Social media and the Internet afford instantaneous communication across a broad constituency of interested parties for rapid reply to questions or concerns.  These same media afford the exposure of faults and shortcomings.  Questions asked target the state of a provider’s rehabilitation practices.  These media are the information super highways driven by novice and expert alike.

This is an incredible resource. In order to take full advantage of this intelligence, users need to learn how to ask better questions and resist the urge to find the quick solution to their need to know. Users will need to learn how to discriminate data quality. There must be a perception that the right elements are being measured in the right ways, and that apples and oranges are not being confused with each other. There needs to be trust in the quality of the information required.

The challenge of implementing clinical intelligence systems will be daunting and learning is required by the provider and the patient for effective use. Asking questions along the way will provide evidence that learning is occurring and the transformation is sustainable.

Do you answer that question after you’ve gathered demographic information and after you know who the insurer is?

I ask this because I recently stumbled upon a Huffington News Post that cited the Federal Government is about to go undercover, and will gather information, on how primary care doctors respond to these  questions.*

In the name of research, these secret shoppers will pose as new patients to gather data on the availability of primary care physicians’ willingness to accept privately insured patients over federally and state insured patients, such as Medicaid and Medicare. They will block the caller ID and will gather data on the proposed ability to access care. Is this required to see the long term effects of healthcare reform?

How does that make you feel? Do you believe federal dollars are used prudently to gather this data? Do you believe, if polled blindly, they can obtain similar results?  Do you think this can spread to hospitals, therapy practices and all other venues of patient care access? I do!

If you are a registered Medicare provider, does it make you appear as though you are “cherry picking” the best case load?

Given this type of information, should you examine how your staff would answer these questions on a blind call?  Let’s find out.

Answer YES if you  believe it is a good idea to see  how your staff would answer these questions,  and NO if you feel it isn’t a concern as to how the question is answered.

[poll id="8"]

*Fox News did the initial story.

In 2010, CMS described these expectations in greater detail with auditable accountability for demonstration of compliance.  Now known as the “2010 Rules,” emphasis on the process of rehabilitation is mandated and for many inpatient rehabilitation providers, this meant doing things differently than before and perhaps needing more resources to do it.  And along came additional costs.

This is apparent when trying to assign nursing hour requirements to patients receiving inpatient rehabilitation.  It is not only the nursing procedures or services to be applied that total the nursing requirement, but also the care process required to deliver them (i.e., problem oriented, goal directed, coordinated and delivered with an interdisciplinary team.)  Nurses attending to the process require additional time to accomplish these requirements.  The costs associated with delivery of the rehabilitation care model are different and require specific analysis and management.  Somewhere between the one bed and one hundred beds hospital is the point where the rehabilitation process just doesn’t have sufficient volume to support the associated costs.

The “2010 Rules” have not changed the expectations of rehabilitation care, but the accountability to demonstrate the process of rehabilitation is followed, creates additional pressure for hospitals to differentiate care on their rehab units. Some have not yet come to understand that the act of rehabilitating patients requires more than the availability of a nurse, a therapist and a doctor.

The number of hospital based rehabilitation units decreased by 10 facilities between 2008 and 2009.  The additional pressure applied by the requirements of the “2010 Rules” will most likely accelerate closure of smaller units who will find difficulty complying with the rehab process requirements.  For the rest, managing the process requirements efficiently will be the key to survival, unless of course a hospital chooses to subsidize the difference.

Clinical practice is steeped in the tradition of paper to record, communicate and reference patient information. Habits are hard to break, especially if it requires learning something new, and exposing skill limitations along the way all at an enormous expense. Holding on to a piece of paper in plain sight is much more reassuring than the virtual reality hiding behind a display screen. Electronic records are a threat to the way we practice and value patient care.

“Meaningful use” is the motivation and driving force behind electronic health records with the goal of creating a digital care environment that improves clinical processes and care delivery. Data entered electronically and then accessed online results in information that is up-to-date, relevant and available anywhere, anytime. With paper records, information is restricted to one at a time access and limited by the physical location of the record; clinicians make decisions without timely or complete information. The electronic record puts this information at the bedside or in the therapy gym when it is needed.

