"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

Tuesday, October 22, 2013

Can EMRs Improve the Physical Therapy Experience?

"With great power comes great responsibility", quoted Heidi Jannenga, PT, MPT, ATC/L at the WebPT Evolve meeting in Orlando, Florida on October 18th, 2013.

Mrs. Jannenga was citing the explosive growth of the WebPT electronic medical record (EMR).  She mentioned the possibility that the WebPT user base at their current growth rate could actually overtake the number of physical therapists who are members in the American Physical Therapy Association.

WebPT growth rate chart

Currently, WebPT has almost 27,000 therapist users who have generated over 38 million patient records since 2008.  WebPT claims that this is one of the largest repository of therapy outcome data in the world.

At the Evolve meeting in Orlando, Mrs. Jannenga and her husband Brad Jannenga, President, and CTO of WebPT had brought together a group of national-level physical therapist speakers. They spoke about Medicare compliance, internet marketing and key business metrics. The speakers delivered their own, original content.  They did not appear biased for or against any commercial EMR. 

I went to this meeting for two reasons: to prepare for an invited blogpost for the Technology Special Interest Group of the American Physical Therapy Association and as a user of WebPT trying to better understand the use of technology in the physical therapy clinic.

The meeting was pretty heady stuff, presented at the fabulous Peabody Hotel on International Drive in Orlando.  I would recommend anyone interested in learning about electronic medical records to attend this meeting.  WebPT opened the session for free to all interested parties.  Plus, they fed us dinner. 

This was the seventh Evolve meeting. The first one was held in Phoenix, AZ in October 2011. There have also been free Evolve meetings in Long Beach, CA, Palo Alto, CA, Chicago, IL, New York City, NY, Jersey City, NJ and Orlando, FL. WebPT will be holding more next year and will update their website with every new event.

To temper all the enthusiasm for electronic medical records however, I must show my readers some sobering facts that have recently come to light about the health information technology sector.

Do EMRs Add Value?
The idea that electronic patient notes will speed up therapy documentation by improving on handwritten notes just seems reasonable. But, new stories of expensive electronic medical record  cost overruns keep popping up in the media. To be fair, most of these stories are on the hospital side of the healthcare industry:
Adoption of expensive electronic medical record systems may hurt a hospital's bottom line, despite promises that the new systems will increase efficiencies and lower costs.  
Yet another hospital is reporting that the high cost of implementing a new EMR is having a negative effect, with Henry Ford Health System reporting its investment in Epic being a major factor in a 15 percent decrease in net income--from $62.9 million in 2011 to $53.1 million in 2012. From FierceEMR
Copy and Paste or 'Sloppy and Paste'?
There are additional concerns with the current generation of EMRs that allow essentially unrestricted copy-and-paste functionality between different dates of service. The clinician is trained to "document everything" which is almost too easy with computers. There is concern that patient information is not accurate.

According to a recent article in the journal of the American Health Information Management Association (AHIMA) called Impact of Electronic Health Record Systems on Information Integrity: Quality and Safety Implications
"Seventy-four to 90 percent of physicians use the copy/paste function in their EHRs, and between 20 to 78 percent of physician notes are copied text...  
It's become such a compliance and payment problem that the U.S. Department of Health and Human Services Secretary Kathleen Sebelius together with Attorney General Eric Holder wrote a letter last year to industry medical groups underscoring the seriousness of doctors "gaming the system, possibly to obtain payments to which they are not entitled."
'Note Bloat' Made EZ with EMRs
Several physicians complained about "note bloat", at an October 9th meeting of the College of Healthcare Information Management Executives (CHIME), where they said the content of the electronic note in the EMR lacked value because it was not "concise, complete and informational".

One example cited by Jim Venturella, CIO of the University of Pittsburgh Medical Center (UMPC), was a concerted effort by the  hospital to move physician documentation from paper to a Cerner EMR, between 2009 and 2012.

The new system produces 3.4 million notes a month in their inpatient EMR and 4 million notes in their ambulatory EMR. But in a survey of nearly 2,000 UPMC clinicians, less than half of respondents thought that the notes were valuable for patient care. (Healthcare IT News)

Is This the Year of the 'Great EMR Switch'?
More physicians and physical therapists are using EMRs.  Currently, the Centers for Disease Control and Prevention (CDC) estimates that 72% of practices in 2012 use an EMR, up from 54% in 2011

However, many providers are dissatisfied with their current EMRs and 17% of physicians are planning to switch their EHR within the next year according to the industry survey Black Book Rankings

The federal Meaningful Use mandates have created a 'one-size-fits-all' EMR model that contains too many features that too many providers don't want. 

Interestingly, specialty providers expressed the highest dissatisfaction with the current crop of EMR vendors due to the lack of customizable features.

Will specialty vendors, such as WebPT, survive the expected industry shake-out by narrowly focusing on the needs of therapists and their patients?  Can WebPT control and mitigate the abuses expected to arise from unrestricted copy-and-paste?   Will a WebPT note reduce 'note bloat'?

I suspect the market will shake out leaving the less fit EMRs in the dust. Many of the smaller EMR companies suffer from the same weaknesses that small physical therapy clinics and small businesses have faced recently - inadequate capitalization and a small user base.

