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Spinal Fusion Rates Continue to Climb

This article from Medscape came across my radar a few days ago, and a number of colleagues had some interesting email dialogue around it (Britt, thanks for initiating the discussion!). The gist of the conclusion is that between 1998 and 2008, the annual number of spinal fusion discharges increased 2.4-fold (137%) from 174,223 to 413,171. In contrast, during the same time period, laminectomy, hip replacement, knee arthroplasty, and percutaneous coronary angioplasty yielded relative increases of only 11.3%, 49.1%, 126.8%, and 38.8% in discharges, while coronary artery bypass graft (CABG) experienced a decrease of 40.1%.

A few points worth considering. First of all, TKA is a close second in growth rate, so clearly there are other surgical procedures that might rival spinal fusion surgery for the “over utilization of the year” award. It would also be interesting to know the percentage growth of spine surgeons compared to other specialties during this same period. In other words, is the rate of increased utilization commensurate with the rate of training spine surgeons? What is definitely clear is that the increased utilization of spine fusion is not commensurate with increasing evidence to support it because none (or very little) exists, especially for chronic pain, which is unfortunately an all too common indication being used to justify doing the procedure.

If you remember our infamous “Whore of the Month” series from a few years ago (George, no worries…we won’t bring it back!), I am afraid spine surgeons (not all of them but certainly the ones doing lots of unnecessary fusion surgeries) might be our first lifetime member because of the frequency with which “bad news” emerges with respect to spine fusion.

I suppose that for the sake of patients with chronic back pain looking for a cure (and willing to be exposed to high risk procedures that offer very little hope for benefit), we can only hope that spinal fusion surgery might soon go the way of coronary artery bypass graft, which is down! As Barb Stevens said in our email dialogue, we should expect to see PT become the safer, less expensive, and more effective alternative to spine surgery just as stents have been to CABG.

What say you?

John

Another POPTS View and Smoking as an Underused tool in Endurance Training

While I am not a regular reader of Advance Magazine for Physical Therapy & Rehab Medicine  (and I doubt this blog is in their RSS reader),  it was with great interest that I read "Another POPTS View.  A healthcare attorney challenges the APTA's campaign against physician-owned PT services".   The article was strangely reminiscent of a published study which clearly demonstrates that cigarette smoking is an underused tool in high performance training.

The study on runners does an excellent job of documenting numerous research which demonstrates that cigarette smoking has an impact on three factors related to endurance performance: serum hemoglobin, lung volume, and weight loss.  There is nothing inherently incorrect about the citations.  However, as Kenneth Myers from the University of Calgary points out, ""if research results are selectively chosen, a review has the potential to create a convincing argument for a faulty hypothesis. Improper correlation or extrapolation of data can result in dangerously flawed conclusions."  This couldn't be any more relative towards Cary Edgar's POPTS viewpoint  (he is founder of Ancillary Care Solutions which works with physician groups on in-house physical therapy).

While the smoking study only made improper correlations, the Advance article provides  major inaccuracies.  The most obvious one is the major point of their contention-the 2005 Medpac report which reports on physical therapy spending per patient in a variety of ways to include practice setting.  The data reported in the 2005 report is for the year 2000, not 2005 as he cites but let's not let the facts get in the way of improper correlation.  Even if the data weren't eleven years old (no shortage of POPTS proliferation during this time), the "spending per patient of $653 in private PT practices, and only $405 in physician groups" is like saying the increased lung capacity of a COPD patient provides an advantage in an ultra marathon.  To be fair, it is probably difficult for an attorney to realize that there are major differences between patients seen in an orthopedic POPTS clinic vs. a freestanding private practice relative to acuity or routines including the "one visit only home program or DME only visits cause the patient lives far away" syndrome that is commonplace.  Of course, there are tons of anecdotes of patients self-discharging because of the cattle call or inconvenience of the POPTS clinic resulting in a lower per episode cost but let's not even go there.  Furthermore, medicare's data in private PT practices includes many POPTS who have obtained medicare numbers and re-assignment of their PT's.  The bottom line is that medicare's own data doesn't unfortunately fully discern between POPTS and non-POPTS.

