FRIDAY HANDOUTS. September 21-22, 2018 Grandover Resort Greensboro, NC NORTH CAROLINA SOCIETY OF EYE PHYSICIANS AND SURGEONS 2018 ANNUAL MEETING

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1 NORTH CAROLINA SOCIETY OF EYE PHYSICIANS AND SURGEONS 2018 ANNUAL MEETING FRIDAY HANDOUTS September 21-22, 2018 Grandover Resort Greensboro, NC This continuing medical education activity is jointly provided by the North Carolina Society of Eye Physicians and Surgeons and Southern Regional Area Health Education Center

Comanagement OMIC Risk Management Hans K Bruhn, MHS OMIC Risk Manager NCSEPS September 21, 2018 Disclosures Hans Bruhn: I have no financial interests to disclose.

2 Comanagement OMIC Risk Management Hans K Bruhn, MHS OMIC Risk Manager NCSEPS September 21, 2018 Disclosures Hans Bruhn: I have no financial interests to disclose. 2 Risks of poorly comanaged patients Delay in diagnosis or treatment Difficulty in perceiving patterns Inadaquate evaluations of credentials. Failure to follow-up Patient confusion regarding direction of care. Lawsuits 3 1

Communication breakdown Communication top contributing factor of medical errors in Joint Commission study 70% of sentinel events At least 50% of these during hand-offs - Transfer of care is a

3 Communication breakdown Communication top contributing factor of medical errors in Joint Commission study 70% of sentinel events At least 50% of these during hand-offs - Transfer of care is a hand-off. 4 Objectives After participating in this presentation, ophthalmologists will be better able to: Develop guidelines for comanagement of patients Communicate needed information during patient hand-offs (providers) Manage patient expectations 5 Question Do you have a written protocol and written guidelines? Comanagement consent? Transfer of care agreement? 6 2

4 Comanagement Federal Guidelines No Safe Harbor for Cataract Surgery. Kickback concerns State Regulatory Requirements. OIG Guidance National Society Guidance. 7 OMIC: Shared Care & Comanagement OD qualifications Reason for comanagement Role of the surgeon Informed consent Communication with the OD Laws, regulations, rules 8 Comanagement Federal Statutory Guidelines Regarding Comanagement Fee Structure Fee Guidelines Dictate Shared Care Responsibilities 9 3

5 Comanagement STATE REGULATION - State board regulations of professional behavior - Multiple state boards involved medical and optometric - Specific surgeon requirements - Referral behavior and expectations 10 Risk Management: Comanagement Obtain informed consent Comanagement consent form Written protocols with review of records Credentialing process Elements of protocol Comanagement of ophthalmic patients 11 Shared Care Communication is critical Active dialogue and participation in care Define the roles of each individual Assure competence and training Review and inspect care 12 4

6 Case Bleph procedure, 62 y/o female Medical hx: depression, anxiety, smoker, hypertension, high cholesterol, diabetes and sleep apnea. Significant surgical hx: gallbladder, knee replacement, acid reflux and hysterectomy. 13 Case 12/15/15, eval for blepharoplasty. Corrected vision 20/25OD, 20/25 OS. Bilateral 3+dermachalasis, normal eyelids. Dx: bilateral dermachalasis upper lids. Discussion on etiology of condition, effect on visual field, risks & benefits of sx. 14 Case 1/27/16: consult with another ophthalmologist. Pt. c/o heavy eyelids and blocked vision. VF test indicates peripheral vision loss due to dermachalasis. 3/16/16 : Pre-op exam, pt on aspirin. Reviewed risks of anticoagulants. Sx set for 4/6/

7 Case 3/16/16 risks and possible complications discussed with patient. Consent signed for blepharoplasty. 4/6/16: Pre-op note, no meds taken that day. Uneventful bilateral upper lid surgery. Post op, advised no aspirin until next day, no pain, discharged same day. Med: Erythromycin ophthalmic solution 2x day. 16 Case 4/6: Patient contacted on call OD to note profuse bleeding left eye along suture line, nausea and vomiting. Pt. reported she could see, could open left eye, denied proptosis. No report of pain. Pictures from pt reviewed by OD and surgeon. OD calls back patient. 17 Case OD advised care companion to contact if signs of increasing hemorrhage. Ice packs and phenergan for nausea/ vomiting. Call back if decreased vision, proptosis and swelling. 4/8/16: Seen by OD with bleeding but no pain. Eye swollen shut, unable to examine the eye. NLP. Sent home, surgeon will contact, if she needs to be seen. 18 6

