Disaster mitigation, management: What ophthalmic practices should know

Within 3 days of Hurricane Katrina wreaking havoc on New Orleans in August 2005, Marguerite B. McDonald, MD, FACS, made the painful but inevitable decision to close her refractive practice permanently.

McDonald’s office was on the seventh floor of a building, although water rose only to the third floor.

“Still, the temperature and humidity went sky high,” she said. “The environment adversely affected my excimer laser and even my medical records, which we had yet to convert to electronic format.” The records were covered with mold.

Only people who wore a hazmat suit and signed a waiver not to sue the federal government were allowed to enter the building, which was considered a hazard zone, McDonald, OSN Refractive Surgery Board Member, said. The structure was closed for 10 months.

McDonald, who started practicing at the location in 1993, donned a hazmat suit and entered the building twice to rescue company-sponsored research data.

“These companies were desperate to get their data sent out,” she said.

When Hurricane Katrina struck New Orleans, “half the population left and those who were left were consumed with loss of life, property and income,” McDonald said. “The last thing on their mind was an elective surgical procedure like LASIK.”

McDonald also realized that she had lost her significant out-of-town patient base due to the devastation. She had arranged for her patients to receive discounts at several local hotels, all of which were closed after the hurricane.

Eleven months later, McDonald joined Ophthalmic Consultants of Long Island as a cornea specialist, where she remains today. Her current practice sustained some damage from Superstorm Sandy in October 2012, but nothing approaching the magnitude of Hurricane Katrina. Some of the OCLI offices were closed for a few days only because of no water and electricity.

Fortunately, with Hurricane Katrina, McDonald had evacuated to Birmingham, Ala., with a computer that contained the addresses and phone numbers of all of her employees, whom she contacted 3 days after the storm. “My office manager was lost for 9 days and presumed dead. But she was finally found alive on part of a municipal building that was half sinking, half floating,” McDonald, who ensured all of her employees received vacation and severance pay, said.

“Having contact information for all employees with you at all times is critical,” she said.

Patients visiting McDonald’s practice website were notified that the practice had closed.

“Patients were instructed to notify my office manager if they had questions about anything — their medical records, billing, etc.,” she said. McDonald retained her office manager for 6 months after Hurricane Katrina. “There were a lot of loose ends to wrap up, including Medicare and insurance billing.”

Patients had also ordered contact lenses that were at the office, but they were unable to pick them up. To help manage the crisis, McDonald kept her executive assistant on the payroll for 4 years after the disaster.

Multiple locations

Practices can better cope with a disaster — whether a hurricane, fire, explosion or toxic spill — if they have more than one location, according to OSN Practice Management Section Editor John B. Pinto.

“During Hurricane Katrina, I had a client in the region with just one office. That one office was badly damaged and the doctor was out of commission for several months,” Pinto said. “But I had another client who had two offices. One office was damaged and basically destroyed, while the other office was fairly serviceable within 1 week. So, that doctor was able to carry on.”

Practices should think ahead and consider the “what ifs,” according to Pinto.

“What could happen?” Pinto said. “A surgeon contemplates several times a day ‘what if’ when it comes to the patient’s eye. ‘What if we lose vitreous or have an infection?’ You want to have the right materials in stock to take care of an adverse event.”

For instance, practices located in parts of the country that experience extremely cold weather should have the operating reserves to close down for a few days or longer in case of a cold snap.

“If you have access to capital, you can continue to employ your staff,” Pinto said. “However, if you don’t have a lot of capital, you need to hedge with slightly more insurance coverage.”

Likewise, a practice in an area prone to earthquakes, particularly in an old building needing extensive repairs, needs to be prepared for a large tremor.

“Unfortunately, the vast majority of practices handle these crises on the fly when they happen,” Pinto said. “I would estimate not more than five practices out of 100 have a written disaster plan.”

A deep bench

The most common disaster practices face, particularly smaller practices of one or two providers, is the temporary or longer disability, or even death, of the provider, according to Pinto.

“Who does the office manager call as a backup doctor to take care of patients?” he said. “And if the doctor is not going to be able to come back to practice, which of the other local practices would we like to divest our practice to?”

During a crisis, practices should contact their insurance agents, attorneys and accountants for options and planning, Pinto said.

“If it is a natural disaster, some of your practice staff may be unavailable for a matter of weeks to come into work because their own lives have been disrupted,” he said.

Today’s typical practice is more fragile than a generation ago, according to Pinto.

“The administrator has less reserve capacity and there is lower profit margin, so there is less resiliency when there is a transient drop in revenue,” he said. “However, a 10-doctor practice is going to have more spring-back power because it probably has multiple offices and a deeper bench of administration.”