As to the claim that APTA is  misrepresenting conflict of interest.   Are you kidding?  The major issue of inherent conflict of interest via self-referral is not cost per episode but in excess referring of patients that don't need the service. There are a plethora of studies that show the problems of referring to entities that a physician owns including this recent one from a few days ago which show there is a different threshold for referral where there are financial incentives.  By the way, if you are going to reference Medpac reports, why wouldn't you provide the one from June 2010 as highlighted in this blog which includes the following quotes:

"Moreover, there is evidence that some diagnostic imaging and physical therapy services ordered by physicians are not clinically appropriate"

"There is evidence that physician investment in ancillary services leads to higher volumes through greater overall capacity and financial incentives for physicians to order additional services.  In addition, there are concerns that physician ownership could skew clinical decisions"

 

APTA's white paper on POPTS was written in 2005 prior to 2010 Medpac and the significant number of published imaging studies which continue to demonstrate self-referral problems.  APTA shouldn't be attacked for this paper, they should be applauded as the evidence since then is more than just a little compelling.  Perhaps my favorite part of the viewpoint is the contention that " APTA's promotion of autonomous private therapy practices has almost undoubtedly resulted in lower payment rates for physical therapy services".    While I completely agree that payment rates for services have been unfortunately lowered, this is mostly due to PT's who sign the contracts and their inability to have any leverage in contract negotiations-something we can't put on the shoulders of APTA.

As to common ground, there is one area that I completely agree with the author:

"While the APTA and its state chapters have devoted a tremendous amount of time, energy and money in their decades' long campaign against POPTS and therapists that work for POPTS, they have apparently not conducted or sponsored any studies seeking to validate their allegations that physician-owned PT results in overutilization and unnecessary cost. Instead, as discussed above, the APTA has chosen to cite outdated and misleading studies that support its position and ignore findings that do not support its position."

 

However, as this blog pointed out a few months ago, the time has come. It would be a little disingenuous for APTA to do its own study on POPTS. This is the role of the independent  Foundation for Physical Therapy (full disclosure, I am a Trustee) and this exact study has been approved pending funding which is why APTA, Private Practice Section of APTA (in a major way), and others are stepping up to earmark a donation to the Foundation.  I believe the results will settle this argument once and for all.  How about it Ancillary Care Solutions?  Put your money where your viewpoint is and send some research dollars to the Foundation (you can even do it online).

larry@physicaltherapist.com

Manage What You Measure

Measurement is the cornerstone of evaluation. In Healthcare, objective metrics help us assess treatment protocols and relative outcomes.  From this process we establish standards that serve as guidelines to help us recognize shortfalls in a procedure and make necessary changes.  Measurement guides our decision-making and provides benchmarks for optimal outcomes. 

Performance measures give providers a way to assess themselves as well as their patients. In a recent article entitled The ABCs of Measurement, the National Quality Forum (NQF) discusses the use of performance measures in evaluating optimal care and how they can improve quality and safety for patients (1).  The NQF offers guidelines, derived from providers and patients, that health professionals should incorporate into their care regimens.  This allows for a standardized, yet comprehensive review of the system and incorporates every endpoint of care.  “Measures light the way, showing where systems are breaking down and where they are succeeding to help patients get and stay well” (1).

Further, measurement drives improvement, informs consumers and influences payment (1).  Measures drive improvement through review of processes and adjustment of care. One example of this can be seen in physical therapy practices, ongoing measurement of a patient’s strength, range of motion and functional ability allow a physical therapist to evaluate effectiveness of treatment being applied and make necessary adjustments to subsequent treatment. Measures educate consumers, allowing them to better understand their condition, assess the quality of care being provided make informed decisions.  Finally, measures also allow payors to accurately and fairly evaluate caregivers and patient progress.

What are the key components of measurement? Communication and monitoring. A continuous feedback loop where patients and providers can actively engage ensures improvement in quality of care. This also allows patients to report errors and potential mishaps in their care.  For example, North Shore-Long Island Jewish Hospital uses performance measures of patient care and public reporting of results (1).  A database has been created to track all patient feedback, which is then used to prioritize improvement initiatives.  Communication ensures that patients “get better and stay better.”  A rural hospital in northern California’s Humboldt County has significantly improved outcomes through new models of patient monitoring. The hospital discovered, through measurement, that patients needed “more follow up: more education, more explicit linking back to primary care, and more help managing their chronic conditions” (1). 

