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.

With Great Power Comes Great Responsibility

...these are the words of Dr. Donald M. Berwick, Administrator, Centers for Medicare and Medicaid Services on October 5th, 2010 as he was wrapping-up a workshop on Accountable Care Organizations in Baltimore.

Dr. Berwick was quoting Spiderman, trying to motivate and incentivize the gathered healthcare providers, attorneys, corporate executives and other stakeholders trying to figure out what the new rules of the game will be from the largest single purchaser of healthcare services in the world.

There is currently much interest among physical therapist private practices in the new Accountable Care Organizations that Dr. Berwick sees as new "...care delivery organizations, not as financing mechanism...".

Yet, there is little reassurance for private practitioners at the bottom of the referral nework that hospitals and large physician organizations will share the gains equitably if they become the "bankers" of the new ACO.

Ten years of research shows that physical therapy reduces costs and improves outcomes for high cost drivers like lower back pain.

Are there any assurances that physical therapists will become primary care providers for these patients? Won't hospitals have the incentive to under-treat these patients?

CMS is betting the farm on the cost-saving features of ACOs and counting on some, as yet undefined, quality measure to prevent undertreatment by hospitals.

Dr. Berwick finished up his speech by saying...

"Let me be clear, in closing, about one final, serious matter: authenticity.
Authenticity matters.
Those who wish only to preserve the status quo are not going to be constructive contributors to our nation’s future.
They cannot be effective partners, and we simply do not have time to pretend that they are.
We just do not have time for games anymore."

Tough talk - I like that - except that, when ACOs do arrive in two years, Spiderman won't be here to save us.