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.

Is Your Electronic Medical Record Ready for Medicare ACO's?

Never ask this question at a party with private practice physical therapist clinic owners:

"So, what's the ROI on your EMR?"

Chances are the party-like mood will end and you'll be left alone, staring at your drink, wondering what happened.

Electronic Medical Records never did promise much return even under traditional Fee-For-Service. Now, under new Medicare ACO's these old models promise to return even less.

A new report called Better to Best: Value Driving Elements of the Patient Centered Medical Home and Accountable Care Organizations calls into question the current versions of your Electronic Medical Records (EMR).

The report from the Commonwealth Fund, the Dartmouth Institute for Health Policy and Clinical Practice, and the Patient-Centered Primary Care Collaborative is a consensus statement from a meeting that took place September 8th, 2010.

Today's health IT...

"...was developed to support a traditional fee-for-service, visit-based reimbursement model, with the focus on documentation requirements to support a billing function,"

according to David Nace, MD, a McKesson executive quoted in the report."

"Health IT requires new functional capabilities, such as the following:

• multiple team member access and permissions 
• care management workflow support 
• integrated personal health records
• registry functionalities
• clinical decision support
• measurement of quality and efficiency
• robust reporting.

 An interconnected health IT network with key capabilities that optimize engagement, coordinate care and support the implementation of value-based payments is required to support Patient Centered Medical Home (practice) and Accountable Care Organization (enterprise) practice transformation."

For a look at a free, functioning version of a Clinical Decision Support system I've been using in my clinic since 2006 to improve quality, such as PQRS, and guarantee Medicare compliance go to BulletproofPT.com.

Physical Therapist at HiMSS (Health Information Management Systems Society)

I'll go the Executive Breakfast titled mHealth's Evolving Role in Achieving Meaningful Use at the HiMSS (Health Information Management Systems Society) Orlando conference on Tuesday, February 22nd.

My purpose in going is to learn and network with people who will create the electronic healthcare system of tomorrow.

This physician at KevinMD goes on about how great his Electronic Medical Records software is and how it helps him treat patients.

Clinical Decision Support features embedded in the EMR is what makes the software better than typical EMR tools.

What might Clinical Decision Support for physical therapists look like? Advise Rehab for physical therapists has answered part of that question already.

What other ways can you use technology to get patients better, work faster or make more money?

Do you use your iPhone at the patient's bedside?

If so, comment on this blog and let me know how you use any new technology.

The future hasn't been decided yet.

I hope I'll see some physical therapists at the HiMSS meeting.

Advise Rehab Predicts Plan of Care for Physical Therapists

What is clinical decision support (CDS)?

Most sources define decision support systems as a systems that links a defined clinical knowledge base with at least two pieces of patient data (eg: name and age).

The decision support prediction tool available at Advise Rehab is an advanced form of decision support that uses a secret algorithm to predict your patient's recovery.

The algorithm has been validated by Mr. Phip Gabel and you can review his list of links here.

I tried it this summer (2010) with two patients of mine.

I was able to predict, with handsome graphs, the recovery of a patient with whiplash from an automobile accident.

My patient's predicted recovery graph was very similar to this graph from the Advise Rehab website.

I think the future of our profession will be determined by how well we understand the factors that drive patients' disablement and chronicity.

Tools that enable physical therapists to predict how long an episode of therapy will take and how much it will cost will enable therapists to manage the change.

I don't usually endorse products but physical therapist entrepreneurs and Information Technology vendors are being counted on to "carry the water" for the federal government since physical therapists currently do not participate in HITECH (Health Information Technology for Economic and Clinical Health) funding for investment in Electronic Medical Records and Clinical Decision Support.

No physical therapy Electronic Medical Records vendors offer CDS technology that is aimed at clinical quality or outcomes management, that I know of.

All of the EMR vendors decision support seems oriented towards revenue enhancement and charge capture.

In the current healthcare environment, revenue enhancement is a rational response to the questionable financial incentives we've received from Medicare.

Mr. Gabel's decision support tool will have to attach to your EMR as an add-on. He charges about $20 per month with discounts for new users and small practices. It works out to about $1 per patient.

