What Can Healthcare Learn from Airlines 81% error rate?

Healthcare providers, administrators and policymakers can take heart from the airlines lessons learned...

Front page news in USA Today February 25th is the jump in all airports' error rate reported by the Federal Aviation Administration (FAA) from 2007 to 2010.

Error rate is defined as military, private planes and commercial planes that got too close together in mid-flight or on the runway.

Don't cancel your flight reservations yet, however. You wont have to pack the kids into the minivan for the annual summer trip to the beach.

The skies are not getting less safe...

This jump is the result of better reporting and increased transparency in airline safety, says the FAA.

"Just being open and getting these reports out is the best way to move forward," says Steven Hansen, safety chairman for the National Air Traffic Controllers Association union.

"We're not going to know what to fix unless we know what it is.

We need the information reported."

Healthcare policymakers have been trying to build safety into the health system since the 2001 Crossing the Quality Chasm identified that 98,000 Americans die each year as a result of medical errors.



The following news report credits a separate reporting system, an anonymous NASA database, for identifying the recent increase. The NASA database gets more reports than the FAA database because NASA reporting is "no fault".

Further, improvements in technology and a "systems approach" to airline crashes and safety errors allows policy makers to focus on procedural causes, rather than human error. Some ways the airlines have made flying safer:

• no fault reporting of perceived or suspected errors
• computer algorithms that spot low-frequency events, like near misses
• changes in performance measurement of air traffic controllers

Watch this 3 minute news report or leave a comment - how can we make your physical therapy clinic safer?

Is Physical Therapy in California a Zero Sum Game?

Is physical therapy in California a zero sum game?

Will all patients, providers and payers rise together or will we all fall together?

By definition, zero sum situations are conflict situations where winners' gains are offset by losers' losses.

Conflict is the case in California where physicians and podiatrists are in a fight with physical therapists and the public.

The physicians are trying to earn kickbacks on referrals to physical therapy services they own.

The California Physical Therapy Association (CPTA) is fighting the profit-oriented physicians with a website called Stop POPTS

The physicians are supporting a bill sponsored by Assembly Member Mary Hayashi (D - Hayward), called AB 783 which...

...would legalize the employment of physical therapists by physicians and podiatrists in their professional corporations by adding physical therapists to the list of healing arts practitioners who may be "shareholders, officers, directors, or professional employees of a medical corporation or a podiatric medical corporation."

The American Physical Therapy Association has the position that professionals supervising other professionals is poor public policy since many studies have demonstrated increased costs under the self-referral model.

Here is a members-only APTA white paper from 2005 discussing the anti-POPTS policy.

Here you can hear California Senator Aanested, an oral surgeon, calling the doctors' professional association "disingenuous" for lobbying to include physical therapists as physician employees.

The Office of the Inspector General determined in 2010 that 91% of the services billed in physicians' offices were improperly documented.

Both sides claim superior outcomes but little published evidence supports physical therapy outcomes in either setting.

The California Assembly-person sponsoring AB 783 is, in turn, sponsored by the California Medical Association (CMA).

The CMA donated $22,608 to Assembly member Mary Hayashi in 2010.

Healthcare reform will be difficult for all parties but physical therapists and physicians can maintain professional integrity by focusing on patient care first and by avoiding situations where conflicts between care and profit may confuse professional decision making.

In situation like AB 783, where the two sides vehemently disagree on policy, physicians have the obligation to avoid these business arrangements rather than seek them out.

Putting patients first can keep health care from becoming a zero sum game.

You can support the California Physical Therapy Association by signing this petition against POPTS.

Stop POPTS twitter page is here.

Three Important Trends in Physical Therapy

Electronic everything. I sound grandiose but I just got back from the 2011 HiMSS (Health Information Management Systems Society) meeting at the Orange County Convention Center which must be one of the largest buildings on Earth. No kidding.

The tools and toys displayed in that building connected the patient to the doctor in every conceivable way: email, phone, text, real-time, trending data, graphics displays, historic data, tablets (7" or 10"), iPhones and many I didn't get a chance to see.

These vendors are betting big that healthcare will converge with electronics in a big way in the next 5-10 years.

Information technology professionals are betting that Health Care Reform will withstand the challenge of the 112th Congress and continue to be the law of the land. Recent Federal appeals court decisions put the tally at 3-2 in favor.

These vendors are ready to capture the $29 billion dollars to be paid out over the next 5 years in HITECH funding for doctors to invest in electronic medical records.

Imagine the future when you get paid based on your ability to predict future adverse events in your patients - and prevent them!

Important, life-changing events like stokes, falls, spinal fractures, blood clots or future disablement and institutionalization can now be predicted by physical therapists using simple, evidence based tools.