8 Case 4/8/16: Surgeon contacted by O.D. Surgeon does canthotomy and cantholysis, IOP 44 after these procedures. Diamox. IOP drops to 26. Left afferent papillary defect noted. Some light and movement from OS. Eye drops and Diamox. 19 Case 4/9/16: Surgeon sees the pt. No pain or nausea. Minimal bleeding at canthotomy site. Mild discomfort looking up. Pt. able to open left eye 5mm on her own. IOP 24. continue drops, Diamox increased. 4/11/16: Pt. examined by OD, NLP OS. Dx: Ischemic optic neuropathy, discussed w/ surgeon. 20 Case 4/12/16: pt examined by OD. No change, NLP OS. 4/13/16: Surgeon examines pt., no change, referred to another ophthalmologist for 2 nd opinion. Seen same day: subacute profound vision loss w/in hours of bleph with fat excision. 21 7

9 Case 4/14-22/16, no change. Referral to 3 rd ophthalmologist. 4/29/16: Brain MRI. Abnormal signal in white matter, moderate small vessel ischemic change of uncertain age. Mild thickening of left sinus. No evidence of intracranial aneurysm or arteriovenous confirmation. 22 Case Possible occlusion of distal left middle cerebral artery trifurcation branch vessel may indicate CVA of uncertain age. Patient advised on vision loss OS. 5/7/16: Pt. presented to ER, concern about infection OS. Hospitalized for periorbital cellulites OS, antibiotics given. Discharge on Keflex. 23 Case 5/11-5/16: pt concerned about possible right eye involvement. 5/16/16: Pt lost to followup. Damages: Initial demand: 1.2M 50% chance of defense verdict 24 8

Case Issues with care: OD (group) failed to communicate properly with the surgeon. Failure to notify the surgeon regarding extent of the bleeding. Poor follow up- no visit on day 1.

10 Case Issues with care: OD (group) failed to communicate properly with the surgeon. Failure to notify the surgeon regarding extent of the bleeding. Poor follow up- no visit on day 1. Relied on camera text imaging from pt. Comanaging optometrist not trained to treat blepharoplasty patients. Poor communication with the patient. 25 Case Verdict range: K, Settlement range K Surgeon non sued Claim against group/entity 26 Bilateral Blepharoplasty Question Claim outcome? A B C D DISMISS $700K $1.2M $450K 27 9

11 Bilateral Blepharoplasty Question Claim outcome? A B C D $450K 28 Comanaged LASIK 38 year old myopic female with astigmatism presented for LASIK evaluation. Optometrist noted dry eyes. Punctal plugs declined by patient. 29 Comanaged LASIK Two days later, bilateral LASIK performed without complications. No pre-operative evaluation by surgeon of dry eyes. Postoperative day 1. Seen by optometrist. C/o dry eyes and poor vision

12 Comanaged LASIK PO day 7, patient c/o dry eyes and poor vision artificial tears, no driving. PO day 13, patient c/o dry eyes and poor vision artificial tears every 30 minutes. 4 weeks postoperative, c/o dry eyes and poor vision- artificial tears. 3 months postoperative, c/o dry eyes and poor vision- lower eyelid punctal plugs. 31 Comanaged LASIK 5 ½ months postoperative c/o dry eyes and poor vision- artificial tears. 6 months postoperative c/o dry eyes and double vision upper eyelid collagen punctal plugs 6 ½ months postoperative-- Refuses to be seen by O.D. and demands to by seen by surgeon. 32 Comanaged LASIK Seven months post op surgeon examines patient. Dry eyes with double vision. Reinserts collagen punctal plugs. Returns patient to comanaging optometrist without long-term plan