Clinical decision support that improve clinical outcomes will be well worth the money.

Are Physical Therapists Waiting for Electronic Medical Records?

"It's not that we don't care, we just know that the fight ain't fair... so we keep on waiting - waiting on the world to change"

Get Where The Light Is: John Mayer Live In Los AngelesDVD.

Physical therapists aren't the only ones waiting... Physicians, too, have traditionally waited before purchasing an electronic medical record (EMR).

However, physical therapists can take heart that we are not too far behind the curve set by physicians in the United States.

Until recently, physician adoption of EMRs has been fairly slow. But, all that changed on February 17, 2009 when President Obama signed the The Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted as part of the American Recovery and Reinvestment Act of 2009, to promote the adoption and meaningful use of health information technology.

"Pursuant to the HiTECH Act, providers can be eligible of incentives of up to $44,000."

Provider, however, is ONLY defined as physicians - not physical therapists...

• Doctor of Medicine
• Doctor of Osteopathy
• Doctor of Podiatric Medicine
• Doctor of Optometry
• Doctor of Oral Surgery
• Doctor of Dental Medicine

For the Medicare reimbursement of up to $44,000, the term eligible professional refers only to physicians as defined by section 1861(r) of the Social Security Act.

Physicians across the nation have increased their adoption of Electronic Medical Records (EMR) according to the Electronic Medical Record Systems of Office-based Physicians: 2009 - 2010:

"Additional survey data from National Center for Health Statistics show that significantly increasing numbers of primary care physicians have already adopted a basic EHR, rising by 50 percent from 19.8 percent of primary care physicians in 2008 to 29.6 percent in 2010."

This data was published by the Centers for Disease Control and Prevention on December 8th, 2010.

Dr. John D. Halamka of Harvard Medical School, estimates that only 2% of physicians have a "full-featured" EMR (2010).

"Full-featured" EMRs have all the bells and whistles that define the Meaningful Use criteria (from Dr. Halanka's blog):

1. Computerized Physician Order Entry (CPOE) - and different orders, such as physical therapy electronically.
2. Drug-drug interaction checks
3. Drug-allergy interaction checks
4. e-Prescribing
5. Report patient demographics
6. Report PQRI quality measures electronically
7. Maintain active problem lists
8. Maintain active medication lists
9. Maintain active allergy lists
10. Check smoking status
11. Check vital signs
12. Clinical Decision Support systems (CDS) to improve quality and save time - right now, most physical therapist EMRs provide reminders and prompts for charge capture and revenue enhancement which, while perfectly rational, do little to enhance clinical quality.
13. Formulary checks
14. Advanced directives
15. Incorporate lab results as structured data
16. Generate patient lists
17. Send patient reminders
18. Electronic outpatient notes
19. Electronic inpatient notes
20. Electronic Medication Administration Records
21. Provide an electronic copy of health information
22. Provide a copy of discharge instructions
23. Patient specific educational resources
24. Web-based download of inpatient records
25. Provide clinical summaries for each office visit
26. Timely electronic access
27. Measures for clinical summaries and timely electronic access
28. Online Secure messaging
29. Patient preference for communication medium
30. Patient Engagement
31. Perform test of HIE
32. Perform Medication reconciliation
33. Provide summary of care record
34. List Care members
35. Longitudinal care plan
36. Submit immunization data
37. Submit reportable lab data
38. Submit syndromic surveillance data
39. Ensure privacy

Many of these Meaningful Use mandates do not apply to physical therapy and physical therapists are not considered "eligible professionals" but many of us are still forging ahead with EMR and CDS purchases..

PhysicalTherapyProductsOnline poll of 19,000 rehab professionals

I'm not waiting on the world to define my future - I'm defining my future by investing in the tools of tomorrow.

In 2011, I'll spend several thousand dollars on software coding for a proprietary Clinical Decision Support system that is HITECH compliant using Treatment Based Classification to improve quality and get better outcomes.

How about the rest of us?

Will you spend money on Electronic Medical Records software in 2011?

Can You Put a Number on Physical Therapy?