The strength of the EMR industry is probably based on the same thing other industries are based on: sound balance sheets and a good cash flow.  Even great technology can't trump the ruthlessness of market forces.

According to surveys comprised from 16,000 EHR users and 550 EHR vendors by Black Book Market Research:
"Nine of 10 EMR industry insiders agree that the majority of EMR vendors currently implemented will fail to sustain operations by 2017.

Eight of ten EMR industry insiders predicted that well-funded, inventive small vendors that carve a niche in specialist sectors should have better foundations for viability than those who failed to resolve the fundamental flaws caused by being all things to all physicians."
I suspect WebPT will continue to gain market share and will remain a leader in the therapy EMR space.  They have a good product.  Their continued dominance will depend on their ability to remain responsive to the needs of their customers. 

Pop Quiz! Who can identify the quote Heidi used for her vision for WebPT at the beginning of this piece?

Tuesday, October 15, 2013

Do doctors of physical therapy need to call themselves 'Doctor'?

I wonder how the rest of the profession should view my physical therapist colleague who, having earned her Doctor of Physical Therapy (DPT) degree from a prestigious university, won't call herself doctor.

Not only will she not call herself doctor in the clinic, she asks people who DO call her doctor NOT to do so again.

I feel disappointed in her, not just because of her behavior, but for the reason she gives people, such as the front desk clerks in the physical therapy clinic, the equipment vendors and the patients when they initially call her doctor.
"I'm not a medical doctor, like some of the physicians I work with, and I don't feel confident that my expertise compares to their expertise - even though we each claim separate bodies of knowledge."
She is still young - only about four years out of her DPT degree. She works in a setting where she is in close contact with physicians - a physician-owned physical therapy clinic.

This physician-owned practice claims they provide collaborative care.  They emphasize the close communication among the physicians and the physical therapists.  From my colleague's behavior however, I suspect her workplace has impaired the development of her professional autonomy.  The American Physical Therapy Association's Vision 2020 Statement states:
Physical Therapy will be provided by physical therapists who are doctors of physical therapy, recognized by consumers and other health care professionals as the practitioners of choice to whom consumers have direct access for the diagnosis of, interventions for, and prevention of impairments, activity limitations, participation restrictions, and environmental barriers related to movement, function, and health.
Do doctors of physical therapy need to call themselves Doctor? 

I believe physical therapists should call themselves doctor if they have earned the right.  Please note, I have not earned the right to call myself Doctor.  Many other physical therapists have learned the specialized knowledge and skills to achieve great results without earning the DPT credential.  However, according to Randall Collins' 1979 book The Credentialed Society:
"In a credential society, such certifications may become more important than actual skills or abilities.  
In some cases, employers may require formal credentials, such as an advanced academic degree, for a job that can be done perfectly well by applying skills acquired through experience or informal study.  
This type of credentialism is common in white-collar jobs, which require workers to have difficult-to-measure skills such as critical thinking.  
Rather than measure or evaluate those skills directly, employers assume that anyone able to earn a credential must possess those skills."
'Skilled physical therapy' is a phrase that can provoke endless discussions among bloggers and commenters. There is a link between greater education and better results for patients.  More importantly, the DPT credential is, I think, an important step in the social legitimization of the physical therapist skill set. Physical therapists need to use the term Doctor to fully capture their investment in the time and money, not to mention for the benefit of the physical therapy profession as a whole.

Physical therapists do have one of those hard-to-measure skill set noted by Collins. So do physicians.  In hospitals, the physician credential is NOT optional.  The culture of medicine does not allow physicians to communicate with patients using their first names.

What go me thinking about my DPT colleague is an article called The Power of Professionalism in the September 2013 PT in Motion magazine (featured at APTA.org) whose print version arrived a couple weeks ago.  In the article, new graduate DPT Jean Miles says...
"What professionalism boils down to for me is being the strongest advocate for your patient that you possibly can be... Not that you have to be a DPT to be a strong patient advocate but I personally gained so much confidence..."
American society will need doctor-level professionals to manage the burgeoning rolls of newly-insured patients who have just become eligible for health insurance coverage on October 1st, 2013 under ObamaCare.

America's 800,000 physicians will face an increase in demand for their services - that, in some cases, they may be unable to deliver.

I first wrote about this in  Can Physical Therapists Replace Physicians as Primary Care Providers in Hospitals? in a November 2011 blogpost on PhysicalTherapyDiagnosis.com.  This post got a good response and a lot of traffic.

Every day, I read about non-physician providers stepping up to fill the demand in America for appropriate, high-quality services the patients need.  Cost and risk are both considered when society shifts tasks away from what physicians have traditionally done.  This article describes Physician Assistants providing basic care to rural and underserved communities.

Physical therapists can fill those roles for patients with chronic pain, sports injuries and other, low-risk conditions.  But first, society needs to understand and accept that the profession of physical therapists is a doctoring profession.  We should call ourselves 'Doctor'.

The American Physical Therapy Association (APTA) maintains a professionalism webpage which contains the core documents defining and describing professionalism in physical therapy.

I wonder if commenters to this blog can help me? 

What can I say to my colleague to encourage her to call herself Doctor?  How can I help her gain confidence so her patients and the physicians she works with can call her Doctor, too?

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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.