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?
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 prototypical top-down decision support technology.
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?