Ten Commandments for Effective Decision Support in Physical Therapy

1. Speed is Everything
2. Anticipate the Physical Therapist's Need and Deliver Them In Real Time 
3. Fit the Technology into the Physical Therapist's Workflow
4. Little Things Make a Big Difference
5. Recognize that Physical Therapists will Strongly Resist Stopping the Treatment
6. Changing Directions is Easier Than Stopping
7. Simple Interventions Work Best
8. Ask For Additional Information from the Physical Therapist ONLY When You Need It
9. Monitor Impact, Get Feedback and Respond
10. Manage and Maintain Clinical Decision Support Systems for Physical Therapists

These commandments were originally written by Dr. David Bates in 2003 in anticipation of the electronic medical records revolution physical therapists and physicians are witnessing now.

They are surely as true now as they were then.

I would humbly suggest one additional commandment to add, in light of the recent, massive failure of the British centralized database of electronic medical records:

11. Empower LOCAL decision makers (eg: physical therapists) to add to, delete or modify the decision support rules and allow interoperable CDS systems to "learn" from each other.

Right now, the ONLY CDS system that applies to physical therapists is a top-down government-mandated program that is, for the most part, paper-based.

I think we can do better.

What do you think?

Please comment.

How Clinical Decision Support Can Help Physical Therapists

It is a forgone conclusion that some sort of decision support technology will become a part of the daily workflow of the American physical therapist within the next 2-5 years.

What is not concluded are several things:

• What will the user interface look like?
• What decision rules will the software contain?
• Will the Clinical Decision Support (CDS) be electronic or paper-based?
• Will the decision rules be determined by a "top down mandate"?
• What level of local control by the physical therapist will be allowed?
• Will the hardware be a handheld tablet or desktop?

Clinical Decision Support tools are electronic tools that link at least two pieces of patient data to a knowledge base that provides a suggestion, a reminder, a prompt or an alert. CDS tools can be electronic or paper-based. The intended purpose of CDS tools is to make medicine more safe.

An example of a decision support tool might be the Physician Quality Reporting System measure for Falls Risk:

"If a patient is 65 years or older, screen for elevated falls risk using a history of a fall within the last year".

This is called the decision "trigger".

If the patient answers "Yes" to the therapist's query they are allocated to a "high risk" group for whom a falls intervention program is medically necessary.

If the patient answers "No" to the therapist's query they are allocated to a "low risk" group for whom falls intervention is NOT medically necessary.
This is called the decision "rule".

Clinical Decision Rules are one type of decision support that currently exists in medicine. Critical pathways are another type of decision support.

Critical pathways are a "top down" management style that work well in large institutions. The well-known Virginia Mason/Aetna Lower Back Pain is a successful example of a critical pathway from the standpoint of the physical therapist, the patient and the payer. Hospitals and sub-specialty physicians don't view the Virginia Mason critical pathway with great enthusiasm.

The Virginia Mason model was recently cited in Health Affairs journal as a "high value" model for institutional healthcare in America.

You can also read this blog post at the Evidence in Motion blog with comments by other physical therapists.

However, about 70% of healthcare in America is consumed in small, outpatient practices where critical pathways and top-down management styles may not work well.

Great Britian's recent failure of their centralized electronic health database was blamed on the heavy-handed, top-down imposition of health information technology on physicians. The physicians were not consulted prior to the mandate to get their input as to the best way to implement the mandate.

Commercial EMR vendors may be expected to be responsive to local physical therapists in designing the format and content of decision support tools. At this time however, only a few commercial clinical decision support systems exist in the physical therapy space.

Almost all of the commercial physical therapy-specific Electronic Medical Records contain prompts and reminders. These prompts and reminders, with the possible exception of a PQRS module, are designed not for patient safety but are designed to drive revenue maximization, code capture and Medicare compliance.

However, PQRS is the prototypical top-down decision support technology.

Clinical physical therapists should control their local technology, their own production and the work processes that produce their outcomes.

What sorts of improvements would readers of this blog recommend for a locally-determined CDS system to replace PQRS?

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.

Three Important Trends in Physical Therapy

Electronic everything. I sound grandiose but I just got back from the 2011 HiMSS (Health Information Management Systems Society) meeting at the Orange County Convention Center which must be one of the largest buildings on Earth. No kidding.

The tools and toys displayed in that building connected the patient to the doctor in every conceivable way: email, phone, text, real-time, trending data, graphics displays, historic data, tablets (7" or 10"), iPhones and many I didn't get a chance to see.

These vendors are betting big that healthcare will converge with electronics in a big way in the next 5-10 years.

Information technology professionals are betting that Health Care Reform will withstand the challenge of the 112th Congress and continue to be the law of the land. Recent Federal appeals court decisions put the tally at 3-2 in favor.

These vendors are ready to capture the $29 billion dollars to be paid out over the next 5 years in HITECH funding for doctors to invest in electronic medical records.

Imagine the future when you get paid based on your ability to predict future adverse events in your patients - and prevent them!

Important, life-changing events like stokes, falls, spinal fractures, blood clots or future disablement and institutionalization can now be predicted by physical therapists using simple, evidence based tools.

At HiMSS, they want to make these tools electronic and as easy to use as your e-mail account.

Care systems built around patients, not doctors. Our American healthcare system is built for the convenience of physicians with 15-minute appointments, fee-for-service and isolated silos of practice and knowledge that leave care fragmented.

The future system will be built around patients' needs, not physicians.

Atul Gawande, MD described in Hot Spotters how unlicensed health coaches can prevent outlier patients from slipping back into bad, old habits and ending up in the Emergency Room for costly care.

James K. Galbraith describes in The American Prospect how expanding the pool of healthcare workers will improve not just our health but also our economy.

Dr. Galbraith proposes expanding, not cutting, Social Security and Medicare, as a way to stimulate jobs in areas that are unlikely to migrate overseas or disappear when financial winds blow ill:

"Another area of clear need relates to our aging population.
As people get older, they need care, and the proportion of the working population employed in providing it must rise.
Further, training is necessary, and standards must be imposed, maintained, and enforced.
This is the opportunity to create a large, labor-intensive, mainly not-for-profit sector, that would employ workers with relatively nontechnical backgrounds and help the elderly live in independence and comfort for as long as possible.
Again, realizing this goal will require new institutions or stronger versions of institutions that already exist."

Increased role of non-surgical providers: I can't find any good news coming from the medical literature on aggregated outcome rates for surgical procedures or diagnostic imaging.

Despite the continuous advances in technical proficiency American medicine has exhausted its ability to help patients by ionizing, radiating, poking, cutting, slicing, stabbing, laser-ing or cauterizing the body.

Quality of Osteoarthritis Management and the Need for Reform in the US describes the pathetic record American healthcare has produced:

"Surgery should be resisted when symptoms can be managed by other treatment modalities.
At present, there is no metric whereby the use of conservative management prior to surgery is monitored."

Physical therapists familiar with this blog and other blogs will appreciate our position.

I'd like to recommend that physical therapist entrepreneurs attempt to enter the electronic space and create decision support technology that can distinguish surgical patients from conservative care patients.

Take a look at our hybrid Clinical Decision Support system - we "married" it to my EMR in a shotgun wedding - the baby's not pretty but, hey, we're family...

Its free to use - just call me or e-mail me to set up an account. Play with it using the demo account Username: joey, Password: test123. This is, to my knowledge, one of just a few CDS systems oriented to improving quality, rather than charge capture.

Further, most of the EMR/CDS systems on the market today are built and sold by a small concentration of IT companies. Large companies with large market share are seldom known for their innovation, are they?