The Best EMR Interface for Physical Therapists

What are the criteria for the "best" Electronic Medical Record?

• Simple to Use
• Improves Revenue!

Top Ten Ways Clinical Decision Support Interferes With Physical Therapist Practice

Stage One Meaningful Use Objectives for Eligible Professionals include 15 "core" measures which ALL must be satisfied to receive up to $44,000 in Electronic Medical Records (EMR) reimbursement.

Core Measure #11 is "Implement Clinical Decision Support".

An example might be an electronic "pop up" that notifies the physical therapist to perform a Falls Risk Screening for Medicare-eligible patients.

Many providers will scramble to implement the "core" measures without fully considering the costs and risks involved.

Here are the risks to using computerized clinical decision support systems (CDSs) in physical therapy:

1. Computerized systems can disconnect us from the source of our data. Consider a physical therapist who enters a numeric self-report score from the OPTIMAL scale without first quizzing the patient on high-scoring items, like Completely Unable to Kneel 5/5.
   
   
2. Computerized systems can cause us to limit our search for data. This fallacy is not limited to CDS systems but is typical of the confirmation bias commonly seen in healthcare settings. Consider the physician who orders an MRI to visualize a lumbar disc in the case of chronic lower back pain but fails to ask about depression.
   
   
3. Computerized systems can disable the intuition of skilled, experienced decision makers who become accustomed to letting the system make all the decisions.
   
   
4. Computerized systems can slow the rate of intuitive learning for new users of the systems (e.g.: new PT graduates) so that it takes longer to build intuitive skills.
   
   
5. Computerized systems can teach dysfunctional skills that actively interfere with learning how to make better decisions. For example, a busy therapist who is paid on a productivity model tries to quickly enter data into her handheld device without conscious reflection or consideration of the data and the resulting CDS recommendations. Do the recommendations make sense?
   
   
6. Computerized systems use an algorithmic, computer logic that humans may be unfamiliar with. Algorithms, like Treatment Based Classification, may hide the story about how the computer “thinks” about our data. Computer logic is not obvious or intuitive. Computer logic may not match our traditional mechanistic models of human function and pathology.
   
   
7. Computerized systems have special needs. According to Gary Klein, author of Sources of Power…

   “…machines need precise, accurate control and information and we tailor our jobs to meet the needs of machines…”

   If we are spending our time with the patient hunched over the keyboard then we can be sure we are serving the needs of the machine but not the patient.
   
   
   
   
8. The computerized clinical decision support logical rules become “institutionalized,” rigid behaviors that may eventually have no further bearing on the outcome.
   
   An example of an institutionalized rule is the physician certification of the plan of care.
   
   At one time in the United States, physicians legitimately directed the patients’ physical therapy plan of care. Now, with the exception of post-surgical patients, physicians cannot claim a body of professional knowledge that improves upon physical therapists’ decisions.
   
   
9. Pop-up fatigue occurs when the CDS delivers excessive “pop-up” windows to the user’s screen during access to the patient record or to the user’s cell phone via text messaging or e-mail.
   
   One study found that 49-96% of alerts were overridden or ignored due to pop-up fatigue. Setting alert triggers to “high severity/critical alerts” can reduce the number of alerts (increased specificity). An example might be an alert that is triggered if the patient’s follow-up functional scores worsen by an amount greater than the MCID/MDC for that test.
   
   
10. Multi-tasking degrades human performance especially for the group known as heavy media multi-taskers. These people may attempt to carry on a cell phone conversation, text message and send an e-mail simultaneously. While they may feel like they perform each task at the same time, high-resolution, functional Magnetic Resonance Imaging scans reveal that their brain actually switches back-and-forth among different activities. This ability is, appropriately, known as task switching.
    
    Two-hundred and sixty two students were segregated by their media use into heavy media multi-taskers (HMM) and light media multi-taskers (LMM). The students were tested for their ability to filter out irrelevant stimuli and for their ability to task switch. In filtering ability, the HMMs were 77ms slower than the LMMs in filtering out irrelevant stimuli.
    
    In task switching ability the HMMs were 426ms slower than LMMs in switching tasks.

