By Allison Evans, assistant managing editor

“We went through hell after Hurricane Katrina. It was pandemonium. Talk about getting caught without any plan in a situation that turned out to be catastrophic.” New Orleans dermatologist Patricia Farris, MD, learned about preparedness the hard way.

Hurricanes. Floods. Fires. Tornadoes. Earthquakes. These are just a handful of natural disasters that can destroy everything in the blink of an eye. From the Camp Fire — the deadliest wildfire in California’s history — to Hurricane Michael — one of the strongest Atlantic hurricanes since 1969 — 2018 was an unprecedented year in the amount and severity of natural disasters. Disasters like these have underscored the need for physicians to prepare for the unthinkable. 

A 2018 national survey from Healthcare Ready found that for a third year in a row, the potential for natural disasters tops the list for threats that cause the most concern among Americans — more than terrorist attacks, cyber attacks, and disease outbreaks. Despite concerns about natural disasters, more than half of Americans do not have any emergency plan in place.

This month, Dermatology World talks with members about their experiences shepherding their practices through natural disasters, and with health care and legal experts about best practices for protecting your practice and your patients. 

Step 1: Assess your risks

Planning and preparing for natural disasters can be overwhelming, especially for small or solo physician practices that may have limited resources. The first step is to perform a risk assessment based on the likelihood of certain disasters occurring in a geographic location, advised Molly Evans, JD, a partner in the health law practice group of D.C.-based law firm Feldesman Tucker Leifer Fidell LLP. If you live in California, you’ll have to account for risks like wildfires, earthquakes, and mudslides; if you live in Kansas, you’d consider tornadoes and other severe weather a risk. In the assessment, physicians should include not only a listing of potential threats, but also note the likelihood of occurrence, impact severity, and current level of preparedness to identify gaps in preparedness and better triage resources toward creating an effective plan.

In September 2016, the Centers for Medicare and Medicaid Services (CMS) published a final rule on emergency preparedness for health care providers that establishes national, consistent emergency preparedness requirements for 17 provider types, including hospitals, participating in Medicare and Medicaid.

While most dermatology practices are not subject to the CMS Emergency Preparedness Rule, Evans recommends starting the planning process by reviewing CMS regulations and seeing how they can be scaled to fit individual practices. “The Department of Health and Human Services (HHS) has published many free resources available to anyone. While the HHS resources are geared toward the 17 provider types covered by the rule, the health center templates may be helpful for dermatology practices,” she said. These resources are available at https://asprtracie.hhs.gov.

“The Kaiser Hazard Vulnerability Assessment (a free online tool) is also a useful template to get started,” said Evans. It includes natural disasters as well as other potential threats and hazards, such as epidemics, power outages, and active shooter situations. View the Hazard Vulnerability Analysis tool at https://www.calhospitalprepare.org/hazard-vulnerability-analysis.

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Step 2: Ensure records access

One of the most critical aspects of a disaster preparedness plan is ensuring physicians have access to patient records, said Julie Brightwell, JD, RN, director in the Department of Patient Safety and Risk Management at The Doctors Company, the nation’s largest physician-owned medical malpractice insurer. “Physicians need to be able to function without a computer for a period of time.” Many physicians utilize a cloud-based EHR, however, it’s also good practice to have multiple backup methods, with at least one backup stored at an off-site location, she said. Online cloud storage, portable hard drives, flash drives, and remote servers are relatively quick and easy ways to create multiple backups. Regardless of backup method, all formats must keep records private and secure in compliance with HIPAA.

Even if physicians are unable to access their EHR system, they still need to keep a thorough record of care. Some EHR vendors will provide backup paper records, Brightwell said. For those using paper records, it’s important that they are kept as free from the elements as possible. If records are stored in boxes or bins, make sure the containers are waterproof, stored off the ground, and kept free from food and drink to avoid vermin. If patient records have been lost or destroyed, the physician will have to re-create the record to the best of his or her ability while indicating that the new record is a re-creation.

The same holds true for financial records, such as accounting, billing, and tax documents. They should always be accessible in some form no matter your location. Dr. Farris also recommends keeping duplications of important paperwork — such as insurance policies, accounting paperwork, tax documents, human resources, and important contact information — and storing them in a remote site — or two. A certificate of insurance for medical malpractice coverage should also be included, Brightwell said, in case a practice relocation is required.

