MyNORCAL, the policyholder-only section of norcalmutual.com/cpg, now allows CPG members to access their policy and billing documents online, greatly reducing the need to store — and later try to find — paper copies.

Password-protected MyNORCAL brings clinics round-the-clock access to policy and billing documents from new and renewed policies effective January 1, 2011, or later, as well as risk management resources and the latest policyholder news

CPG clinics can say goodbye to storing (and looking for) paper copies of their policy documents. With your MyNORCAL Log-In accounts, you can:

• View billing history and current roster.
• Generate and download policies and credentialing letters.
• See billing documents, including: invoices/billing statements, notice of cancellations, billing plan summaries and payment reminders.
• Review policy documents, including: declaration pages and endorsement forms.
• Make online bill payments with a credit card.
• Update address and/or contact information.
• Request claims loss runs.

And because it’s online, you can do all this when it’s convenient, from home or office.

If you do not already have a MyNORCAL Log-In, call Policyholder Services at (877) 443-7232 to receive the Client ID needed to create your account. A Policyholder Services representative will assist you in setting up the account.

As clinics transition to an electronic health record (EHR) system, the added capabilities and functionality of an EHR can tempt providers to delegate new duties to unlicensed assistive personnel such as medical assistants (MAs). Therefore, providers need to remember the limitations on scope of service of MAs, ensuring that MAs don’t exceed their appropriate range of tasks and responsibilities. An inappropriate delegation of duties creates medical liability risks, not only for the MA but also for clinicians and their clinics.

State Law and Medical Assistants

The line between what an MA may and may not do is often faint, and failure to observe the distinction can lead to serious problems for physicians and their patients. State law often dictates the general requirements for an MA’s scope of practice and should always be referenced to ensure the practice meets regulatory criteria.

For instance, in California, the requirements, derived from Business & Professions Code §2069, state that MAs may perform administrative and clerical functions, and with training and certification may also provide certain technical supportive services.

In Arizona, the MA scope of service is defined in Arizona Revised Statutes, Title 32, Professions and Occupations. Arizona Medical Board regulations regarding MAs are derived from these statutes.

New Mexico does not define the specific scope of service of the MA, but it is among the states that have specific regulations addressing the MA’s actions.

It is important to note that MAs are not licensed, nor are they trained and/or educated to do many things that licensed staffs are allowed to do. For example, in California MAs cannot give medical advice, interpret data, make diagnoses or perform procedures routinely done by a licensed clinician. When a patient is harmed as a result of an MA’s negligent treatment, the patient may bring claims against the supervising clinician and/or the clinic, not only for the MA’s negligence (vicarious liability), but also for negligent hiring, training and supervision (direct liability).

Clinical Scope of Service of MAs

When working with and supervising an MA, providers should keep in mind specific situations that can tempt an MA to act outside scope of service. For example, when rooming a patient an MA might make the clinical decision to obtain a urinalysis; while obtaining health information from the patient the MA might write an interpretation of clinical data; or when updating a patient record in the EHR the MA might add or delete a medication.

As most providers realize, in the case of EHRs there are many fields to complete that didn’t exist in the paper world. Completing these fields can take up a lot of time, tempting one to delegate entry duties to an MA. If, for example, an MA alters a medication, allergy, or problem list in the EHR — changes that require assessment, patient education, discussion, and evaluation — this pushes the task outside the MA scope and a liability issue may arise. Ensuring that such lists are reflected accurately in the EHR is the responsibility of the licensed clinician and should not be delegated to an MA.

Whether using an EHR or paper record, experienced MAs may be tempted to enter their own interpretation of a patient’s complaint rather than a verbatim record of what the patient states. Clinicians should train their MAs to record the patient’s complaint verbatim, rather than providing an analysis of what the patient may have said. There is a significant difference between “patient stated ‘I have pain every time I urinate’” and “the patient is here today for a urinary tract infection.” The latter entry implies that the MA is using his/her judgment to make a possible diagnosis, an action outside scope of service.

It is the licensed clinician’s responsibility to assess the patient, conduct the examination, make the diagnosis, prescribe any necessary medications, and write any orders for follow-up tests or treatment. In an EHR setting, a clinician is sometimes tempted to have an MA write, “pend” or “tee-up” an order that the clinician can later authenticate or approve. The danger, however, is that the MA will then deliver care based on the order before receiving such approval, in effect practicing medicine without a license.

Be mindful of your state’s regulatory restrictions. For example, even the most highly trained and experienced MA may not be allowed to follow condition-specific standing orders or written instructions, such as administering immunizations according to a general immunization schedule, but may be able to follow a patient-specific order.