One of the most popular Simpsons episodes ever - MoneyBART - succinctly describes the struggle between intuitive and algorithmic decision making in physical therapy.

(video length 2min 50sec.)


This struggle, catapulted to prominence in 2002 with the publication of Flynn's manipulation rule, is not unique to physical therapists.

Physicians, too, resist the influence of decision rules and adhere poorly to clinical practice guidelines.

Physical therapists share some commonalities with physicians in that we overestimate our ability to access medical knowledge relevant to the patient, to screen for low-frequency events and to apply effective treatments while mitigating the use of ineffective treatments.

MoneyBART captures what I think is one of the drivers for the low utilization of evidence-based decision rules (including treatment-based classification). This driver is captured in the struggle between Lisa and Bart.

Lisa argues for numbers and statistics - the "brains" of the algorithmic, "computer logic" behind treatment based classification - while Bart argues for his "gut" - the intuitive, naturalistic basis for pattern matching traditionally employed by physical therapists.

Plot synopsis: Lisa becomes the manager of Bart's Little League baseball team even though she doesn't know anything about baseball ("Go kick a field goal, Bart!").

To learn about baseball, Lisa turns to a team of statisticians who meet to discuss sabremetrics at Moe's Tavern. Using this brand of statistical baseball analysis, Lisa begins winning games and Bart complains that she has taken the fun out of the game. Bart gets kicked off the team after disobeying Lisa's instructions to walk off a pitch and hits a home run, winning the game.

Lisa eventually makes the city championship and she asks Bart to come back because she needs Bart to pinch run from first base. He agrees to help but again disobeys her management and tries to steal all the way home. As Bart makes his move, Lisa calculates the odds as being vastly against him but, instead of being mad, comes to love the thrill and excitement of the game. Bart is tagged out at home, losing the game and the championship, but Lisa thanks him for showing her how to love baseball as a game.

In fairness, I've made some simplifying assumptions that physicians and physical therapists resist clinical decision support (CDS) because of personal factors ("It takes the fun out of the game") when, in fact, clinicians are professionals who may resist the "top-down" management of complex doctor-patient interactions they perceive as limiting.

Physicians typically not trained, incented or supported for using evidence-based decision rules. The rational response, then, is not to use them.

But, we do have good evidence that safety and efficiency, from high-quality impact studies, are both improved when algorithmic decision making replaces intuition.

Does that take the "fun" out of the game?

Medicine isn't Little League so, if we're going to play, let's play to win.

Is the United States Government Biased Against Private Practice Physical Therapists?

I've thought about this subject for several months - ever since March 2010 when MedPAC delivered its annual Report to the Congress: Medicare Payment Policy.

Now comes this recent article from The Annals of Internal Medicine, picked up on the Evidence in Motion blog, that verifies the implications of the MedPAC report and my suspicions.

The report was black and white evidence that our government is biased against small healthcare providers - where 70% of American healthcare takes place!

Medicare "guess-timates" on adjustments to the Physician Fee Schedule based on access to capital markets for selected healthcare sectors.

"Substantial increases in the number of providers may suggest that payments are more than adequate and could raise concerns about the value of the services being furnished...

The volume of services can be an indirect indicator of beneficiary access to services...

Volume is also an indicator of payment adequacy; an increase in volume beyond that expected for the increase in the number of beneficiaries could suggest that Medicare’s payment rates are too high."

Providers’ access to capital

"Access to capital is necessary for providers to maintain and modernize their facilities and capabilities for patient care.
Widespread inability to access capital throughout a sector might in part reflect on the adequacy of Medicare payments (or, in some cases, even on the expectation of changes in the adequacy of Medicare payments).
However, access to capital may not be a useful indicator of the adequacy of Medicare payments when the sector has little need for large capital investments, when providers derive most of their payments from other payers or other lines of business, or when conditions in the credit markets are extreme."

Guess what? Small clinics like mine and yours DON'T have access to the capital markets! These days we may not even have access to bank lines-of-credit anymore!

The MedPAC report implies that only large firms with scale economies, access to capital markets and administrative staff that can maximize revenue and compliance will succeed in the future.