    “These results suggest that heavy media multi-taskers are distracted by the multiple streams of media they are consuming or, alternatively, that those who infrequently multi-task are more effective at volitionally allocating their attention in the face of distractions......(HMMs) may be sacrificing performance on the primary task to let in other sources of information.”

    Since the primary task is the care of the patient in front of the physical therapist an awareness of the danger posed by heavy media multitasking with a CDS system seems imperative.

Physical therapists considering the purchase of an Electronic Medical Record with Clinical Decision Support features should carefully consider the costs and the risks, as well as the benefits, before purchasing.

California to Take Action Against POPTs Physical Therapists

Three Major Developments in the California POPTS Battle

Development 1

Department of Consumer Affairs (DCA) Legal Opinion Confirms PTs Working in POPTS Arrangement are Subject to Discipline by the CA PT Board.

The CA Private Practice Group discovered this document posted on www.stoppopts.org, which confirms five other legal opinions, clarifying that it is illegal for physical therapists to work for a medical corporation. The DCA can apparently no longer keep the CA PT Board from bringing physical therapists into compliance with the law.

Quote from DCA Legal Affairs Opinion

"It is evident from the applicable statutes that the Physical Therapy Board of California has jurisdiction over physical therapists and is empowered to enforce obedience to its regulations and all statutes governing the corporate practice of physical therapy.  Consequently, it our opinion that a physical therapist may be subject to discipline by the Physical Therapy Board of California for providing professional physical therapy services as an employee of a professional corporation, other than a naturopathic doctor corporation."

Development 2

The CA Physical Therapy Board held its usual meeting yesterday. In light of this legal counsel opinion, they voted unanimously 5 yes,0 no, to begin the disciplinary process.

The first 153 physical therapists accused of working for POPTS, will now be investigated.

Finally, enforcement of the law begins. Those physical therapists working in POPTS clinics risk suspension or revocation of their license if they do not come into compliance with the law.

Development 3

On the legislative front, AB 783, which if passed would legalize POPTS, passed through the Assembly floor 51 yes, 0 No, and over a dozen abstentions. This in itself is a significant improvement. In 2009, when AB 1152 was voted on in the Assembly, there was unanimous approval. The next major stop is the Senate Business and Professions Committee, where a similar bill to AB 783 was soundly defeated in 2009.

It might be time for POPTS physical therapists to jump ship.

Get many more answers on May 19th, 2011 when the CA Private Practice Group will hold it’s meeting to update its members on POPTS and the future of physical therapy.

Sign up now – go to www.cppsig.com

The CA PPG Board of Directors 

**The California Private Practice Group is a special interest group of the California Physical Therapy Association.

Screening Template for Fear Avoidance Beliefs

Screening for Fear Avoidance Beliefs
Go Scribd to download the template for your clinic's use.

Let me know what you think.

Comparative Effectiveness Research Under Attack

A cornerstone of the healthcare overhaul and a vital tool outlining the value of physical therapist practice is under attack.

Comparative Effectiveness Research (CER) will cost the United States $4 trillion in economic activity, according to a new report from the Center for Medicine in the Public Interest (CMPI).

The report argues that investment in new drugs and medical devices would suffer:

"Investments in medical research provide among the most productive uses of capital in the economy.
Americans will suffer economically and physically if the government forces CER on the U.S. healthcare system", said Robert Goldberg, vice president of CMPI and a study author.

Investments in one of the most lucrative medical devices, pedicle rods and screws, made by publicly-traded firms like Zimmer, DePuy and Stryker are a major cost driver in healthcare cost inflation.

These firms have driven the rate of dangerous, complex spinal fusion surgery up 20 times since 2002. These patients have three times the risk of dangerous complications and twice the risk of a rehospitalization.

Oh, and by the way, the new surgeries sponsored by the medical device "investors" cost at least $80,888, compared to $23,724 for regular back surgery.

Physical therapists treatments for similar conditions don't carry these hefty price tags and dangerous risk profiles.

A survey of 111 major stakeholders in drug and device manufacturers believe that, in the long run, CER will improve healthcare outcomes and "expressed tempered optimism" about its implementation by the government.

