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TMLT risk management: Then and now

Case Closed publications offer CME and a risk management discount.

by Lesley Viner

Risk management services are an integral part of TMLT’s commitment to protect physicians, improve patient safety, and reduce the risk of claims. TMLT’s first annual report from 1979 pronounced “The Board of Trustees and Trust management are dedicated to developing and implementing an effective risk management program for Texas physicians. The objective will be the prevention of true patient injuries and developing aids to defense for those claims which should be resisted.”

The risk management department has seen significant growth over TMLT’s 40-year history. There have been changes and enhancements in all risk management service areas, including continuing medical education (CME) programs, practice reviews, and consultations. Services have been updated and improved to meet physician needs in what has become a continuously evolving and challenging health care environment.

Outlined below are the most notable changes seen in the risk management department over the last 20 years.

CME programs
TMLT began exploring CME accreditation in 1991, when the risk management department developed education programs with the Texas Medical Association (TMA). When TMLT began insuring large physician groups and networks in 1994, these policyholders requested CME programs on medical liability topics.

TMLT pursued CME accreditation through the Accreditation Council for Continuing Medical Education (ACCME). In 1999, TMLT became a fully accredited CME provider. That year, 941 physicians earned CME through TMLT-developed programs, while 2,127 physicians earned credit through TMLT-TMA seminars. The department also offered a spring seminar series for medical office staff, with 661 in attendance. In addition, TMLT’s first online CME course, Streetwise, made its debut on the TMLT website. 

In 2003, TMLT was awarded Accreditation with Commendation for six years from the ACCME, and was the first medical liability carrier in Texas to achieve this recognition. Also that year, a one-hour CME course was incorporated into each issue of the TMLT newsletter, the Reporter. The CME articles were developed by risk management staff members and covered a variety of medical liability issues.

In 2005 — with claim frequency increasing — the fall seminar series entitled You’ve Been Sued: Successfully Navigating the Litigation Process was introduced. Close to 1,000 physicians attended. The program was later offered as a DVD.

Also that year, TMLT’s first Case Closed CME publication — the result of a collaboration between the risk management, claims, and marketing departments — was produced. Shortly thereafter, risk management staff worked with the claims department to provide CME credits for the Claims Review Committee (CRC) meetings, where the medical issues in TMLT’s most complex cases are evaluated.

The department conducted an outcomes measurement study in 2009 to determine the relationship between a physician’s CME participation and subsequent claims experience. The results indicated that physicians who participated in CME courses experienced a 14% decrease in claim activity.

Additional follow-up studies showed that claim payments were reduced for physicians participating in TMLT CME activities, and that policyholder retention rates were positively affected.

TMLT’s first CME video was offered on the website in 2010; the topic was deposition preparation. In 2014, the CME site for Lone Star Alliance (LSA), an affiliated TMLT company, was launched. In 2015, the first out-of-state CME seminar, EHR Best Practices, was presented for a group in Orlando, Florida. In 2017, TMLT hosted its first family-friendly summer CME event for young physicians.

Today, the total number of TMLT CME completions is more than 13,000 with more than 25,000 CME hours awarded to physicians annually. Course options include online courses (including videos); live seminars (including practice-based CME activities); and CME in TMLT publications.

TMLT presents more than 100 customized seminars for policyholder groups each year, in addition to the annual spring and fall programs. TMLT’s CME site has approximately 50 CME courses to choose from.

TMLT addresses a variety of topics through CME programming, including physician stress and burnout; the national opioid crisis; the risks of telehealth; how to manage patient complaints; and online reputation management.

Practice reviews
During a practice review, a risk management representative identifies — through an analysis of medical records and practice protocols — areas that make a physician especially vulnerable to claims.

In 1999, 1,100 policyholders participated in practice reviews. The review process was automated that year, decreasing turnaround time for completion of review correspondence from 3 weeks to 2 to 5 days. An exit interview was also added to the review process to give physicians immediate feedback.

Next, TMLT offered CME credits through the practice review. Credits were awarded after a discussion of practice-specific liability risks and suggested improvements. The five most common review recommendations during that time period involved medical records, tracking and follow-up, patient procedures, medication administration, and informed consent.

Based on feedback from TMLT board members and policyholders, the practice review process was modified in 2005 to increase the emphasis on critical medical liability issues.

In 2008, TMLT was selected to provide practice review services to JUA policyholders on a fee-for-service basis. (The JUA — Texas Medical Liability Insurance Underwriting Association — is the Texas-sponsored insurance program for health care professionals with limited or no access to professional liability insurance.)

In 2010, the department conducted a study to determine the relationship between physicians participating in practice reviews and their claims experience. The results were positive, indicating that physicians who participated in practice reviews had a 17% decrease in claim activity.

In 2014, the department began offering remote practice reviews, where records are accessed electronically. Customized review options were also developed, such as group-specific recommendations; wrap-up discussions focused on a specific topic or practice gap; and the ability for groups to modify the frequency of practice reviews.

Additional outcome measurement studies conducted that year indicated that claim payments were reduced for physicians participating in practice reviews, and that policyholder retention rates were positively affected.

Today, approximately 2,500 physicians and non-physician providers participate in practice reviews each year. The five most common recommendations given to practices include:

  • update the medical record to reflect the patient's current complaints and check for unintended system defaults to normal or negative;
  • the practice should have written policies for electronic health record (EHR) security and processes, and policies should be kept current;
  • incoming consultant reports, diagnostic results, or outside tests should include documentation of physician or provider review;
  • preformatted text or templates in the EHR should be edited; and
  • documentation of after‑hours patient calls should be evident in the medical record.

Consultations and resources
In 1997, the department received close to 1,500 requests for risk management help. Most of these requests were by phone. In 2000, the department developed a list of frequently asked questions for use on the TMLT website. Risk Alerts — important pharmaceutical and medical device advisories  — were also added to the website. Risk management staff wrote articles and closed claim studies for the Reporter and specialty-specific Reporter editions to further inform physicians.  

In 2009, several resources were added to the TMLT website including A Risk Management Guide, Health Information Release Booklet, and Informed Consent: Physician’s Guide. In 2016, videos on specific topics were added to the website.

The five most common inquiries received by risk management representatives today include:

  • appropriate termination of the physician-patient relationship;
  • general office issues, such as office policies and call coverage;
  • medical records release and retention;
  • selling or closing a practice; and
  • Health Insurance Portability and Accountability Act (HIPAA).

The department works diligently to develop and update resources, and partners with the Texas A&M Medical School on research projects. Additionally, consultation services are now offered to LSA policyholders nationwide. The department receives approximately 2,000 inquiries annually via e-mail, phone, and the TMLT website.  

Today, TMLT holds true to its core belief in risk management and is dedicated to the development of activities to educate and protect physicians. Services continue to be customized and provided to physicians in all specialties and practice settings. The risk management department looks forward, with anticipation and enthusiasm, to another 40 years of providing unmatched service to policyholders.