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.

Quality Measures Physical Therapists can Use to Prepare for Meaningful Use

Physical therapists can begin using these quality indicators in their clinics, if you're not already:

Treatment of depression: ask "Are you depressed or have you felt sad or blue during the last 30 days".

Smoking cessation advice among smokers: I read this this on a pack of Camels... "Quitting smoking now can greatly reduce your risk of death from cancer, heart attack or stroke".

I usually ask the patient if any other medical provider has asked them to give up smoking. Over 80% say that their doctor has asked them - but, that means that up to 20% have not been asked to quit!

Diet advice in high-risk adults: I'm 175lbs, 42 years old and I still look good in a Speedo so I punt this one, "I know a registered dietitian who can help you cook tasty meals from your favorite foods and you won't have to give up desserts!"

Exercise advice in high-risk adults: "I'd like to show you some simple things to do at home to feel better and get stronger. Later, if you like, I can show you how you can start to do more things that you like to do".

I actually try not to use the word exercise until the patient has used that word, with me, at least once.

Diet advice in adolescents: same as with the adults, "I know a registered dietitian who can help you cook tasty meals from your favorite foods and you won't have to give up desserts!"

Exercise advice in adolescents: same as with the adults, "I'd like to show you some simple things to do at home to feel better and get stronger. Later, if you like, I can show you how you can start to do more things that you like to do".

I'll usually mention sports, or for the college bound, I'll mention the rigors of studying and computer use.

Blood pressure measurements: This is, by now I think, routine in most physical therapists offices and clinics but I could be wrong.

One point of discussion we haven't settled... Do you take blood pressure on EVERYBODY or just those you consider "high risk". Good resource allocation principles would indicate that your therapists' time is valuable and routine screening on everyone is wasteful.

The Impact of Quality

These measures come from the National Ambulatory Medical Care Survey (NAMCS) that has been collected on a sample of patient visits to non-federal employed office-based physicians who are primarily engaged in direct patient care since 1973.

A recent impact study in the Archives of Internal Medicine on the effectiveness of Electronic Medical Records (EMR) with Clinical Decision Support(CDS) prompting the use of these quality indicators in 255,402 physicians' practices found that only two of twenty possible indicators were improved with the use of the EMR/CDS.

This new study casts doubt on the wisdom of the $27 billion dollar HITECH investement for EMR showing meaningful use capabilities.

Many recent studies of electronic clinical decision support have found improvements in the process of care, like inappropriate antibiotic prescriptions, with the use of electronic aids at the clinic or the hospital level.

This study looked at visit data aggregated nationally to see if the same local trends persisted but they didn't.

Can Physical Therapists Move Forward?

Absolutely. The first step would be to adopt these quality measures - there is no controversy about quitting smoking. Its good for your patient and its within your skill set.

Don't rush out and buy yourself an electronic EMR/CDS just yet - 80% of physical therapists are still on paper.

Fax the paper to your referral sources and let them scan it into their new, government sponsored EMR.

I think the future will reward those of us who focus on quality.

Are Physical Therapists Waiting for Electronic Medical Records?

"It's not that we don't care, we just know that the fight ain't fair... so we keep on waiting - waiting on the world to change"

Get Where The Light Is: John Mayer Live In Los AngelesDVD.

Physical therapists aren't the only ones waiting... Physicians, too, have traditionally waited before purchasing an electronic medical record (EMR).

However, physical therapists can take heart that we are not too far behind the curve set by physicians in the United States.

Until recently, physician adoption of EMRs has been fairly slow. But, all that changed on February 17, 2009 when President Obama signed the The Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted as part of the American Recovery and Reinvestment Act of 2009, to promote the adoption and meaningful use of health information technology.

"Pursuant to the HiTECH Act, providers can be eligible of incentives of up to $44,000."

Provider, however, is ONLY defined as physicians - not physical therapists...

• Doctor of Medicine
• Doctor of Osteopathy
• Doctor of Podiatric Medicine
• Doctor of Optometry
• Doctor of Oral Surgery
• Doctor of Dental Medicine

For the Medicare reimbursement of up to $44,000, the term eligible professional refers only to physicians as defined by section 1861(r) of the Social Security Act.

Physicians across the nation have increased their adoption of Electronic Medical Records (EMR) according to the Electronic Medical Record Systems of Office-based Physicians: 2009 - 2010:

"Additional survey data from National Center for Health Statistics show that significantly increasing numbers of primary care physicians have already adopted a basic EHR, rising by 50 percent from 19.8 percent of primary care physicians in 2008 to 29.6 percent in 2010."

This data was published by the Centers for Disease Control and Prevention on December 8th, 2010.

Dr. John D. Halamka of Harvard Medical School, estimates that only 2% of physicians have a "full-featured" EMR (2010).

"Full-featured" EMRs have all the bells and whistles that define the Meaningful Use criteria (from Dr. Halanka's blog):

1. Computerized Physician Order Entry (CPOE) - and different orders, such as physical therapy electronically.
2. Drug-drug interaction checks
3. Drug-allergy interaction checks
4. e-Prescribing
5. Report patient demographics
6. Report PQRI quality measures electronically
7. Maintain active problem lists
8. Maintain active medication lists
9. Maintain active allergy lists
10. Check smoking status
11. Check vital signs
12. Clinical Decision Support systems (CDS) to improve quality and save time - right now, most physical therapist EMRs provide reminders and prompts for charge capture and revenue enhancement which, while perfectly rational, do little to enhance clinical quality.
13. Formulary checks
14. Advanced directives
15. Incorporate lab results as structured data
16. Generate patient lists
17. Send patient reminders
18. Electronic outpatient notes
19. Electronic inpatient notes
20. Electronic Medication Administration Records
21. Provide an electronic copy of health information
22. Provide a copy of discharge instructions
23. Patient specific educational resources
24. Web-based download of inpatient records
25. Provide clinical summaries for each office visit
26. Timely electronic access
27. Measures for clinical summaries and timely electronic access
28. Online Secure messaging
29. Patient preference for communication medium
30. Patient Engagement
31. Perform test of HIE
32. Perform Medication reconciliation
33. Provide summary of care record
34. List Care members
35. Longitudinal care plan
36. Submit immunization data
37. Submit reportable lab data
38. Submit syndromic surveillance data
39. Ensure privacy

Many of these Meaningful Use mandates do not apply to physical therapy and physical therapists are not considered "eligible professionals" but many of us are still forging ahead with EMR and CDS purchases..

PhysicalTherapyProductsOnline poll of 19,000 rehab professionals

I'm not waiting on the world to define my future - I'm defining my future by investing in the tools of tomorrow.

In 2011, I'll spend several thousand dollars on software coding for a proprietary Clinical Decision Support system that is HITECH compliant using Treatment Based Classification to improve quality and get better outcomes.

How about the rest of us?

Will you spend money on Electronic Medical Records software in 2011?