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As part of the American Recovery and Reinvestment Act of 2009, which earmarks federal funds for economic stimulus, reimbursement may be provided to eligible OTs, PTs, and speech-language pathologists whose practices establish a qualified electronic health/medical record system. Some have already incorporated these systems into their practices, and the financial incentive is an effort to spur others to follow suit.
At Advanced Prosthetics Center LLC, Omaha, Neb, Mark T. Maguire, CPO, prosthetist and owner, transitioned to electronic medical records (EMRs) about 5 years ago, aiming to streamline his adherence to regulatory rules. “Our business is very complex with regard to Medicare compliance and managing that, administratively, can be quite challenging,” says Maguire, who simultaneously embraced a twofold transition. “I brought a resident prosthetist on to train him, so I felt that was a good time to bring EMR on and help simplify the learning process for him and the teaching process for me, and also keep our company compliant.” Maguire started the business about 8 years ago, and while some in his geographic area and industry operate multiple-clinic sites, Maguire opts to run one large facility specializing in limb-loss rehabilitation. The town encompasses a roughly 30-mile geographic radius, with 600,000 to 800,000 people. The center staffs two therapists, who will soon be joined by another.
Advanced Prosthetics uses the OPIE Practice Management Suite platform. The transition to EMR was smooth, but not effortless. “Certainly, there was a pretty big learning curve associated with the program itself, and implementing it and learning how to use it—but the transition was welcome for us because it actually made a lot of our day-to-day processes much easier, more convenient, and a little bit more efficient,” says Maguire, who often pens long progress notes for compliance and medical recordkeeping. “In some ways, it may have added a little bit of work, but I do believe the increased compliance our program gave us relative to the work it created was a fair trade-off.”
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Some six staff members are using the program—three clinicians, two technicians, and one or two administrative staff members. The trio of patient rooms have computers, the bill processor has two computers, a server and network, and the business implements a backup protocol for all data each night.
In-house technicians who fabricate the company’s products tap into the EMR for fabrication instructions sent by clinicians. The system also comprises full-feature billing. “When we as clinicians do billing, we send billing to administration, and our administrators access the billing and check compliance prior to billing—and it also has an electronic billing feature so they can bill it right from the same software,” says Maguire. “Our system is a 100%, all-inclusive medical record system.”
The sole administrative staff member in charge of billing no longer has to manually enter anywhere from six to 15 billing codes into a separate system prior to billing clients. “When we went live with electronic billing, her billing time was probably cut in half,” says Maguire. The facility provides therapy too, but prosthetics is its core business. Maguire planned ahead for the company’s expected growth. Since implementing the EMR system 5 years ago, Maguire has not hired any additional people to assist with billing or compliance, and his business has almost doubled, if not tripled, in that time, he says.
Advanced Prosthetics buys components to build prostheses, and the EMR’s purchasing component is among Maguire’s favorites. “The ability to retrieve information 1 to 3 years down the road—what’s the serial number of this product?—to be able to find out what socks we ordered for a patient, or what foot we ordered … to be able to easily retrieve that information as compared to a paper system, is five to 10 times easier and less hassle, less headache, a huge time-saver,” says Maguire.
The company was among the computer maker’s beta test facilities. When Advanced Prosthetics sought to tweak or improve features, Maguire would notify the maker, and he says some of his recommendations were incorporated over the years. The occasional downside of being reliant on such a sophisticated system is that glitches—maybe three or four times a year—sideline the system for a day or two. But Maguire says he can’t imagine functioning without it anymore.
The Physical Therapy & Wellness Institute, Lansdale, Quakertown, and Montgomeryville, Pa, is on the verge of purchasing an EMR system. “We are in research mode, and I’m sending four staff members to the private practice annual conference of the APTA to make our decisions,’’ says owner Robert Babb, PT, MBA, who expects several attendees to offer the needed service. “Intuitively, I think we might be early in our stages, but we have to make a push toward this effort. I feel the foundation of the basic requirements has not been determined, and as a result, anyone purchasing now will likely go through revisions.”
Among Babb’s criteria: that the company has been in business for more than 5 years, they are among the industry leaders in physical therapy, and they must use a Web-based platform. “We need seamless and meaningful connections between the billing, daily notes, transcriptions, scheduling, outcome management, collections, and other administrative functions between all offices to justify the cost,’’ says Babb.
The Tallahassee Memorial Rehabilitation Center and Neuro Rehabilitation outpatient unit, Tallahassee, Fla, has partially transitioned to EMRs in the past year. Sylvia Young, OT, has been integral in helping the seven-member inpatient OT team adopt 100% electronic recordkeeping. “We decided to start it out as a pilot with the OTs because Sylvia is very computer savvy,” says Sheree L. Porter, MS, CCC-SLP, rehab program manager at the facility, a freestanding rehab unit at Tallahassee Memorial Hospital (TMH).
“We were able to use some of the documentation that our acute care therapists were using in the main hospital, so that did help to give us a base to start with,” says Young. The rehabilitation facility and the main hospital use the Cerner system. “But because we do things very differently here—as far as documenting—some of it had to be built from the ground up.”
TMH, a not-for-profit hospital, is the seventh largest in the state of Florida, with 770 beds and a rehabilitation continuum of care that spans acute care, the postacute rehab center, outpatient, and home health. Porter says the rehab center admits about 80 patients a month, and more than 98% return to the home. She also supervises the outpatient neurological clinic, which schedules more than 1,000 patient visits a month and where the environment is fast-paced.