Clinics leverage technology to become better informed. The NQF endorses wider use of electronic health records (EHRs) suggesting that, “EHRs will also make measurement and performance data available on a real-time basis, making healthcare much more responsive to patient needs.”

So how do we apply health care measurement in physical therapy?  What tools do we have at our disposal to document patient performance and drive better care?  Best practices dictate that we start the rehabilitation process by gathering baseline data against a set of standardized objective scales i.e. strength, range of motion and balance. Ongoing tracking of these metrics keep therapists and patients focused on specific, measurable goals. Engaging the patient in this process will allow providers to constantly re-evaluate care and make necessary adjustments. Available technology like the FORCE TherEx platform facilitates a continuous feedback loop between patient and provider. The NQF has made it a priority to endorse the use of performance measures to improve the healthcare system and it is imperative that we apply these standards the arena of physical therapy; “Measures can best succeed when they are backed by all involved in healthcare, reported to the public, and used for continuous improvement.” 

In the wellness arena, measurement devices and applications like ‘fitbit’ and ‘runkeeper’ have demonstrated traction with consumers. It seems that people manage what they measure, in which case, including patients in monitoring their physical progress should improve their participation in rehab programs and their resultant outcomes.

Resources

1. Robert Wood Johnson Foundation (RWJF). 2010 . The ABCs of Measurement, National Quality Forum, www.qualityforum.org/Measuring_Performance/ABCs_of_Measurement.aspx.

Authored by Bronwyn Spira, PT. Bronwyn Spira is Founder and President of Force Therapeutics, a web-based comprehensive patient management solution for physical therapists. She owns a private practice in New York City where she treats orthopedic and sports injured patients. Bronwyn can be reached at bronwyn@forcetherapeutics.com. Force Therapeutics can be found at www.forcetherex.com.

Physical Therapists and Clinical Decision Support

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 proto-typical top-down government mandate.

Can't we do better?

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?

Tim Richardson, PT
www.PhysicalTherapyDiagnosis.com

"Trial of #physicaltherapy" Pet Peeve #2

We started a series entitled Physical Therapist Pet Peeves a few weeks ago with #1 being the term “skilled physical therapy”.

Pet Peeve #2 is the the referral for a “trial of physical therapy”.  The scenario usually unfolds like this.  A patient with low back pain who has been seen by their primary care doctor is now referred to a spine doc.  The first level of treatment was a “trial of anti-inflammatories” and in all likelihood pain medication.  Since the patient didn’t respond entirely to the meds and complaints include some radiation to the leg, the patient was referred to a “specialist” who ordered an MRI (and if the doc owned the MRI, evidence shows it was self-referred).  There was undoubtedly seen some “bulging disk(s)”.  The specialist believes that surgery would relieve the symptoms. However, the patients insurance will not approve the surgery unless a “trial of physical therapy” did not result in improvement.  The conversation:  “Mrs. Jones, you need surgery. Unfortunately, your $%X@^ insurance company won’t let me help you and they say you have to have a “trial physical therapy” which of course can’t possibly help a surgical condition.  Perhaps it was a little softer conversation, “Mrs. Jones, you need surgery but let’s do a “trial of physical therapy””.    In all likelihood, this “trial” was done in the physician’s own PT clinic.  Regardless of where treatment was sought, there is no basis or assurance that the physical therapist upholds the best current evidence in the treatment of LBP (another post for another time).  I refer to this scenario which occurs every day (and several times a day if you live in Greeley, CO), as being “set up by the knife”.   

Today, the so called “Iowa study” was published which shows not surprisingly that directly accessing a PT results in lower overall cost associated with the initiating complaint and less visits then when referred by a physician to a physical therapist.  Imagine if patient consumers really weren’t brainwashed by language such as “trial of physical therapy”. Just imagine the savings in unnecessary tests and medications (or just read this post about a recent published paper of the impact of direct access for LBP).  With 2 legs of the stool now in the public domain (direct access and savings in downstream costs for LBP done by a PT), we now only need a referral for profit study published to propel independent PT’s to the upper echelon of the food chain.

We don’t tell patients, “you appear to have an ear infection, let’s do a “trial of primary care””.  We don’t tell patients, “you have torn ACL, let’s do a “trial of orthopedic surgery””.  So, it is time to represent physical therapists as what we are, a solution and the preferred specialist referral option based on evidence, not a modality with the same poor odds of success as an anti-inflammatory medication.

Thoughts?

