"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

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? :)

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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 .

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Consistent with the American Physical Therapy Association Vision Statement for Physical Therapy 2020, the American Physical Therapy Association supports exclusive physical therapist ownership and operation of physical therapy services.