Bulletproof Expert Systems: Clinical Decision Support for Physical Therapists in the Outpatient Setting is a physical therapist manager's workbook with stories, checklists, charts, graphs and tables.
Bulletproof Expert Systems also provides many paper-based and electronic templates for use in your clinic's Electronic Medical Record.
Bulletproof Expert Systems describes how you can use evidence-informed practice patterns to improve your clinic's Medicare compliance, process-of-care and patient outcomes.
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BULLET PROOF EXPERT SYSTEMS:Clinical Decision Support for Physical Therapists in the Outpatient Setting
By Timothy Richardson
AuthorHouseCopyright © 2011 Timothy Richardson
All right reserved.
Chapter OneBob's story
Heavy metals leeched from chemicals used in old style print-making processes through the skin and hands of printmakers and into their bones and blood. The printing process exposed workers not only through their skin but also through the air they breathed – the chemicals became aerated through heating and splashing.
"Bob Smith" retired after thirty years of printmaking and exposing himself to dozens of potentially toxic heavy metals that leeched into his blood. The heavy metals caused a rare nerve disease that weakened his muscles, deadened the sensation in his feet and caused him to stumble and fall. Bob's name has been changed but he is a real person in our physical therapy clinic.
Bob has a disease called peripheral neuropathy that caused the smallest tips of his leg nerves to slowly stop working. The nerves began to lose function, working backwards from his toes. Peripheral refers to the outermost body parts –the fingers of the hands or in this case, toes of the feet. Neuropathy means a disease of the nerves. Peripheral neuropathy normally begins in the outermost regions, the toes, and works its way up the nerves destroying sensation and muscle control – first in the toes and feet and then into the thighs. The nerves stop working in a steady, progressive pattern, from the bottom up. Bob should have had months or years to totally lose the function of his legs, such as walking and stair climbing.
Peripheral neuropathy typically affects older adults. Diabetic people frequently get peripheral neuropathy also because their elevated blood sugar can cause tiny blood vessels to constrict and send less oxygen to the nerve cells. But, Bob didn't have diabetes.
Bob could have slowly learned to adapt to the irreversible loss of muscle strength in his legs. Many people adapt to neuropathy by limiting their activities, by walking more slowly and by looking at the ground while walking. Bob didn't have time to learn these new behaviors. Bob woke up one balmy Florida morning in September 2008 to find the nerves of his left foot and leg felt dead. His leg did not just feel numb, his leg felt dead. No feeling. No muscle power. Nothing.
Bob's doctor was puzzled however when he gave his devastating diagnosis. Bob had no symptoms in his right leg. Normally, peripheral neuropathy is evenly distributed on both legs at the same time.
Bob began physical therapy in mid-September. Based on his age, Bob was given a template with several self-report questions related to physical activity, medication use, home environment and mental state. Bob was given the option to fill the questionnaires on paper, at an electronic kiosk in our clinic's waiting room or at home via secure e-mail.
Bob's physical therapist had access to a Clinical Decision Support (CDSs) system that allowed her to select validated measures specific to Bob's clinical presentation. The CDS was a module that attached to the clinic's Electronic Medical Record (EMR). The EMR was interoperable with Bob's medical record at the local hospital with pulled Bob's vital statistics, recent medical history, past surgeries and diagnostic imaging tests pertinent to physical therapy. Bob had previously opted to allow certain providers, such as physical therapists, to view this private data.
The therapist reviewed Bob's medical record and focused her attention on a recently recorded falling episode. Since this indicated that Bob was at risk for future falls she selected the Activities and Balance Confidence Index (ABC) from the prompted list on her laptop computer display. The CDS matched Bob's medical diagnosis, peripheral neuropathy, with the drop-down list. The list contained the possible self-report questionnaires that could be administered.
Because the physical therapist selected the ABC test from the drop-down menu, the CDSs suggested a new list of performance measures specific to balance and confidence that the physical therapist might use to evaluate Bob's condition. Among the tests, the physical therapist selected from the new list were the following:
Single Leg Stance—time in seconds
Tandem Standing – eyes open (Sharpened Rhomberg test)
Standing Feet Together – eyes closed (Rhomberg test)
Four Square Stepping Test—time in seconds
Bob attended physical therapy for the next three weeks. Unexpectedly, Bob suddenly began to regain function in the left leg. Bob could feel his toes again. He could put weight on the left foot and stand on the left leg. Some of Bob's leg strength began to return. Bob and his wife Joann were ecstatic but his doctor was even more puzzled – peripheral neuropathy doesn't normally resolve spontaneously.
