"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 29, 2012

Florida Physical Therapy Bill Passes House 114 to 0

A committee substitution (CS 1228) passed unanimously through the Florida House of Representatives today for the Florida Physical Therapy Association's (FPTA) Temporary Licensure bill attempting to change the physical therapist practice act.

This is not the final action for this piece of legislation since it still needs to pass the Florida Senate.

Keep up the communication with your local representatives and stay tuned to the FPTA website for up-to-date information on which legislator needs to be contacted for specific committee votes.

Great job from the grassroots so far.

Let's keep it up!

Tuesday, February 28, 2012

Management and Measurement of Primary Care Physical Therapy

I'm sure the BEST primary care physicians in America are consistently measuring this important clinical variable in their older patients as a predictor of mortality and a gauge for the medical necessity for certain services, such as physical therapy.

However, I'm even more sure that MOST physical therapists are using this important clinical tool.

Physical therapist managers may even use 10' Gait Velocity to improve their clinical documentation and prevent a Medicare Audit.

This television news report shows how walking speed measurement is becoming more contemporary.


The August 2009 Journal of Geriatric Physical Therapy paper titled Walking Speed: The Sixth Vital Sign presents a helpful graph that I recommend every physical therapist manager include in their therapists' toolkit.

This 2001 Journal of the American Medical Association (JAMA) paper describes how the best academic physicians are beginning to recognize the value in documenting and treating slowed gait in elderly people as a primary source of disability.

I'd like to see the 10' Gait Velocity (Walking Speed) tool used as a screening device in a primary care setting that might allow physical therapists to do the following:
  • assess populations of patients eligible for treatment
  • score their risk for a future fall or disabling condition
  • treat them proactively or refer them, as necessary
  • and lower future health care costs.

Who else thinks this is a good idea?

Monday, February 27, 2012

The Value of Physical Therapy: Reimbursement Can Increase 160% Before We Hit a "Break Even"

A new 6-month cost-effectiveness study of 515 musculoskeletal pain patients treated in a self-referred, direct access Welsh system found that the gains from primary physical therapy treatment of injured workers dramatically outstripped the costs.

The costs varied from £194 to £360 (about $300 to $569) per episode of care.

The gains received were £1,386 to £7,760 ($2,180 to $12,261).

Note that the gains DID NOT include wider societal effects of physical therapy rehabiliation, including:
  • reduced sickness benefits costs
  • reduced costs to employers attributed to improved production
  • reduced absence rates from work
All measured outcomes improved over the 6 month treatment period, including...
  • standardized functional scores
  • psychosocial vartiables
  • pain
  • work loss and
  • medical resource use
However, since this was a small study with no control group and no randomization the treatment effect could not be exclusively attributed to the physical therapy.

The authors results, however, indicated that, based on prevailing payment rates for physical therapists in Wales and the social value of preventing musculoskeletal injuries on workers' quality of life the following conclusion could be made:
"Sensitivity analyses demonstrated that the service would remain cost effective until the service costs were increased to 160% per user."
More studies like this need to be done that measure the cost effectiveness of surgery, injections and pharmaceuticals in the treatment of musculoskeletal pain syndomes affecting workers.

This study was published on the 23rd of February, 2012 by BMC Musculoskeletal Disorders.

Friday, February 24, 2012

Physical Therapy Apps

The physical therapy application marketplace is growing.

The iPhone is just the first mobile platform where consumer apps really exploded.

But, the iPhone provides some lessons about where app developers and medical device innovators are heading within the physical therapy space.

According to Office of National Coordinator of Health Indormation Technology (ONC HIT) staff member Jacob Reider, MD all new medical apps need these features:
  • Functional (it does what it is claimed to do)
  • Reliable (it works consistently)
  • Usable (it works in a way that is consistent with the user’s expectations)
  • Meaningful (it does something important or valuable)
  • Pleasurable (it is enjoyable to use)
The ONC HIT website takes Dr. Reider's message a step further:

"...the iPhone, for instance, uses a software platform with a published interface. This interface needs the ability to have both core components and applications (apps).

On the iPhone, core components include cameras, geolocation, networking capabilities, etc. The platform functionally separates the core components from the apps, and the apps are substitutable.

For instance, a consumer can download a calendar reminder system, reject it, and easily replace it with a new one.

Substitutability is the capability of a system to replace one application with another of similar functionality. As we define it, substitutability requires that the purchaser of an application can replace one application with another without being technically expert, without requiring re-engineering of other applications they are using, and without having to seek assistance from any of the vendors of previously or currently installed applications.