Physical Therapists Can Improve Patient Safety in Hospitals

One of the "failure modes" in preventing hospital-acquired venous thromboembolism (VTE) - a blood clot - is that risk assessment is not routine or standardized.

Physical therapists who treat post-surgical patients can provide screening to diagnose this problem in high-risk patients. Screening rules, such as the Wells' Criteria can aid the physical therapist in diagnosing a blood clot.

But, one physical therapist cannot create a culture of safety.

To create a culture of safety in preventing hospital-acquired infections the Agency for Healthcare Research and Quality has sponsored a Comprehensive Unit-based Safety Program (CUSP). The CUSP is a structured strategic framework for safety improvement that integrates communication, teamwork, and leadership to create and support a culture of patient safety that can prevent harms.

The program features: evidence-based safety practices, staff training tools, standards for consistently measuring infection rates, engagement of leadership, and tools to improve teamwork among doctors, nurses, and other members of the health care team.

The CUSP uses a checklist of evidence-based safety practices; staff training and other tools for preventing infections that can be implemented in hospital units; standard and consistent measurement of infection rates; and tools to improve teamwork among doctors, nurses and hospital leaders.

Step 1 Staff are educated on the science of safety.

Step 2 Staff complete an assessment of patient safety culture. Safety is everyones' responsibility - we as physical therapists cannot continue to defer our responsibility to physicians on the "sharp end" of healthcare.

Step 3 A senior hospital executive partners with the unit to improve communications and educate leadership. Staff (MDs, nurses, PTs, etc) need to know we have support from the top.

Step 4 Staff learn from unit defects. These defects get reported by staff members unafraid of personal attacks.

Transparency, like in the airline industry, celebrates the reporting of medical errors as the opportunity to learn and improve. Instead, in healthcare, we've had a habit of "naming, blaming and shaming" people who make mistakes. A broken tort system of punitive legal redress is the product of these habits.

Step 5 Staff use tools, including checklists and electronic decision support, to improve teamwork, communication, and other systems of work.

Clinical decision support tools, with reminder pop-ups, prompts and suggestions can help physical therapists provide guideline-adherent care.

The most common preventable cause of hospital death is VTE.

"Over 1 year, a 300-bed hospital that lacks a systematic approach to VTE prevention can expect roughly 150 cases of hospital-acquired VTE.
Approximately 50 to 75 of those cases will be potentially preventable because of missed opportunities to provide appropriate prophylaxis.
Approximately five of those patients will die from potentially preventable PE."

Highly focused initiatives using these five principles have achieved success in reducing preventable infections, such as central line-associated blood stream infections (CLABSIs), catheter-associated urinary tract infections, and ventilator-associated pneumonia, in intensive care units (ICUs) and other hospital units.

Healthcare leaders can address the growing rate of blood clots by attacking this problem with teams of providers implementing a standardized approach.

Support Texas Physical Therapists!

Texas direct access bill, HB 637, needs your help!

This screenshot shows that the Texas Direct Access bill has been stuck in committee since April 20th and the session is winding down.

The expected vote is a dead heat, 3-3.

The session began on January 6th and lasts for 140 days. That leaves only about three more weeks for physical therapists to gain direct access in Texas! The Texas legislature meets every odd-numbered year so this will be our last chance until 2013.

Go here - the Texas Direct Access website - where you can call a Texas legislator, donate money or sign a petition.

Florida's Direct Access to Physical Therapists Website is Live!

Mad props (whatever that means) to Paul Hardin of the Texas Physical Therapist Association for giving Florida physical therapists our own direct access web site at AccessYourPhysicalTherapist.com/Florida.

The Texas group are leaders in direct access - they have legislation in place that would give them unrestricted direct access

Seventeen states currently do not require a referral to see a physical therapist and none of those states have experienced an increase in liability claims.

Go to the new AccessYourPhysicalTherapist.com/Florida page, sign the petition and donate to the cause!

Connect Physical Therapists to Patients

Dr. Deborah Jefferies demonstrates PolyCom's Intelligent Core technology for remote patient connection at the American Telemedicine Association 2011 annual conference.