In contrast, smaller practices need to use their fewer reserves and resources “more sparingly,” Pinto said. “It may also mean the end of the practice — pulling up roots and moving to another part of the country.”

Business interruption

Robert J. Widi, vice president of marketing and sales at Ophthalmic Mutual Insurance Company (OMIC) in San Francisco, which provides professional liability and limited regulatory and office premises insurance to ophthalmologists who are U.S. members of the American Academy of Ophthalmology, said that ophthalmic practices often confuse office overhead insurance with business interruption insurance.

“Office overhead insurance is meant to cover expenses if a physician suffers a disability and is forced to shut down practice, while business interruption insurance will cover expenses, and usually compensate for revenue you would have earned, as a result of a practice shut-down after a natural disaster,” Widi said.

Business interruption coverage might be included within a business owner’s policy.

“However, it might be covered at a sublimit that is inadequate, not full policy limits,” Widi said. “Therefore, ask the insurance agent or carrier about any coverages that are specifically segregated at a lower limit than the overall policy limit, and ask whether it is enough based on your risk assessment and geographical area.”

Practices should be persistent because the carrier/agent may have a vested interest in not covering likely losses, or providing coverage for them at a lower limit, within the policy.

“It is hard to know with certainty what expenses will arise if your practice or a location is shut down for a significant period for rebuilding,” Widi said. “Based on your risk assessment, make an educated guess and then discuss with your insurance representative. If you feel you are not covered adequately, ask about a rider or endorsement on your policy. If none is available, shop around to see if other carriers will offer what you need.”

It is also important that insurance be kept up to date. Widi recalled one situation in which an ophthalmologist’s satellite office in Georgia was devastated by a tornado but his insurance coverage did not include the office.

“When the physician opened the office years earlier, he assumed that all locations were automatically covered by his policy. In fact, each location needed to be endorsed to the policy separately,” Widi said. “The loss was in the hundreds of thousands of dollars, not to mention the loss of use during the rebuild.”

Prompt action

Practices should plan for self-sufficiency and assume that it will take at least 3 days before electricity and basic services are restored, according to Widi.

“It was reported that after Hurricane Sandy, certain businesses were able to continue to use their satellite service for email communication,” he said.

During disasters, many ophthalmologists volunteer their services to assist in recovery and treatment of victims.

“OMIC generally covers Good Samaritan activities performed to prevent or stabilize a patient’s medical condition,” Widi said. “Local laws will also often shield physicians from liability in these circumstances.”

Still, practices should query their malpractice carrier about coverage under such circumstances if a suit is filed, he said.

Following a disaster, practices should contact their insurance company immediately.

“The carrier will often have a quick response team that has the clean-up resources already set up to help you,” Widi said. “By letting the carrier take care of the clean-up, you do not need to worry about them refusing coverage for actions you took in the aftermath, and you will have an accurate estimate for damages.”

Some ophthalmic practices submit claims months after an incident.

“But, insurance policies usually have a ‘timely notice’ clause, which means you must report the claim for damages immediately or as soon as possible, or it could jeopardize coverage,” Widi said.

Boy Scout’s motto

“My father was a Boy Scout leader, and he drilled into me the importance of always being prepared,” Nancy A. Baker, a practice administrator at the Elander Eye Medical Group in Santa Monica, Calif., and board member of the American Academy of Ophthalmic Executives, said. “Assess your needs ahead of time. In other words, is it an anticipated disaster like a 24-hour warning for a massive snow event or a sudden disaster like an earthquake? Having a checklist ahead of time keeps the brainwork out of it.”

Baker said a checklist is a work in progress.

“Don’t look upon a completed checklist as never changing,” she said.

For an anticipated disaster, she recommended triaging equipment to evacuate, based on the time available.

“For example, if I had a 24-hour warning, I would probably take my computer server, the doctor’s diamond blade instruments, the employee files and definitely the checkbook.”

In the case of a sudden disaster, however, Baker suggested an off-site back-up of the practice management system, which would include the patient schedule for the next few days.

Both a fire-proof and water-proof safe is recommended, as well.

“Most people think about the fire, but they do not think about the water used to put out the fire,” Baker said.

A checklist for after a crisis is important, as well, including where a practice might potentially rent space and borrow equipment.

“You might request two mornings a week temporarily until you are up and running,” Baker said. Also, in case of a principal physician dying or going on disability, “you should identify a locum tenens (a temporary physician) to work under your tax ID, so you avoid a break in patient care and mitigate your monetary dip.”