13 Comanaged LASIK Two weeks later, patient c/o dry eyes and poor vision artificial tears. Two weeks later c/o dry eyes and poor vision, sent to a new comanaging O.D. Three weeks later (8 ½ months postoperative) c/o dry eyes and poor vision planned visit with surgeon but did not occur. 34 Comanaged LASIK Patient sought care elsewhere. Six weeks later, c/o dry eyes and poor vision no driving or work. Three weeks later (10 ½ months after surgery), c/o dry eyes and poor vision declines further follow up (bad sign). Last visit BCVA OD 20/70 OS 20/80 35 Comanaged LASIK Patient files suit Plaintiff expert felt needed better preoperative evaluation of tear film and detailed informed consent Expert witness: dry eye known complication 36 12

14 Comanaged- LASIK Poor communication - Initially regarding the dry eyes - Post op regarding patient complaints and response to treatment to surgeon. - Then - Post op by surgeon to the comanaging optometrist - With the patient regarding plan and prognosis 37 Comanaged- LASIK No initial surgeon evaluation No inspection of care Minimal active intervention post operatively by surgeon. Unqualified optometric care Poor consent process regarding dry eye. Poor Outcome 38 Comanaged LASIK Question Claim outcome? A B C D DISMISS $50K $500K $250K 39 13

15 Comanaged LASIK Question Claim outcome? A B C D $250K Settled 1 st day of trial 40 Comanaged LASIK Outcome Settled for $250,000 on first day of trial 41 Comanaged Cataract Surgery 80 year old male had cataract surgery and IOL OD PO day 1: No complications so care transferred to OD PO day 6: seen by comanaging OD. c/o pain. Increased steroids. RTC 2 weeks 42 14

16 Comanaged Cataract Surgery Two days later (PO day 8), patient s daughter asks surgeon to see her father. Surgeon diagnoses endophthalmitis and starts antibiotic treatment Next day, improved, so surgeon referred patient back to OD in 2 days Recall same OD had missed diagnosis 43 Comanaged Cataract Surgery Next day (PO day 10), patient called surgeon to report pain. Told to use Motrin and eye drops. Called back later same day to report improvement. Told to follow-up with OD, who saw him that day. 44 Comanaged Cataract Surgery PO day 15, went to E.R. with c/o poor vision and pain retained cortex, increase steroids. Seen that day by optometrist who noted improvement no dilation. PO day 17, saw retina specialist, VA HM, pseudomonas endophthalmitis. Final outcome VA HM 45 15

17 Comanaged Cataract Surgery Patient files suit Alleges surgery contraindicated with history of blepharitis Delay in diagnosis endophthalmitis by OD Negligent management of endophthalmitis by ophthalmologist and optometrists. 46 Comanaged Cataract Surgery DEFENSE EVALUATION Poor communication between surgeon and optometrist on multiple occasions. - Initial complaints misdiagnosed by OD not qualified. - F/U complaints and ER visit- misdiagnosis. Surgeon should have reviewed f/u plan dilation. Surgeon should have followed patient with endophthalmitis 47 Comanaged Cataract Surgery Plaintiff Attorney Allegations: Poor communication No active or continued dialogue No comanaging protocol Poor oversight 48 16

18 Comanaged Cataract Surgery Question Claim outcome? A B C D DISMISS $75K $500K $250K 49 Comanaged Cataract Surgery Question Claim outcome? A B C D $75K Oph. $79K OD 50 Comanaged Glaucoma 60 year old female with DM is evaluated by optometrist in group. Diagnosis: Cataracts, diabetic macular edema, rubeosis iridis, and narrow angles. Refer to M.D. in group in 2 months

19 Comanaged Glaucoma Patient no show for 2 month follow-up. MD indicates f/u on next available date. Four months after initial visit, patient presents emergently with pain VA LP, IOP 76 OS. MD notes neovascular glaucoma, angle closure, PDR, hyphema. 52 Comanaged Glaucoma Expert Analysis - MD and OD below SOC - Optometrist should have referred immediately - Physician should have reviewed chart and seen immediately after missed appointment 53 Comanaged Glaucoma Poor communication No examination of optometrist s skills Poor oversight by ophthalmologist 54 18

20 Comanaged Glaucoma Question Claim outcome? A B C D DISMISS $50K $500K $250K 55 Comanaged Glaucoma Question Claim outcome? A B C D $250K OD Oph. dismissed 56 Shared Care Communication is critical Active dialogue and participation in care Define the roles of each individual Assure competence and training Review and inspect care 57 19

