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SUNDAY, JULY 10, 2016 7:00am 8:00am 8:50am 9:20am - 8:00am - 8:50am - 11:00am - 9:20am 11:00am - 12:00pm 12:00pm - 1:50pm 2:20pm - 1:50pm 2:20pm 4:00pm Registration, Exhibit Hall, & Continental Breakfast Scleral Lens Patient Selection and Fitting Maria Walker, OD, MS & Karen Lee, OD Exhibit Hall & Refreshment Break Scleral Lens Management: Troubleshooting and Video Grand Rounds Karen Lee, OD & Maria Walker, OD, MS Exhibit Hall & Lunch - 5:00pm COPE ID# 49954-CL Scleral Lens Hands-On Workshop Maria Walker, OD, MS, Ryan Dimit, OD, Katrina Parker, OD, Randy Charrier, OD, Tom Arnold, OD, Ashley Tucker, OD, Roxana Hemmati, OD COPE ID# 49974-CL Exhibit Hall & Refreshment Break Scleral Case Grand Rounds Moderated by Jan PG Bergmanson, OD, PhD Karen Lee, OD, Maria Walker, OD, MS, Katrina Parker, OD, Roxana Hemmati, OD, & Edward Bennett, OD, MSEd COPE ID# 49957-CL 2016 Professional Responsibility Course for Texas Optometrists Joe DeLoach, OD, FAAO 4:00pm COPE ID# 49952-CL COPE ID# 48222-EJ NOTE: This course will include a screening of a previously recorded session presented by Joe DeLoach, OD. Participants will receive CE credit for viewing the course – NO EXAM REQUIRED. Health and Biomedical Sciences Building in the Molly and Doug Barnes Vision Institute 4811 Calhoun Road, Houston, TX 77204 Scleral Lens Patient Selection and Fitting Instructors: Maria K Walker, OD MS (Lead Instructor) University of Houston College of Optometry [email protected] 713-743-6421 Karen Lee, OD University of California San Francisco, Department of Ophthalmology [email protected] 415-353-2938 Course Description: This course will be an introductory course for specialty contact lens fitting. We will discuss the different types of indications and the specialty lens options available in modern practice. We will focus the discussion on scleral lenses, as they have become a standard of care for many specialty lens indications. An overview of scleral lenses and fitting techniques will be reviewed. Course Objectives: - To review the indications for specialty contact lenses, and give an up-to-date overview of the current lens modalities available for specialty lens fitting. - To familiarize the audience with the basic fitting principles concerning scleral lenses. - To review the wearing procedures and management of scleral lens wear, and introduce the common complications associated with their use. Course Outline: 1. Indications for specialty contact lenses a. Irregular corneal shape i. Keratoconus – irregular prolate shape and higher order aberrations ii. Post-corneal transplant – oblate shape with varying aberrations iii. Post-refractive surgery – newer procedures have relatively benign refractive complications, mostly focus on post-RK in specialty fitting b. Ocular surface disease i. Dry Eye therapies with contact lenses ii. Exposure keratopathy treatments with contact lenses c. Normal cornea, special considerations (vision, comfort) i. Multifocals – specialty options sometimes necessary for stable adequate multifocal vision ii. High refractive error or astigmatism– may merit use of customized lenses for maximized vision 2. Specialty lenses available today a. Custom soft i. Ideal for mildly irregular corneas – rule of thumb is they are suitable for 20/30 or better vision in specs ii. Appropriate for certain types of dry eye – exposure conditions 1. Not good for reduced tear production (hormonal, medication-related) b. Corneal GP i. Established wearers and mild to moderate irregularities ii. Use topography to deem appropriateness 1. Level of asymmetry in anterior corneal shape most important factor c. Hybrid i. Used with poor corneal GP lens tolerance d. Scleral lenses i. They are becoming standard of care for many irregular cornea conditions ii. Important to remember that these are not appropriate for all individuals 1. Considerations: dexterity/anatomy, corneal (endothelial) health, familial support – Scleral lenses are a lifestyle 3. Scleral lens management – based on the recent trends in specialty lens fitting, we focus primarily on management of the irregular and normal cornea with scleral lenses a. Basics of scleral lens fitting i. Application – primary goal is to avoid application bubbles 1. Implications of small apertures, sensitive corneal reflex, poor dexterity and/or visual feedback reliance 2. Tools and tips for application ii. Removal 1. Properties of the lens fitting relationship and the implications for removal 2. Tools and tips for removal iii. Cleaning and storage 1. Several cleaners are available for use in disinfecting, conditioning, and rinsing the scleral lenses 2. Application solutions (preservative free) are unique to this lens modality iv. Fitting techniques 1. Diameter and diagnostic lens selection 2. Apical clearance a. As little as possible while still clearing at the highest elevated point b. Complications associated with reduced and excess apical clearance 3. Limbal alignment a. Too much clearance will promote discomfort and midday fogging b. Bearing may induce surface epithelial breakdown 4. Scleral landing a. Even and along the most distributed surface possible i. Avoid “high-heel effect” ii. Avoid impingement and haptic compression Scleral Lens Management: Troubleshooting and Video Grand Rounds Course Outline: Karen Lee, OD University of California San Francisco, Department of Ophthalmology [email protected] 415-353-2938 Maria Walker, OD, MS University of Houston College of Optometry [email protected] 713-743-6421 1. General fitting issues a. Excessive apical clearance i. Flatten the base curve ii. Decrease the overall