Checklists and preparation plans should also be stored in more than one location.

“If your building burns down and that is where the information was, you are in trouble,” Baker said.

Wiped out

Monica L. Monica, MD, PhD, a general ophthalmologist and spokesperson for AAO, was also devastated by Hurricane Katrina.

“My practice was under 10 feet of water for 30 days,” she said. “The 16th Street Canal levee broke right into my office, which was on the first floor. I lost everything. The equipment was literally melted into a glob of mud and debris. The charts were gone and things were washed out with the current.”

Two days before the storm hit, Monica accompanied her daughter to New York University for a 3-day sojourn that lasted 2 months. Upon Monica’s return, she had to push her way through the National Guard line to see her office.

“There was no office to open or close,” she said. “The primary mission at that point was clean up the debris and the mess because it was a health hazard. There was mold on things.” Debris was removed so that the landlord could arrange for a toxic clean-up crew to gut the office.

Three months after Hurricane Katrina, Monica, who started her private practice on the Lakefront and in an older area of New Orleans in 1986, joined the practice of her husband, Daniel A. Long, MD, an anterior segment specialist, on the West Bank of New Orleans.

“No one in this country has preparation for disasters of such massive proportion, including the medical field,” Monica said. “There are no action plans for what I consider the equivalent of a nuclear holocaust.”

Experience speaks

For those practices that experience a disruption of electricity alone, Monica recommended an action plan for perishable medical device supplies.

“Make an inventory,” she said. “Know what you have in the freezer because those things will need to be replaced, such as amniotic membranes for patients with recurrent erosion.” She also advocated videotaping and writing down the age of all equipment.

For those who are fortunate to be forewarned of a disaster, important papers should be removed, such as the lease agreement or documents that indicate ownership, lists of equipment and supply contacts, and medical licenses and certifications.

“All of that I lost,” Monica, who encourages clinicians to treat their practice like their home, said. “Your homeowner insurance tells you to do certain things, such as videotaping your belongings and putting together a folder of important documents that can be grabbed should there be a hurricane or some other impending disaster.”

Hurricane Katrina was an impetus for the electronic transmission of data for patients, according to Monica. “But, you need to take with you whatever disk or whatever hardware is necessary to perverse those records,” she said.

For solo practices, a large disaster “could be the defining moment that wipes you out,” Monica said. “Twenty-percent of the doctors in the New Orleans area did not reboot. Some left to join practices elsewhere in the country, while others who were old enough just quit.”

In retrospect, McDonald wishes she had switched to electronic medical records before Katrina hit so she could have logged on remotely to answer patient questions and communicate with other people. She also said that it is best to analyze your post-catastrophe situation objectively and immediately; if the decision is made to close, then close the practice quickly to avoid further financial losses.

“Otherwise, you owe your employees weeks and months of pay. You are hemorrhaging cash and nothing is coming in,” she said. “Many local doctors were catatonic with depression, confusion and despair; they just did not get around to closing their offices, or notifying their insurance carriers, even though their offices were completely unusable and there were no patients to come in.”

McDonald recommended documenting all business assets before disaster strikes for insurance purposes.

When a practitioner is out of town or the office is slow, the office manager should walk around and take pictures “of absolutely every office wall and floor. Everything in each desk drawer should also be photographed, as well as the contents of each sterilized instrument tray,” she said. “When you are catatonic with grief over the loss of your office, you will not be able to remember half the things you own. You will be in tremendous turmoil, basically in an agitated depression.”

In the wake of a major upheaval, McDonald said clinicians should not lose sight that they have transferable skills.

“It is possible to pick up and go some-where else,” she said. “A crisis is character building. But you need to keep the big picture in mind, which is that you survived the disaster, and hopefully your family did too, and you can relocate and use those skills.” – by Bob Kronemyer

• Nancy A. Baker, can be reached at Elander Eye Medical Group, 242 26th St., Santa Monica, CA 90402; email: nbaker@elandereye.com.
• Marguerite B. McDonald, MD, FACS, can be reached at OCLI, 360 Merrick Road, Lynbrook, NY 11563; email: margueritemcdmd@aol.com.
• Monica L. Monica, MD, PhD, can be reached 120 Meadowcrest St., Suite 330, Gretna, LA 70056; email: mlong511@bellsouth.net.
• John B. Pinto can be reached at J. Pinto & Associates Inc., 1576 Willow St., San Diego, CA 92106; email: pintoinc@aol.com; website: www.pintoinc.com.
• Robert J. Widi, can be reached at American Academy of Ophthalmology Bldg., c/o OMIC, 655 Beach St., San Francisco, CA 94109-1336; email: rwidi@omic.com.
• Disclosure: No products or companies are mentioned that would require financial disclosure.

