How a Well-Designed Physical Therapy EMR System Makes it Easier

When we were setting up Clinicient’s first office in my garage ten years ago I remember complaining that setting up a computer on our secured network was “too hard.” My young, bright network engineer said, “It should be hard, if it was easy, it wouldn’t be very secure.” Today, setting up computer networks is much easier than it was 10 years ago, but it is still far from easy (at least for me).

With a well-designed EMR, documentation is easier, but I am not sure it will ever be easy.  I am not even sure that it should be easy.  How can it be, when you are trying to accurately and succinctly describe something very complex, like a patient’s condition?

Telling a Story

Your clinical documentation should tell a brief, accurate, story and make it clear to the reader what you are doing and The WHYS… why your treatment is necessary, why your treatment plan is appropriate, why it should be effective, and why it is preferable to some other treatment or no treatment at all.  In addition to all of this, of course, your documentation should help you comply with all applicable insurance requirements and government regulations. Easy, right?

Checkboxes

In an attempt to make clinical documentation easy, some EMR systems rely on page after page of checkboxes, akin to a Chinese menu. Does that really work?   This article  The Checkbox is Not the Patient  makes some compelling points about the challenges in designing EMR systems that help tell the WHYS.  In the article, the point is made that really telling a story and explaining the WHYS is very difficult with a series of checkboxes. If you are currently using an EMR system that has a series of tabs with checkbox after checkbox, you know what I mean.

On the other hand if you are going to rely totally on free text to tell your story, there is no structure, framework, or guidance for the therapist. I know from experience in owning and managing physical therapy practices that there are very few therapists who really excel at telling a succinct story and explaining the WHYS when left to their own devices.  In the early days of my first private practice, we dictated our evaluations and had them transcribed. The quality of the documentation we produced as a practice was inconsistent from therapist to therapist and, I am embarrassed to admit, the overall quality was poor.

At Clinicient, we believe that the ideal solution lies somewhere in between.  A system that guides the therapist to make sure that important items are at least considered if not required, but doesn’t keep the therapist from being able to easily add important details that help tell the WHYS.  It is important that the entire document is on the same screen so that the therapist can see the story as they are building the story.  Jumping from tab to tab to enter different sections of your clinical documentation makes it even more difficult to maintain context and tell a story that helps you provide quality care to your patients and demonstrate medical necessity.

Smart EMR Systems

How smart should your EMR be?  Some EMR systems have put tremendous resources into what are called Clinical Decision Support Systems.  These are valiant attempts to help the therapist think.  They have been widely criticized for being laborious and creating what is called “Alert Fatigue,” which I wrote about in an earlier blog. We believe guiding the therapist by showing the therapist documentation that is potentially important, developing flexible protocols, and allowing the therapist to look up information is preferable to requiring the therapist to review information that they already know. We don’t believe that the EMR is smarter than the therapist or a replacement for clinical judgment.

Structured Data

To the fullest extent possible, the results from clinical tests, performance tests, and functional assessment tools should be entered as structured data, so it can be used for outcome reporting.

Configurable

We believe that the system has to be completely configurable by our users.  As a piece of our Clinical Content Management System, we want to help them strike a balance between flexibility and standardization within their organization.

Charge Capture

We believe that charges should be tightly coupled to the clinical documentation. In Clinicient’s software, charges are captured directly from the clinical documentation. The system audits the charges based on billing rules for the patient’s payer and warns the therapist about potential under or over billing based on the length of the visit and the documented procedures.  Checking off procedures from a list is no better than using a paper superbill.

One System

The EMR system should be much more than just a clinical documentation system.  One system for seamless patient registration, scheduling, charge capture, claims management and reporting is different than “integrating” with a third party billing system by simply exporting charges to it.

As my colleague and Medicare compliance expert Nancy Beckley always advises, adopting an EMR system is the most important thing that practices should do right now. And, it’s a daunting task for most practices. Hopefully, sharing our philosophy, based on the past 10 years of helping thousands of therapists learn to be successful with an EMR, can help.