Inside Medical LiabilityA P I A A P U B L I C A T I O N F O R T H E M E D I C A L P R O F E S S I O N A L L I A B I L I T Y C O M M U N I T Y

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CMOs:Navigating

Healthcare’s Stormy Seas

Material Risks in Reserves

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C O V E R S T O R Y

The role of chief medical officer (CMO) within hospitals and healthcare systems has been established formany years. But for medical professional liability (MPL) insurers, it is relatively new. In the hospital set-ting, the CMO is typically responsible for providing oversight and medical expertise for all clinical services.In concert with the entity’s executive team, the CMO develops and promotes organizational goals andobjectives and assures that quality, well-coordinated healthcare services are provided to its patients.

In the MPL setting, the CMO position, in part a consequence of the recent introduction of the position, plays amore fluid, evolving role in ensuring patient safety and the optimal use of the company’s resources.

Because of the important contributions made by incumbents in this emerging position in many MPL organiza-tions, Inside Medical Liability is presenting a two-part series of articles that explore the role and accomplishments ofCMOs. In Part One, we discuss with CMOs some key trends now shaping the volatile healthcare landscape. In PartTwo, to be published in the Second Quarter issue, we take a closer look at the evolving role of the CMO.

To get a sense of the CMO’s perspective on some important topics in MPL, Inside Medical Liability spoke withfour CMOs who had participated in the recent PIAA CMO Roundtable in New Orleans:■ Luke Sato, MD, Senior Vice President and Chief Medical Officer, CRICO and Assistant Clinical Professor of

Medicine at Harvard Medical School ■ Laurie Drill-Mellum, MD MPH, Chief Medical Officer, MMIC Group■ Dana Welle, MD, DO, JD, FACOG, FACS, Chief Medical Officer, Stanford University Medical Network Risk

Authority, LLC (The Risk Authority) ■ Graham Billingham, MD, FACEP, FAAEM, Chief Medical Officer, Medical Protective Company

In particular, we asked about two issues of emerging importance: the impact of electronic health records(EHRs) and HIT in medicine and MPL and the challenges in insuring different generations of physicians.

We got some fascinating and thoughtful answers. Please read on, to find out for yourself.

Chief Medical OfficersHelp Insurers NavigateToday’s Stormy HealthcareEnvironment Insights on the Impact of EHRs and HIT,Challenges of Insuring Different Generations of Physicians, and More

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EHRs and HIT

IML: What are the major impacts of EHRsand HIT on healthcare professionals, and arethese technologies improving risk and reduc-ing exposure for healthcare professionals?

Sato: EHRs and HIT are changing the deliv-ery of healthcare for the patients. One of thethings that we’re seeing, at least within some ofthe organizations that we insure, is that they’reusing EHRs and HIT, via the patient portals, toactually provide access to patients so they canlook at their own visit notes.

I think that’s a tremendous opportunity,because the patient can add another set ofeyes to look at their medical record. It’s also agreat opportunity to engage the patient ortheir family. Issues that may have been dis-cussed but missed, dropped, or haven’t beenin the line of sight of the physician thepatients can bring up.

From our perspective, this can potentiallybe utilized as a tool to mitigate missed anddelayed diagnosis claims. It’s a tremendousopportunity and we would like to see this spreadand implemented much more pervasively.

Several preliminary studies have exam-ined the impact of Open Notes where therewere myths that clinicians, initially, were fear-ful that, by opening up these notes to patients,they were going to be bombarded with ques-tions, change their workflow dramatically,increase risk, and so forth. But so far, the evi-dence has indicated that’s not true at all. Someclinicians are actually asking—Is the patientportal really on? They haven’t seen a dramaticincrease in e-mail traffic from their patients.

We’re still new in this game, so this tech-nology could potentially be used down theroad in a negative fashion against the clini-cians but right now, our hypothesis is that thebenefits seem to outweigh the risks.

Welle: In terms of improving risk andreducing exposure, I don’t know if I can reallyanswer that question, because we don’t haveenough information to decide about it yet. Iknow that we have seen some claims aroundthe EHR, but I don’t know nationally whatthat might look like. We may need to get PIAAData Sharing Project information to deter-mine the issue.

There is a growing body of researchbeing done on EHRs and physician burnout.It is important to realize how the EHRs haveimpacted burnout levels and professional ful-fillment levels in our providers. And whatmight have been thought of as something thatwas going to be a time saver may actually endup as something that is also causing duress

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for our providers.Patients often complain about a lack of

interaction because the doctor is so busylooking at a screen, rather than talking tothem. It really is important for providers tounderstand that they need to be able to stepaway from the screen and actually interactwith the patients.

IML: Has claims experience changed withEHRs?

Sato: These EHRs are meant to provide alot more data and information to the health-care providers in real-time. The benefit is thatit provides the needed information very quick-ly at point of care. But the downside is thatpeople are experiencing the phenomenon of“too much information.” The critical issue is,how can information be provided and dis-played to the clinicians in a way the helps theirworkflow and workload without overwhelm-ing their senses. We would like to work withthe EHR vendors to address this problem.