The Annals article, titled The Affordable Care Act and the Future of Clinical Medicine: The Opportunities and Challenges was written by physicians with close ties to the present administration. Their opinion echoed the MedPAC report:

"The economic forces put in motion by the Act are likely to lead to vertical organization of providers and accelerate physician employment by hospitals and aggregation into larger physician groups.
The most successful physicians will be those who most effectively collaborate with other providers to improve outcomes, care productivity, and patient experience."

No rebuttal was printed by the Annals editors but many online readers voiced vigorous opposition to the politically positive tone of the Annals article.

Physical Therapists and the Multiple Procedures Payment Reduction Policy (MPPR)

The recent, proposed Multiple Procedure Payment Reduction (MPPR), is just the end result of policy discussions at high levels that those of us in private practice can only react to - we usually don't get a voice in these decisions.

Hopefully, many of us wrote letters to the head of the Centers for Medicare Services, Dr. Donald Berwick, pointing out that the projected 13% revenue "savings" will be disasterous for private practice physical therapists and their patients.

Here is a copy of the letter I sent.  The comment period closed August 24th and we'll learn the final adjudication November 1, 2010.

Take Home Message

I don't think the future of physical therapy belongs just to large firms - private practice physical therapists can still effectively compete.

The Annals authors, however, do not believe managing future change is possible in small practices:

"Only hospitals or health plans can afford to make the necessary investments in information technology and management skills."

They appear to have reached the conclusion already that small businesses in medicine and physical therapy will go the way of the dinosaur.

In order to prevent our own extinction we will need to gain control of the one thing that we have that the government wants - our patient data. We need to control not just outcomes data but also baseline data on patient characteristics that affect outcome. Also, we need to show that our decisions on patient care are BETTER than physicians decisions.

Why are physicians referring patients to us? We should be referring patients to them! We should be the point of entry!

But, to gain control of our data we will need better systems for managing data.  Not just Electronic Medical Records (EMR). And not just Clinical Decision Support (CDS) systems, either.

We'll need a marriage of EMR and CDS that will improvement the process of care - as delivered by physical therapists.  We'll need to show that ONE care process in particular: care delivered hands-on by physical therapists DOES lead to better outcomes.

While outcomes are difficult to measure, process measures are much easier. I have not been especially happy with many burdensome process measures in physical therapy but hands-on care is a "no-brainer".

This new study in the August 2010 Physical Therapy Journal is just the second published article showing that PT process measures improve patient outcomes.

What to Do?

Ask your EMR vendor about integrated decision support - what are you doing with your data?  If you don't have an EMR you can still use pen-and-paper decision support tools - usually paper templates - that can be stored in the patients' chart.

These templates can be set up to predict the duration, frequency, total cost and expected outcome. Baseline co-factors can alert us ahead of time to those patients at risk for "failing" in physical therapy - these are the "outliers" that Medicare so desperately wants to identify.

Some "outliers" will need more therapy, some will need referral to psychological screening and some will need surgery.

I hope we can convince the Congress soon that the most efficient setting for physical therapists to serve Americans in this way is often the small, outpatient physical therapy office.

What Kind of Decision Maker are You?

Jill was a bright new PT graduate with a quick smile and a winning personality. She had worked her tail off in physical therapy school and she had a head full of knowledge she was ready to use.

Jill was especially keen on treatment based classification and new clinical decision rules. Her training surpassed the education of many of her older peers, though, and she was sensitive to their professional pride when making her treatment recommendations. Nevertheless, Jill was "on fire" to use her new skills and she did so with gusto - impressing her patients and the rest of the staff with her authority and her good results.

Bill was Jill's boss. Bill was a seasoned expert in many therapy settings - currently he worked as Director of Rehab in a hospital outpatient department and treated patients about half of each day.

Bill had also learned about the new clinical decision rules through some directed self-study and had used the rules on some of his patients.

After 20 years of treating patients, however, Bill felt that he could do just as good as the rules in predicting treatments - he had even subjected his judgement to his own little test.

He evaluated some patients with his judgement and then measured them using the rule - he found that his judgement matched the rule almost all of the time.

