This new catch phrase describes an office where the patient feels comfortable seeking all sorts of medical advice, and where efforts are made to go beyond a focus on acute care.

The Geisinger Health System, operator of a health insurance plan and a network of clinics and hospitals in Pennsylvania, has begun paying the salaries of extra nurses in doctors’ offices with the understanding that these nurses will devote all of their time to helping patients with chronic conditions adhere to their medical regimens. [New York Times “A Health Insurer Pays More to Save” 21 June 2010]

The anecdotes recounted by the Times include one about a woman whose difficulties in controlling her diabetes caused her to resort to the emergency room when her blood sugars were low. After she was encouraged to call a nurse she felt com- fortable with this problem ended.  Previously, she felt her doctor was too busy to be bothered with questions.

Whether the Geisinger approach is adopted more widely or not, the idea of a “medical home” seems likely to take hold, particularly if, as seems likely, the Patient Protection and Affordable Care Act of 2010 brings more new patients to doctors’ offices.

Useful information concerning the medical home concept can be found at the web site of the American Academy of Family Physicians.

In this environment specialists, although more linked to acute care, are more likely to embrace the idea of employing “practice-extenders”. The goal is to help patients understand and follow post-treatment advice, in hope of preventing relapses and the need for follow-up treatments.

Practice-Extenders

If we are moving into an era where doctors are busier than ever, and if an increasing amount of medical advice and treatment will require patients to adhere to schedules for taking medicine, modify lifestyle issues, and generally be more aware of the health implications of the choices they make, then it seems inevitable that physicians will turn ever more frequently to nurses, physician’s assistants, and other allied professionals for help with compliance.

In a way this is old news, although the addition to the insured population of 30 million new people (thanks to our new health insurance reforms) will certainly accelerate this evolution. Other influential factors include the aging of baby-boomers and the continued progress of medicine in the treatment of conditions such as cancer and heart disease.

An increase in patients with chronic problems means follow up becomes more important if relapses and trips to the emergency room are to be avoided. Whether or not the idea of a medical home changes the way doctors practice, the role of practice-extenders appears likely to grow in scope and importance.

Vicarious Liability

Increased reliance on practice extenders, through adoption of the medical home idea or just as a result of being busy, will bring increased exposure to the risk of vicarious liability.

Vicarious liability is a concept that allows a jury to find someone responsible for the actions of someone else.  A claim that you are vicariously responsible for something questions whether a person who works for or under you failed to meet the standard of care.  Your direct medical treatment is largely beside the point.

The concept of vicarious liability will come into play with increasing frequency in a world where physicians rely more on assistants.  Under this theory a doctor can be challenged concerning the activities of those he or she supervises.  This includes the operating room nurse who makes a mistake and the physician’s assistant who gives inappropriate advice in a phone call.

Vicarious liability means you may be found to be at fault because someone else provided sub-standard care.

Self-Protection

Here are some steps one can take to reduce the risk of being found liable for the actions of another.

1. Choose your Associates with Care

Hiring a nurse without checking credentials is like gambling.  Assigning nurses or physician’s  assistants responsibilities for which they have inadequate training is reckless.  Just as coaches select the best players you should select the best people you can find and give them the training and directions they need.

If you plan to do a procedure, before you go through the check list in the operating room do a check of the personnel who will be assisting you and make certain that you have confidence in their ability to perform the necessary tasks.  If you want the nurse to give the patient an initial exam or a shot make your expectations clear and be certain the person you choose is up to the task.

2. Document and follow up

When you decide to rely on someone to call a patient and make certain prescribed medicine is being taken, something that proprietors of medical homes do, then you should have a system for making certain that this sort of follow-up is actually taking place.  Ideally, such a call would be noted on a chart by your delegate when it is made.  As in most things involving professional liability, a contemporaneous record is worth a great deal when questions about past treatment are raised.

In this context regular conversations with practice extenders can help physicians stay informed about issues patients are experiencing and problems the allied professionals may have. You should know what they are doing and they should know what you think they are doing. If something is going off the rails you can only intervene if you know about it.  Early intervention is important in preventing vicarious liability problems and in protecting patients.

There will be instances where you leave instructions that are not followed or followed incorrectly.  Sometimes patients will suffer harm as a result and a claim may be filed.  If the question of vicarious liability arises it will turn upon whether or not the persons you work with performed their assignment correctly.

Collaboration is an essential part of modern medicine.  It won’t go away and it has many good aspects.  If you choose your collaborators with care and make clear what they are employed to do, vicarious liability should remain a hypothetical concern.

The Risk Manager is an occasional publication of Galen Insurance Company. The foregoing should not be construed as legal advice, and questions about specific fact situations should be discussed with your professional liability insurance company and any lawyer it retains to defend you.