Treatment Based Classification: Where Does it Fit In?

A recent webinar from the Healthcare Information Management Systems Society (HiMSS) called Improving Care with Predictive Analytics: The Next Generation of Clinical Decision Support offered this nice schematic of where decision rules fit into the "black box" that we call clinical decision making.

I've circled in red the "Rule Based" decision format used by TBC

CDS = clinical decision support, ANN = artifical neural network

Individual, idiosyncratic clinician decision making is not pictured in this schematic - just computer based.

I'm hopeful that, going forward, that these types of decision support will continue to expand to incorporate more of physical therapist practice.

I believe that handing off some of the automatic functions, such as documentation, will enable physical therapists to spend more time face-to-face with their patients.

My new book, pictured in the upper left hand corner of this page, describes the current state of Clinical Decision Support in  physical therapy and where we can go from here.

Are Patients Protected from Healthcare Algorithms?

Physical therapists are considering algorithms, such as Treatment Based Classification, to help improve patient care.

But, according to this TED talk, algorithms sometimes run amok, conflicting with one another in an endless loop.

Such an endless loop may have caused the 2:45 "Flash Crash" that caused $1 trillion dollars to just disappear



Healthcare algorithms can provide clinical decision support in Electronic Medical Records (EMR).

If they can behave anything like financial algorithms then physical therapists must demand proper protection for patients before using them.

New Book on Clinical Decision Support in Physical Therapy

The new book is finally done!

Bulletproof Expert Systems began in 2006 when myself and six other physical therapists and physical therapist assistants attempted to standardize our clinical documentation.

From those early beginnings, in a series of workbooks, clinical manuals and in-services and, finally, seminars - this book was born.

Bulletproof Expert Systems: Clinical Decision Support for Physical Therapists in the Outpatient Setting shows how physical therapist mangers and clinic owners can use existing clinical tools (such as paper-based or electronic outcome measures) to do the following:

1. standardize documentation
2. improve decision making
3. improve productivity
4. create a brief, transparent clinical record that will defy a Medicare audit
5. improve your clinical outcomes

The publisher's web page went live January 7th, 2012 where I am providing the book at a substantial (~40%) discount from the on-line retailers.

You can buy the discounted book at the publisher's web site.

Finally, I need help selecting the final banner design - if you could just vote for one of the three finalists below I will be all set.

Thank you for your patience and the encouragement I have recieved from all my readers!

This have been an amazing educational and professional journey and its one I could not have made without you!


Thank you!

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?