open-ended questions that cannot be answered with a "yes" or “no” answer, for example, "What have you tried for exercise?" or "What worked?" or "What didn’t work?"
Document the patient's adherence to recommended treatment.
Include in every progress note a brief statement about the patient’s adherence to diet, exercise, glucose monitoring and medication.
Quantify the degree of adherence to each aspect of the patient's diabetes care regimen by using percentages or number of days per week, asking the patient to estimate these measures.
Include which issues were addressed; how well the patient understood his or her diagnosis and instructions for self-care, follow-up, tests or medication regimens; and your decision-making rationale.
Confirm patient understanding of the risks of nonadherence.
Take advantage of the wealth of resources available online for diabetes management, including:
National Institute of Diabetes and Digestive and Kidney Diseases. "Medication Adherence: Resources for Health Care Teams" Available at: www.niddk.nih.gov/... (accessed 9/25/2017).
National Institute of Diabetes and Digestive and Kidney Diseases. "Guiding Principles for the Care of People With or at Risk for Diabetes" Available at: www.niddk.nih.gov/... (accessed 9/25/2017).
National Diabetes Education Program (NDEP) Practice Transformation website Available at: www.niddk.nih.gov/... (accessed 9/25/2017).
Diabetes Clinical Guidelines
Use diabetes clinical guidelines to develop strategies for screening, prevention and management of diabetes policies and procedures, for example:
American Academy of Family Physicians: "Management of Newly Diagnosed Type 2 Diabetes Mellitus in Children and Adolescents" Available at: www.aafp.org/... (accessed 9/25/2017)
American Association of Clinical Endocrinologists and American College of Endocrinology: "Consensus Statement by the American Association of Clinical Endocrinologists and American College of Endocrinology on the Comprehensive Type 2 Diabetes Management Algorithm – 2017 Executive Summary" Available at: www.aace.com/... (accessed 9/25/2017)
American College of Physicians: "Oral Pharmacologic Treatment of Type 2 Diabetes Mellitus: A Clinical Practice Guideline Update from the American College of Physicians" Available at: annals.org/... (accessed 9/25/2017)
American Diabetes Association: "2017 Standards of Medical Care in Diabetes" Available at: professional.diabetes.org/... (accessed 9/25/2017)
American Heart Association: "Update on Prevention of Cardiovascular Disease in Adults With Type 2 Diabetes Mellitus in Light of Recent Evidence: A Scientific Statement From the American Heart Association and the American Diabetes Association" Available at: circ.ahajournals.org/... (accessed 9/25/2017)
Endocrine Society: Clinical Practice Guidelines Available at: www.endocrine.org/... (accessed 9/25/2017)
Low Health Literacy and Diabetes Education
Patients with low health literacy and numeracy (the ability to apply numerical concepts) can have difficulty converting traditional diabetes education programs and materials into effective self-care.i Low health literacy predisposes an individual to being labeled a "difficult" patient and can contribute to a patient's decision to file a malpractice lawsuit in the event of a negative clinical outcome.ii,iii Various behaviors may appear to be willful nonadherence, but may actually indicate that a patient is having difficulty understanding healthcare instructions and recommendations. For example, signs of low health literacy include:iv
Returning incomplete or inaccurate patient information forms
Frequently missing appointments
Not complying with medication directions
Failing to follow up with referrals and tests
When presented with printed materials, claiming to have forgotten reading glasses; asking the physician to read materials; promising the material will be read at home; or claiming the materials need to be taken home so they can be discussed with a family member
Looking at the color and shape of medications to identify them, instead of reading the name on the label
Not knowing the reason for taking a particular medication
Being unable to explain how and when to take a medication
Health literacy can be assessed as part of the diabetic work-up. This assessment can be administered by a medical assistant while he or she is taking vital signs. To take the test, the patient reads an ice cream label and answers some questions about it. The test, background and scoring sheet is available at no cost at: www.pfizer.com/... (accessed 9/25/2017).
There are a great variety of resources available for effectively communicating with patients with limited health literacy. For example, the Diabetes Literacy and Numeracy Education Toolkit (DLNET) is a 24-module resource to facilitate communication between patients and clinicians to promote effective diabetes learning and self-care. Module topics include blood glucose monitoring, medication administration and dietary instructions. The toolkit is available at: www.ncbi.nlm.nih.gov/... (accessed 9/28/2017).
For general health literacy training, NORCAL policyholders can also access the NORCAL CME Webinar entitled "Health Literacy: Making Patients Safer Through Understanding" in MyACCOUNT.
