All community clinics maintain private information regarding their patients. While such information has always been subject to breaches, the increased use of computers and electronic data — especially electronic medical records — exposes clinics to greater risk.

To better serve our policyholders, NORCAL Mutual has initiated a new coverage enhancement for CPG clinics at no extra premium that will protect policyholders from information, computer and network risk.

Effective April 1, 2011, DataShield™ provides substantial protection from the growing risks associated with information technology and patients' personal health information. It will be added to the policies of all CPG clinics.

Each clinic's coverage will have a $50,000 limit per covered event and a $150,000 annual aggregate limit.*

• Information & network security liability — Protection against claims alleging unauthorized release of personal information, violations of information privacy law, or unauthorized use of/access to your computer system.
• Media liability — Protection against claims arising from material published on a Web site, in ads, etc., including allegations of libel, slander, copyright infringement, or trademark violations.
• Regulatory privacy proceedings & regulatory fines & penalties — Coverage for defense of HIPAA violations, state and federal information privacy law violations, etc; and for certain related fines and penalties.
• Customer notification & credit monitoring expenses — Coverage for expenses incurred as a result of information breaches, including costs of notifying affected parties and providing them with credit monitoring services.
• Electronic data recovery & replacement expenses — Coverage for expenses incurred to recover or replace electronic data lost or damaged because of a computer virus, hacking or other system invasion.

*Please review your policy and check with Chapman, your CPG broker (phone 800-288-3095), or a NORCAL Mutual Policyholder Services representative (877-443-7232) for detailed terms of coverage.

CPG clinics that want to improve the way confidential information is handled in their offices now have an exclusive set of tools. The DataShield Learning Center offers a wide array of webinars, interactive programs, bulletins and posters — all aimed at reducing the risk of an information breach and minimizing the damage when a breach occurs.

The resource is housed in the Risk Solutions section of MyNORCAL, the policyholder-only part of www.norcalmutual.com. It takes its name from DataShield, the new coverage enhancement that covers costs for information and network security liability and related risks. While DataShield provides substantial coverage, the DataShield Learning Center empowers physicians to avoid information-related risks in the first place.

For example, when users go to the Learning Center and click the Training tab, they find:

• Webinar training—Two 45-minute programs ("Incidence Response Plans" and "The First 72 Hours").
• Training Bulletins—Includes Comic Strip Training, Employee Training Bulletins, and IT Department Training Bulletins.
• Online Training Programs—Educational and entertaining videos, 4–6 minutes in length, on topics such as "Avoiding Spyware."
• Healthcare Training and Awareness Programs—Includes bulletins and posters, plus a PowerPoint presentation on HIPAA ("Risk Assessment Training Program").

Other tabs on the DataShield Learning Center homepage include Reduce Risk, Handle Breach, and Policies, where physicians will find sample policies and procedures related to information security.

CPG providers who would like to open MyNORCAL Accounts should call NORCAL Mutual's Policyholders Services Department at (877) 443-7232. A representative will assist them.

One of the most valuable benefits community clinics enjoy as members of CPG is Claims Rx, the monthly risk management publication produced by NORCAL Mutual. Each issue tackles a vital clinical or administrative issue, recommending ways to improve patient safety and reduce risk.

To date, we have posted Claims Rx on the CPG Web site, www.norcalmutual.com/cpg. In February we will remove it from the site because the site is open to the public. This change is part of our overall strategy to reserve this valuable resource exclusively for NORCAL Mutual and CPG insureds.

Claims Rx is available three ways to CPG clinics and their providers:

• An online version is available in MyNORCAL, the policyholder-only section of the NORCAL Mutual Web site, www.norcalmutual.com. Your providers are entitled to open a MyNORCAL account. By doing so, they can receive CME credit for Claims Rx. To open an account, call NORCAL Mutual Policyholder Services at (877) 443-7232.
• A hardcopy version is mailed to each CPG clinic. (Note: In 2011, three issues of Claims Rx will be published only electronically as part of our long-term strategy to reduce paper usage.)
• A hardcopy version can be mailed to individual providers upon request. To request a copy of the publication, email sarmenta@norcalmutual.com or call Risk Management at (800) 652-1051, ext. 2244.

Clinic representatives often call the NORCAL Mutual Risk Management Department to discuss a patient who has become a "problem." Nearly every physician has felt the need to terminate such patients from his or her practice at some point. You can assure your physicians that terminating a patient may be appropriate and ethical in a variety of circumstances.

Who should you consider dropping?
Patients who persistently fail to make or keep appointments, refuse to comply with treatment recommendations, fail to pay bills, or who act in a violent or offensive manner that endangers other patients or healthcare personnel may be terminated from a physician’s practice, subject to certain limitations.

Though community-based clinics may have more barriers to terminating patients from the clinic than other medical practices, there are circumstances under which discharging a patient from the clinic is appropriate.

The decision to terminate the relationship between the patient and a provider or clinic cannot be made lightly. Each case needs to be examined individually. However, in cases where violence is threatened or violent behavior has occurred, NORCAL’s risk management recommendation often is to terminate the patient from the clinic immediately and clearly document the reasons.

