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.

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?

Open Notes Can be Transformational for Physical Therapy

I've been using video to record the patient experience in my outpatient physical therapy clinic for several years. I've never shared that video via the internet with my patient. But, the technology to do that now is simple.

Further, patient functional status, vital signs, objective tests - all these can be shared via the electronic medical record in the physical therapists' clinic.

Watch this video below to see how OpenNotes can change lives and improve health care, including physical therapy:

 

I posted on OpenNotes here.

Some of the ways I think OpenNotes can help physical therapists include the following:

• Reduce overblown estimates of "Fraud and Abuse" that are due to good, smart hardworking therapists working in a stupid system.
• Increase patient involvement and compliance with their plan of care. 
• Improve therapist productivity that is whittled away working on archaic, frequently handwritten, narrative summaries of the patient experience.
• Pass control and responsibility for the rehabilitative process from the therapist to the patient. 
• Increase the role of the "coach" and the "mentor" played by the physical therapist. 
• Reduce the administrative burden (currently 100%) borne by the therapist for the creation of the patient record. 

Do you think OpenNotes of some sort could improve physical therapy?

How?

Please leave a comment.

De-Skilled Physical Therapy?

De-skilling can occur to physicians who use Electronic Medical Records (EMR) and who follow Clinical Practice Guidelines (CPG). The de-skilling process includes the following:

• decreased clinical knowledge
• decreased patient trust
• increased stereotyping of patients
• decreased confidence in making clinical decisions.

These findings are not surprising to many clinicians who warn against losing the personal touch as clinics adopt EMRs.

Both physicians and physical therapists resent the tyranny of the computer screen that prevents them from spending face time with their patient while they enter quality measures.

These findings, presented in the October 2011 Health Care Management Review may be troubling to advocates of EMRs and Clinical Practice Guidelines.

"These deskilling dynamics are often presumed to be a byproduct of select managerial innovations designed to improve efficiency and lower cost, which force workers to perform their work in a more standardized, compartmentalized, and routine way."

My initial knee-jerk reaction to this article is to sympathize with clinicians, forced to work with first-generation EMR software and population-based practice guidelines that strictly limit individual preferences in clinical decision making.

But, the authors continue:

"It can be argued that professionals, like physicians, actively contribute to their own deskilling through how they adapt on an everyday basis...

• to maintain job satisfaction
• get needed work done in a timely manner
• to show that they are performing appropriately
• to survive economically
• to keep control
• to maintain order in their lives."

The main problem with EMRs and boilerplate treatment recommendation, such as we might get from Clinical Practice Guidelines, was the tendency of the 78 primary care physicians in the study to "cut-and-paste" patient data from one session to the next.

"The net result was that primary care doctors believed they were increasingly getting less patient-specific information from specialists via the EMR which hindered their ability to make informed decisions around diagnosis and treatment."

According to these same doctors, this situation did not happen with paper records. That is because paper records forced doctors to dictate patient specific information into a patient’s record each session.

Physical therapist managers can help prevent the deskilling process from occurring by soliciting physical therapist input during their EMR implementation.

Physical therapist managers can preserve their clinicians ability to control their workflow and their ability to apply their professional expertise in desired ways.

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.