At HiMSS, they want to make these tools electronic and as easy to use as your e-mail account.

Care systems built around patients, not doctors. Our American healthcare system is built for the convenience of physicians with 15-minute appointments, fee-for-service and isolated silos of practice and knowledge that leave care fragmented.

The future system will be built around patients' needs, not physicians.

Atul Gawande, MD described in Hot Spotters how unlicensed health coaches can prevent outlier patients from slipping back into bad, old habits and ending up in the Emergency Room for costly care.

James K. Galbraith describes in The American Prospect how expanding the pool of healthcare workers will improve not just our health but also our economy.

Dr. Galbraith proposes expanding, not cutting, Social Security and Medicare, as a way to stimulate jobs in areas that are unlikely to migrate overseas or disappear when financial winds blow ill:

"Another area of clear need relates to our aging population.
As people get older, they need care, and the proportion of the working population employed in providing it must rise.
Further, training is necessary, and standards must be imposed, maintained, and enforced.
This is the opportunity to create a large, labor-intensive, mainly not-for-profit sector, that would employ workers with relatively nontechnical backgrounds and help the elderly live in independence and comfort for as long as possible.
Again, realizing this goal will require new institutions or stronger versions of institutions that already exist."

Increased role of non-surgical providers: I can't find any good news coming from the medical literature on aggregated outcome rates for surgical procedures or diagnostic imaging.

Despite the continuous advances in technical proficiency American medicine has exhausted its ability to help patients by ionizing, radiating, poking, cutting, slicing, stabbing, laser-ing or cauterizing the body.

Quality of Osteoarthritis Management and the Need for Reform in the US describes the pathetic record American healthcare has produced:

"Surgery should be resisted when symptoms can be managed by other treatment modalities.
At present, there is no metric whereby the use of conservative management prior to surgery is monitored."

Physical therapists familiar with this blog and other blogs will appreciate our position.

I'd like to recommend that physical therapist entrepreneurs attempt to enter the electronic space and create decision support technology that can distinguish surgical patients from conservative care patients.

Take a look at our hybrid Clinical Decision Support system - we "married" it to my EMR in a shotgun wedding - the baby's not pretty but, hey, we're family...

Its free to use - just call me or e-mail me to set up an account. Play with it using the demo account Username: joey, Password: test123. This is, to my knowledge, one of just a few CDS systems oriented to improving quality, rather than charge capture.

Further, most of the EMR/CDS systems on the market today are built and sold by a small concentration of IT companies. Large companies with large market share are seldom known for their innovation, are they?

Physical Therapist at HiMSS (Health Information Management Systems Society)

I'll go the Executive Breakfast titled mHealth's Evolving Role in Achieving Meaningful Use at the HiMSS (Health Information Management Systems Society) Orlando conference on Tuesday, February 22nd.

My purpose in going is to learn and network with people who will create the electronic healthcare system of tomorrow.

This physician at KevinMD goes on about how great his Electronic Medical Records software is and how it helps him treat patients.

Clinical Decision Support features embedded in the EMR is what makes the software better than typical EMR tools.

What might Clinical Decision Support for physical therapists look like? Advise Rehab for physical therapists has answered part of that question already.

What other ways can you use technology to get patients better, work faster or make more money?

Do you use your iPhone at the patient's bedside?

If so, comment on this blog and let me know how you use any new technology.

The future hasn't been decided yet.

I hope I'll see some physical therapists at the HiMSS meeting.

Advise Rehab Predicts Plan of Care for Physical Therapists

What is clinical decision support (CDS)?

Most sources define decision support systems as a systems that links a defined clinical knowledge base with at least two pieces of patient data (eg: name and age).

The decision support prediction tool available at Advise Rehab is an advanced form of decision support that uses a secret algorithm to predict your patient's recovery.

The algorithm has been validated by Mr. Phip Gabel and you can review his list of links here.

I tried it this summer (2010) with two patients of mine.

I was able to predict, with handsome graphs, the recovery of a patient with whiplash from an automobile accident.

My patient's predicted recovery graph was very similar to this graph from the Advise Rehab website.

I think the future of our profession will be determined by how well we understand the factors that drive patients' disablement and chronicity.

Tools that enable physical therapists to predict how long an episode of therapy will take and how much it will cost will enable therapists to manage the change.

I don't usually endorse products but physical therapist entrepreneurs and Information Technology vendors are being counted on to "carry the water" for the federal government since physical therapists currently do not participate in HITECH (Health Information Technology for Economic and Clinical Health) funding for investment in Electronic Medical Records and Clinical Decision Support.