So I think that that’s a risk from our per-spective: when you’re offered so much infor-mation, we humans are bound to miss, notknow, or not be aware what information is rel-evant such as critical test results or a referralthat needs follow-up.

Currently, the responsibility is on the

provider to look through the medical record tofind labs and other results and quickly decidewhat’s important and not important. To date,we’ve mostly relied on the humans for thistask, but I feel very strongly that as technologyimproves, we’re going to have to find ways thattechnology could help with this process.

Welle: Our overall claims have not changedbecause of EHRs. We have seen a couple ofclaims that are related to the EHR, or wherethe EHR is mentioned in the claim, but thedata is not sufficiently conclusive to say what’sactually going on.

IML: How are you approaching risk man-agement with your insureds when it comes toEHRs and IT?

Sato: What we have done is to develop aprocess-of-care framework that focuses onthe diagnosis processes and analyze andassess where EHR or HIT could help mitigaterisk in each step of the process. This way, wecan provide clear recommendations to ourconstituents, as well as identify risk aroundspecific areas where they are vulnerable fromthe technology perspective.

So I hope the value that we can bring isto provide a very different lens to help themreduce missed and delayed diagnoses errors,which as you know are very expensive—notjust to us, but also to the defendant. It’s dev-astating, to get served with a case and sud-denly become involved in a lawsuit.

Welle: We have a somewhat differentapproach. In our organization, we recentlywent about a rollout of a replacement EHRsystem. There was a lot of training, coupledwith education on safety and quality. In ourhospital, when they implemented EHRs, theychanged their staffing ratios, and the clinicschanged the number of patients they wereseeing. So in regard to risk management, it isimportant to be proactive—to decrease therisk around EHRs.

We do have conversations with ourphysicians because the EHR allows the cut-and-paste feature, to try and move them awayfrom cutting and pasting, and instead entermore original content to accurately capturethe provider patient interaction.

C H I E F M E D I C A L O F F I C E R S

DANA WELLE, MD, DO, JD, FACOG, FACS

LUKE SATO, MD

“We can pro-vide a very

differentlens to help

them reducemissed and

delayeddiagnoses

errors.”

“Patients oftencomplain about alack of interac-tion because thedoctor is so busylooking at ascreen.”

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IntergenerationalDifferences

IML: What are the challenges for MPL insur-ers when providing coverage for youngerhealthcare professionals?

Billingham: If you look at it from a busi-ness perspective, one of the greatest chal-lenges facing the MPL carriers is that themajority of the younger physicians are goingto become employees of a self-insured vehiclesuch as a hospital.

Drill-Mellum: We don’t see particularchallenges in underwriting younger physi-cians. We’re thrilled to underwrite them. Thesooner we get them in, the better.

IML: What are the differences you are see-ing with associated risks?

Billingham: From a risk perspective,there are a couple of interesting observationsabout the younger generation: They learnvery quickly, and they are very technologysavvy. They readily use and embrace socialmedia, texting, and smart technology whiletaking care of patients. Although this is goodin many ways, it also has the potential to leadto HIPAA breaches or cyber-attacks that com-

promise PHI [protected health information]and other sensitive information.

Further, the younger generation hassomewhat of a dependence on technology. Anexample is surgical training; many young sur-geons are trained in robotic surgery orlaparoscopy. They’re very technically compe-tent, and they are used to using the laparo-scope. However, if a complication occurs, theyhave less experience converting from a mini-mally invasive approach to a traditional openapproach. MedPro’s General SurgerySpecialty Advisory Board has discussed howolder surgeons were traditionally trained andhow many of the procedures were open. Now,many surgical procedures are done through ascope, which presents new risks.

That’s just one example of the difference

in training and the utilization of technology.Another example is diagnostic work: theyounger doctors with less clinical experiencetend to do a lot of imaging on patients.Probably the biggest challenge for older physi-cians is how to keep up with clinical compe-tency over the years. We have physicians prac-ticing into their 70s. How do we make surethat they can do certain procedures—some ofwhich may be high risk—especially if theydon’t do them all of the time?

That’s why you see advances in training,such as simulation training—I think that’s agood change. But I also think that it’s impor-tant to evaluate competency as physicians getolder. Hospitals that have healthcare profes-sionals practicing into their seventies mightneed to consider various issues as part of cre-dentialing, such as whether older practition-ers have adequate stamina, dexterity,hand–eye coordination, vision, and more.This will be an interesting issue to monitor.

IML: Has your claims experience differedfor the two age groups?

Drill-Mellum: We looked at data on ourcovered physicians in five-year age bandsrecently, and we found that the percentage oftotal claims generated by each age bandtracks pretty closely with the percentage ofour total insured physicians in that age band,with a couple of exceptions.

Overall, the highest number of claimsoccurs among physicians between ages 35and 64. That is also when physicians are theirGRAHAM BILLINGHAM, MD, FACEP, FAAEM

LAURIE DRILL-MELLUM, MD, MPH

“As a generalrule, youngerphysicians aremore dependenton technology,and leverage itmore.“

“Probably thebiggest challenge forolder physicians ishow to keep up withclinical competencyover the years.”

