Why Physical Therapists Should Care About Interoperability

I just got back from the 2013 Florida Perspectives: Transforming Healthcare through Health Information Technology on Friday, July 19th, 3013 at the University of Central Florida, Lake Nona Medical Center in Orlando.

This program was put on by the Central and North Florida Health Information Management Systems Society (CNF-HIMSS).

Why should you care?

Physical therapists can help answer the problems of interoperability in healthcare which are far from solved. Nobody has all the answers yet - not policymakers, not administrators, not physicians and not even the technical gurus that help us keep our computers running.

Some of the challenges outlined by CNF-HIMSS are near-universal among healthcare workers and include the following:

• How should we train our new clinicians to use Electronic Medical Records in our daily work?
• How should we incorporate the legions of newly eligible patients under ObamaCare?
• How should Florida structure its new Medicaid program?
• Can the Florida legislature quickly reach agreement on important matters concerning healthcare?
• For that matter, can the Federal Congress reach agreement on important issues regarding funding?

Rich Rasmussen, the Vice President of Member Relations of the Florida Hospital Association got up about midway through the meeting and issued a call to action...

"We're all in this together!" he said, referring to the importance of adequate funding for state Medicaid recipients accessing care through the emergency room... 

"My healthcare and your healthcare costs are about $1,100 per year higher than they would otherwise be because of these uninsured patients."

What can physical therapists do? We can stay informed of the issues and support those that dovetail with issues important to physical therapists.

For instance, most of my readers know that in 2012 the Florida House of Representatives failed to support Governor Rick Scott's proposal to accept Federal funds for about 1.3 million state Medicaid recipients. The Florida Senate passed the Governor's plan but the House responded with a plan that would cover only about 100,000 Floridians. That still left over 1 million uninsured Florida residents!

Physical therapists, especially physical therapist private practice owners, would probably like very much for those 1 million Floridians to have access to physical therapy. Rich Rasmussen wants those people to have access to his hospitals.

When we can find this common ground with hospitals and other advocacy groups then physical therapists can really come together with a common voice to speak to our legislators. We can show our leader that we really are in this together.

'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.

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.

Happy Birthday! Paper SOAP Notes Turn 44 Years Old!

On March 21st, 1968 the SOAP note was proposed in an article from the New England Journal of Medicine Medical Records that Guide and Teach.

The SOAP format, popularized by physician Lawrence Weed is the most widely used and simple documentation algorithm in Western medicine.

According to Margalit Gur-Arie, MD at her blog On Health Care Technology:

"Practically every EHR in existence today is based on Dr. Lawrence Weed’s SOAP note format...with the singular purpose of speeding up documentation and ensuring that the finished note is a proper clinical, legal and financial document. And as most of us know only too well, we are not there yet."

However, the time for the SOAP note in adult ambulatory physical therapy clinics is over.

The congruence of Electronic Medical Records (EMR)and changing healthcare processes present a once-in-a-lifetime opportunity to improve a paradigm that, in most physical therapy settings, is akin to shoving a square peg into a round hole.

Most of the over 900 EMRs currently in the commercial and federal marketplace use some version of the SOAP format.

Yet, SOAP was originally developed for medical sub-specialty physicians working within the high-cost, acute care hospital to "talk" to one another in an asynchonous fashion.

Asynchronous just refers to the fact that one physician didn't have to actually speak to the other, they could just read each others standardized SOAP notes.

Today, the "killer app" of asynchronous communication is called e-mail.

The birthday of SOAP is convenient in the context of this discussion begun March 16, 2012 on the technological value of paper vs. Electronic Medical Records (EMR) records from the EMR and HIPAA blog called Paper Has Healthcare Spoiled.

 

The above video, also from the EMR & HIPAA blog, skewers the traditional technology Help Desk that requries every computer/EMR user to need a Help Desk. Healthcare should be easier that this.

SOAP is part of the problem because physical therapists, most of whom practice outside the acute hospital setting, are forced into using the SOAP format. Most PTs still use SOAP written on paper.

According to the EMR and HIPAA blog:

Paper is...

"Flexible to an infinite number of documentation methods.

Does paper support the SOAP format? Yes!

Does paper support every specialty? Yes!

Paper has the ability to morph to every medical specialty’s documentation needs."

While paper has certain, underappreciated, technological virtues SOAP is vulnerable to criticism as a documentation format, especially for chronic health conditions.

SOAP encourages a clinical record that is...

• Described from the provider’s perspective only
• Brief and vague
• Focused on the patient’s immediate painful symptoms
• Focused on the provider’s particular treatment
• Repetitive
• Narrative, rather than data driven

SOAP does NOT fulfill its mission for chronic health conditions seen in the ambulatory PT setting.