diameter b. Apical touch i. Steepen the base curve c. Limbal touch i. Steepen the limbal curves ii. Lengthen the limbal curves iii. May need to compensate as this will increase your central clearance d. Excessive limbal clearance i. Flatten the limbal curves ii. Shorten the limbal curves e. Edge lift f. Impingement vs compression i. Heel-toe effect 2. Lens decentration 3. Midperipheral touch 4. Benign Issues a. Early onset bubbles and late onset bubbles b. Epithelial bogging c. Conjunctival prolapse 5. Post-surgical scleral lens fitting a. Radial keratotomy i. Radial incisions and sometimes flat incisions ii. Long term consequences: corneal irregularity, iatrogenic ectasia, poor vision iii. Poor visual outcome with glasses and soft lenses, difficult to fit with small diameter GPs, better success with scleral lenses iv. Complications to be aware of when fitting a post-RK patient v. Live fitting and scleral lens assessment with post-RK patient b. Penetrating keratoplasty i. Post-corneal transplant – oblate shape with varying aberrations ii. Endothelial cell loss despite successful surgical outcome, critical number when scleral lenses are contraindicated due to corneal edema iii. Median graft survival rate iv. Complications to be aware of when fitting a post-PK patient 6. Ocular surface disease a. Tear chamber debris i. Troubleshooting and management a. Edge lift b. Managing lid disease c. Thicker PFAT in tear chamber b. Poor surface wettability i. Troubleshooting and management a. Squeegee front surface b. Change care system c. Change lens material or defective lens 7. Conjunctival elevations a. Pingueculae i. When to notch ii. Troubleshooting and management b. Pterygium i. To fit or not to fit ii. Troubleshooting and management c. Glaucoma surgery i. To fit or not to fit ii. Troubleshooting and management d. Thinning conjunctival tissue e. Monitoring IOP with scleral lens wear 8. Highly asymmetric scleral shape a. Sclera is not symmetric i. Not an issue if fitting less than 15.0mm OAD ii. Not an issue if less than 1D difference b. Certain conditions with extreme scleral asymmetry i. Stevens-Johnson Syndrome ii. Scleral buckle 9. Therapeutics beneath a scleral lens a. Non-preserved b. Concomitant treatment 10. Piggybacking with soft lenses a. Traumatic mydriasis i. Cosmesis or photophobic purposes ii. Troubleshooting and managing possible complications 11. Application and removal a. Handling challenges and tools that can help i. Plunger stand ii. See green monster iii. Dark plunger vs light plunger iv. EZI lens applicator b. Care regime challenges i. Product availability ii. Patient compliance iii. Patient variability Scleral Lens Hands-On Workshop Maria K. Walker, OD, MS (Course Master) 4901 Calhoun Road Houston, TX 77098 Tel: (713) 743-6421 [email protected] Additional Faculty Participants: Ashley Wallace-Tucker, OD [email protected] Randy Charrier [email protected] Thomas Arnold, OD 15337 Southwest Freeway Sugar Land, TX 77478 281-242-2020 [email protected] Ryan Dimit, OD [email protected] Katrina Parker, OD 4901 Calhoun Road Houston, Texas 77204 713-743-1956 [email protected] Roxana Hemmati, OD 4901 Calhoun Road Houston, Texas 77204 Tel: (713) 743-6421 [email protected] Course Description: This course is intended to provide practitioners with hands on experience in fitting a scleral lens on the eye and managing scleral lens patients. In addition, we will review and provide experience with modern technology that can be used to evaluate scleral lenses and manage patient care. Course Objectives: o To train practitioners with hands-on direction how to fit and evaluate a scleral lens o To teach scleral lens practitioners how to incorporate technology such as the specular microscope and OCT into their scleral lens practice o To familiarize practitioners with several designs of scleral lenses and provide them with handling and patient feedback experience. Course Outline: I. Review of scleral lenses a. Designs i. Those fit using base curve vs sagittal depth ii. Variations in lens design (ie. Toric haptics, microvault) b. Differences between scleral lenses for regular cornea vs. irregular cornea i. Prolate vs oblate vs standard corneal design – changes in apical profile II. Review of the technology available to fit scleral lenses a. Topography and Tomography i. Follow curvature changes as well as CCT with tomography b. Ocular Coherence Tomography i. Evaluate tear reservoir depth and peripheral lens profile c. Specular Microscopy i. Monitoring for endothelial problems and changes d. Confocal Microscopy (in vivo) i. High resolution epithelial and anterior stromal imaging e. Scleral topography mapping i. Used to measure the curvature and elevations of the perilimbal sclera III. Scleral lens Designs a. Diameters – range from 13.5 to 24.0 i. Patient characteristics when choosing a diameter b. Materials – all with Dk greater than 100 i. Compare Dk of 125 – 162 and appropriateness for individual patients c. Fitting guides for each different design d. Edge designs i. Spherical ii. Toric iii. Quadrant based iv. Customized molds e. Available alterations of various fitting parameters IV. Scleral lens fitting a. Unique cleaning techniques prior to application b. How to apply lenses i. Large plunger – most common 1. Tips for using the large plunger ii. Tripod method or Two finger method – most convenient 1. Importance of good hygiene iii. Scleral ring insertion – uncommon iv. Dalsey adaptives – system for application with LED light v. Application solution to use for insertion – artificial tears and c. How to remove lenses i. Small plunger – most common ii. Eyelid pressure method – important in emergencies iii. Complications associated with improper removal 1. Ocular damage, consider corneal thickness and anatomy d. Evaluating lenses on eye i. Vision 1. Scleral lens over-refractions a. Spherical vs sphero-cyl 2. Using technology to evaluate flexure – keratometer or topography ii. Proper slit lamp technique to evaluate lenses 1. Cobalt blue vs white light 2. Using known lens thickness to estimate central clearance iii. Apical profile 1. Tear profiles – base up, base down, plano 2. Minimum clearance over most elevated point to reduce excess clearance elsewhere. iv. Limbal profile 1. Excess clearance vs minimal clearance 2. Complications associated with minimal limbal clearance v. Scleral landing zone 1. Blanching vs impingement 2. Use of toric haptic zones to even out scleral landing e. Evaluation of scleral lens with OCT i. Central clearance evaluation ii. Limbal clearance evaluation iii. Lens edge evaluation and conjunctiva f. Keratometry or topography over scleral lenses i. Evaluate flexure ii. Methods to reduce or eliminate flexure g. Removing a lens on a live patient i. Different removal methods will be trialed on different patients ii. Pop out method iii. Plunger method V. Complications associated with scleral lenses a. Application and removal difficulties i. Using education and technology to improve compliance and understanding b. Solution and material sensitivities i. Most compatible solutions for scleral lens wear. c. Acute-wear complications i. Ocular discomfort / stinging, visual distortions d. Long-term wear complications i. Tissue changes, impression of conjunctiva, endothelial health VI. Wrap up and conclusions a. Building a scleral lens practice into your private practice i. Delegation of training and instillation of lenses ii. Use of diagnostic equipment to aid in the flow of patients b. How to order a scleral lens i. Empirical ordering through labs as well as online ordering. c. Cost and replacement of scleral lenses i. Setting up a system for fitting costs and warranties in your practice Scleral Case Grand Rounds Maria K. Walker, OD, MS (Course Master) 4901 Calhoun Road Houston, TX 77098 Tel: (713) 743-6421 [email protected] Roxana Hemmati, OD 4901 Calhoun Road Houston, TX 77098 [email protected] Edward Bennett OD, MSEd One University Boulevard St. Louis, MO 63121 Tel: 314-516-6258 [email protected] Karen Lee, OD 400 Parnassus Avenue, suite A750A San Francisco, CA. 94143 Tel: 415.353-2938 [email protected] Katrina Parker, OD 4901 Calhoun Road Houston, Texas 77204 713-743-1956 [email protected] Moderated by: Jan PG Bergmanson, OD, PhD 4901 Calhoun Road 713-743-1950 [email protected] Course Description: This course is intended to provide practitioners with case examples of fitting a scleral lens on the irregular cornea and other advanced scleral lens fitting scenarios. Course Objectives: o To inform scleral lens practitioners on the available options and the decision-making process when fitting scleral lenses. o To deepen the practitioner understanding of scleral lens designs and the applicable patients in which they are best suited. o To provide practitioners with specific cases that outline the management of scleral lenses on irregular and regular cornea. Course Outline: Case One I. II. III. IV. Patient History a. 26yo male with normal cornea, high astigmatism Scleral Lens fitting a. Diagnostic lenses ordered and dispensed – toric periphery Lens follow-up and management a. Initial lenses – bubbles superior nasally due to asymmetric sclera b. Re-ordering of lenses with higher amount of haptic toricity c. Follow-up with new lenses showed less bubbles – increased toricity more d. Final lenses had maximum toricity and reduced bubbles Discussion and Conclusions a. Available haptic zones in scleral lens designs b. Mapping and evaluating scleral toricity c. Fitting normal corneas with scleral lenses Case Two I. II. III. IV. Patient History a. 64yo male with normal cornea, interested in presbyopic correction Scleral Lens fitting a. Diagnostic lenses ordered and dispensed – toric periphery with near center aspheric multifocal optics Lens follow-up and management a. Initial lenses – good fit and comfort with +1.00OR of left eye (distance dominant eye) b. Re-ordering of lenses with higher amount of plus power OS c. Follow-up with new lenses with good vision Discussion and Conclusions a. Multifocal designs available with scleral lenses b. Optics and visual stability of a scleral lens c. Management of the normal cornea in scleral lenses Case Three I. II. III. IV. History a. 24 y/o AAM with h/o LASIK surgery resulting in residual myopia Fitting and Evaluation a. Initially fit in a 16.8mm Custom Stable Elite (toric haptic design) lens. Ordered OD: -3.50DS, 8.65mm BC, 4510 SAG, SLS 1/-4; OS: -2.00DS, 8.65mm BC, 4510 SAG, SLS -2/-1 Dispense and follow up 1 a. At the dispense of the initial lenses, KT achieve 20/20 DVA OD, OS,; both lenses showed acceptable central and limbal clearance, but there was edge lift at 3&9 and excessive movement (leading to discomfort) b. New lenses were ordered; OD was kept in a 16.8mm Custom Stable Elite lens, 4.00 DS, 8.65mm BC, 4510 SAG, with a toric scleral landing zone of -2/-5, and OS was changed to a 16.8mm Custom Stable Lens, -2.50 DS, 8.65mm BC, 4510 SAG, with a spherical scleral landing zone in a -3 Dispense and follow up 2 a. Along with 20/15 DVA OD/OS and acceptable central and limbal clearance, the new lenses showed ideal scleral alignment b. KT reported great comfort and the lenses were successfully dispensed. No changes have been needed to be made to the lenses at any subsequent follow-ups