"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

Thursday, March 10, 2011

The "Smart" Electronic Physical Therapists' Office

John gets out of his car to go to his physical therapists' office.

A digital camera records John's 10-foot gait velocity walking up the ramp to the front door.  Another digital camera photographs John's face and, from minute changes in his facial blood flow, calculates his blood pressure as accurately as a sphygmanomometer.

He says "Hi" the smiling young lady at the front desk and presses his thumb print to the electronic sign-in screen.  Since this is John's first visit in over six months he reviews his informed consent form, financial responsibility form and HIPAA form.  He also checks "Yes" on the checkbox that asks if his wants to use the credit card number that is securely stored by the clinic.

An electronic kiosk inquires with an authentic female voice about the John's primary impairment and asks for a self-report using standardized language from validated tests.

After taking about ten minutes interacting with a mix of human and electronic interfaces, John heads back into the clinic.

John spends most of his time with a physical therapist who asks him questions, listens and, most importantly, allows John time to express his needs and problems.  The physical therapist does not have a paper chart, clipboard or computer keyboard between herself and her patient.

A smart goniometer that "remembers" every patient and every limb that it has ever measured is used to measure John's range-of-motion. A smart blood pressure cuff measures his systolic and diastolic pressure. A smart Wii or center-of-pressure device measures John's balance. A smart grip dynamometer measures his grip.

A smart medications list that downloads real-time from the community-wide Electronic Health Record is used to update the clinic Electronic Medical Record for John.

After John leaves his session he goes home and, since he forgot to ask his therapist a question, fires off an e-mail that is automatically routed and recorded in his record.

Later, John receives a text message with the answer he needed from his therapist.  John will receive several timely text messages over the next two weeks, reminding him to do specific therapeutic activities at certain times of the day.

For perpetuity, John will continue to receive a mix of text and e-mail messages aimed at promoting activity and reducing his need for pain medications and unscheduled follow-up visits.

This is not a dream.

Do not pinch yourself.

The only question is this: Who will invent, distribute, pay for and create the future by providing these devices for the physical therapist?

I hope it is the physical therapist.


  1. It just strikes me as a bit unnatural, or should I say a-natural, that technology oftentimes is used to supplant approaches to wellness and rehab that require more personal responsibility for the individual to lead a mobile life. One that places primacy on intelligent movement, thoughtful decision-making and heightened mind-body connection. Some of the things you describe sound great given the current system for delivering healthcare (documentation and billing tech could fall into this methodology, too). The question for me is not who will create these technologies for the PT, but how do we get away from needing to create them in the first place? Sure we can gather MORE information but is it all valuable information? Can we eliminate healthcare policies that currently get in the way of providing high ROI during a patient encounter?

    In some of the applications you describe technology is used to quantify movement, streamline the patient experience and encourage better movement habits, but I fear that a reliance on too much tech for these things is externalizing the problem (although biometrics is, admittedly, cool). We need to be educating at a more fundamental level on the change we wish to see. Tech can certainly make for a persuasive argument be we mustn't forget that Physical Therapy is an interactive, human-oriented profession. We are agents of change and humans at the same time. Certainly we can use new ideas to assist overcoming human nature tendencies to not heed good advice, develop bad habits and avoid/deny/neglect issues that affect our health, but what shouldn't be lost in the conversation is the subsequent transition to independence without these tech aids.

    And the notion that these tech systems will help us do our job better is tantalizing as long as it doesn't become like specialized imaging tests for MDs...a slippery slope to either CYA or obfuscate the real humanity of our profession. (And I give props to the PT who doesn't have a tech device between themselves and the patient during the IE.)

  2. Thank you, Bob, for your thoughtful comments.

    You're right - physical therapists need to be careful that we not let tech come between us and our patients.

    My desire is to use tech to improve the speed and veracity of our data collection for two reasons:

    Narrative notes, whether in bulky paper charts or even on a slender iPad2, are a waste of clinical time and energy.

    Quantification of human movement, either by video or by standardized tests, seems like a more robust basis of a physical therapy value statement.

    Tech can eliminate issues like Medicare compliance, adherence to evidence-based practice guidelines and coding/billing problems that waste enormous resources - usually the time of talented physical therapist managers.

    Finally, costs in most industries are driven down by innovation - doing more with less.

    Innovation in healthcare, unfortunately, means higher productivity under fee-for-service.

    Tech will create a new definition of innovation in healthcare that means getting and keeping more people healthy with the same or fewer resources.

    Thank you for your comments,


  3. I agree that any of our current methods of documentation are inefficient and could be dramatically enhanced by technologies that automatically document certain parameters for us.

    In regards to who will make this change, as an owner in a company that enhances the home exercise experience through technology, I find there are few incentives currently in place to encourage practice owners to invest in these technologies, even when the price point is quite low.

    The only points of distinction we have been able to sell our technology on at this point are: 1) conscientious professionals who are seeking a better resource for the sake of their patients and their own professional image 2) practices wishing to differentiate from competition.

    Unless a service can be billed directly, the incentive to change what your are currently doing is very low. It would be nice if healthcare reform does actually encourage these types of efficiencies.

    Finally, if we imagine a world in which an electronic means is constantly employed to remind us to what we need to do, we will eventually tune out. Especially with activities related to our health, I do think the personal connection is critical to encouraging long term behavior change. I know that even my least adherent patients finally begin to come around when they can't face the idea of disappointing me. Once they begin to feel the benefits of the behavior change, the behavior will reinforce itself, but that personal connection can be critical in the beginning.

  4. Great point, Angela. They'll never be able to outsource the personal connection physical therapists bring.

    Right now physical therapists change behavior one-on-one. Can you think of how physical therapists could begin to influence behavior change at the population level?


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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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