"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

Saturday, February 9, 2013

'Blow Up' Physical Therapy Documentation, too

Hate G-codes? Think the Severity Modifier are a waste of your time? Dr. Halamka shares your pain:
"The way we document in medicine has grown up over decades for medical reasons, for billing, for medical-legal justification,” said Dr. Halamka, chief information officer at Beth Israel Deaconess Medical Center in Boston. “You wind up with 17 pages of replicated and duplicated and challenging-to-read documentation.  
I propose we blow up the way we do documentation altogether and replace it with a Wikipedia-like structure.”
Dr. Halamka made these comments in the article EHRs: “Sloppy and paste” endures despite patient safety risk in American Medical News, February 4th, 2013. The article discusses rampant 'cloning' of patient notes in electronic medical records.

Dr. Halamka's statement references an article published in the February 2013 edition of Critical Care Medicine:
"The study examined 2,068 progress notes by 62 residents and 11 attending physicians of 135 intensive care unit patients in a medical center in Cleveland, using plagiarism detection software. 
The researchers found that more than four-fifths (82 percent) of the residents and three-fourths (74 percent) of the attendings' notes contained at least 20 percent of copied information." 
Dr. Halamka seems to go beyond the cloning issue - that could be solved by merely disabling the 'copy-and-paste' function in the EMR.  He wants to 'blow up' the whole documentation format which, I assume, includes SOAP.

SOAP has survived in medicine this long, I think, because medical notes are substantially more 'data-rich' than physical therapy notes. Another doctor could read the note and, despite its limitations, still glean sufficient data to make decisions. Physical therapy notes, however, are 'data-poor'.

But, 'cloning' is nothing new.  Physical therapists for years have handwritten 'meaningless drivel' on paper notes, according to Anthony Delitto, PhD, PT in Are Measures of Function and Disability Important in Low Back Care?

Any PT manager who has ever done a chart audit knows that many PT notes are repetitive and uninformative.  Why?  I'm not sure but I suspect that training and inertia are big factors.

Physical therapy documentation is way past its expiration date.  My students tell me they are still trained to write notes the way I was taught in 1990!  Don't believe that physical therapists are stuck on SOAP?  Read "What is a SOAP Note?" written in 2008 with over 17,000 page views!  SOAP notes were first described in 1968!

Physicians have adopted EMR software more quickly than physical therapists.  It is natural that they would use electronic  tools like 'copy-and-paste' to speed-up their work.  But, 'copy-and-paste' becomes 'sloppy-and-paste' when new technology catches up to our old, inefficient documentation format.

Many Electronic Medical Record (EMR) designers copied the SOAP format when they moved from paper to electronic to ease the burden on providers. Doctors could learn the new computer interface as long as they didn't also have to learn a new documentation format.

Physical therapists seem comfortable sticking with our traditional narrative-driven, SOAP-based format because it is comfortable, not because it is the right thing to do.

I would also like to see better ways of recording the patient experience and making better therapeutic decisions.  I think electronic communication tools can help providers do that.  But, medicine is substantially different from rehab.  Any electronic solution physicians adopt is unlikely to be ideal for therapists.

What ideas do readers of this blog have?  Video?  Photos?  Self-reports?

How can therapists collect better data?

If physical therapists don't come up with better ways of documenting then the government will do it for us.  You know what that gets us: G-codes and Severity Modifiers.

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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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