"Physical therapy is not a subspecialty of the medical profession and physical therapists are not medical doctors; we are a separate profession that provides a unique service that physicians are unable and untrained to provide."

Letter to the AMA from the APTA, Dec 2009

Wednesday, February 2, 2011

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.


  1. I think the blood pressure one is a place we could do some AMAZING work if we put our minds to it...

    Also, what bout exercise in medical conditions and chronic conditions as well as prevention of functional decline??

  2. Hi Kyle,

    I agree. Exercise for medical conditions and prevention of functional decline should be our core specialization.

    Screening for these medical and behavioral conditions mentioned above are primary care strategies that tend to cost very little.

    The impact study I cited above used 20 quality measures to evaluate the performance of over a quarter million physicians in ambulatory care settings in the US from 2005 - 2007.

    The physicians' performance on these quality measures (# times checked/ # total patients) entered into their EMR was pretty low (2/10).

    What I found interesting was that 7 of the 20 quality measures fall squarely within the skill set of physical therapists.

    If I'm a hospital CEO or Medicare Accountable Care Org. (ACO) executive I'm thinking about "How can I find more primary care practitioners right now? Nurses can do some of this work but nurses don't have autonomous outpatient clinics located in the patients' zip codes.

    Private practice PTs do.

    Using quality measures and practicing with a primary care mindset can position physical therapists very nicely going forward, I think.



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Tim Richardson, PT owns a private practice at Medical Arts Rehabilitation, Inc in Palmetto, Florida. The clinic website is at MedicalArtsRehab.com.

Bulletproof Expert Systems: Clinical Decision Support for Physical Therapists in the Outpatient Setting is a manager's workbook with stories, checklists, charts, graphs, tables, and templates describing how you can use paper-based or computerized tools to improve your clinic's Medicare compliance, process adherence and patient outcomes.

Tim has implemented a computerized Clinical Decision Support (CDS) system in his clinic since 2006 that serves as a Reminder, Alerting, Prompting and Predicting CDS using evidence-based tests and measures.

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