SOAP's appeal lies in its universal acceptance rather than its ability to describe the patient experience.

SOAP is easy to teach to students who have been, as the EMR & HIPAA blogpost states:

"Trained in the ... ability to write (which) is near universal thanks to training in doing so since we were children."

We should use the convergence of electronic tools and medical documentation as an opportunity. An opportunity not just to decrease paper medical records but also to change the SOAP format and start over using modern tools to describe disabling conditions experienced by our patients.

I bet physical therapists could come up with some good ideas.

Comments?

Name That Country Quiz!

Can you name this country?

• Primary care physicians earn 20% more than specialty physicians in this country.
• This country has highly coordinated care: specialty referrals are closely tracked by the referring PCP.
• They have sophisticated electronic medical records.
• They have high patient satisfaction.
• They have low costs.
• They have good patient outcomes.
• They have 100% access to healthcare services by everyone.

What country are we describing? Find out here.

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?

British EMR Failure Invites Comparisons to USA HITECH Program

American physical therapists may breathe a sigh of relief that the Office of the National Coordinator of Health Information Technology (ONC HIT) will be less likely now to impose "top down" mandates for the purchase and use of interoperable health information technology now that Great Britain has decided to dismantle their failed system.

On September 22, 2011, the National Health Service (NHS) issued a Press Release announced that it was discontinuing its 10-year, $18.5 billion dollar effort to collect, computerize and centralize all of its electronic medical records. Existing electronic systems in hospitals and clinics would continue to operate but would not be interoperable across all of England.

The announcement essentially killed what had been hailed as “the world’s biggest civil information technology program” at that time.

The NHS program began in 2002 and was described as “top-down engineering” that met substantial resistance from physicians and other users of the system. The Press Release announcing the end of the program cited the lack of local control as the prime reason for the failure of its interoperable system:

“In a modernised NHS, which puts patients and clinicians in the driving seat for achieving health outcomes amongst the best in the world, it is no longer appropriate for a centralised authority to make decisions on behalf of local organisations.”

Authorities in the United States were quick to assure providers that a similar information technology (IT) effort stimulated by Title XIII of the American Recovery and Reinvestment Act of 2009, called the Health Information Technology for Economic and Clinical Health Act (HITECH) would not fail.

Faith in American electronic medical records is largely voiced by policymakers who say they are collaborating with providers, such as hospitals and physicians, rather than mandating a top-down structure.

Authorities claim that Electronic Medical Records strategy, standards and outcomes are set by HITECH Meaningful Use criteria but implementation is being set at the local level by any of the 900 certified IT vendors that the providers may choose to use. However, providers complains that 900 choices is NO better than no choice at all.

Why should private practice physical therapists care?

Used to be, we could just hang a shingle, treat your patients and expect to make a decent living. Now, if you want to work for yourself and your patients, you need to comply with all sorts of regulations that may or may not improve your patient care or add to your patient's outcomes.

For example, the Physican Quality Reporting System (PQRS) is a quality measure reporting program that has, since 2007, paid physical therapists up to 2% extra for treating and reporting Medicare claims data. In 2014, this little "extra" will turn into a discount and the program will turn into a top down mandate.

Can authorities in the USA learn from the British disaster?

I hope that authorities will learn that physical therapists, acting at the local level can determine what is quality and that some of these local measures can be used in place of centrally-determined, top down quality mandates.

The Treatment Trap

Author Rosemary Gibson, MD details the ills of the US healthcare system in her new book The Treatment Trap:



She spoke July 26th, 2010 at St. Peter's Healthcare System which was aired on C-Span 2 on September 5th, 2010 at 10:30am EST.

Here are some of her discussion points from her book:

• Those who speak out against medical over-treatment risk being labelled, in this current political climate, as "rationing". Dr. Gibson speaks of over-treatment from a quality perspective, however, not from a financial perspective.
• High-technology may not be the solution. Even Electronic Medical Records (EMR), the "savior" of modern healthcare, may not always deliver what it promises.
• Obama's failure to implement tort reform with healthcare reform saddles doctors with a "fear factor" which drives wasteful medical spending.
• The "fear factor" produces a "wall of silence" among doctors that perpetuate medical errors and prevents learning.
• Palliative care produces better outcomes than expensive, high-risk, end-of-life care that often leaves the patient worse off.

This book is targeted to patients as well as non-policymaking practitioners. Dr Gibson presents "Twenty Ways to Protect Yourself" as practical advice for patients trying to negotiate American healthcare.

Perhaps one of her statements made in front of the TV camera provided me with the most compelling reason to order this book:

"Health insurance used to be about giving patients access to providers.
Now, it's about giving providers access to patients".