No physical therapy Electronic Medical Records vendors offer CDS technology that is aimed at clinical quality or outcomes management, that I know of.

All of the EMR vendors decision support seems oriented towards revenue enhancement and charge capture.

In the current healthcare environment, revenue enhancement is a rational response to the questionable financial incentives we've received from Medicare.

Mr. Gabel's decision support tool will have to attach to your EMR as an add-on. He charges about $20 per month with discounts for new users and small practices. It works out to about $1 per patient.

Clinical decision support that improve clinical outcomes will be well worth the money.

Disability Rising Due to Inappropriate Primary Care for Lower Back Pain

Would you go to see an emergency room doctor for treatment of your painful back?

I wouldn't.

Busy emergency room doctors don't want us there either. They are busy saving peoples' lives.

But, this recent report from the Healthcare Cost and Utilization Project at the Agency for Healthcare Research and Quality (AHRQ) indicates that more people are getting treatment for lower back pain in the emergency room than might be warranted.

Hospitalizations doubled from 1993 to 2008 for patients with back problems.

Hospitalized patients with back pain cost $14,338 while patients without back pain cost $9,055. This may be due to the outlier effect of increasing rates of complex, multi-level spinal fusion surgeries that cost $88,000.

"...hospitalizations for back problems in general were more expensive than all other inpatient stays..."

The aggregate costs for inpatient stays principally for back problems was over $9.5 billion in 2008, making it the 9th most expensive condition treated in U.S. hospitals.

Disability Rising

A study from North Carolina followed-up on 5,357 households to calculate the trend in disability due to lower back problems. From 1992 to 2006 chronic, impairing lower back pain rose in North Carolina from 3.9% to 10.2% of the population.

The study authors speculated the causes might be the following:

• Rising rates of Obesity: the number of obese people in North Carolina has increased from 13.4% to 26.6% of the population. Obesity is defined a Body Mass Index greater than 30.0 (weight in kilograms per height in meters squared).
• Increases in depression prevalence: rates of depression doubled from 3.3% to 7.06% through 2002. Chronic pain and depression are linked and individuals with depression are 3 times more likely to develop lower back pain.
• Medicalization of lower back pain: competing healthcare professionals, some advertising on the Internet, have increased public awareness of treatment possibilities despite the fact that many of these treatments are expensive and offer no better long-term improvement than no treatment.

The most at-risk group of North Carolinians are the age group from 45 to 54 years: they became chronically painful at the highest rate of any cohort. Their incidence increased from 15.2% to 26.7% over the time period.

Heavy, Sad and High Tech

According to a recent report in the Journal of the American College of Radiology up to 50% of diagnostic imaging tests are unnecessary and don't add to the patient's improvement.

Imaging scans cost $100 billion annually and these costs are growing 17% per year.

Physician could improve their targeted care of emergent conditions and better serve patient in need by reducing unnecessary imaging for lower back pain.

The following guideline from the American College of Radiology shows a clinical summary of imaging advice.

Further, physicians could reduce the medicalization of common, age-related physical impairments associated with lower back pain by encouraging their patients to exercise and take care of themselves before problems arise.

Behavior Changes in Physical Therapy

Thomas Goetz, MPH cites Albert Bandura, PhD to explain how we can motivate our patients to take control of their own health:



I'm reminded of the passage from the Institute of Medicine's seminal 2001 Crossing the Quality Chasm:

"...care should be understood as a healing relationship that rests primarily on the transfer of knowledge through face-to-face visits and various forms of electronic communication.

Information is not inert; rather the transfer of knowledge is care."

Who Will Own (dot) PhysicalTherapy?

The universe of web domain names is about to expand...

First there was .com, .net, .org, .edu and so on.

Currently, there are 21 generic domain names including country names like .us and .de (for Germany).

Now, ICANN (The Internet Corporation for Assigned Names and Numbers) will open up new domains, some controversial, such as .islam, .amazon, and .sport and so on.

The question, as in the case of .amazon, is who gets to own the domain name, the company or the country of Brazil?

Deciding these questions is the little-known company from Marina Del Rey, California who will hold its final meeting in April 2011.

The final meeting culminates a decision made in 2008 to increase the number of available internet domain names.

The application fee for ownership of the new domain names is $185,000 with a $25,000annual fee.

I wonder who will bid for .PhysicalTherapy ?

Unlicensed lifting technique

MOVNAT’s Erwan LeCorre demonstrates a natural lifting technique.



He probably doesn't have a physical therapy license but I'm not going to be the one to tell him to stop teaching.

Are you?