@physicaltherapy 

#Physical Therapist Value Stream. We are Force Multipliers

We interrupt my series on Physical Therapist Pet Peeves to bring you some excellent data from Health Affairs Sept edition on Virginia Mason, Collaboration Among Providers, Employers, And Health Plans to Transform Care Cut Costs And Improve Quality (abstract only, full text for subscribers only).

EIM blog reported to the  physical therapist community on the day of publication the now widely distributed WSJ article on Virginia Mason's novel efforts to wean itself off pricey tests through the use of Physical Therapists (not physical therapy!) as front line patient access points.  It has been our belief for some time that physical therapists are truly force multipliers that achieve cost effectiveness and outcome through the consistent adherence of EBP for low back pain.  (another example is here).  There is also no question that downstream costs in imaging, pharmacy, and surgery can be realized by greater utilization of physical therapists. Fortunately, as the Health Affairs Article points out, we now have empirical evidence.

The article details the importance of the collaborative process in getting groups of providers to agree on defined clinical pathways for high cost drivers resulting in a "value stream".  Virginia Mason's group defines quality in terms of access, high patient satisfaction, rapid return of functioning and the use of evidence based care at an affordable price.  While we often think of EBP in terms of our own profession, the most critical point of agreement amongst collaborators is that EBP be based on a particular clinical question as opposed to the expertise of a single practitioner.  The majority of providers participating in the clinical value stream complete full course in EBP and their belief is that the first office visit where the appropriate treatment is determined and initiated is the most important step.  For low back pain, this is the job of physical therapists.

While much of the article points out the significant savings in value stream headache by avoiding over utilized MRI's in the diagnosis, LBP is given ample coverage.  Rapid access to care is deemed critical in achieving correct care AND savings.  From the article:

For our back pain value stream, the use of physical therapists to perform some functions previously assigned to physicians improved Virginia Mason’s financial performance by increasing the number of patients seen and making more efficient use of physician time. Under the back pain value stream, we were able to accommodate 2,300 new patients per year, compared to 1,404 under the old system, in the same physical space. The physicians also became more efficient under the new system, with an average billing of 58.3 relative value units per day compared to 28.1 relative value units per day under the old system. Relative value units are the basis for physician payment under fee-for- service, so they represent an estimate of revenue generated.

Costs to the employers were decreased through the elimination of unnecessary imaging tests and fewer patient visits to providers. In addition, rapid access to care and increased efficiency of care delivery contributed to more rapid return to work. Postvisit surveys of patients seen in our back pain collaborative value stream revealed that patients in this collaborative required fewer physical therapy visits and fewer lost work days than local averages (4.4 compared to 8.8 and 4.3 compared to 9.0 for physical therapy visits and lost work days, respectively)

Perhaps even more indicting on cost elements is the dollar assessments of providers:

Providing the services of an orthopedic surgeon or other procedural specialist costs approximately $4 per minute. A generalist physician whose practice consists predominantly of patient evaluation and management, rather than performing procedures, costs Virginia Mason $2 per minute. A nurse practitioner or physical therapist costs $1 per minute or less.

Acuity is likely a factor in the decreased number of visits vs. local averages which supports early and direct referral to physical therapists.  While there are advantages to organizations of a vertically oriented system like Virginia Mason, it is not a difficult task for a payor to direct care on low back pain to physical therapists. This should be the standard.

We will likely continue to pile up evidence that PT's are the force multipliers in healthcare. We now have to actively advocate for appropriate changes to make it happen.

Thoughts?

larry@physicaltherapist.com

More Top 5

1. Quit giving patients explanations about their conditions that are the equivalent of "X-rated stories" about disease and disability with all sorts of graphic images not suitable for patients' eyes. Instead, share patient appropriate explanation that are the equivalent of “children’s stories” (the imaginative kind where the prince always gets the girl and they live happily ever after), which consists of direct, healthy and simple messaging. (from a numbers fanatic and prolific clinical researcher)
2. Stop calling the following physical therapy: internet driven "therapy" advice, an iPhone application or licensed/unlicensed personnel watching patients as they ride a bike. (from another well respected, evidence-based clinical expert)
3. Question 'stabilization' exercise for everyone (evidence-based clinical expert with an incredibly busy private practice.)
4. Over-emphasis on the actual care process and disregard or not enough emphasis on customer service (another one from the numbers fanatic and prolific clinical researcher)

Bonus Bullet: Stop using a successful case(s) as a Silver-bullet cure poster child for LBP (“ripping fascia”  really?!).

