"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, November 16, 2011

De-Skilled Physical Therapy?

De-skilling can occur to physicians who use Electronic Medical Records (EMR) and who follow Clinical Practice Guidelines (CPG). The de-skilling process includes the following:
  • decreased clinical knowledge
  • decreased patient trust
  • increased stereotyping of patients
  • decreased confidence in making clinical decisions.
These findings are not surprising to many clinicians who warn against losing the personal touch as clinics adopt EMRs.

Both physicians and physical therapists resent the tyranny of the computer screen that prevents them from spending face time with their patient while they enter quality measures.

These findings, presented in the October 2011 Health Care Management Review may be troubling to advocates of EMRs and Clinical Practice Guidelines.
"These deskilling dynamics are often presumed to be a byproduct of select managerial innovations designed to improve efficiency and lower cost, which force workers to perform their work in a more standardized, compartmentalized, and routine way."
My initial knee-jerk reaction to this article is to sympathize with clinicians, forced to work with first-generation EMR software and population-based practice guidelines that strictly limit individual preferences in clinical decision making.

But, the authors continue:
"It can be argued that professionals, like physicians, actively contribute to their own deskilling through how they adapt on an everyday basis...
  • to maintain job satisfaction
  • get needed work done in a timely manner
  • to show that they are performing appropriately
  • to survive economically
  • to keep control
  • to maintain order in their lives."
The main problem with EMRs and boilerplate treatment recommendation, such as we might get from Clinical Practice Guidelines, was the tendency of the 78 primary care physicians in the study to "cut-and-paste" patient data from one session to the next.
"The net result was that primary care doctors believed they were increasingly getting less patient-specific information from specialists via the EMR which hindered their ability to make informed decisions around diagnosis and treatment."
According to these same doctors, this situation did not happen with paper records. That is because paper records forced doctors to dictate patient specific information into a patient’s record each session.

Physical therapist managers can help prevent the deskilling process from occurring by soliciting physical therapist input during their EMR implementation.

Physical therapist managers can preserve their clinicians ability to control their workflow and their ability to apply their professional expertise in desired ways.

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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.

Tim can be reached at
TimRichPT@BulletproofPT.com .

"Make Decisions like Doctors"

Copyright 2007-2010 by Tim Richardson, PT.
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