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busiest—they’re doing the most work andhave the largest patient panels. So it’s not sur-prising to see this.

It’s also not surprising that physiciansjust starting their careers have fewer claims,proportionally. They haven’t built large patientpanels yet, and also, claims can sometimestake several years to develop.

Things get more interesting when welook at late-career physicians.

Starting about age 60, they comprise asmaller portion of our insured population,about 7%, and that number decreases to lessthan 1% for physicians past age 80. But thesegroups are over-represented in our claims.

Billingham: That’s a very interestingquestion. Hard science is somewhat lacking,but let me share some observations. Riskseems to vary more based on specialty thanbased on age.

It’s probably safe to say that someonewho is less experienced might be more sus-ceptible to technical skill or performanceissues. But, by the same token, a very sea-soned physician might be susceptible to cer-tain cognitive biases, such as overconfidence.In other words, they have so much experiencethat they rely a lot on their intuition and judg-ment. I think that these are two importantissues to monitor in claims trends.

Our general finding is that frequencypeaks for physicians in their fifties anddeclines with age over 60. Presumably, that’sdue to doctors winding down their practice;they might not see quite the volume that theydid prior to age 60. Also, there doesn’t seemto be a measurable change in severity ofclaims with age.

IML: Have you drilled down to find out thereason?

Drill-Mellum: We haven’t done a deepanalysis of the data yet, so it’s early to imputecausation. But there are contributors of lossfor everybody. There are technical perform-ance issues. There are cognitive error issues. I can’t tell you that in the older group, thereare technical performance issues versussomebody a few years younger. On the other

hand, I can speculate that my younger col-leagues are better at flipping their schedulesaround—pulling nights and days—and morepracticed at some of the new technologiesthan I am.

IML: How does your risk managementapproach differ in terms of younger vs. olderhealthcare professionals?

Billingham: What’s clear to us, as a mal-practice carrier, is that physicians in all agegroups are requesting more electronic con-tent. Digital content allows them to access thematerials at their convenience. Yet, some stillprefer in-person conferences and hard-copymaterials.

Typically, though, the younger physicians prefer social media and immediateaccess. Across MedPro’s specialty advisoryboards, for example, the younger physicianswill use platforms like Twitter, whereas theolder physicians don’t. The younger genera-tion is communicating patient safety and risk management information using social media.

My general perception is that the olderphysicians place more value on face-to-faceinteractions and printed materials—although, I would say that this trend is chang-ing over time. To effectively provide risk man-agement education, I think MPL insurers haveto provide programs and content in a varietyof formats. Further, regardless of age, every-one learns differently, which necessitates mul-tiple formats.

Additionally, a growing concern for MPLcompanies is “sub-specialization.” Healthcareprofessionals tend to like seeing certain typesof patients and doing certain types of procedures.

Drill-Mellum: Our risk managementapproach is evolving as we see technology playa greater role in medical care and communica-tions. As a general rule, younger physicians aremore dependent on technology, and leverage itmore. That has upsides and downsides.

There is a lot to be gained from the useof technology. But over-reliance on technolo-gy and under-reliance on the history and

physical exam, and face-to-face communica-tion, can lead to problems.

Take the problem of false negatives. I was at the 2013 PIAA Claims/RiskManagement Workshop in Seattle and a radiologist there said that the rate of initialfalse negative readings of CT scans is 17% to 19%.

We see that in our claims. I recall an elderly patient with abdominal pain. She had a history of kidney stones, which wasnoted on the x-ray requisition. The radiologistsimply recorded “kidney stone,” and did notnote early signs of swelling around the appendix, because the CT scan was read asnegative with respect to the appendix. Theyoung doctor over-relied on that negative,which was ultimately false. She didn’t go back to the radiologist and say, “This personstill has abdominal pain, which is gettingworse—what do you think?” She didn’t get a surgery consult.

This patient languished in the hospitalfor three days, at which point her appendixruptured. All sorts of complications ensued.

That’s a perfect example of over-relianceon technology coupled with an under-relianceon the physical exam and history—and thatcan happen to any physician, old or young. I think the attempt to categorize physicianrisk by age may be a bit of a red herring. Allage groups can have problems communicat-ing. And we are concerned about certain prac-tices that cross all ages, such as unsecuredtexting of what should be HIPAA-protectedpatient information. All physicians do thatnow. Residents are texting information totheir attendings at home. ER docs are textingphotos or echocardiograms to consultants athome, because it’s easier, and it’s quick. I don’tthink that’s generational.

I will say that the way we deliver our riskmanagement services is changing. We aremaking more of our risk education programavailable online 24/7, because we know that,in general, younger physicians are interestedin online CME and education.

Editor’s Note: Look for Part Two, on the evolv-ing role of the CMO, in the Second Quarter2016 issue.

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C H I E F M E D I C A L O F F I C E R S

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