Administrative Scope of Service for Medical Assistants

In addition to using MAs in the clinical setting, many practices use them for administrative tasks such as calling patients back with test results. While this is acceptable, there are some criteria to which your MAs should adhere.

When communicating test results, MAs should make sure they don’t say anything that could be interpreted as using medical judgment, making diagnoses, or discussing treatment options. For example, it is acceptable for MAs to state, “The physician asked me to tell you that your PSA is normal and that you should return for another PSA test next year.” But it would be inappropriate to say, “Your PSA is normal and you should return for a repeat PSA next year.” The latter implies that the MA (rather than the physician) is interpreting the results of the test and telling the patient the treatment plan. Alternatively, MAs can communicate test results by using a standard template letter or, if using an EHR, by using the available patient portal feature.

Additionally, MAs should not relay abnormal test results to patients without an authorization from a licensed clinician. For the same reasons, MAs should not answer health-related questions; instead, they should refer such questions back to the clinician.

Risk Management Recommendations

• State in writing the role and duties of the MA, ensuring that the duties are within scope of service. This information should be included in the MA job description and reviewed as part of new hire orientation and periodic performance review.
• Recognize the limitations on the roles of MAs. Use these professionals to the greatest benefit of the practice while maintaining safe patient care and avoiding liability exposure.
• Ensure that MAs document verbatim complaints from patients when entering complaints into the “Chief Complaint” section of the EHR. Offer staff training and education regarding appropriate medical record entries.
• Do not allow MAs to provide independent telephone advice or triage, as they are not legally authorized to interpret data or diagnose symptoms.
• Do not refer to MAs as “nurses,” or allow them to refer to themselves as such. They should always be identified as “medical assistants.”
• Under California law, a “health care practitioner” subject to regulation or licensure must disclose, while working, his or her name and “practitioner’s license status” on a name tag, with the license status in at least 18-point type, e.g:

• Ensure that your clinic system for prescription refills reflects proper physician supervision and does not allow MAs or any unlicensed staff to call in or authorize via the EHR a patient refill without direct, patient-specific physician authorization.
• In addition to direct observation of MA practice, conduct periodic medical record reviews to evaluate adherence by the MA and the supervising physician to MA scope of service.
• Include MA scope of service in orientation and training for new hires, as well as in regular staff meetings.

Conclusion

In this new era of EHRs, clinics can allow “scope creep” to occur by allowing too many duties to be delegated, perhaps inappropriately, to unlicensed assistive personnel. When deciding what can or cannot be delegated to unlicensed staff, keep in mind each person’s role on the healthcare team, their training and limitations, as well as state laws and regulations. With a thorough understanding of their roles and restrictions, and a concerted effort to communicate well with each other, the team can achieve healthy patients with good outcomes while reducing medical liability exposure.

Resources on training, supervision and documentation requirements of medical assistants can be found in CMA On-Call Document #1605: Medical Assistants (California publication), and in the Risk Solutions section of MyNORCAL, the policyholder-only section of NORCAL Mutual’s website. Also look for an upcoming 2011 Claims Rx that will focus on scope of practice issues.

One of a doctor’s most difficult tasks is disclosing an unanticipated outcome to a patient. Done poorly, it can aggravate the situation and increase the odds of a lawsuit. A new webcast from the NORCAL Group Risk Management Department recommends best practices for managing and disclosing an adverse event.

The goals of the webcast are to help providers handle a difficult situation as compassionately and safely as possible while reducing the risk of a malpractice claim. After explaining how to use informed consent properly to prepare patients for the possibility of such an event, the webcast goes on to describe the best way to disclose the event.

“An analysis of claims shows that the manner in which a patient learns of an unanticipated outcome influences subsequent actions,” explained Steve Farber, Vice President of Risk Management and Continuing Medical Education. “Through this webcast, we hope to see a positive impact on claims stemming from adverse events.”

The Nine Steps

The webcast breaks down disclosure into nine steps:

1. Take care of the patient.
2. Preserve the evidence.
3. Document the event.
4. Complete mandatory reports.
5. Notify the medical professional liability insurer.
6. Disclose the event to the patient.
7. Analyze the event.
8. Follow through with the patient.
9. Support the healthcare team.

The webcast can be accessed by CPG policyholders in MyNORCAL, the policyholder-only section of norcalmutual.com/cpg. Login to MyNORCAL, go to Risk Solutions, then to Claims Rx & MyCME.