'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.

Reimbursement for G-codes?

We're using G-codes as a stepping-stone to an outcomes-based reimbursement system, aren't we?" asked my client today. Jami is a nurse running a occupational theapy hand clinic. Jami is preparing her office for mandatory G-code reporting on July 1st, 2013.

"No", I replied. "We're just reporting our compliance.  We're not measuring function."

"Well, we showing we're getting the patient better, aren't we?", replied Jani.

"No, not really", I replied. I paused in the conversation, not sure how I could quickly explain the statistical concepts needed to understand why Functional Reporting using G-codes and Severity Modifiers could not lead physical therapists to true outcomes reporting.

"What a bust for FOTO", I thought.  Focus on Therapeutic Outcomes had the Cadillac risk-adjusted outcomes measurement system for therapy services in the world and the US government took a pass on them and chose G-codes and Severity Modifiers instead.

Of course, FOTO costs $250 for set-up and $25 per month per therapist.  And, they own the outcomes marketplace.  There is essentially no competition.  I could just imagine the hue and cry if the government granted a de facto monopoly to FOTO and mandated that every therapist measure patient outcomes using a risk-adjusted measurement scale, like FOTO.

"We know how to measure outcomes!", Jami said, eagerly. "We're using the DASH already!"

"I use the DASH, too", I explained.  "And, that's what Medicare wants.  But, a discharge score on the DASH that is, say. 20-points better than the initial score can't be used to compare your clinic to mine."

There are four levels of measurement (adapted from Jewell):

Level of Measurement	Example
Nominal	apple, orange, pear
Ordinal	happy/sad OR hot/warm/cold OR MMT grades
Interval	temperature, height, weight
Ratio	blood pressure, speed and distance

There is not a fixed interval between values such as "happy" or "sad" or, for that matter, the rank ordered scales of the OPTIMAL, the DASH or any of the other paper questionnaires.

These rank orderings are not numbers but are indicators for modifying words. The OPTIMAL uses words for values such as 2 = "little difficulty".

The lack of a fixed interval between these values means that mathmatical functions cannot be performed on them. The difference between a "1" and a "2" is not the same as the difference between a "2" and a "3". We can't add, subtract, multiply or divide OPTIMAL, DASH or any of the other self-report scales becuse they lack intervals.

The interval level of measurement has a fixed interval between each number which allows addition and subtraction. A 10-point change in temperature from ninety degrees to eighty degrees is the same ten point change from fifty to forty degrees.

The ratio level of measurement has a known zero point which indicates the absence of the chacteristic being measured. Zero miles per hour means the car is standing still. Ratio data can be manipulated like interval data with addition and subtraction. Also, ratio data can be manipulated with multiplication and division.

All of these techniques are being used to convert self-report scale data from raw scores to the new Medicare Severity Modifier scale.

That is probably fine for simple reporting to prove to Medicare that physical therapists can report functional scores.

But, when Medicare starts paying one therapist more money for better outcomes based on functional data they had better create something better than G-codes and the Severity Modifiers.