Case Four I. II. III. History a. 71 y/o CM, OcHx of Fuch’s endothelial dystrophy and POAG b. OcSxHx including DSAEK OD, PKP OS, PCIOL OU, LPI OS, Aqueous tube shunt OS Corneal GP lens ordered empirically Follow up a. Corneal GP lens showed a very poor fit and inadequate vision. EyePrintPRO lens was recommended to patient b. EyePrinttPRO impression was used to design a scleral prosthetic c. Vision with lens was 20/40-2; assessment of lens fit showed acceptable central and limbal clearance with alignment over sclera including bleb Patient has continued to wear lens successfully d. Patient’s IOP, corneal thickness, and endothelial cell count have all been closely and consistently monitored; no significant changes from pre-lens wear have been noted Case Five I. II. Patient introduction Sjogren’s Syndrome Review III. IV. V. VI. VII. VIII. IX. a. Primary Sjogren’s syndrome b. Secondary Sjogren’s syndrome c. Sjogren’s syndrome is a SYSTEMIC disease process i. GI issues, pulmonary problems, renal involvement ii. Higher risk of developing lymphoma iii. Pts are affected physically, psychologically, and socially Sjogren’s syndrome: diagnosis a. American-European Consensus Classification Criteria Sjogren’s syndrome ocular findings a. Most commonly complains of dry, red, itchy, painful, gritty or sandy sensation in the eyes. b. Slitlamp findings c. Schirmer test Dry eye evaluation Dry eye treatment Significant findings at initial visit One week scleral lens follow up Videos documenting scleral lens fit assessment a. Central clearance and limbal clearance without NaFl b. Assessing scleral lens haptics c. How to search for edge lift with NaFl d. Pumping NaFl into the anterior chamber e. Assessing tightness of lens while distributing NaFl f. Reassessing central and limbal clearance with the use of NaFl g. Ocular health and patient reaction after wearing scleral lenses for one week Case Six I. II. III. IV. V. VI. VII. VIII. Patient introduction slide Keratoconus Review a. Cause b. Onset c. Symptoms d. Associations Keratoconus Diagnosis Significant findings at initial visit Scleral lens dispense findings a. When to notch and when not to notch a scleral lens Two week follow up findings with video a. Assessing scleral lens haptics and notch b. Assessing central and limbal clearance with the use of NaFl Pingueculae Review a. Causes b. Symptoms c. Treatment and prevention Finalized lens findings videos a. Assessing scleral lens haptics and notch b. Assessing central and limbal clearance with the use of NaFl c. Ocular health and patient reaction after wearing scleral lenses for one week central corneal thickness. Case Seven I. II. III. History A. 69 y/o FM, 16 incision radial keratotomy OU in 1990s B. OD (since RK): History of retinal detachments ultimately resulting in a vitrectomy and loss of vision C. Came to clinic wearing spectacles with a balance lens OD; VA was 20/40 OS with correction Fitting and Evaluation A. Fit OS only, Initially fit with intralimbal (11.2mm overall diameter) which resulted in excessive movement, midperipheral bearing and excessive edge lift B. Refit into Jupiter Semi-Scleral Reverse Curve 15.6mm overall diameter, 8.23mm base curve radius, and -5.75D power C. Initially there was excessive clearance (400mm with OCT), nasal-temporal blanching, and mild awareness D. Patient was refit into a 8.65mm BCR, -3.75D power Follow up A. At the end of 10 weeks, an optimum fitting relationship, corrected visual acuity improvement to 20/25-, and very good patient satisfaction. Case Eight I. II. III. History a. Diagnosed with herpetic keratitis at age two and had a corneal transplant OD at age 11 b. Originally seen in late 2008 and her refractive information was: i. OD: Pl – 6.50 x 150 20/80 50.50/45 @ 155 ii. OS: Pl – 2.00 x 165 20/150 47.62/42.50 @ 005 c. At that time she was fit into intra-limbal lenses OU Fitting and Evaluation a. In May, 2009 she reported persistent lens awareness with the intralimbal lenses and had difficulty wearing them. At 16, she was strongly motivated to pass her driver’s license exam but exhibited concern that she could not do so with her spectacles. b. She was fit into the Jupiter Reverse Geometry semi-scleral lens design OU: OD: 7.18mm BCR, 15.6 OAD, -5.00D power; OS: 7.5mm BCR, 15.6mm OAD, 3.25. c. These lenses provided an optimum fitting relationship and resulted in a visual acuity of 20/30 OD; 20/40 OS Follow-up a. After dispensing of the lenses she returned at her first follow-up visit reporting (enthusiastically) that she had passed her diver’s license examination. b. As of April, 2016 she is still wearing these lenses with the same visual results. Her lens parameters at this time are: OD: 7.46mm BCR, 16.0mm OAD, -3.75D. OS: 7.50mm BCR, 15.0mm OA 1/15/2016 2016 PROFESSIONAL RESPONSIBILITY COURSE Joe W DeLoach, OD, FAAO Coursemaster University of Houston College of Optometry The development and production of the Professional Responsibility Course is underwritten by the Harris Lee Nussenblatt Lecture Series Endowment. This endowment was established in 1992 by the Nussenblatt Family in memory of former Associate Professor Harris Nussenblatt, OD. The Lecture Series focuses on issues related to professional ethics, public health and practice administration First – Who Is the TOB? The Staff Chris Kloeris Patty Ortiz Dennis Riggins Vincent Piña Donna Montgomery Mark Patterson Clay Nieman Executive Director Executive Assistant Investigations Licensing Continuing Education Accountant IT Welcome to the Professional Responsibility Course sponsored by the University of Houston College of Optometry. This course is a requirement for Texas license