Bill had seen many new graduates and he recognized Jill's enthusiasm but he also noticed that she seemed to have something different from the other new graduates he had mentored - more than just enthusiasm and intensity - Jill also had a systematic approach to measuring her patients and making decisions.

Their differences came to an impasse when Jill requested that Bill create new, computerized templates for the hospital electronic medical records (EMR) program. Jill needed specific outputs, such as expected frequencies, duration and outcomes based on her patients' individual data.

Jill had been entering her data into the EMR but the data just sat there - nothing was printed on the Plan of Care that went to the physician for signature. Jill wanted the EMR to automatically interpret her data based on existing decision rules and make recommendations. Jill had to manually enter her recommendations using free text typing which took valuable time away from patients.

Bill knew that Jill's request would be problematic:

1. software coding for the EMR would cost money,
2. no therapist consensus existed on the need or the efficacy of TBC,
3. the literature on TBC was incomplete
4. and many, experienced staff would resist changing their documentation habits based on the recommendation of a new graduate.

What Should Bill do?

Jill uses quantitative models to make her decisions. Quantitative decision making is on the rise in healthcare - although providers, especially physicians and physical therapists - still have a ways to go in improving our decision making fidelity.

Bill, however, uses qualitative decision models that are the hallmark of experienced professionals in many fields.  There is substantial evidence that physicians use qualitative over quantitative decision models. According to the University of Texas Medical Informatics Department physicians...

1. have difficulty with quantitative reasoning
2. have difficulty diagnosis using Bayesian analysis (making diagnoses based on prevalence, test results and posterior probabilities)
3. have difficulty interpreting effectiveness of treatments
4. have difficulty estimating probabilities (and, as a result, infrequently use probabilities in practice)

As a result of these deficits in quantitative reasoning physicians may...

1. order excessive, expensive and invasive diagnostic tests
2. incorrectly interpret the test results
3. inconsistently interpret the post-test probabilities of disease
4. make inconsistent treatment decisions
5. and over-treat conditions with infrequent poor outcomes

Decision researchers usually contrast quantitative vs. qualitative decision making although decision researcher Gary Klein, in his book Sources of Power, uses the term "naturalistic" instead of qualitiative.

Naturalistic decision making (also called "pattern recognition") has also been criticized over the last 25 years in decision research as computers and "computer-like" decision algorithms have become more popular.

Klein argues that both models are helpful and uses the metaphor of peripheral and foveal vision to illustrate that naturalistic decision making is a "wide angle" approach that captures all relevant (and some irrelevant) data while quantitative decision making (TBC/CDR) is a "narrow" approach that captures only relevant data and rules out all other options.

Klein presents the case that naturalistic decision makers in fields as diverse as...

1. US Navy missle defense and flight commanders
2. Firefighters
3. Chess grandmasters
4. Smokejumpers
5. Nuclear power plant risk managers
6. Software designers
7. Corporate CEO's

...do not use quantitative models for over 90% of their decision making tasks. Instead, these experienced experts rely on naturalistic decision making to manage their day-to-day tasks.

Which is Better?

The current healthcare crisis may imply that "something" needs to be done and perhaps improving our decision making models will improve...

1. costs
2. outcomes
3. medical errors
4. provider liability to audits
5. provider liability to medical malpractice
6. efficient allocation of societal resources

There is good evidence that costs, outcomes and medical errors can be improved using CDR. Current data suggest that the medical error rate across various settings and geographic regions are similar:

Region	Error Rate
Great Britain	3.7%
Colorado	2.9%
Utah	3.7%

Error rates in industries that have implemented computerized clinical decision support, however, are markedly different:

Industy	Error Rate
Airlines	less than 0.01%
Banking	less than 0.01%

What Did Bill Do?

Bill could see the writing on the wall - he knew the day of pure naturalistic decision makers in healthcare - the old guard who relied on "gut instinct" and experience to provide care - was coming to an end. Cost pressures and the enthusiasm of people like Jill would usher in a new dawn that used computers and algorithms for the simple decisions. He hoped he would still have a role to play.

When Bill watched Jill at work he felt better - if the future depended on people like her then he knew that physical therapy was in good hands.