This allows developers to rapidly create a large marketplace of apps for consumers to choose from.
A HIT environment characterized by substitutable apps constructed around shared core components would drive down healthcare technology costs, support standards evolution, accommodate difference in care workflow, foster competition in the market, and accelerate innovation. 

Competition on quality, cost, and usability would become fierce. 

With the cost of switching kept low, a physician using an electronic health record (EHR), a CIO running a hospital system, or a patient using a personally controlled health record (PHR) would all be empowered to readily discard an under-performing app and install a better one."

Sunday, February 19, 2012

"Stealing" Patients from Physicians, Part 1 of 3

Right now in America, most physical therapists accept referrals from physicians for conditions like simple ankle sprains and lower back injuries.

What if I told that soon, physical therapists will "steal" these patients from physicians' caseloads?

And, physicians will thank us for stealing their patients.

How can we do that?

How can physical therapists steal patients from physicians and get a big "Thank You" in return?

By following Clayton Christensens's "rules-based medicine".

Rules-based Medicine

"Rules-based" medicine is described in Harvard professor Clayton Christensen's Innovator's Prescription (2011)

Professor Christensen describes a clear process by which professions inevitably transform their bodies of knowledge upon which they are built from an art into a science.
Rules-based medicine is the "technological enabler" that physical therapists need to "steal" physician market share
"Work that was once intuitive and complex becomes routine, and specific rules are eventually developed to handle the steps in the process.  
Abilities that previously resided in the intuition of a select group of experts ultimately become so explicitly teachable that rules-based work can be performed by people with much less experience and training... 
The term "technology" that we use here refers to... mathematical equations (algorithms)...  
However, at the heart of this evolution of work is the conversion of complex, intuitive processes into simple rules-based work, and the handoff of this work from expensive, highly trained experts (physicians) to less costly providers (physical therapists, nurses, physician assistants, etc.)."
Clinical decision rules are available now which can help physical therapists diagnose the following patients BETTER than the unaided physician:
  • acute stroke in dizzy patient
  • foot fracture in trauma/sports patients
  • ankle fracture in trauma/sports patients
  • knee fracture in trauma/sport patients
  • pneumonia in community-based patients
  • spinal fracture in older patients with lower back pain
  • cancer in patients with lower back pain
"Stealing" market share may be an uncomfortable concept for private practice physical therapists who have been accustomed to close, collaborative relationships with family physicians.

The primary argument against Direct Access legislation is that patient are not safe to see a physical therapist without a physician referral.

"Stealing" Patients from Physicians, Part 2 of 3 will discuss who is currently "stealing" market share from our physician colleagues.

They are getting GREAT outcomes and making money, too.

Friday, February 17, 2012

What's So Bad about Physical Therapy Documentation?

I subscribe to a number of web feeds - some good, some bad.

I recieved the following e-mail the other day. It is a Medicare Compliance advice column that purports to help physical therapists improve their documentation "quality".
"To improve the efficiency of your note writing, eliminate words or phrases that don't lend to the quality of the note such as, "Patient reports they really enjoy coming to therapy".   
Instead write, "Patient reports now being able to bend their knee to tie their shoe."  
The first statement, who cares? The second statement is a subjective report of objective functional improvement."
What's so bad about this advice?
Nothing. You might get an A+ from your physical therapy school professor.

But, does this note add value to your physical therapy encounter?
  • Does your narrative note improve the patients' functional outcome?
  • Does it improve patient satisfaction?
  • Does your choice of words lower healthcare costs, going forward?
I'm not trying to pick on the author of this note. His advice might prevent or ameliorate a Medicare Audit. I might have given this same advice earlier in my career.

That's the problem.

Physical therapists are some of the highly educated, patient-focused and cost-effective healthcare providers in the United States today. There are about 177,000 of us and we can make SO MUCH of a difference in peoples lives.

But, instead we're being told to write this garbage.

Physical therapists must write these notes, we are told, to protect the clinic from a Medicare Audit.

Yet, the future of healthcare is moving towards a technologically-driven workforce that anticipates adverse patient events rather than responding to them. Adverse events such as...
Physical therapists should be focused on how to PREVENT these future adverse events and episodes of disablement and institutional care.

Physical therapists should NOT be writing narrative notes.

What Will Future Physical Therapy Documentation Look Like?

We can get a clue from the Health Information Management Systems Society (HiMSS) criteria for Electronic Medical Records implementation. Their highest level, achieved by several medical centers in America, Canada and Europe, is called the Health Level Stage 7 (HL7).