Resources
i. Wolff K, Cavanaugh K, Malone R, et al. The Diabetes Literacy and Numeracy Education Toolkit (DLNET): Materials to facilitate diabetes education and management in patients with low literacy and numeracy skills. The Diabetes Educator. 2009;35(2):233-245. Available at: www.ncbi.nlm.nih.gov/... (accessed 9/30/2017).
ii. American Medical Association. Health literacy and patient safety: Help patients understand. 2007. Available at: www.pogoe.org/... (accessed 9/28/2017).
iii. Lindsey H. Facing the Difficult Issue of Potentially Litigious Patients. Oncology Times. 2007 Feb 10; 29(3):40-42. Available at: journals.lww.com/... (accessed 9/30/2017).
iv. Cornett S. Assessing and Addressing Health Literacy. OJIN. 2009 Sep 30; 14(3). Available at: www.nursingworld.org/... (accessed 9/30/2017).
Adherence and the Cost of Diabetes Management
It can be difficult for patients to be engaged in their diabetes management when they cannot afford medications and supplies. In one study, almost one in five adults aged 45 to 64 with diabetes reported having reduced or delayed medication to save money in the last year.v Therefore, it is important to find a way to discuss treatment cost and to provide alternatives to those patients in need. Consider the following strategies:vi,vii,viii
Learn how to recognize patients at risk. For example, patients who are low income, uninsured, historically noncompliant with medications, have high co-pays, complain about the cost of medication or take multiple medications for chronic diseases are more likely to have difficulty affording medications.
Find nonjudgmental and empathetic ways to ask if the cost of the medication will keep the patient from taking it as prescribed. (Of patients who are noncompliant because of medication cost, 66% never mention it because they weren’t asked.ix)
If you suspect or are informed that a medication will be financially prohibitive, help the patient obtain the medication at a lower cost.
If the patient has a prescription drug plan, consider prescribing drugs that are "preferred."
Consider prescribing a generic version of a medication.
Encourage the patient to comparison shop to find their medications at the lowest cost.
Prices can vary significantly between pharmacies. Various websites provide medication price comparisons; for example, these two websites show the price of a medication at various pharmacies within a designated zip code.
Document your offer of assistance in the medical record.
Even when a patient's inability to pay for a particular treatment is clear, it is important to make recommendations for care based on the standard of practice and clinical guidelines, rather than the patient's ability to pay.
Resources
v. Lawrence L. Adult diabetic medication adherence tied directly to financial issues. Medical Economics. 2017 Aug 1. Available at: medicaleconomics... (accessed 9/29/2017).
vi. Heisler M, Wagner TH, Peitte JD. Clinician identification of chronically ill patients who have problems paying for prescription medications. Am J Med. 2004;116(11):753-8. Available at: www.amjmed.com/... (accessed 9/29/2017).
vii. Rx Partnership and the Virginia Pharmacists Association. How to recognize and help patients who are uninsured or underinsured access medication. Virginia Pharmacist. 2010 May/June. Available at: learning.rxassist.org/... (accessed 9/29/2017).
viii. Newman KL, Varkey J, Rykowski J, Mohan AV. Yelp for Prescribers: A Quasi-Experimental Study of Providing Antibiotic Cost Data and Prescription of High-Cost Antibiotics in an Academic and Tertiary Care Hospital. J Gen Intern Med. 2015 Aug;30(8):1140-6. Available at: www.ncbi.nlm.nih.gov/... (accessed 9/29/2017).
ix. Piette JD, Heisler M, Wagner TH. Cost-Related Medication Underuse: Do Patients with Chronic Illnesses Tell Their Doctors? Arch Intern Med. 2004;164(16):1749-55. Available at: jamanetwork.com/... (accessed 9/29/2017).
Preventing and Managing Diabetes Complications
Diabetic foot ulcer (DFU) is the most common complication of diabetes.17 It can also be the most costly and devastating if not properly managed. Prevention is optimal, but proper management of DFU can greatly reduce the severity of DFU complications, for example amputations and death.17 The endocrinology expert who reviewed the following case noted that the progression of diabetes to DFU to amputation was a textbook illustration of the ravaging effects of diabetes if left uncontrolled.
Case Two
Allegation:
Negligent management of diabetes and foot ulcers resulted in amputation.