holders wishing to renew their license in 2017. All fees associated with this course are devoted to permanent projects at the University that are important for the future of our profession. Thank you for choosing UHCO for your continuing education. Preface The content of the Professional Responsibility Course is at the direction of the Texas Optometry Board. This year, the Board requested specific issues that will fill the entire content of the course. First – Who Is the TOB? The Board Members Doctor Members Public Members John Coble, OD (Chair) Judith Chambers Melvin Cleveland, OD Larry Fields Mario Gutierrez, OD Rena Pena Ron Hopping, OD Carey Patrick, OD Virginia Sosa, OD 1 1/15/2016 Key Points • The Board is underfunded and under staffed – they work very hard for you especially around license renewal time (like your last minute CE…) • They are doing a time consuming, essential but thankless job – might consider thanking them for their service now and then • It is a service – the Board member’s compensation is a whopping $36 a day plus travel expenses LESS lost revenue from the office 8+ days a year • They really are there to help – they are your colleagues but their obligation is to protect the citizens of Texas by upholding the law as it is written The Optometry Board Newsletter • First, it’s for YOU ‐ they don’t have to do it! • It is an easy way to keep up with new laws, new rules and other Board activity • It is your reminder and direction for renewing your license each year Few likely read it cover to cover. That is really dumb… Rule 280.6 – Why?? • Payer issues • Common sense vs statute • Medical bias So that makes the real problem with 65778… 2016 AGENDA 1. THE Newsletter 2. Rule 280.6 regarding the administration, dispensing and charging for therapeutic contact lenses and amniotic membranes 3. Obligations regarding suspected child abuse or domestic violence 4. Communications and Social Media Rule 280.6 – Amniotic Membranes (a)Under the authority of §351.358 of the Act, a therapeutic optometrist may administer, perform, or prescribe ophthalmic devices, procedures, and appropriate medications administered by topical means, to diagnose or treat visual defects, abnormal conditions, or diseases of the human vision system, including the eye and adnexa. (b) Pursuant to the limitations in subsection (a) of this title, a therapeutic optometrist may: (1) administer an amniotic membrane in a procedure that does not involve suturing; and (2) dispense and charge for therapeutic contact lenses in accordance with §551.004 of the Texas Pharmacy Act. Domestic Violence – from the law • An optometrist who treats injuries he or she suspects were caused by family violence is required to document the treatment in the patient’s medical record including an explanation of why he or she believes the injury was caused by a domestic violence situation. • Additionally, the optometrist is required to give the patient: • Information regarding the nearest shelter • A written statement with language at least equivalent to the language proposed in Texas Family Code 91.003 2 1/15/2016 Patient Domestic Violence Form Domestic Violence – Key Points NOTICE TO ADULT VICTIMS OF FAMILY VIOLENCE It is a crime for any person to cause you any physical injury or harm even if that person is a member or former member of your family or household. • These are not recommendations, they are the law. Failure to abide by these rules can result in action against you professionally (action against your license) and personally (civil action against you) You may report family violence to a law enforcement officer by calling the following telephone numbers: _____________________________. If you, your child, or any other household resident has been injured or if you feel you are going to be in danger after a law enforcement officer investigating family violence leaves your residence or at a later time, you have the right to: - Ask the local prosecutor to file a criminal complaint against the person committing family violence; and - Apply to a court for an order to protect you. You may want to consult with a legal aid office, a prosecuting attorney, or a private attorney. A court can enter an order that: (1) prohibits the abuser from committing further acts of violence; (2) prohibits the abuser from threatening, harassing, or contacting you at home; (3) directs the abuser to leave your household; and (4) establishes temporary custody of the children or any property. A VIOLATION OF CERTAIN PROVISIONS OF COURT-ORDERED PROTECTION MAY BE A FELONY. CALL THE FOLLOWING VIOLENCE SHELTERS OR SOCIAL ORGANIZATIONS IF YOU NEED PROTECTION: _____________________________. Our big topic…. Office communications What’s hot, what’s legal ‐ what’s not Social media What’s hot, what’s legal ‐ what’s not Communications with Patients What’s Legal Answers to issues regarding communication legalities are for the most part found in two major pieces of Federal legislation • HIPAA • Telephone Consumer Protection Act of 1991 What do they say about all this and what is new? • It is a fine line – be very sure the evidence is supportive enough to likely be more than just suspicious. Erroneous claims of domestic violence can be damaging to you personally but more so to the individuals and families involved Communications with Patients What’s Hot • Talking to our patients in person, on the phone, through email, via text…it’s all important • Laws regulating this extend far beyond HIPAA and most have been in place for a very long time • With advancement in communication technology, those laws are now being revised and interpreted. Not keeping up