Rob

The Value of a Patient Portal: Increasing compliance while reducing cost

As patients become more and more interested in engaging and communicating with their healthcare providers online, the demand for portal applications will only increase.  Patients are looking for innovative ways to access their health information and care providers – what better way than online patient portals? 

Portals are healthcare related online applications that allow patients to interact with their healthcare providers through secure websites or integrated electronic medical records (EMRs).   These applications can give patients the ability to request prescription refills, make appointments, receive medical reminders, view billing statements, and ask providers questions about ongoing treatment regimens (2).  The key is engagement and it’s a growing trend among individuals who expect the most out of their provider-patient relationships.

While portals empower patients to take control of their treatment and recovery, they hold even greater potential for healthcare providers.  In particular, these platforms can substantially enhance the quality of physical therapy care.  Compliance is an overarching issue for ensuring proper recovery during the physical rehabilitative process.  Think home exercise regimens, post-surgical contraindications, body mechanics… physical therapists always have so much to communicate and monitor. As we discussed in past blogs, compliance plays a direct role in patient outcomes.  Portals provide a secure platform for sending important messages directly to patients and monitoring their compliance at the clinic and outside of it. The downstream effects are increased efficiency and productivity, reduction in administrative overhead costs and improved patient outcomes.  These applications also allow therapists to expand their practices’ reach by providing innovative solutions for patients that are geographically inaccessible.

So, you may well ask: is now really the time to integrate this type of technology in my practice?  In a recent survey conducted by Intuit Health, 73% of respondents said that they would use an online communication application to pay medical bills, communicate with their physician or physician office, make appointments and view lab results (1).  More than 40% said they would consider switching physicians in order to obtain such access.  Research such as this makes it clear that patients are eager to adopt such applications and now is the time for providers to get on board.

The use of portal technology is inevitable as patients take control of their health and demand two-way communication platforms from their providers. As we innovate around ways to increase the quality of care provided to patients, the integration of secure portals should become a mainstay for effective clinical practice.  

Resources

1.  Shinkman, R. 2011. Americans want more online access to physicians, FierceHealthIT, http://www.fiercehealthit.com/story/americans-want-more-online-access-physicians/2011-03-07.

2.  Terry, K. 2011. Patient portal use becoming an inevitability, ForceHealthIT, http://www.fiercehealthit.com/story/patient-portal-use-becoming-inevitability/2011-04-23.

This guest post was co‐authored by Bronwyn Spira, P.T., President of Force Therapeutics and Mark Anthony Fields, Ph.D., M.P.H, Digital Media Associate of Force Therapeutics. Force Therapeutics is an online suite of solutions tailored for the busy physical therapist.  Force Therapeutics can be found at www.forcetherapeutics.com, www.facebook.com/forcetherapeutics, or www.twitter.com/ForceTherEx.

 

Avoiding the Breach: Is our patient data really protected?

Electronic 
health 
records
 (EHRs) 
are 
the 
future
 of 
the
 provider‐patient
 relationship.

 As 
the
 storage,

retrieval
 and
 sharing 
of 
information 
via 
EHR 
accelerates, 
providers 
benefit
 from
 the 
most 
accurate
 and

up‐to‐date 
information 
available.

 The 
delivery 
of 
care 
is 
optimized 
through 
these
 systems
 giving

providers 
the 
information 
necessary 
to 
make 
the 
most 
effective 
clinical 
decisions
 for 
their 
patients.

The
 issue
 of 
patient 
security 
is 
an 
ongoing
 concern.
 Privacy 
of 
our 
medical
 data 
is 
one 
of 
the

cornerstones 
of 
our
 healthcare 
system. 

This 
code
 of 
confidentiality 
empowers 
patients 
to 
share
 critical

information 
with 
providers 
and, 
in
 turn, 
allows 
them
 to 
make 
the 
most 
appropriate 
diagnosis 
and 
plan

of
 care 
necessary. 

In 
a
 recent 
blog 
entitled Living 
on 
a 
Cloud, 
we 
discussed 
how
 physical
 therapists 
are

beginning 
to 
embrace 
‘cloud
 computing’ 
as 
the 
new 
standard
 for 
accessing 
patient 
information 
any
time

and
 anywhere
 without 
having
 to 
purchase 
a 
server, 
upload 
a 
program 
or 
even 
back
 up 
their 
information.