The patient is able to use their own computer to connect (privately) with their physical therapist or orthopedic surgeon in real time.

This technology has application for remote areas, like rural health care.

Dr. Jefferies also believes clinician education will be enhanced with the PolyCom technology by connecting academic centers of excellence to clinicians from around the world for virtual conferences and continuing education seminars.

Breadcrumbs for Patients

Hansel and Gretel left breadcrumbs behind their path so that they could find their way home after their wicked stepmother lures them into the dark forest and abandons them.

Mark Ratliff creates electronic breadcrumbs with Global Positioning Systems (GPS) bracelets for dementia patients who wander off into city streets.

His company is Breadcrumbs and he is displaying his technology at the American Telemedicine Association conference in Tampa.



Mark also has "Dick Tracy's knockoff watch" that patients who fall down can use to call for help.

If the patient is unconscious or unable to speak, the watch will send an alert and help for the patient will be summoned.

Video Technology Frees Physical Therapists from the Tyranny of Narrative

Jay Culver demonstrates camera technology by GlobalMedia at the American Telemedicine Association annual conference in Tampa, Florida that may be applicable to physical therapist documentation of movement impairments such as squatting, walking and kneeling.



Could we replace thick charts of paper documentation?

Many paper charts are full of what some physical therapist leaders call "meaningless drivel".

Further, therapists are tyrannized by the garbage concept of "skilled physical therapy" that we must try to communicate through written narrative.

Can pictures and video free us from the tyranny of narrative?

As Jay Culver says in this video - "A video is worth a thousand words!"

Calorie Counting and Metabolic Feedback for Physical Therapists' Patients

The Aipermotion Active Body Control device:

Physical therapists can use Aipermon's new Active Body Control device to help their patients adhere to their diet using instant feedback of calories burned and calories taken in.

The device is part calorie calculator and part pedometer with an internet connection that sends your results to your doctor.

Poor Nancy has not had breakfast yet but she's a good trooper and she demonstrates the Aipermotion for me at the American Telemedicine Association (ATA) meeting in Tampa using her own metabolic data.



Thanks Nancy! Now, go get some breakfast!

Cell Phone Inventor at ATA Says "People Want to Move..."

Martin Cooper was an engineer at Motorola in 1973 when he stood on a Manhattan street corner on April 3rd and placed the world's first public cellular telephone call.

The rest, they say, is history.

Cooper expected millions, not billions, of cell phone users to use his product. This image is a replica of the original 2.2lb. cell phone that had a 20-minute battery life.

Today, there are 6,915,756,494 people in the world and over five billion cell phone users.

More people have access to cell phone networks than have access to...

• clean running water
• electricity
• regular dental hygiene

But Cooper doesn't bear the stigma for these social inequities - he is still hopeful that mobile technology can help solve some of the world's most pressing disease burdens.

"Technology doesn't mean a thing unless it makes people's lives better..."

...he said at the Keynote Speech kicking off the American Telemedicine Association 2011 annual conference in Tampa, Florida.

"People are mobile, they're naturally mobile - they want to move around".

Cooper envisions mobile technology implanted in our bodies - able to detect the genesis of new cancer cells and call that finding into a doctor who will then call the patient back for an appointment.

"Every disease can be actionably prevented," he said, "The cellular industry is still in its infancy..."

I admire Mr. Cooper's optimism.

I wonder what creative uses physical therapists can find for cellular technology to encourage our patients to "move around"?

Overheard at the American Telemedicine Association Meeting...

Tampa Convention Center: May 1, 2011 - Morning Session. Some snippets of conversation I overheard at ATA 2011...

Telerehabilitation or Telemedicine?

• No professional associations 50 years ago
• Power-based relationships – students, clients, consumers
• Asynchronous vs. synchronous? Store-and-forward (dermatology and radiology) use one way communications to help diagnose patients. Interactive video is synchronous because it happens in real time.
• “Follow the money”
• Who had the most control in 2011? Payers, consumers, providers?
• Ossifying technologies? Eg: BLACKBOARD in academia

“Store-and-Forward” Technologies in Telerehabilitation

• Asynchronous sharing for home exercises and physical therapy prevention of falls. Content server contains files, videos such as a home exercise library.
• Poor broadband connection in Australia?