can be very costly to your reputation and your pocketbook Telephone Consumer Protection Act July 2015 Declaratory Ruling – First Issue Implied Consent • Makes it clear that if a patient provides a telephone number to a provider, use of that number for communications regarding health care information is IMPLIED and does not require patient authorization (it wasn’t always?) • Ruling does not extend to emails; ruling is silent related to use of telephone number for text communication • Only exception is written instructions / prohibitions from the patient to the contrary 3 1/15/2016 Telephone Consumer Protection Act July 2015 Declaratory Ruling – Second Issue Telephone Consumer Protection Act July 2015 Declaratory Ruling – Third Issue Incapacitated Third Party Rule End to End User Call Regulation • Clarifies that a patient has the right to designate prior communication consent for a provider to contact a third party for information in the event the patient is incapacitated • Also grants rights to the provider to contact a third party in emergency situations if the patient is incapacitated and cannot provide consent • Establishes regulations regarding rights of provider to contact a patient through communication channels for which the patient pays a fee and the communication could impact that fee (and it wouldn’t when?) • Classifies the nature of the communication as exempt or non‐ exempt – in other words what kinds of communications fall under the rule and which do not Telephone Consumer Protection Act July 2015 Declaratory Ruling – Third Issue Exempt Communications Non‐Exempt Communications • Health care treatment information • Payment information • Appointment calls and reminders • Debt collection • Pre‐Post operative instructions • Any other financial information • Rx notifications • Marketing information • Lab result information • Any advertising • Home health care information Telephone Consumer Protection Act July 2015 Declaratory Ruling – Summary Communications (phone and text) for health care purposes are generally fine and have some implied consent. Implied becomes suspect when: • The communication becomes a text message • The communication does not relate directly to the healthcare of the patient • The communication contains any marketing or advertising SOLUTION / RECOMMENDATION 1. Place in your NPP a statement that you utilize the phone numbers provided to you by the patient to communicate with them regarding their healthcare needs 2. For all other phone, text and email considerations the best choice is to have a separate authorization from the patient Telephone Consumer Protection Act July 2015 Declaratory Ruling – Third Issue Even exempt calls are regulated: • Phone number(s) limited to those specifically provided by the patient • Communications must include name of the provider and contact information for the provider • Must be related only to the specific health care information of concern – cannot include any marketing or advertising information • Voice messages must be limited to one minute or less and text messages to 160 characters or less • Communications are limited to one per day or three per week • Communication must include clear instructions as to how the patient can opt out of future communications HIPAA Privacy & Security Clarifications Means What? 45 CFR164 522-530 All covered entities and business associates are required by law to implement measures that “guard against unauthorized access to PHI that is being transmitted over an electronic communications network”. Communications can be made three ways: 1. To the patient 2. From the patient 3. To anyone except the patient 4 1/15/2016 HIPAA Privacy and Security Clarifications Communications TO the Patient “The Security Rule does not expressly prohibit the use of email to communicate with a patient. However, the standards require procedures to restrict access, protect the integrity of and guard against unauthorized access to PHI.” What are “certain procedures”? Finally defined – “reasonable precautions… equivalent to encryption (my emphasis)” www.hhs.gov/ocr/privacy/hipaa/faq/securityrule HIPAA Privacy and Security Clarifications Communications FROM the Patient • The HIPAA Privacy and Security Rules do NOT apply to communications FROM the patient. But as soon as the provider receives the email, the information now must be protected by the provider. • Any communication BACK to the patient from their initial response, refer back to previous two slides Social Media ‐ What’s hot? HIPAA Privacy and Security Clarifications Communications TO the Patient ‐ Summary If you elect to communicate with your patient via email, you have two choices: Secure the Transmission • Not sure what is “equivalent to encryption” ‐ so suggest all communications are encrypted. HHS suggests email communication be limited to only secure patient portal systems. www.healthit.gov/providers‐professionals/guide‐privacy‐and‐security‐electronic‐health‐information Or “Warn” the Patient • Required to inform the patient the communication may not be secure and the potential consequences of that • Patient must confirm they understand the risks and wish to continue. Does not state HOW they confirm this but anything less than written authorization would be foolish. HIPAA Privacy and Security Clarifications Communications to Anyone EXCEPT the Patient • No stated exception to the encryption criteria and no expressed authority for the patient to “waive” these security measures • Specifically includes text communication • Warns that providers should check with their respective text communications company to see if they store communications, which