Expert advice

On Oct. 10, 2018, Hurricane Michael, a Category 5 hurricane, made landfall near Panama City, Florida, where Jon Ward, MD, the founder of Dermatology Specialists, worked to keep the practice operational. Because of his location, Dr. Ward’s practice had a robust plan to ensure access to electronic patient records. “We had an electronic medical records system and a Voice over Internet Protocol (VoIP) phone system, both of which had a main fiber-based internet line and a backup fiber-based line from two separate providers. The thought being if one provider goes down, you just switch to the other.” During the hurricane, both lines failed.

Yet, the practice had a plan C, which involved the chief information officer physically removing the servers and driving them to the nearest practice location where he would then reconnect all the offices within the networks that were not affected. Even after successfully executing plan C, it was another 24 hours before the practice was back online, Dr. Ward said.

“Hurricane Michael hit on Wednesday, although we were aware on Tuesday of the potential to encounter serious problems. On Tuesday, management communicated with everyone in the practices to be ready to lose EMR connectivity for the rest of the week,” Dr. Ward said. “Staff printed off schedules and paper encounter forms. We had a plan in place for everyone to be on paper for the rest of the week.”

Step 3: Plan a communication strategy

When disaster strikes, communication with staff and patients is critical for safety and business continuity. Regardless of practice size, all staff should be informed of emergency plans. Dr. Farris keeps a folder that contains the emergency response plans with the responsibilities of staff, and each year at the beginning of hurricane season, she reviews the plan with staff. Physicians should develop a full-circle call tree with home, office, cell phone, and email contact information included. Staff will need to know whether they should come in to work, whether certain procedures are cancelled, or what tasks need to get done if they can work, Brightwell said. Additionally, the plan should include how to get in touch with local and federal emergency response officials, Evans said.

If physicians are in a situation where there is no cell service or electricity, there should be a plan in place for how to alert staff and patients, such as using instant messaging technology, social media, patient portals, practice website updates, or taglines on the news. There are also apps (like FireChat) available that allow people to connect without Wi-Fi or a cellular network.

Patients must also be contacted. If the disaster allows adequate warning, print upcoming patient schedules and contact information for the next week or so and make a list of which patients are waiting on diagnostic tests.

Expert advice

For Dr. Ward, social media was the primary way his practice communicated with patients. “Facebook was probably the most instrumental social media source for everyone.” Since the primary cellular service provider was down, everyone used burner phones on alternate networks for the next few months, he said.

After Hurricane Katrina, cell service was down, and the mail had stopped. This was before Dr. Farris had implemented an EHR system, so she was unable to communicate with her patients. “After Katrina, I happened to be in the office assessing the damage and my landline rang. It was a lady, who had evacuated to Florida, calling to find out about the results of her biopsy. After searching, I found her report in the office undamaged, and sure enough that patient had a melanoma. Had she not called me, I don’t know if I could have ever found her. There was no finding anybody at that point. It was like you were in the Twilight Zone.”

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Step 4: Don’t skimp on insurance

It may be tempting to save on mounting costs by shopping around for cheaper insurance. If you find that you are able to swap plans and save money, ask your agent what coverage you’re sacrificing. Know exactly what your policy covers and what it does not cover. Ask questions based on the risks you may face, Brightwell recommended. If you live along the Gulf Coast, you’ll want to know whether you’re covered for hurricane damage. If you live in California, you’ll want to make sure you have wildfire and earthquake protection. One of the easiest things physicians can do to prepare for disasters is to call their insurance agent and learn about their coverage. “Thoroughly researching your insurance policies will be critical, especially for solo physicians and smaller practices,” Dr. Ward said.

Business interruption policy

When asked what dermatologists should do to prepare for a natural disaster, Dr. Farris unequivocally responded: Make sure you have business interruption insurance, which is designed to cover lost income when a business is temporarily closed because of events beyond the business’s control. A typical business interruption policy can provide coverage for the profits you would have earned, normal operating expenses, and the expense of moving to a temporary location. Insurance payouts are based on records of business income and expenses, so have these records in at least one other location off-site.

“You’ve got all the overhead because rent doesn’t stop, malpractice doesn’t stop, all your insurance policies are still in effect — nothing stops except business income. That’s where business interruption insurance really comes into play,” Dr. Farris said.

Dr. Ward echoed this advice, but he also advised to be ready to battle. During a time of loss and hardship, a boxing match with an insurance company is the last thing anyone should have to do. But Dr. Ward’s experience was that insurance companies will find any reason to delay or deny payment. “You’re expected to pay your premium the day it’s due. The insurance company, in turn, does not pay you in a timely manner. They assume everything that you’re telling them or asking them to do is fraud. And they delay,” he said.

Business interruption insurance also helps cover staff salaries. Staff may be living paycheck to paycheck, especially if their lives were impacted by the disaster. If they can’t be paid, they’ll leave, and when things finally return to normal, the practice will be unable to function, Dr. Ward said.