We 
emphasized 
that 
these 
services
 must 
provide
 Health 
Insurance
 Portability 
and
 Accountability 
Act

(HIPAA) 
compliant
 user 
logins 
to 
ensure
 patient‐therapist 
confidentiality 
and
 should 
be 
SSL
 encrypted
 to

the 
level 
required 
by 
CMS
 guidelines.

So, 
just 
as 
with 
our 
financial 
information 
we 
must 
ask 
the 
same
 questions 
concerning 
our 
patient 
data:


Is 
this 
data 
vulnerable 
to 
internet 
attacks 
and
 security 
breaches?
 
What 
precautions 
are 
providers 
taking

to 
avoid
 these 
issues?

So
 here 
are 
some
 facts 
on
 EHR
 security.
 A
 recent
 study
 conducted 
by 
the 
consulting 
firm,
 Software

Advice,
 found 
that
 security
 breaches 
of 
patient
 data 
through
 internet 
hacking 
only 
account 
for 
a 
small

percentage
 (6%) 
of 
HIPAA 
violations 
(2,
3). 

A 
majority 
(63%) 
actually 
came
 from
 physical
 theft 
and

unauthorized 
access
or 
disclosure 
(16%). 

Of 
EHR
 violations,
 all 
involved
 on‐premise 
violations 
as

opposed
 to 
‘cloud
 based’
 breaches. 

The 
author 
of 
the
 study
 points 
out 
that,
 “HIPAA
 violations 
aren’t

happening 
in 
the 
cloud, 
rather, 
they’re 
happening
 in 
the 
doctor’s 
office,
 hospital 
IT 
closets,
 cars,

subways, 
and 
homes.”

In
 order 
to 
continue
 the
 safety
 of 
patient
 data,
 providers 
need 
to 
take 
precautions 
to 
comply 
with 
HIPAA

Privacy, 
Security, 
and 
Breach
 Notification
 Rules 
(1).
 

These
 include:

• Ensuring
 that 
any 
disclosure 
of 
patient
 information 
comply
 with 
HIPAA
 Privacy
 Rule

• Ensure
 the
 service 
performs 
a 
HIPAA
 Security
 Rule
 risk
 analysis 
indentifying
 potential 
threats

and
 vulnerabilities 
to 
protected
 health
 information

• Ensure 
that
 service 
conforms
 to 
the 
HIPAA 
Breach 
Notification 
Rule 
which
 requires
 the
 reporting

of
 breaches 
of 
protected 
health
 information

It 
is 
clear 
that 
EHRs
 can 
enhance
 the 
quality 
of 
patient 
care 
and 
that 
taking 
the 
necessary
 precautions
 to

protect 
privacy 
is 
a 
crucial
 step
 to 
ensure
 that 
our 
health care 
system
 moves 
closer 
to 
a 
paperless

practice 
model.

Resources
1.

Dolan,
 B. 
2011. 
Mobile 
Health:
 How
 to 
Comply
 with 
HIPAA, 
mobihealthnews,

http://mobihealthnews.com/11272/mobile‐health‐how‐to‐comply‐with‐hipaa/.

2.

Koploy,
 M. 
2011. 
HHS
 Data 
Tells 
the
 True 
Story 
of 
HIPAA
 Violations 
in 
the 
Cloud,

http://www.softwareadvice.com/articles/medical/hipaa‐violations‐arent‐in‐the‐cloud‐
1062011/#ixzz1TYEUKe4G.


3.

Simmons,
 J. 
2011. 
Can
 'clouds' 
protect 
patient 
data
 from
 security 
breaches?, 
Fierce EMR,

http://www.fierceemr.com/story/can‐clouds‐protect‐patient‐data‐security‐breaches/2011‐06‐23.


This 
guest 
post
 was
 co‐authored
 by 
Bronwyn
 Spira, 
P.T., 
President
 of 
Force 
Therapeutics 
and 
Mark
Anthony 
Fields, 
Ph.D., 
M.P.H. 


Force 
Therapeutics
 can
 be 
found
 at 
www.forcetherapeutics.com,
www.facebook.com/forcetherapeutics, 
or 
www.twitter.com/ForceTherEx.