Half of Japanese Physical Therapy Practices are Insolvent

Insolvent.

In the red.

More liabilities than assets.

That's where Japanese medical providers (and physical therapists) are financially.

No, it's not due to the current financial crisis.

It's due to Japan's chronic under-spending on health care.

Spending on Health Care	...as a per cent of GDP
Japan	8%
US	16%
Medicare	8%
Note: Medicare pays for half of US health care consumption

The take home message is that US health care providers rely too much on Medicare.

Currently, most US health care providers are solvent.

However, a 21% cut in the Physicians' Fee Schedule on Jan 1, 2010 threatens the largest, quickest-paying revenue stream for many physical therapist private practices.

The Obama administration has affirmed its intent to embrace Electronic Medical Records (EMR) as a means of of cutting costs in the Medicare program.

What does that mean for physical therapists?

Medicare is desperately trying to cut costs before the wave of aging Baby Boomers washes over our heads and drowns us in red ink.

Can physical therapist private practices cut costs faster than Medicare cuts theirs?

Will electronic medical records help physical therapists cut costs?

What do you think?

People use Health Information Technology

Some people are pessimistic about the benefits of health care information technology.

Some people say health care IT might be dangerous.

Don't bet against it.

Some people estimate a $90 billion return on investment (ROI) in 10 years.

Don't bet on it.

I think the return will be positive, maybe not in dollars - but maybe in lives.

I just started investing in health care IT: $4,800 for new software and $5,000 for a new server and installation.

We've been at it for one month now.

We're not quite there yet.

Reinventing the physical therapy chart electronically means I have to undo years of 'training'.

The hardest part is time - time spent re-creating clinical templates, work flows and data collection.

Time spent away from patients is lost revenue - that's another 'investment

I might be tempted to get depressed or pessimistic about the process.

I might not see a big, positive return on my dollars.

But, I'm going to keep trying.

Some people think computers will improve our future.

Computer costs for physical therapy falling

Physical therapy computer costs are falling. Mine especially.

This article from CNN Money talks about the Obama stimulus plan and the huge expense of training the labor force to implement a computerized health infrastructure.

$100 billion of the $800 billion Obama stimulus plan is proposed to be spent on making all health records standard and electronic by 2014.

17% of physicians and physical therapists now use electronic medical records. 8% of all hospitals use them.

We started a new electronic medical records system last week at Medical Arts Rehabilitation, Inc. in Manatee County, Florida.

Costs have really come down.

The first system I priced two years ago was $60,000 and I would have had to buy two servers to host it all.

The system I bought in December 2008 cost $4,800 and we are up and running in two weeks. It's called Clinic Controller by A2C Medical.

I'll blog my results regularly to keep the physical therapy community updated on our efforts.

We set it up ourselves (I paid an IT guy 2 thousand to configure the system and set the backups - I think I overpaid).

Now, I'm building templates of my

1. Evaluation


2. Progress Notes


3. Daily Notes


4. Re-certification Notes


5. Superbill


6. Patient schedule/calendar

The system is quick and intuitive.

I'm sure I haven't seen the glitches yet or the workarounds that inevitably come with any mechanical device but we're better off than we were with our old DOS-based system (yes, DOS).

We are running both systems in tandem for the time being.

Today, we shut down the old scheduling system but we still have to collect money and post accounts to the old system, probably for three-to-six more months.

I wont see any increase in revenue by switching but I guess I'm getting ready for the new health care infrastructure from the Obama administration.

I figure we'll have our new computers running smoothly before Obama has fixed the health care system.

Physical Therapy Technology

Physical Therapy Diagnosis blog uses technology such as blogs, YouTube videos, Google AdWords and AdSense and Web 2.0 in general to drive home the message that Physical Therapy Diagnosis is simple and easy.

Every Physical Therapist should perform Physical Therapy Diagnosis using skills learned in our entry-level program (BS, MS or DPT).

One physical therapist, Mark Schwall, uses technology in general to improve our lives and our businesses at his website at Tech4PT.com .

In Mark's words...

"TECH4PT.com is dedicated to informing and educating Physical Therapists and anybody else with an interest in utilization of technology to improve their personal lives, business productivity and the visibility of their practices through leveraging the power of availability of technology and the Internet ."

Technology is not usually found in physical therapy education curricula. Technology is also usually not in the skill set of the physical therapist - just look at the low acceptance of 'paperless' or electronic medical records in small outpatient physical therapist offices.

I congratulate Mark on his new website.

I also challenge Mark to find meaningful and useful ways to help physical therapists improve our patients lives through the power and the wonder of technology.