Is your Telerehabilitation Practice HIPAA Compliant?

• Is Voice Over Internet Protocol (VoIP) HIPAA compliant? Is VoIP a Business Associate (BA) under HIPAA?
• If VoIP is a BA then they must meet the HIPAA Privacy Rule requirements. If VoIP (eg: Skype) works for a covered entity then they are a BA.
• Top 10 Risk Assessment: 58 question checklist (is the checklist validated and published?)
• Non-recorded data falls under the Privacy Rule but not the Security Rule. If data is not in electronic format at the time of transmission (eg: a fax piece of paper or a real –time synchronous video chat) the data does not fall under the Security Rule.
• Hackers are ALWAYS thinking about how to gain access to PHI but are hospital administrators ALWAYS thinking about how to protect their data?

Licensure and Reimbursement for TeleRehabilitation

• SLP doesn’t have “practice acts” but have “licensure laws”.
• SLP Assistants not recognized by Medicare.
• Texas has prescriptive (3 pages) in practice act. Some experts state that “…Texas is a leader...” in telerehabilitation
• APTA Definitions and Guidelines recommend a PT be licensed in the state in which they practice telemedicine.
• Some experts surprised that this definition was not provided by the Federation of State Boards of Physical Therapy (FSBPT)

Model Telerehabilitation Program for Rural Areas

• Kentucky pilot telerehabilitation in rural areas
• Community based rate $89/ 1-hr. session
• Telehealth rate $63/ 1-hr. session

Model Telerehabilitation Program for Occupational Therapy

• 30 sessions on telehealth at AOTA 2011.
• Works in the home. Training spouse/family members. Cash-based OT practice in West LA. Lots of DSL and 4G networks.
• Life coaching for cancer survivors – 12 week program.
• Work in industry using video conferencing to assess work stations and make recommendations for adaptive equipment.
• Does not see an issue with offering “wellness” services for Medicare patients and is able to avoid the “opt out” issue for physical therapists in private practice.
• Using mobile and video devices to connect with patient in a direct access model with “store-and-forward” technology that enables therapists and patients to interact asynchronously (at different times).

You may get the impression from this blogpost that telerehabilitation is a bulleted list of techniques and technologies rather than an integrated body of knowledge, practices and standards...

Your assessment would not be incorrect...

Can anyone help me define and refine this field for physical therapists?

American Telemedicine Association Advocates for Physical Therapists

The American Telemedicine Association (ATA) is advocating for physical therapists to deliver telerehabilitation services and receive Medicare reimbursement in order to succeed under Medicare Accountable Care Organizations (ACO):

"Medicare law bars some providers from delivering telehealth services - even as they are otherwise permitted under Medicare.
Notably, physical therapists, occupational therapists and speech-language pathologists, are barred from delivering telehealth services."

The ATA sent Medicare administrator Dr. Donald Berwick a letter on April 25th asking for five regulatory waivers, including the restriction on physical therapists performing telerehabilitation services.

The ATA request reads:

"ATA strongly urges the Secretary to waive this restriction. Otherwise, the ACOs will fail to fulfill Congressional and Agency intent...

...section 1834(m)(4)(E) needs to be waived... to permit any beneficiary to get the otherwise covered Medicare services of physical therapy, occupational therapy and speech-language pathology and audiology..."

The American Telemedicine Association is the leading international resource and advocate promoting the use of advanced remote medical technologies.

ATA and its diverse membership, works to fully integrate telemedicine into transformed healthcare systems to improve quality, equity and affordability of healthcare throughout the world.

The ATA 2011 annual meeting started today, Saturday April 30th in Tampa, Florida and runs through Tuesday, May 3rd.

I'll be attending the pre-course meetings, presentations and trade shows and posting the technology and innovations I find to this blog.

Tell me what you'd like to know about the emerging telemedicine industry.

How do you think physical therapists should fit into this new paradigm?