On June 1, 2014, a 52-year-old woman with a family history of diabetes presented to a FP as a new patient for an annual physical. Blood was drawn for various tests. The patient’s postprandial glucose was 200 mg/dL (normal is <140). The FP sent the patient a letter summarizing her test results and instructed her to have her blood glucose tested one more time to determine whether she had diabetes. On June 20, the patient had blood drawn for the repeat blood glucose test. This time, the patient's postprandial glucose was 230 mg/dL. The results were reported to the FP, but the FP never reported the results to the patient or initiated treatment. The patient was seen various times during 2014 and 2015 for specific medical issues. The glucose test results never came up during the visits, and the patient assumed that she did not have diabetes.
Two years later, on July 1, 2016, the patient presented with a large, deep ulcer on the outside of her heel and two blisters on her instep. She told the FP that a new pair of shoes had given her blisters on the outside of her heel a few weeks earlier. The blister had turned into the deep ulcer. She could not explain the blisters on her instep. They had simply appeared. The FP prescribed Cipro and advised foot soaks two times per day. At this appointment, the FP realized the patient had never been treated for diabetes and, therefore, prescribed metformin and referred the patient for diabetes counseling. Blood test results from this date were consistent with significant infection and uncontrolled diabetes.
The patient returned for follow-up on July 3. She complained the ulcer on the outside of her foot was draining foul-smelling liquid. There were also two new blisters on the top of her foot, and her whole foot was swollen. She received an antibiotic injection and was told to stay off her foot and continue foot soaks.
The FP documented improvement in the heel ulcer and recommended follow-up in one week. At the follow-up appointment on July 10, the FP debrided the wound and took a culture, which would later grow out gram negative rods and anaerobic bacteria. The FP referred the patient for a surgical evaluation the following day. On July 11, the consultant surgeon diagnosed gangrene and sent the patient to the hospital for IV antibiotics and debridement. The patient was immediately taken to surgery, where it was determined her foot could not be salvaged and an above-the-knee amputation was performed.
There were a number of issues that complicated the defense of this claim. Primarily, experts believed the diabetes treatment delay of two years and the delay in referring the patient to the hospital for wound treatment were breaches of the standard of care, and these breaches caused the amputation. More specifically, the standard of care required the FP to inform the patient that she had diabetes in June 2014, and to initiate diabetes treatment with a combination of diet, exercise, glucose monitoring and medication. Since the patient had been compliant with diet and medication when she was finally advised that she had diabetes in 2016, it could be assumed that she would have been compliant in 2014. If the patient's diabetes had been under control, her original blisters most likely would not have progressed to gangrene, because they would have been treated earlier and more aggressively and would have been more responsive to antibiotics. Furthermore, experts believed that the patient should have been referred to the hospital for surgical debridement and intravenous antibiotics no later than July 3, 2016. By the time the patient was finally hospitalized on July 11, 2016, the amputation was inevitable.
Follow-Up
Evidence of absent or inadequate follow-up systems or poorly utilized systems can be used to support negligence allegations and to shed a generally negative light on defendant clinicians and their practices during malpractice litigation. Depending on the size of the practice, clinicians may only be peripherally involved in setting up and maintaining the systems aspects of follow-up. However, clinicians play a crucial role in the follow-up process.
Clinicians
There are a variety of things clinicians can do to ensure patients receive diagnoses and treatment in a timely manner. Consider the following recommendations:18,19
Ensure patients understand the importance of follow-up tests, consultations and appointments.
When ordering tests, tell patients approximately how long it will take to obtain results and advise them to call by an appropriate date if they have not been advised of the results.
Requesting the patient's involvement in follow-up should enhance, not replace, the office follow-up system.
When a result is received, review, initial and date it or, if using an electronic health record, note the receipt electronically, note what action is required or has been implemented and ensure the recommended action is entered into the follow-up system.
Document in the patient's medical record that the patient was notified of results, and, if abnormal, the recommended interventions.
Review the patient's medical record when he or she presents for problem visits to ensure any new patient information that has been entered into the file since the patient's last visit is considered when providing treatment.
Administrators
Follow-up is not complicated, but it does require a concerted effort to create a reliable system. Consider the following recommendations:
Develop standardized procedures/workflows that ensure a consistent follow-up care and tracking system is in place to monitor test results and consultant reports and to reconcile incomplete tasks.
Establish with the laboratory how long it will take to provide results and use this time frame when developing a follow-up system.
Utilize a tracking mechanism to compare all tests ordered with the corresponding results.
Implement a system that ensures test results are reviewed and acted upon by a clinician and communicated to the patient or other clinician when appropriate before they are filed.
Contact patients who fail to schedule follow-up tests or appointments. Enter new due dates into the follow-up system.