After four weeks, the CDS alerted the physical therapist that the Medicare Progress Note is due on Bob's tenth therapy visit. "Goals from the Evaluation" automatically popped up on her screen. Further, those tests that need quantitative measurements also popped up with a flashing cursor, asking for a numeric input. Bob filled out another ABC test and the therapist also retook the four performance tests. She recorded the time-based tests in the data fields. She also opened the selection menu for additional tests of impairment-level variables that she had discovered while working with Bob. The two additional tests were:
Ankle dorsiflexion ROM and strength
Self-reported hip abduction difficulty
The CDSs system electronically saved or stored information from the follow- up tests and the Progress Note. The Progress Note did not need to go to the physician since Bob's initial Plan of Care was for 90 days, the maximum allowed by Medicare without physician re-certification. No paper copy was generated since the clinic had completed its transition to paperless charts.
The Progress Note, including Bob's standardized functional status, was uploaded to Bob's interoperable Personal Health Record (PHR). This record, much like the EMR at the clinic and the EMR at the hospital, was a real-time, privacy-and-security protected medical record. Bob's PHR was a commercial version that charged Bob a small annual fee. Bob's commercial PMR "talked to", or was interoperable with, the hospital EMR and the PT clinic EMR.
The physical therapist could access the clinic EMR, the hospital EMR and Bob's commercial PHR from any computer, including her home computer, through her secure, encrypted log-in. As with his hospital data, Bob had opted which tests to share with his physical therapist.
By Thanksgiving Day of 2008 (roughly 2 months after Bob started physical therapy), Bob was walking with only a lightweight plastic brace on his left foot and already planning his holiday travel up north with his family. He finished physical therapy and said goodbye to his therapists. We said goodbye and closed Bob's chart, happy to see such a successful ending to Bob's story.
But, that wasn't the end of Bob's story. Bob was out of therapy only a couple of weeks later when devastation struck again – this time it happened in the daytime – to the right leg! Bob reported numbness and weakness all the way to his right hip. As he sat down (thank goodness he didn't fall down), Bob reported that the right leg began to feel exactly as the left leg had felt back in September.
Bob's specialist medical doctor was stumped and referred Bob to the Mayo Clinic in Jacksonville, Florida for a complete work up. Bob's hope for a new diagnosis was ironically but tragically ful lled when the Mayo clinic doctors told him he had TWO types of neuropathy, not just one. Bob also had neurogenic claudication from chronic lumbar spinal stenosis – in addition to his peripheral neuropathy from heavy metal poisoning.
Bob struggled through Christmas and New Year's and it wasn't until the beginning of February the following year (2009) that his doctor ordered Bob back to therapy. Bob had deliberately held off coming to physical therapy to see if his right leg function would spontaneously return with time, but also because he was rationing his Medicare physical therapy benefits which were capped at a finite yearly amount.
Bob's prior measurements from mid-October were, of course, still retained in the PT clinic EMR. Bob's new measurements in February clearly showed a decline in function over the Christmas holidays.
The therapist also began assessing Bob's fear avoidance behaviors using the Fear Avoidance Beliefs Questionnaire because of the new onset of acute lower back pain due to Bob's spinal stenosis. She had him fill out the Oswestry Disability Questionnaire. She staggered the questionnaires over different treatment sessions, including follow-up sessions, so Bob would not feel unduly burdened.
In April, Bob stopped using a walker and began using a cane instead. He never experienced a dramatic return of function in the right leg similar to the return he experienced in the left leg but he did recover his independence. Bob made steady progress and his therapists pushed him every day. His wife, Joann, came to every therapy session and pushed him as hard as the physical therapists pushed him.
Bob's therapy easily exceeded the arbitrary financial cap placed on Medicare beneficiaries for physical and occupational therapy but, due to an automatic exceptions process based on medical necessity, skill and progress, Bob was able to keep attending therapy until the end of April. Bob never willingly missed a single therapy session in over eight months.
At Bob's discharge, the CDSs pulled up three self-report questionnaires, over a half-dozen performance measures and a similar number of impairment-level tests specific to Bob's condition. The therapist was able to select the tests expressed as goals that were still included in Bob's Plan of Care (several goals had already been met during regular Progress reports).
The CDSs recommended to the physical therapist that, since Bob had exceeded his arbitrary financial cap, she should write an extra Justification Statement describing why Bob needed therapy and how much benefit was expected. The therapist had the option to select "yes" or "no". She selected "yes" and the Justification Template opened up, pre-populated with Bob's tests, his test results and a graphic trend line showing clinical change from his initial evaluation to his final discharge.
This image is one example of the type of data output Bob's therapist could generate from her CDS for her Justification Statement, if she desired:
Bob improved during each session of physical therapy. Note the upward sloping trend lines displayed graphically with the push of a button by the physical therapist.
Two years later, Bob is still living at home with his wife Joann. He is walking with a four-point walker but he is not using his leg braces anymore. (In fact, he can't remember where he put them). Bob's doctor has not offered any new diagnoses or explanations for the spontaneous return of function of his left leg.