21 Time Check One more case? 58 Shared Care Not Abrogated Care 59 Glaucoma-Retina GLAUCOMA EVALUATION 66-year-old female 25-year history of advanced uncontrolled chronic angle closure glaucoma 10 degree islands 60 20

22 Glaucoma-Retina Trabeculectomy performed OS PO day 4: IOP mid teens A/C formed but diffusely shallow Referred to retina with? diagnosis of aqueous misdirection (malignant glaucoma) 61 Glaucoma-Retina RETINA EVALUATION VA 20/30 OD, CF OS IOP 14 OD, 16 OS Filtered eye (OS) diffuse bleb Anterior chamber moderately shallow Ultrasound: Diagnosis? choroidal detachment 62 Glaucoma-Retina RETINA Lensectomy/vitrectomy to reverse aqueous misdirection Operative note: found choroidal detachment Surgery stopped due to suprachoroidal hemorrhage Final outcome: Enucleation 63 21

23 Glaucoma-Retina Plaintiff allegations Glaucoma specialist (non-omic) and retina specialist (OMIC) BOTH SUED for misdiagnosis and unnecessary surgery 64 Glaucoma-Retina PLAINTIFF EXPERT CONTENTIONS Glaucoma made wrong diagnosis: problem was over-filtering Retina should have known that choroidal detachment common after filtration surgery. Performed unnecessary surgery Surgery complications led to enucleation 65 Glaucoma-Retina RETINA DEFENSE EXPERT Initially supportive, later felt wrong diagnosis by glaucoma expert Sympathetic on referral to glaucoma expertise, and desire to save vision If choroidal detachment, need to wait due to bleeding risk caught between a rock and a hard place 66 22

24 Glaucoma-Retina OTHER PROBLEMS Missing operative report Letters to glaucoma had information and dates that differed from other records When record found, stated preoperative deep anterior chamber, mild choroidal detachment Felt would lead to credibility issues 67 Glaucoma -Retina Claim Outcome? A B C D $200K (Settlement) Retina Unknwn for Glaucoma 68 Thank You! OMIC insureds: Be sure to complete an attendance form to receive your OMIC premium discount of 10% 69 23

25 Burnout & Resilience From Surviving to Thriving Jullia Rosdahl MD PhD Duke Ophthalmology NCSEPS 2018 Annual Meeting 1 I feel burned out from my work 2 I have become more callous towards people since I took this job 3 1

26 I feel burned out from my work I have become more callous towards people since I took this job 1 time per week = BURNOUT

27 National & State level Health Care Environment Ourselves Local Organization & Culture (including EMR)

28 and square wheels illustrations/ 10 Karen Kingsolver PhD Skills for Well being

29 Paying attention in a particular way: on purpose, in the present moment, and non judgmentally. Jon Kabat Zinn Negative Positive 15 5

30 No problem can be solved from the same level of consciousness that created it. Albert Einstein

31 19 Instructions 1. Complete the selfassessment wheel(s). 2. Where is your tire flat?

example S Simple, Specific I want to stop eating out as much this year, to help my family eat more

R Realistic, Relevant The babysitter can help, if I can t get home in time.

32 example S Simple, Specific I want to stop eating out as much this year, to help my family eat more healthy M Measurable I will go the to Farmers Market 1 time per week and the kids will each pick out 1 vegetable to try. A Achievable, We can use the Farmers Market Food Attainable Truck that comes to the neighborhood. R Realistic, Relevant The babysitter can help, if I can t get home in time. T Time related, Trackable, Tangible I ll try this for 3 weeks and see how we did. Instructions 1. Focus area? Something you want to change? 2. Make a SMART goal Breathe Create Positivity + Activated? Connect 24 8

33 @DrJulliaEyeMD 25 9

FRIDAY PRESENTATIONS

NORTH CAROLINA SOCIETY OF EYE PHYSICIANS AND SURGEONS 2018 ANNUAL MEETING FRIDAY PRESENTATIONS September 21-22, 2018 Grandover Resort Greensboro, NC This continuing medical education activity is jointly