These criteria included the following:
  • No paper charts
  • All images are contained in a Picture Archiving and Communications System (PACS) within the EHR in the hospital.
  • All data is entered as a discrete element called “structured data”.
  • All structured data is contained in a Clinical Data Warehouse (CDW) where sophisticated algorithms look for patterns, such as disease outbreaks or heightened risk profiles in individuals.
  • The CDW also puts out regular outcome reports at the level of the hospital, the clinic and the clinician.
  • All services (eg: inpatient, outpatient, urgent care, PT, etc.) can produce standardized Summary Data for improved transfers and discharges.
  • All computer systems are interoperable (eg: EMR, EHR, PHR)
Note that there is no place for physical therapists' free text narrative drivel in the HL7 paradigm.

I wonder where all the Medicare Auditors will find work once every hospital system and clinic is at the HL7 level in a few more years? :)

Wednesday, February 15, 2012

New Electronic Health Records Toolkit available from the APTA

An Electronic Health Records (EHR) adoption toolkit is now available at the American Physical Therapy Association (APTA) website. Member log-in is required.

The site is divided into four parts for ease of assimilation. As described on the website:
  1. Decision - why there is a push to adopt EHR and an introduction to the issues that impact physical therapists' practice.
  2. Preparation - What you need for successful adoption of an EHR system. Also, what is an EHR? How does an EHR fit in your current environment and workflow.
  3. Selection - What are the available types of EHR software and hardware?
  4. Implementation - A smooth transition when adopting an EHR requires an organized approach and clear communication with your facility's staff.
According to the APTA:
"Although PTs are not yet required or incentivized to adopt EHR systems for such initiatives as Medicare's Meaningful Use Program, which in 2015 will penalize eligible providers that do not meet the requirements for "meaningful use," physicians and facilities that are included in the program will expect the PTs with whom they share patients use compatible EHR systems."
In other words, physical therapists are not yet invited to the party but we need to get dressed like we're going anyways :)

Monday, February 13, 2012

Pathology Screening by Physical Therapists

Here are the clinical prediction rules I routinely use in the clinic.

They are included as a separate chapter in my new book Bulletproof Expert Systems: Clinical Decision Support for Physical Therapists in the Outpatient Setting available by AuthorHouse publishers.

Please let me know if you see any omissions. Do you use any rules that I have not included here?

A separate table of decision rules used to to predict treatment, called Treatment Based Classification, was published December 28th, 2012.

Rule Author Year Level of Rule Development
Presence of Community Acquired Pneumonia Heckerling et al 1990 Level 1 Impact Analysis
Ottawa Ankle and Foot Rules Stiell et al 1992 Level 1 Impact Analysis
Well's Criteria for Deep Vein Thrombosis Well's et al 1995 Level 1 Impact Analysis
Ottawa Knee Rule Stiell et al 1996 Level 1 Impact Analysis
Canadian Cervical Spine Rule for Alert and Stable Trauma Patients Stiell et al 2001 Level 1 Impact Analysis
Cancer Rule in Lower Back Pain Patients Joines et al 2001 Cost Effectiveness study
Carpal Tunnel Syndrome Wainner et al 2005 Derivation
Elbow Fracture in Trauma or Sports patients Appelboam et al 2008 Level 2 Narrow Validation
Screening for Vertebral Fractures in Patients with Lower Back Pain Henschke et al 2009 Derivation
Stroke in Dizzy Patients Kattah et al 2011 Derivation

The "take away" I get from this table is that the low-hanging fruit has already been picked.

There doesn't seen to be an new impact study in screening for pathology using clinical decision rules in the last decade.

Do we know if clinical decision rules actually influence clinician behavior, improve patient outcomes or lower costs?

Let me know.

Wednesday, February 8, 2012

Why Outpatient Physical Therapy Will Survive and Thrive

This bears repeating...

The following is a response to a comment thread on Peter Kovacek's PTManager.com . You need a username and password to access Peter's site (which I highly recommend - its no cost and there's a TON of great information).
The author is Larry Benz, DPT of EvidenceinMotion.com who I also recommend. Larry's site not only provides you with information but Larry (and others on his site) can distill that information into a vision that can lead physical therpists towards the future.