Joann makes sure that Bob still does his physical therapy exercises every day at home.
Chapter TwoClinical Decisions Support
"If a 747 jetliner crashed every day, killing all 500 people aboard, there would be a national uproar over aviation safety and an all-out mobilization to x the problem.
In the nations' hospitals, though, about the same number die on average every day from medical adverse events many of them preventable errors such as infections or incorrect medications." USA Today, Nov. 10th, 2010
There are, of course, major differences between airlines and healthcare. It is the similarities among safety and efficiency problems in airlines and healthcare that spark curiosity in people studying complex systems. Large, complex systems that work well employ simple rules to govern the actions of autonomous agents working towards a common purpose.
This book will seek to describe these simple rules for physical therapists working in the American health care system. Also, what is physical therapists' common purpose in the outpatient physical therapy setting? And, what does it mean to act autonomously within a complex system?
A physician may face over 100 decisions, per patient, in one 24-hour period in an intensive care unit. The outcome, life or death, may depend on a zero error rate. Currently, a few errors slip through due to the sheer number of opportunities for error. One error is too many. Healthcare has a high error rate: estimates range up to 2.3%, on average. This error rate accounts for the 500 people per day that we lose to medical errors. Similar error rates in critical industries, like airlines and banking, are less than 0.01%.
What is a Clinical Decision Support System (CDSs)?
Clinical Decision Support is any system, paper or electronic, that is designed to improve clinical decision making by linking at least two discrete pieces of patient data with a clinical knowledge base. The knowledge base then generates recommendations or assessments which are presented to the clinician for consideration.
There are three basic pieces of a CDS: the knowledge base, an "inference engine" or rules-based logical computer, and a graphic interface used to present the results of the rule. The graphic interface may be a paper template with data-collection fields or a computer display with those same fields in electronic format.
Computerized Clinical Decision Support Systems
The Healthcare Information and Management Systems Society (HIMSS) definition of computerized CDSs is:
" ... health information technology functionality that builds upon the foundation of an Electronic Health Record to provide persons involved in care processes with general and person-specific information, intelligently filtered and organized, at appropriate times, to enhance health and health care."
For example, the CDSs may select or "match" patients 65 years and older with an "if-then" statement that causes a prompt to appear on the therapists' computer screen asking "In the last year, has your patient fallen down and, if so, were they injured?"
Excerpted from BULLET PROOF EXPERT SYSTEMS: by Timothy Richardson Copyright © 2011 by Timothy Richardson. Excerpted by permission of AuthorHouse. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.
Table of Contents
ContentsIntroduction: How did a clinical physical therapist decide to develop an electronic decision support system and then write a book about the process?....................6
Chapter 1: Bob's story – A vivid example of electronic Clinical Decision Support (CDS) in the outpatient setting in the case of Bob, a man with a complex medical presentation....................8
Chapter 2: Clinical Decision Support – What is Clinical Decision Support and how can you use it to help your patients and improve your physical therapy clinic? What are some of the barriers and pitfalls to introducing an electronic CDS system? help Help you achieve better outcomes, better and faster processes and lower costs?....................13
Chapter 3: Patient Self Reports – Use these time-saving and reliable indicators of patient function to begin your data collection process....................39
Chapter 4: Impairment and Pathology – These classic tests and measures form the traditional skill set of physical therapist practice. Use newer screening tests to detect pathology....................46
Chapter 5: Algorithms – Use treatment based classification to make decisions like doctors. Use medical prediction rules to detect pathology better than high-cost imaging....................53
Appendix 1: Self Report Measures – descriptions of tests used by physical therapists today with suggestions for using them in CDS systems for the future....................72
Appendix 2: Performance Measures–descriptions of tests used by physical therapists today with suggestions for using them in CDS systems for the future....................118
Appendix 3: Impairment Measures and Predictive Screening Tests – descriptions of tests used by physical therapists today with suggestions for using them in CDS systems for the future....................132
Appendix 4: Treatment Based Classification and Medical Decision Rules – these tests formed the basis for the prototype Bulletproof Expert System, available since 2010 as a free, web-based CDS for physical therapists....................166
Appendix 5: Treatment Based Classification template for CDS system designers – our physical therapists used this template to communicate with software programmers to build the prototype Bulletproof Expert System....................205
Appendix 6: Performance and Self-Report Measures for next generation CDS systems designers to communicate with their software programmers....................209
Appendix 7: McGee's Bedside Estimates for predicting the likelihood of a diagnosis or outcome....................211
Afterward: Clinical Decision Support in physical therapy is an ongoing practice, much like clinical practice. The physical therapists who accept the challenge of designing our future CDS systems will decide what comes next....................212
Bibliography – Your physical therapy profession has undergone a revolution in the last 20 years – a revolution driven by the data-packed studies listed here....................214