is stated as a risk to consider SUMMARY Communications to ANYONE except the patient, only use secured / encrypted text systems, secured / encrypted email systems with strong recommendation for use of secure patient portal Social Media ‐ What’s hot? EVERYTHING!!! Texas Workforce Commission quotes re: Social Media Unfortunately resulting in one of the largest areas of problems with patient communication, privacy of patient PHI and human resource issues “Fools names and fools faces often appear in public places” “Although social media regulation and technology has improved dramatically, there has been no corresponding upswing in common sense or decency in society” 5 1/15/2016 Social Media The Four Major Legal Challenges 1. Data protection and privacy HIPAA is real and the privacy and security rules apply no matter where information is posted 2. Employee rights Employees have a legal “right to know” employer policies regarding social media and those policies cannot violate their protection under the National Labor Relations Board and the 4th Amendment Social Media What’s Legal and What’s Not All In One Six Social Media Situations for Health Care Practitioners Social Media The Four Major Legal Challenges 3. Disclosures and third party endorsements Your employees are a legal extension of your practice – what they say, endorse or “like” may be problematic 4. Governance and oversight You have a legal obligation to monitor your business and enforce your policies Social Media Communications with Patients • Let’s start with this is, in general, not a great idea unless: • Communications with patients on social media • Communications on blogs / websites • Using social media for background checks, investigations of current or potential employees • Employee communication on social media during business hours (“on duty posting”) • Employee communications on social media outside the business (“off duty posting”) • Employer liability for employee postings on social media Social Media Communications on Blogs / Websites • Obvious examples – OD Wire, ODs on Facebook, etc • What you CANNOT do without patient authorization ‐ Post anything that could POTENTIALLY identify the patient • The obvious – names, patient numbers, SS#, DL#, address, occupation, too much history information – and the list goes on and on. HIPAA describes a problem as “any combination of information that could potentially identify” • Evidently not so obvious – identifying pictures. Definitely full or partial facial photos but could also include any mark, irregularity or pathology that could identify the patient •Patient initiates the communication •Communication is generic to patient base •Communication involves marketing, advertising or general health information that is also generic to the patient base •And end with there is NEVER justification or rationale for posting any PHI on social media, even with attempted patient authorization (can a patient “waive” their HIPAA rights?) Social Media Communications on Blogs / Websites • This issue is generally scoffed at by blog participants. There have already been privacy violations on this. The California Supreme Court has ruled that the simple “act of posting” is a violation even if human eyes never see the post. • The argument of “a private blog” doesn’t hold water. Nothing on the internet is private, forever! • The question of patient authorization is still up for grabs. It is likely a good protection but not the safest action. Safest action is do not post anything that could even POTENTIALLY identify a patient. 6 1/15/2016 Social Media Using social media to “check up on them” • This may include n0n‐private background checks; n0n‐private credit checks; evaluating them based on Facebook page ‐ comments, likes, photos; evaluating them based on Twitter postings • This is a VERY bad idea – because: • The information is often incorrect and not verifiable • Employers can be held liable for any decision regarding a new or existing employee based on this information, even if the information was posted incorrectly by the employee or applicant Social Media Employee on duty vs off duty communication DEFINE: ON DUTY communication – posting through the internet during time the employee is “on the clock”. The posting can be performed using the employer’s equipment or the employee’s equipment – and this does make a difference! OFF DUTY communication – posting through the internet during time the employee is NOT “on the clock” Repeat – bad idea. Don’t do it! Social Media Employee on duty vs off duty communication The Most Common Problems •Inefficient use of work time •Harassment (other employees or even patients) •Endorsements •Pornography Social Media Employee on duty communication BE CAREFUL! Monitoring activities must be: • Legal in your state (legal in Texas) • Based on written office policies • Uniformly applied to all employees • Authorized by the employee – not a legal requirement in Texas but a very good idea • Based on some rational reason – surreptitious monitoring is definitely illegal Social Media Employee on duty communication Employers have every right to monitor employee activity on the internet when such communications are: • Made during the hours they are working for you • Made on equipment you own or manage • Work related – and to some degree when they are not work related Social Media Employee off duty communication This one is far trickier! The National Relations Labor Board allows employers to monitor off duty employee postings as long as the activity might directly effect: • Fellow co‐workers • The employer’s business • The employer’s patients, customers