Expert advice

Dr. Farris considered herself lucky to have had the business interruption policy. “It was an expensive policy that I carried for many years. Before Katrina, I asked my accountant, ‘Why am I still paying for this? It’s so expensive.’” Three months later, she made a claim on the policy, which kept her practice afloat while it was closed for the next seven months being rebuilt. “If I hadn’t had the business interruption policy, I don’t know what would have happened,” she said.

Contents coverage

There is property coverage — and then there’s everything else inside. Dermatology practices can have extremely expensive equipment within their walls, and so it’s important to get clarification about contents coverage in the policy. The first day Dr. Farris returned to her practice, Old Metairie, she saw “damage everywhere. There was mold growing up the walls because the water had just poured down, and it was 100 degrees with no air conditioning.” Everything had been ruined, including lasers and other costly equipment.

Expert advice

The only way to ensure physicians get adequate coverage is to document everything in your office by taking photographs or video, said Dr. Farris. “Once a year, we go around the office and take a new set of photographs. We have new equipment, new rooms, we have all kinds of things that we keep embellishing the office with,” she said.

“If you have a $200,000 piece of equipment that you’ve only got insured for $20,000, you’re in trouble,” Dr. Ward said. “That is one thing I’ve heard universally within Panama City is that medical practices were able to get their building repaired, but then have to pay out-of-pocket for surgical tables, surgical lights, and other equipment.”

Step 5: Mind your dollars and cents

Even with solid insurance protection, having liquid income at hand is essential. “Every dermatology practice should have a line of credit set up in advance — even if you never draw upon it. Aside from natural disasters, there could be a delay in Medicare payments for a month or something else that may disrupt payment,” Dr. Ward said. Ideally, physicians should have a line of credit for at least six months of after-tax liquid income as a personal contingency.

Unfortunately, dealing with payers during times of disaster is not cut and dry, Evans said. There is no guarantee that payers will waive the rules about timely filing. Often they will if the area is declared an official disaster area. Regardless of the disaster, be sure to contact payers and ask for filing extensions.

Step 6: Keep perishables from perishing

Having a plan to manage perishables can prevent thousands of dollars in losses, Dr. Farris said. During Hurricane Katrina, she lost quite a bit of money on perishable items. If you’ve got perishables like neurotoxins and things that are extremely expensive, you need to take those with you, she said. “You need to decide in advance who is responsible for taking what out of the office,” she said.

If a physician rents office space, they should insist that the landlord provide generators that are regularly maintained. If office space is owned, have generators in an area protected from flooding. Some of Dr. Ward’s practice locations relied on backup generators to protect medications; however, they failed and the practice lost everything. The silver lining: “All of our refrigerated items went bad, but they were covered under our contents policy. We did not have any losses that we weren’t reimbursed for,” he said.

Dermatologists will also need to consider how to safeguard tissue specimens. “We left biopsy specimens in the office, which won’t get damaged in formalin, but if I had a plan in place to take them, I could have sent them to our pathologist who was at a path lab out of town.” Additionally, it’s important to know where samples are in the pipeline. Are specimens awaiting pickup? Are they at the lab? Are results expected soon? If there is an evacuation with some notice, have this information accessible.

Step 7: Search for backup

While not always feasible, a practice may be able to identify an alternate location to practice in the event of an emergency. Check with local hospitals to see whether they may be able to provide a space to see patients, or scout out another building or practice that may have space available to rent. Physicians in larger practices with multiple locations may have an advantage in that some practice locations may expand beyond the disaster zone.

Expert advice

Dr. Ward owned an empty commercial building — and this building happened to be in the minority of buildings relatively untarnished by Hurricane Michael. He and his staff were able to use this space to set up a call center and billing station.

Step 8: Review and testing

The last piece of the puzzle is planning an annual review of the emergency plan and conducting an emergency response drill at least once per year. Local emergency response teams and the Federal Emergency Management Agency (FEMA) website are often good resources to help practices plan and execute drills.

The least resource-intensive drill is called a tabletop exercise, which is typically held in an informal setting. This type of exercise is intended to generate constructive discussions regarding a hypothetical emergency. Staff participate in talking through scenarios, discussing options, and finding things that have not yet been addressed in the plan.

“What surprised me most is just how vulnerable you really are,” Dr. Farris said. “Something like a natural disaster can completely change everything. Usually, physicians are good at keeping things in order, but something like that can pull the carpet out from beneath your feet financially and emotionally. The amount of loss can be significant,” she said, “so better to be safe than sorry.”