Measuring Quality in #PhysicalTherapy

What is quality? How do we really know we provide quality care?

The majority would probably believe using a measurement tool to capture the change that happens between two points in time is adequate. Did the patient's initial presentation change enough to indicate something really happened? If quality care isn't provided, not much change will occur, right?

I'm beginning to think measuring quality is a lot more complex than any of us originally thought. First off, if we look into the diversity in which we have a role, you'll easily see, in certain situations, we may not be able to truly measure quality. When we provide services, the person in front of us drives the process. People will choose to receive physical therapy services for probably four distinct reasons: 1) to stay healthy, 2) to get better, 3) to learn to live/cope with a disability or illness, or 4) to cope with end of life. The measurement tools readily available to us tend to focus on reason #2. What do we do in the other three situations to capture the quality or impact of our services? In those three other scenarios, I'd like to think we have an impact, yes, but... the capability to capture the impact or the quality of what we provided is difficult. As our future unfolds, how will we help mold the changes to allow for three situations where our services are needed and not pigeon-hole ourselves into regulatory requirements demanding we standardize a process to document changes in presentation for payment for services?

How about adding another factor into the complexity of using standardized tools to measure change which ultimately would be extrapolated to help prove "quality?" Take the 6 Minute Walk Test. This is a standardized, functional test measuring the distance a person is able to walk. This is a really, really easy test to implement and answers the question of how far a person is able to walk in 6 minutes. Easy to do; easy to document; easy to readily know if distance changed. The question to be answered when comparing distance results is... was the change in distance relevant? This brings us to the concept of minimal detectable change (MDC). Are MDC fixed variables? Sadly, no, they are not. More and more, it is becoming apparent that each patient population may have a designated MDC. In other words, I may want to get excited that after 4 weeks of physical therapy, my patient who has Parkinson's Disease walked 80 feet farther. I really can't get excited though because research indicates for a person with Parkinson's Disease 269 feet is the MDC. (I will admit, I do think some of the MDC are crazy... it honestly doesn't seem reasonable to have 269 feet as the distance indicating that the change in distance isn't measurement error. Have you ever walked with someone who has Parkinson's Disease? I don't quite understand how the standard error measurement can be 50-60 feet. Seriously, are we that inadept at measuring distance or hitting the start/stop stopwatch buttons?) Someone's going to need to design an app for the various outcome measures, populations and matching MDC or a really smart physical therapy based electronic health record with this kind of information built into the system and frequently updated. Seriously, look at the Berg - who's going to easily remember these details?

So, if minimal detectable change isn't your forte. For some outcome measurement tools, minimal clinically important difference is the relevant factor. How about pain? Quite a few people seeking our services report pain. If we choose to use reduction of pain as a quality indicator, it isn't as simple as we'd intuitively think. The location of pain and the onset of pain are factors to be considered when interpreting change in pain. The duration of the episode of care might even need to be considered. So, again, another example of a measure not having a fixed score that readily indicates clinical change occurred.

And now... now we have a fairly new concept to enter into the mix of complexity - minimally clinically important improvement (MCII). In 2007, French biostatistians and/or rheumatologists (not sure which) introduced the concepts of MCII and patient acceptable symptomatic state (PASS). In a nutshell, these two concepts bring the patient's opinion into the picture too - in other words, a stand alone outcome tool measurement score was kind of meshed with the patient's perception of improvement. That's probably a good idea because there are times I have patients indicating to me improvement yet the outcome tool doesn't have a large enough change in score to be clinically relevant. MCII was recently introduced in physical therapy literature by the statistical, superstar, number crunchers associated with Focus on Therapeutic Outcomes. Meshing a Global Rating of Change (GROC) with the FOTO Functional Status (FS) score creates huge complexities in attempting to use the results to prove quality. Significant differences in MCII were noted in various groups of patients who: 1) had really low intake FS scores, 2) were males, 3) had an onset of symptoms <22 days and 4) were 18-44 years of age. These findings again bring home reality - in order to determine change or improvement, the defining number to use isn't some fixed, consistent constant variable.

So how do we utilize all this type of evidence in the future during dialog and negotiations with outside stakeholders when they attempt to create quality reporting mechanisms and policies for reporting change... which of course will be tied to payment methodologies which include "quality of care" in the equation?

~Selena