Porter has worked at the rehab center for 14 years, Young for 13 years. Most of the staff members—some 34 therapists across an inpatient/outpatient setting, including seven physical therapists—have worked there for at least 8 to 10 years, and were somewhat set in their ways, says Porter. “That was part of the barrier to our transition, finding the information we needed to access, and helping nursing staff and the physicians and the other ancillary staff also to navigate our new forms,” says Porter.
Young says initially it took much longer to input information in the computer versus writing on paper in the patient’s room, and the biggest drawback is the limited number of computers. Desktop computers are shared by four therapists or so. The nursing staff, which transitioned to EMRs last year, was given CR5s—small screens that can be transported bedside, and Porter says she plans to earmark funds in the budget for CR5s. In the meantime, some workers are part-time and only about 35% of the staff members are documenting solely online right now.
The EMR push has a different spin for the five speech therapists, among them, Porter. “Speech therapists are the most resistant, because we, as a profession, tend to be writers and can get wordy,” she says. “Some goals can be cookie-cutter in nature, but typically a speech therapy goal is not, nor is anything to do with speech-language pathology documentation. That makes it a little bit more challenging for SLPs. We do a lot at bedside, as far as documentation, and are learning to adjust.”
Despite the initial challenges, they say most embrace the benefits yielded by the new system. “We sure appreciate when we can see the notes from previous therapists who have run through our own hospital system—or even if it’s a printout of an electronic record from another hospital or another setting,” says Porter. And they extol the merits of enhanced legibility, which helps increase safety and potentially decrease the number of medical errors. “We have some therapists whose handwriting is very difficult to read,” says Young. “I can read this. I don’t have to translate it, I don’t have to figure it out, I don’t have to guess. And when we do our weekly notes, our discharge summaries, those are definitely faster for everybody to complete, because that information carries over from the evaluation, to the weekly note, to the discharge.”
They have also converted other paper tasks to the EMR. “Because we are licensed as a skilled nursing facility—although we don’t operate that way—our license says we are responsible for putting our therapy minutes into the minimal data set,” Porter says. “We had a spreadsheet in a notebook where everybody used to input their minutes, and a page might come missing here or there, resulting in extra work for everyone. Sylvia devised a system that’s on a shared drive in our computer network, that any therapist can access to input their minutes, and it automatically calculates it for you.” The system also streamlines the workload for the nurse who submits the minutes to the government.
“And because we’re such a large staff and we provide 7 days of treatment, therapists need to be off from time to time,” says Porter. “They need to endorse their patients and leave some type of notes for the next therapist treating their patient, and that’s all done electronically now, thank you to Sylvia.”
At the opposite end of the spectrum is Kevin R. Stone, MD, of The Stone Clinic, San Francisco. The orthopedic surgeon specializes in sports medicine, focusing on knee and shoulder injuries. Stone, who has evaluated multiple EMR plans but has adopted none, has concerns about EMRs.
The first is noncompatibility. “The software is not compatible with many existing or planned programs, so when Google and Microsoft come out with their program, it may be very difficult—read: expensive—to switch,’’ he says. Stone cites nonportability as another potential problem. “In the past we have been unable to migrate to a new vendor, not just for compatibility problems but for political and economic ones as well. Who owns your patients’ data? What if the vendor goes bankrupt? Remember the too big to fail. …”’
A potential lack of patient confidentiality concerns him too. “If you care for Angelina Jolie, do you think she wants her data accessible to every networked doctor who wants to peek?’’ he says. Another of his concerns is nonsecurity. “Every high school hacker can break into the Pentagon,’’ he says. “What worm placed into these files won’t damage the entire network? You don’t have private backup or paper files.”
He also critiques nonindependence. “The beauty to a separation between medical plans and private docs and the hospitals is that if one goes bankrupt, the other might not—and doctors have some ability to walk,’’ says Stone. “If one health plan controls your patient records, how far can you go?”
He also mentions nonprofitability. “The $200 special introductory offer only available from your local sponsor if you sign up now … may become $2,000 per month when the economics go in unplanned directions. The cost then of escaping is too high.” Stone also considers a potential lack of purity in the overall big picture. “The most likely use of this pooled data is for advertising and for economic segregation,’’ he says. “Advertising by a drug company on your medical file that has a ‘diabetic’ code will clearly be for preferred diabetic drugs. This is the only model that makes any economic sense for the software company.”
Next he worries about a lack of fairness. “By combining the billing program with the EMR, the insurers will clearly use this data not just to screen previous disease states and charge higher rates but actually determine how much an individual patient costs the insurer—a great screening tool to eliminate both patients and doctors who cost too much,’’ he says, noting a lack of competition could also result down the road. “Only an open-source program will permit doctors and hospitals to use an EMR and switch when better ones come along. Have you heard about the competition?”
Stone says some may wish to wait on the sidelines until more is known. “Wait and you will see better options shortly,’’ he says. “Just because the government wants to pay you doesn’t mean you should jump.”
Many therapists are opening their minds and doors to the potential benefits of electronic medical recordkeeping, and as with all things technical, they will discover what offerings the future holds.
Judy O’Rourke is the associate editor of Rehab Management. She may be contacted at .
