Electronic Health Records

Kevin Svoboda, PT, discusses treatment with a patient. Therapists who use documentation software can preserve interaction between patients and themselves by positioning a laptop so patients can read the monitor and make intermittent eye contact with the therapist.

As technology continues to impact the medical industry in the 21st century, electronic health records (EHR) are an area of constant innovation. These innovations are helping some clinics realize significant gains in productivity and efficiency as EHR systems are implemented and lead practices to greater success through time savings and high levels of documentation accuracy. This article chronicles the process of selecting an EHR for an outpatient private practice physical therapy clinic, and demonstrates why, after extensive internal research, it was determined that the advantages of an EHR more than justified the costs, and that selecting a fully integrated solution would allow the practice to remain at the forefront of technology.

Originally, the clinic was served by a partially paper-based system for clinical documentation operations that included daily notes, treatment logs, progress reports, evaluations, reevaluations, and home exercise programs. As part of the clinic’s original information infrastructure, some systems were already in place to maintain specific records, such as a database of physicians, patients, and daily schedules. Similar systems were also in place at that time to handle demographic information such as patient e-mails, birthdays, addresses, and insurance information. These systems were not fully integrated with all documentation components, however, which made it difficult to run practice analysis reports, maintain physician referral statistics, and prevent redundancy in the collection of information.

Once the decision was made to implement an EHR system practice-wide, the first step toward selecting a system was to form a committee that represented the clinical and administrative sides of the practice. This committee became responsible for championing progressive thinking throughout the clinic and cultivating support for the new technology. Committee members also accepted the responsibility to serve as a support system for their colleagues during the implementation process, and took on the task of encouraging buy-in and soliciting feedback from all staff members. This committee would ultimately be recognized as a key factor in the success of implementation.

Following the formation of the selection committee, research into many different EHR systems was conducted to determine which would satisfy the complex requirements of the practice. After forming an idea about which features and functions would be essential to the practice, the committee researched and selected vendor candidates, then interviewed the candidates and were presented with software demonstrations. This was an enlightening period of the selection process because it demonstrated the sheer volume of EHR systems and options available. A vendor’s knowledge about the physical therapy industry was one of many key factors taken into consideration throughout the interview process. Clearly, the therapy industry has its own unique set of challenges and requirements. A vendor who understood those challenges and how to tailor a software solution to meet them would be well-positioned in the competitive landscape. For example, an essential function an EHR system must provide in a physical therapy setting is the ability to demonstrate medical necessity and integrate that proof into documentation. A vendor whose software did not offer that function would fail to earn serious consideration by the committee.

The interview process ultimately helped the committee narrow the EHR system to one solution that would weave seamlessly into the practice’s existing systems. It also helped identify a system that would integrate documentation for the practice’s clinical needs as well as provide billing functions for the practice’s administrative demands.

It was also important during the interview period to determine whether the documentation software under consideration for purchase was actually existing software that had been modified for use by physical therapists. Other important questions emerged during the vendor interviews such as whether to select a Web-based system or server-based system. In a Web-based system, all information is stored on the vendor’s secure Web site and is accessible from any location where there is an Internet connection. After researching and comparing the two types of technology, the committee determined the benefits of a Web-based system were preferable to those of a server-based system.

At the close of the interview process, a vendor was selected and a testing phase was begun. This period allowed practice staff hands-on experience using the system and an opportunity for clinical and administrative representatives to test the software for compatibility with existing practice systems. Along the way, we observed notable aspects of human interaction with an EHR that therapists who are thinking about implementing an EHR may want to consider. One noteworthy observation was how humans transition from a paper-based system and become comfortable with daily use of EHR software. For a healthy return on investment, any EHR solution requires a solid foundation of systems and knowledge that should already be in place, such as documenting for medical necessity, skilled care, and functional deficits and the ability to submit claims according to the expectations and rules of each payor.

Once the committee made its final selection for an EHR system, a testing phase began to allow future users of the system hands-on experience with the software and stir feedback for the selection committee to analyze. Throughout the testing phase, the selection committee worked to ensure the new EHR system would be compatible with the existing systems of the practice. This would ensure a seamless integration with the needs of the clinical and administrative staffs.

The testing phase presented a great opportunity to evaluate the needs of both teams. On the clinical side, for example, one important preference that emerged among staff was the ability for them to type text freely in the documentation area. This feature ranked well above other methods that limited users to phrases predetermined by the software. Another vital factor that becomes apparent through testing is whether a system has a fast learning curve. This was an important consideration where members of the clinical staff may not all be savvy computer users. The software also was scrutinized for its ability to convert data about current patients from the old system into the new system retroactively. This was important to ensure the continuity of the patients’ documentation.

The needs of the administrative staff were also taken into consideration, and initially some anxiety existed among these team members. Having become accustomed to the reliable access of on-site paper documents, this group chiefly feared that patient records might not always be accessible due to network connection problems or server-related issues. Much consideration was given, therefore, to researching the system’s uptime—the percentage of time a company guarantees their Web-based product will be accessible. Other concerns lingered among staff relative to the new system’s reliability, such as fear of losing data and losing the ability to quickly start a new note. As the system’s future users gain more trust through training and experience, however, these concerns continue to be resolved.

Therapists expressed concern about the loss of interaction between themselves and a patient, which might possibly be caused by the therapist’s preoccupation with using a computer. This situation, the committee discovered, can be prevented if the therapist positions the laptop in a way that allows the patient to read the monitor and also allows the therapist intermittent eye contact with the patient. Other concerns from the administrative staff included having flexibility in scheduling, the ability to view documentation prior to billing for service, and the ability to obtain technical support from the vendor should a problem arise.

Many benefits are anticipated after the full implementation of this software. One of the most significant benefits anticipated is that documentation legibility will be improved for referral sources, payors, and providers. This is significant because the professional-quality documents clinicians are able to send to recipients reflect the pride they have in their profession. This was previously a problem because of poor legibility and a perceived lack of quality that comes from issuing a handwritten medical document in the information age. Other features that make EHR systems attractive include their ability to e-mail reports to physicians, generate home exercise programs for patients, and upload images. Previously, these documents would have to be sent by mail, fax, or e-mail. Now, the EHR is a one-source solution, which saves on the labor costs of performing those tasks.

The clinic staff anticipates several outcomes from the implementation of the new EHR system. First, documenting at the time of service will be more efficient than documenting on paper. Second, because therapists put less labor against routine tasks associated with documentation, they will be able to focus more on patient care and growing the practice. With an EHR, a provider can use a laptop or desktop computer to complete many different tasks at once, which used to take considerably more time. Finally, it is anticipated that because of the reduction in the redundancy of administrative tasks, the clinic support staff will be more efficient and better able to assist the clinical staff more often on larger projects, instead of performing tasks technology can now handle.

Kevin Svoboda, PT, is the Clinical Growth & Development Director of Rehab Management Solutions. An actively practicing physical therapist, Svoboda also is the Membership Chair of the APTA’s Occupational Health Special Interest Group. He can be reached at .

Connie Ziccarelli is the Chief Operations Officer of Rehab Management Solutions. She is a member of the APTA’s Private Practice Section Administrator’s Council and Liaison to the Private Practice Section Annual Program Work Group Committee. She can be reached at .