September 21-22, 2018 • Grandover Resort • Greensboro, NC
2018 ANNUAL MEETING FRIDAY PRESENTATIONS
NORTH CAROLINA SOCIETY OF EYE PHYSICIANS AND SURGEONS
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
ComanagementOMIC Risk Management
Hans K Bruhn, MHS OMIC Risk ManagerNCSEPS
September 21, 2018
Disclosures
• Hans Bruhn: I have no financial interests to disclose.
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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
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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.
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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
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Question
• Do you have a written protocol and written guidelines?
• Comanagement consent?• Transfer of care agreement?
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Comanagement
• Federal Guidelines – No Safe Harbor for Cataract Surgery. Kickback concerns
• State Regulatory Requirements.• OIG Guidance • National Society Guidance.
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OMIC: Shared Care & Comanagement
• OD qualifications• Reason for comanagement• Role of the surgeon• Informed consent• Communication with the OD• Laws, regulations, rules
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Comanagement
• Federal Statutory Guidelines Regarding Comanagement Fee Structure
• Fee Guidelines Dictate Shared Care Responsibilities
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Comanagement
• STATE REGULATION- State board regulations of professional
behavior- Multiple state boards involved medical and
optometric - Specific surgeon requirements- Referral behavior and expectations
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Risk Management:Comanagement
• Obtain informed consent– Comanagement consent form – Written protocols with review of records– Credentialing process– Elements of protocol – “Comanagement of ophthalmic patients”
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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
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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.
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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.
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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 4/6/16.
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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.
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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.
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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.
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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.
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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.
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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 2nd
opinion. Seen same day: subacute profound vision loss w/in hours of bleph with fat excision.
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Case
• 4/14-22/16, no change. Referral to 3rd
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.
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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
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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.
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Case
• Verdict range: 700-900K, Settlement range 600-750K
• Surgeon non sued• Claim against group/entity
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Bilateral Blepharoplasty Question
• Claim outcome?• A B C D
DISMISS $700K $1.2M$450K
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Bilateral Blepharoplasty Question
• Claim outcome?• A B C D
$450K
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Comanaged LASIK
• 38 year old myopic female with astigmatism presented for LASIK evaluation.
• Optometrist noted dry eyes. • Punctal plugs declined by patient.
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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.
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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.
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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.
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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.
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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.
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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
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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
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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
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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
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Comanaged LASIK Question
• Claim outcome?• A B C D
DISMISS $50K $500K$250K
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Comanaged LASIK Question
• Claim outcome?• A B C D
$250K
Settled 1st day of
trial
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Comanaged LASIK
• Outcome • Settled for $250,000 on first day of trial
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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
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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
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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.
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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
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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.
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• 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
Comanaged Cataract Surgery
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Comanaged Cataract Surgery
Plaintiff Attorney Allegations:• Poor communication• No active or continued dialogue• No comanaging protocol• Poor oversight
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Comanaged Cataract Surgery Question
• Claim outcome?A B C D
DISMISS $75K $500K$250K
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Comanaged Cataract Surgery Question
• Claim outcome?A B C D
$75K
Oph.
$79K
OD50
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.
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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.
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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
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Comanaged Glaucoma
• Poor communication• No examination of optometrist’s skills• Poor oversight by ophthalmologist
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Comanaged Glaucoma Question
• Claim outcome?• A B C D
DISMISS $50K $500K$250K
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Comanaged Glaucoma Question
• Claim outcome?• A B C D
$250K
OD
Oph. dismissed
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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
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Time CheckOne more case?
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Shared CareNot
Abrogated Care
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Glaucoma-Retina
• GLAUCOMA EVALUATION• 66-year-old female• 25-year history of advanced
uncontrolled chronic angle closure glaucoma
• 10 degree islands
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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)
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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
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Glaucoma-Retina
• RETINA• Lensectomy/vitrectomy to reverse
aqueous misdirection• Operative note: found choroidal
detachment• Surgery stopped due to
suprachoroidal hemorrhage• Final outcome: Enucleation
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Glaucoma-Retina
Plaintiff allegations• Glaucoma specialist (non-OMIC) and
retina specialist (OMIC) BOTH SUED for misdiagnosis and unnecessary surgery
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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
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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”
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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
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Glaucoma -Retina
• Claim Outcome?• A B C D
$200K
(Settlement)
Retina
Unknwn for Glaucoma
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Thank You!
OMIC insureds: Be sure to complete an attendance form to
receive your OMIC premium discount of 10%
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Burnout & Resilience
From Surviving to Thriving
Jullia Rosdahl MD PhDDuke Ophthalmology
NCSEPS 2018 Annual Meeting1
I feel burned out from my work
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I have become more callous towards people since I took this job
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I feel burned out from my work
I have become more callous towards people since I took this job
1 time per week = BURNOUT
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National & State‐levelHealth CareEnvironment
Local Organization & Culture
(including EMR)
Ourselves
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https://performancemanagementcompanyblog.wordpress.com/tag/lego‐and‐square‐wheels‐illustrations/ 10
Skills for Well‐being
Karen Kingsolver PhD
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Paying attention in a particular way:
on purpose, in the present moment, and non‐judgmentally.
Jon Kabat‐Zinn
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Positive
Negative
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“No problem can be solved from the same level of
consciousness that created it.”
Albert Einstein
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Instructions1. Complete the self‐
assessment wheel(s).2. Where is your tire flat?
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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,Attainable
We can use the Farmers Market Food 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.
Instructions1. Focus area? Something
you want to change?2. Make a SMART goal
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BreatheCreate Positivity
Activated?
Connect
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[email protected]@DrJulliaEyeMD
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