What are the benefits and challenges of an ophthalmic practice committing to global outreach when a disaster occurs?

What is great about responding to disasters as ophthalmologists is that we have the opportunity to restore people’s sight. It offers a vivid reminder of why we went into medicine in the first place: to do good and to help people. It is so immediate; we can practice medicine the way we would love to, without the backdrop of administrative concerns.

Since 1993 I have assisted in Haiti, on average, two to three times a year plus numerous visits following the 2010 earthquake. Some of those trips have been as short as 24 hours, whereas others have been as long as 2 weeks.

If you have never been in a disaster location before, you may not realize how crippling refractive error becomes. In survival situations, when people lose their glasses, they cannot read signs or instructions for help, cannot find loved ones. As an ophthalmologist, you can be a life-saver by restoring sight with glasses for myopic and presbyopic individuals or by performing overdue cataract surgery. In fact, correcting refractive error is probably the way we most help people internationally.

Ophthalmology is a relatively portable specialty. Even if we lack some of the equipment that we normally use, we can easily do basic exams. For example, we can still use direct ophthalmoscopes to look at optic nerves and penlights to evaluate the depth of chambers. A simple vision chart can help determine what a person is seeing.

Coordination is critical in a disaster. Time and resources are precious, so you need everyone onsite, including local care providers and volunteers from abroad, working together effectively. After the 2010 earthquake, the American Academy of Ophthalmology Task Force on Haiti Recovery had the ability to mobilize relief efforts beyond what any individual could do.

For ophthalmologists seeking to begin global outreach, I recommend joining a group that is already going to a specified destination. It could be an organization such as Orbis International, Surgical Eye Exhibitions or the AAO volunteer program, all of which are very organized. The AAO website is a good place to start learning about what other ophthalmologists are doing to help.

I think it is even more important to realize that when one volunteers globally, it is really about the opportunity for skills transfer. We can teach people and they can often teach us in return, such as how to use particular techniques in difficult situations, or how to evaluate patients under those conditions. I am a zealous proponent of teaching someone how to fish so they continue to fish for many years to come.

The pharmaceutical industry has been a great support in relief efforts, helping people not only in our own communities, but also abroad in both disaster and underserved areas. For example, companies have been generous in providing antibiotics and glaucoma medications that make a tremendous difference in critical situations. In addition, some equipment companies have provided equipment and transport for these efforts.

Voluntarism provides opportunities to continue to grow professionally in our teaching and leadership styles. There are many ways to help. Telemedicine is also an option. You might be able to review a case over the Internet, or you can donate money, equipment or supplies. Perhaps you have a box of collected glasses in the office. You do not necessarily have to travel to have a positive impact in other places where your help is needed.

Mildred M.G. Olivier, MD, FACS, is the CEO of Midwest Glaucoma Center at Hoffman Estates, Ill. Disclosure: Olivier is on the speakers bureau for several companies that have donated supplies for her volunteer efforts.

Global outreach is challenging, but rewarding. Like illness or any other sudden change in direction, a practice’s choice to assist in global outreach derails its normal operating rhythm. Global outreach also brings every kind of clinical and logistical challenge because it is impossible to know what we need to take when we suddenly leave for another country to provide aid. It is impossible to know what facilities will be available or in working order. And items as simple as rubber gloves are not a certainty at the destination.

In the past, I have kept every industry contact and friendship that might provide supplies, and have exhausted my supply cabinets and other sources for medications and materials. I have also leaned on my staff to take time off and travel with me, as well as disrupt family plans.

But the rewards of doing global outreach far exceed any inconveniences. It is truly the highest level of service we can provide as physicians to help those most in need. When we return from a trip to an impoverished or tragedy-stricken region, we truly understand the global sense of medical need, and our own daily complaints about imperfections in our practice seem insignificant or petty. I highly recommend it.

However, providing global outreach is a financial burden on the office. When a physician leaves, the means of production are absent, yet the office continues to generate expense without revenue — the same as occurs anytime a private practitioner goes on vacation. And when the outreach trip occurs suddenly, there is no opportunity to plan ahead and schedule around it.

If we are going to do global outreach, we should tell our patients about it. They genuinely admire us for our desire to help those in need. Patients are also happy to accommodate our schedules when we make such personal sacrifice, and will loyally refer their friends to a doctor whose ethics they so admire.

John A. Hovanesian, MD, FACS, is OSN Cataract Surgery Section Editor. Disclosure: Hovanesian has no relevant financial disclosures.