Things to consider first
The patient has the right to continuity of healthcare. The physician has an obligation to cooperate in the coordination of medically-indicated care with other healthcare providers treating the patient. The physician may not discontinue treatment of a patient as long as further treatment is medically indicated, without giving the patient reasonable assistance and sufficient opportunity to make alternative arrangements for care. (AMA) Ethical Guidelines:

The patient has the right to continuity of healthcare. The physician has an obligation to cooperate in the coordination of medically-indicated care with other healthcare providers treating the patient. The physician may not discontinue treatment of a patient as long as further treatment is medically indicated, without giving the patient reasonable assistance and sufficient opportunity to make alternative arrangements for care. (AMA Policy E-10.01.)

A NORCAL Mutual Risk Management Specialist can help you with the decision-making process and, if indicated, the termination process.

The problem of access to alternate care
The dilemma faced by some clinics, particularly those in rural areas, is a lack of available alternatives for the patient. To avoid the risk of an allegation of abandonment, the clinic planning to terminate a patient needs to take into account the patient's current healthcare needs and his/her ability to find another provider. When alternatives for healthcare are extremely limited, and the patient may need to travel a significant distance to obtain care, the decision to terminate needs to be carefully considered.

In cases in which travel to a new provider is impractical because of complex medical needs or because it would otherwise cause extreme hardship, it is recommended the clinic find ways to manage the difficult patient. (It is also important to note that some managed care and government contracts may include specific rules on the termination of patients.)

Alternatives to termination
As alternatives to termination, there are creative methods to deal with some problem patients. For example, a patient who is chronically late or misses appointments may be scheduled as the last appointment of the day. Then, if the patient is late or misses the appointment, staff and providers can clean up for the day, finish their documentation and pull charts for the next day, rather than suffer a schedule disruption.

In the case of patients who have difficulty following a treatment plan, many providers meet with the patient and, if possible, a family member to discuss the reasons for the treatment plan and the potential harm of failing to follow it. If a patient is consciously resisting a treatment plan, it may be necessary to ask the patient to sign a "Refusal of Treatment" form.

When considering terminating a patient from the clinic for something other than violent or otherwise threatening behavior, remember that:

• Acute conditions that currently warrant treatment must first be resolved or stabilized.
• Medical causes of objectionable behavior should be addressed and ruled out.

For example, before terminating a patient for what appears to be drug-seeking behavior, the physician should ensure that:

• The patient's need for more drugs can be attributed to substance abuse and not inadequate pain relief (or a condition known as "pseudo addiction").
• The physician has voiced concern and addressed apparent drug-seeking behavior with the patient.
• The patient has been informed that a diagnosis of substance abuse has been made.
• An appropriate treatment has been offered and refused.

When faced with a difficult patient who may need to be terminated from the clinic, contact your NORCAL Mutual Risk Management Specialist to discuss the situation. The specialist will help you review your options, discuss possible alternatives to resolve the problem, and, if necessary, explain how to effect the termination while ensuring responsible and ethical treatment of the patient and avoiding allegations of abandonment.

• Named Insured.
• Endorsed physicians and health care extenders while providing services on behalf of the Named Insured.
• Other employed and contracted licensed health care professionals while providing services on behalf of the Named Insured.

A new document in the EHR Tools section of Risk Solutions in MyNORCAL (the protected section of NORCAL Mutual's Web site, www.norcalmutual.com) walks clinics through the steps they should take before purchasing an electronic health record (EHR), as well as providing tools to help complete each step.

The article, "Things to Consider Before Purchasing an EHR System," will help you select the correct EHR for your clinic the first time around, saving time, money, productivity and aggravation. Here is a summary of the article:

First of all, a needs assessment must be done in order to find out what the clinic requires from an EHR. After that is concluded, the clinic will need to do a readiness assessment to make sure it is ready to move to an EHR and has the necessary resources (including staff) to do so. The next step is to conduct a workflow analysis to correct any workflow problems that exist in the clinic's paper environment — a vital process that should continue through the implementation phase and beyond.

Finally, there are system and vendor issues to consider, budgeting to do, HIPAA/security issues to take into account, and "meaningful use" requirements to meet (should the clinic want to qualify for Medicare or Medicaid EHR incentive payments).

The article has a myriad of tools to assist a clinic in its selection process, including sample needs, readiness, and workflow assessments; questions to ask prospective vendors; and a sample calculation that can help clinics prepare for a temporary loss of provider productivity when they move to an EHR system.

In addition to this new document, the EHR Tools section of MyNORCAL contains other recent documents detailing the "meaningful use" requirements for the Medicare and Medicaid EHR incentive programs (and how to meet them); the contract issues clinics should know about before signing an EHR contract with a vendor; and the top ten things they should know about EHRs.

Coming soon will be documents on EHR implementation and HIPAA/security issues, among others. CPG policyholders should regularly check back on the EHR Tools page, as well as in future newsletters, for more EHR information.

CPG providers who would like to open MyNORCAL Accounts should call NORCAL Mutual's Policyholders Services Department at (877) 443-7232. A representative will assist them.