Here's why outpatient physical therapy is still a good bet, going forward...
  • ...I would put the responsibility of "survival" on the backs of our own rather than externalities.
  • Yes, we can thrive provided we resist the natural urge to become a rule-driven profession that is guided by prescription rather than permission.
    • One that is dedicated to being collaborative rather than subordinate.
    • One that is dedicated to research rather than self-policing.
    • One that seeks legislative changes rather than be victim of political inactivity.
    • One that puts the physical therapist back into physical therapy.
    • One where the physical therapist is the force multiplier in musculoskeletal medicine.
  • ...Outpatient PT will be fine.
Although Larry nailed the essence of what physical therapists in private practice need to thrive I'll just add my two cents...
  • Let's not ask what the "government" or the American Physical Therapy Association (APTA) can do FOR us. They have their role but its not to protect private practice from market forces.
  • Let's not trust in physician referrals to be the source of our livelihoods and our revenue.
  • Let's go straight to the patient when we ask "How can I help you today?"

Monday, February 6, 2012

Six Foods to Help You Recover More Quickly after an Injury

All-natural, whole foods are the basis of any healthy diet. In addition to providing the nutrients needed for basic health and wellness, these foods also help to fight disease, prevent infection, and even help the body repair itself after an injury.

Whether your injury was sustained through an accident or from working out, there are many foods that you can incorporate into your diet to speed recovery. Here are a few of the best foods to help you recover more quickly after an injury:
  1. Pineapple - This tropical fruit contains an enzyme called bromelain that helps to fight pain and reduce inflammation in the body. Eat plenty of fresh pineapple to help heal injuries. Add pineapple to smoothies, eat it whole for breakfast or a snack, or use it as a salad topper. There are many more ways to enjoy this delicious fruit.
  2. Berries - Strawberries, blueberries, raspberries, blackberries and goji berries are all nutritional powerhouses that are loaded with antioxidants that help reduce inflammation and reverse cell damage. Berries also improve circulation and strengthen collagen. Choose fresh and whole versions of the fruit, rather than juices or frozen berries. You can add them to smoothies, muffins, breakfast cereals, granola, and more, or you can enjoy them plain as a snack.
  3. Ginger - Ginger has been shown to help all kinds of ailments in the body, including fighting the flu, relieving nausea, and improving digestion. It has also been shown to reduce muscle pain. Enjoy ginger tea or snack on crystallized, candied ginger for a sweet snack. You can also add it to stir fries or soups for a more savory treat.
  4. Mango - Here's another delicious tropical fruit that helps to reduce inflammation in the body. Enjoy it as you would other fruits, by adding it to smoothies, salads, or breakfast dishes. You can even get creative and turn it into a salsa or throw it into a stir fry.
  5. Protein - Protein is the building block of muscles. It helps to enhance glycogen stores and to rebuild muscle tissue, speeding recovery. Choose lean sources of protein, such as fish, poultry, and beans. When choosing meats, select sources that have been grass-fed or wild caught.
  6. Raw Foods - Raw foods contain living enzymes that encourage cellular regeneration and help to fight inflammation in the body. Eating foods in their raw form also ensures that nutrients are not destroyed in the cooking process, allowing your body to get the greatest benefit from them. Meats and dairy should not be consumed raw as bacteria can cause illness. However, raw fruits and vegetables should be consumed in large quantities each day for optimal health. Even some grains can be sprouted and eaten raw.
Experiment with different recipes to find ways to add more raw fruits and vegetables to your diet each day. Eating a healthy diet comprised of all-natural, whole foods will not only promote your general health and well-being, but will also help you to fight infection and promote recovery after an injury. These foods have additional properties that can help your body heal even faster. Try adding them to your diet after an injury to speed recovery.

About the Author: Bridget Sandorford is a grant researcher and writer for CulinarySchools.org. Along with her passion for whipping up recipes that incorporate “superfoods”, she recently finished research on California Culinary Schools and Culinary Arts Schools in Florida.

Wednesday, February 1, 2012

Florida Physical Therapy Bill Recieves Unanimous Support in Sub-Committee

Fourteen out of fourteen Florida House of Representatives in the Health Human Services Quality Subcommittee voted to adopt the Temprary License (HB 799) bill for new graduate physical therapists and physical therapist assistants without objection.

Congratulations to the Florida Physical Therapy Association (FPTA)!

Now, on to the House Education Committee and the House Health & Human Services Committe as detailed on the House Bill Tracker website.
Then, on to the Florida Senate.

If HB 799 passes this will be a significant victory for the Florida Physical Therapy Association.

Check the FPTA website for timely announcements to call your House members to ask for support of HB 799.

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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.
No reproduction without authorization.

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