or other clients • Employer’s “trade secrets” – poorly defined 7 1/15/2016 Social Media Employee off duty communication The problem – poor clarity: •The biggie – NLRB states employee’s 4th amendment rights must be protected. Again, how far does that go? •“Directly effects” poorly defined – always remember labor laws are designed to help the employee, not you •Employees have to right to post anything related to the “conditions of their employment” – also loosely defined but definitely includes working conditions, compensation, hours, benefits, demeanor of the employer. And there is significant leniency regarding the complete “accuracy” of the post! Texas chimes in here… Texas Penal Code 33.07 • Employers may take action against an employee for conduct that has the effect of damaging the company business (poor clarity and in many cases will conflict with rights granted to employee by Federal NLRB) • It is illegal to use a false identity to create or post on a website where the post has the intent to harm, defraud or threaten (3rd Degree Felony) • It is illegal to post a communication posted by another person without their consent where the intent of “carrying forward” the post is to harm, defraud or threaten (Class A Misdemeanor) Social Media Employer Liability for Employee Actions • Without question…regarding protection of patient privacy – HIPAA holds YOU liable for the actions of your staff unless you have followed HIPAA privacy and security regulations • Regarding protection of your clients and business associates, the employer has liability for the postings of an employee that are damaging if the posting is deemed to be an endorsement or degrading action “approved by the employer”* • Back to tricky again – poorly defined, potential infringement of 4th amendment rights • Are we really going to take it this far? Likely to also be determined in courts How Far Can An Employee Go? Hold on to your hats… You finish a somewhat negative annual review that does not result in a pay increase for your employee. The employee is very upset and posts on Facebook: “ABC Company is is horrible place to work. Mr. ABC is a cheap, fatso piece of s#*%! who doesn’t care about anything but his pocketbook” NLRB can and likely would declare the post is allowable as the employee’s profanity and derogatory comments about the employer were made related to their “working conditions” and made during an emotional outburst that was the result of their disappointing review. Social Media ‐ Summary Employee on and off duty communication Monitoring for ANY reason in ANY situation can be tricky! NLRB states employees have a right to “reasonable protection of their privacy” – again, poorly defined. Likely to be defined in court if you want to contribute to that process. Social Media Employer Liability for Employee Actions How far are they going to take it? The SEC Release encourages employers to have a policy that any “endorsement” by an employee should include a disclosure statement clarifying the endorsement like “this does not necessarily reflect the opinion of my employer ABC Eyes”. But your choice… * SEC Release No. 34-58288 8 1/15/2016 And life is just not fair sometimes! All these “protections” do not flow both ways • The Communications Decency Act of 1996 rules that you may not claim damages for a network hosting site or social media site for not monitoring disparaging comments made by an employee (essentially these companies are immune from actions resulting from communications by 3rd party) • Courts have ruled that employers may be held liable for the actions of their employees on social media even when such actions are performed “off duty” Social Media – Recommended Policies Social Media – Most Important •At a minimum, employers should include a social media policy in their employee handbook. Contents are left to discretion of the employer based on the individual nature of the business. •The main policy should be “Your job comes first” •Like other HR policies, you must oversee your business and apply your policies in a fair and consistent manner for all employees Social Media – Recommended Policies Company postings should never contain: • Confidential business information (usually financial) Without approval, company postings should not contain: • Discriminatory, defamatory, disrespectful or derogatory statements about other employees, patients or any client of the practice • Endorsements of or references to products or services • Any illegal, sexual or unprofessional information • Material copied from another source • Comments of a personal or emotional nature such as politics, religion and the like • Information not related to the operation and purpose of the business • Material or information not approved by the employer • False, unconfirmed or misleading information Social Media – Recommended Policies Without approval, personal postings should not contain: • Endorsements of products or services except personal opinion – disclaimers recommended • Confidential business information (usually financial) • Discriminatory, defamatory, disrespectful or derogatory statements about other employees, patients or any client of the practice • Items that could be damaging to the employer’s business You can find many examples of social media policies on line or as part of a human resource management product from a compliance company. Customize to fit your style and needs. 9 1/15/2016 Bottom Line for Safety • Be aware of the law – esp HIPAA •Have concrete, fair and reasonable policies in your office regarding social media • KEEP EMPLOYEES HAPPY Thank You Have a Great 2016 [email protected] 10