Quality Measures Physical Therapists can Use to Prepare for Meaningful Use

Physical therapists can begin using these quality indicators in their clinics, if you're not already:

Treatment of depression: ask "Are you depressed or have you felt sad or blue during the last 30 days".

Smoking cessation advice among smokers: I read this this on a pack of Camels... "Quitting smoking now can greatly reduce your risk of death from cancer, heart attack or stroke".

I usually ask the patient if any other medical provider has asked them to give up smoking. Over 80% say that their doctor has asked them - but, that means that up to 20% have not been asked to quit!

Diet advice in high-risk adults: I'm 175lbs, 42 years old and I still look good in a Speedo so I punt this one, "I know a registered dietitian who can help you cook tasty meals from your favorite foods and you won't have to give up desserts!"

Exercise advice in high-risk adults: "I'd like to show you some simple things to do at home to feel better and get stronger. Later, if you like, I can show you how you can start to do more things that you like to do".

I actually try not to use the word exercise until the patient has used that word, with me, at least once.

Diet advice in adolescents: same as with the adults, "I know a registered dietitian who can help you cook tasty meals from your favorite foods and you won't have to give up desserts!"

Exercise advice in adolescents: same as with the adults, "I'd like to show you some simple things to do at home to feel better and get stronger. Later, if you like, I can show you how you can start to do more things that you like to do".

I'll usually mention sports, or for the college bound, I'll mention the rigors of studying and computer use.

Blood pressure measurements: This is, by now I think, routine in most physical therapists offices and clinics but I could be wrong.

One point of discussion we haven't settled... Do you take blood pressure on EVERYBODY or just those you consider "high risk". Good resource allocation principles would indicate that your therapists' time is valuable and routine screening on everyone is wasteful.

The Impact of Quality

These measures come from the National Ambulatory Medical Care Survey (NAMCS) that has been collected on a sample of patient visits to non-federal employed office-based physicians who are primarily engaged in direct patient care since 1973.

A recent impact study in the Archives of Internal Medicine on the effectiveness of Electronic Medical Records (EMR) with Clinical Decision Support(CDS) prompting the use of these quality indicators in 255,402 physicians' practices found that only two of twenty possible indicators were improved with the use of the EMR/CDS.

This new study casts doubt on the wisdom of the $27 billion dollar HITECH investement for EMR showing meaningful use capabilities.

Many recent studies of electronic clinical decision support have found improvements in the process of care, like inappropriate antibiotic prescriptions, with the use of electronic aids at the clinic or the hospital level.

This study looked at visit data aggregated nationally to see if the same local trends persisted but they didn't.

Can Physical Therapists Move Forward?

Absolutely. The first step would be to adopt these quality measures - there is no controversy about quitting smoking. Its good for your patient and its within your skill set.

Don't rush out and buy yourself an electronic EMR/CDS just yet - 80% of physical therapists are still on paper.

Fax the paper to your referral sources and let them scan it into their new, government sponsored EMR.

I think the future will reward those of us who focus on quality.

New Uncertainty for Private Practice Physical Therapists

Senior United States District Judge Roger Vinson of Pensacola, Florida sent the private practice physical therapist community into greater uncertainty Monday January 31st by overturning the Individual Mandate of the Patient Protection and Affordable Care Act (ObamaCare).

Vinson's court Order Granting Summary Judgement granted the plaintiff's motion against the defendant, the UNITED STATES DEPARTMENT OF HEALTH AND HUMAN SERVICES ruling the following:

"...a Declaratory Judgment shall be entered separately, declaring “The Patient Protection and Affordable Care Act” (PPACA) unconstitutional."

How might Vinson's ruling upset the provider apple cart?

Early Adopters of Accountable Care Organizations (ACO) may now feel like we're "too early".

The Federal rollout of alternative, bundled payments for hospitalizations for specified conditions such as total joint replacements, heart procedures and episodes of pneumonia has had providers nationwide scrambling to find the right path to position ourselves with the right partners.

Now, it seems all this maneuvering was premature.

Unlike the first partial defeat of PPACA, Vinson's ruling threw out the whole law - ACOs included.

In Virginia, Federal court Judge Henry Hudson found the Individual Mandate unconstitutional but left the remnants of PPACA, including support for ACOs, intact.

The Score

Two federal courts have now ruled against the PPACA while two courts have ruled for the Act.

Fourteen other courts have dismissed lawsuits against PPACA.

The appeals process should last eighteen months until the Vinson and Hudson decisions wind up in the Supreme Court where court watchers have called it a split-decision.

How NOT to set up your Accountable Care Organization

Before you run off to set up an Accountable Care Organization (ACO) involving physical therapists, please watch this video...



Now that you've watched the video go and set up your ACO!