Fully utilize follow-up tools in the EHR.
Train clinicians and staff on EHR features that can facilitate follow-up and tracking.
Ensure ongoing EHR training and optimization resources are available to clinicians on a regular or as needed basis.
Diabetic Foot Care
Providing foot care services and preventive care can reduce the risk of amputation among patients with diabetes, but studies indicate that adequate attention is not being given to the feet of diabetics in the primary care setting.20 This may be caused in part by sensory loss due to neuropathy, which may mask the early signs of infection, skin breakdown and ulcer formation.20 Consequently, clinicians should not rely on their diabetic patients to prompt foot care services. Consider the following:17,20
Flag diabetic patients' medical records in an obvious way so that foot care is less likely to be overlooked.
Stratify patient risk for diabetic foot complications on a regular basis. For example, review the patient's diabetic history, blood glucose control, previous diabetic complications, history of peripheral vascular disease, quality of peripheral protective sensation and previous lower-limb interventions and operations.
Carefully inspect diabetic and suspected diabetic patients' feet at every visit.
Consider using the strategies outlined in "How to Do a 3-Minute Diabetic Foot Exam" (available at: diabetesed.net/...)
Integrate foot care education into diabetic self-care education, for example:
Ensure patients are aware of risk factors and the importance of foot care, including the need for self-inspection, monitoring foot temperature, appropriate daily foot hygiene and proper footwear.
Explain how inadequate blood sugar control can increase the frequency and morbidity of limb-threatening complications. (Inadequate control of blood sugar is the primary cause of diabetic foot ulcers.17)
Keep up-to-date on advancements in wound treatment and dressings.
Know when to refer the patient for wound treatment with a specialist, surgical intervention or hospitalization for antibiotic treatment.
Diabetes management can be a major aspect of a primary care physician's practice. As the number of patients with diabetes increases, it is likely that professional liability risk exposure caused by diagnosis failures of diabetes and diabetes-related illness will also increase. Therefore, it is important for primary care physicians to proactively inspect and improve existing office systems and treatment protocols in ways that will increase patient safety and decrease liability risk.
The NORCAL documents referenced in this article, along with many other Risk Management Resource documents and past editions of the Claims Rx, are available in the Risk Solutions area of MyACCOUNT, or by policyholder request at 855.882.3412.
Centers for Disease Control and Prevention (CDC). National Diabetes Statistics Report, 2017. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Dept of Health and Human Services; 2017. Available at: www.cdc.gov/... (accessed 9/25/2017).
CDC Division of Diabetes Translation. Long Term Trends in Diabetes. 2017. Available at: www.cdc.gov/... (accessed 9/25/2017).
Rowley WR, Bezold C, Arikan Y, Byrne E, Krohe S. Diabetes 2030: Insights from Yesterday, Today, and Future Trends. Population Health Management. 2017;20(1):6-12. Available at: www.ncbi.nlm.nih.gov/... (accessed 9/25/2017).
Freeman JS. The increasing epidemiology of diabetes and review of current treatment algorithms. J Am Osteopath Assoc. 2010;110 (Suppl 7):eS2-6. Available at: jaoa.org/... (accessed 9/25/2017).
Hendriks M, Rademakers J. Relationships between patient activation, disease-specific knowledge and health outcomes among people with diabetes; a survey study. BMC Health Services Research. 2014;14:393. Available at: www.ncbi.nlm.nih.gov/... (accessed 9/25/2017).
Hibbard JH, Gilburt H. Supporting people to manage their health: An introduction to patient activation. 2014 May. Available at: www.kingsfund.org... (accessed 9/25/2017).
Fullam F, Garman AN, Johnson TJ, Hedberg EC. The Use of Patient Satisfaction Surveys and Alternative Coding Procedures to Predict Malpractice Risk. Medical Care. 2009;47(5):553-9.
Noteboom, MR. What does 'patient engagement' really mean? Healthcare IT News. 2015 May. Available at: www.healthcareitnews.com/... (accessed 9/25/2017).
Hibbard JH, Stockard J, Mahoney ER, Tusler M. Development of the Patient Activation Measure (PAM®): conceptualizing and measuring activation in patients and consumers. Health Serv Res. 2004;39(4 Pt 1):1005–26. Available at: www.ncbi.nlm.nih.gov/... (accessed 9/25/2017).
Insignia Health. PAM®, MACRA and MIPS Fact Sheet. 2017. Available at: s3-us-west-2.amazonaws.com/... (accessed 9/25/2017).
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