Clinical decision-making, patient safety and the operational benefits associated with digital records should be sufficient motivation to move away from a paper environment. However, the reluctance to let go of our paper habit has slowed the transformation to a crawl. Each step taken by a hospital to adopt electronic vs. paper practices is made agonizingly painful by cautious scrutiny and “test as we go” implementations. Thought leaders insist upon maintaining the paper record as a backup or safety net in case something gets missed. The phase in approach may seem like a prudent strategy to enter digital practice with a paper backup always ready. The cost and frustration of operating dual systems is evident to all who take this approach only to push out further the clinical and financial benefits of meaningful use. Holding on to paper when electronic data is available may be comforting to those just learning to walk in this electronic environment, but at some point it becomes the limiting factor in getting to where you need to go. Printing information that exists electronically and archiving it in a binder is a symptom of unnecessary cost and effort only to support old habit conveniences.

Rehab exists on the back end of most healthcare episodes and does not always receive the technological and resource benefits of acute care venues. The transformation to electronic records and digital practice for the rehab program will most likely happen only after it occurs upstream in the continuum. The risk here is the digital record systems and practices eventually handed down from the acute venue to rehab are often the equivalent of an older sibling’s second hand running shoes. The fit and ultimate performance lacks the specific application to your individual purpose. This realization should not occur after a lengthy transition process prolonged by implementation with uncertainty practices and paper based backups. Clinical transformation will be accelerated and the resulting operational and clinical efficiencies become readily apparent if only one rehab specific system exists and whenever digital information is available its shadow is expired from the paper record.

The digital rehab requirement will not likely be met with second hand solutions. Learning to do something digitally while maintaining alternative requirements to do the same task in another system is wasteful and if prolonged will generate revolt among clinicians.

A plan to achieve meaningful use by converting existing paper based habits, documents and forms often falls short of meeting the expectations for practice improvement and quality initiatives. With comprehensive digital strategies and policies in place, organizations transition to electronic processes all at once rather than converting paper processes one-by-one and replacing each with an electronic process. The fear and pain of change is minimized when leaders mandate to solve operational problems without paper. Old habits die hard and paper has always been the easy answer.

Clinical information readily available at the point of care helps improve care. When electronic systems provide clinical alerts and easy access to best practice information clinical activities and decision-making optimize the value of patient care. With the continuing challenges of cost and effectiveness of rehabilitation facing all providers, one must ask, how long can we support old habits as the plan to succeed in the future?

The data gathered by information systems, clinical, financial or operational has no real dollar value. And not until that data is transformed into the information that causes someone to do something different, the economic change is meaningless.

In his recent blog for Information Management, Rob Karel recently posted an important observation on the subject. Continuing to emphasize the dollar value of system’s data leads to no real value and may mislead the prospective user away from the opportunities to realize significant returns on their investments.

In healthcare, we are data rich, even in rehabilitation we collect more data in a month that most business collect in a year. Transforming that data into actionable processes to improve performance requires analytics. And that is where the ROI of IT investments show their dollar value. But, that takes meaningful use and the healthcare industry is just starting to figure out what that means.

Reference: (Karel, Rob. Stop Trying to Put a Monetary Value on Data – It’s the Wrong Path. March 30, 2011)

All too often, we, as clinicians, sit by the side line and let the demands for various guidelines be dictated to us. Now is the time to be involved in setting appropriate measures for the various levels of care mentioned.

CMS has standard guidelines for how they adopt quality measures. Review and print this blueprint (http://www.cms.gov/MMS/Downloads/QualityMeasuresDevelopmentOverview103009.pdf)

At the very least, toward the end of this process, there will be public comment and most likely public need to volunteer as test sites. Visit this site often and stay engaged in what demands will be placed on our future practices. Pay for performance is closer than you may realize.  Know how you will be measured!

Contributing to the blog are some of MediServe’s most valued subject matter experts. Bob Habasevich, Darlene D’Altorio-Jones and Darren Manley are the main contributors to the blog. To get you acquainted with our subject matter experts, we’ve provided an introduction highlighting their areas of expertise.

Bob is a Senior Strategist for Quality and Performance Improvement at MediServe. Bob holds a solid history of success in clinical operations including startup, business development and operations management. In addition to being a Physical Therapist, his experience includes hospital accreditation, regulatory compliance, clinical information systems, performance management monitoring and reporting, clinical outcomes systems development and deployment. Bob is highly knowledgeable in clinical process analysis and improvement, clinical error and complications reduction, patient flow improvement, clinical analytics methods for timely identification and reversal of problematic outcomes. Bob has effectively integrated information technology and clinical expertise through training, coaching, facilitation and management to effect change in process and practice to realize clinical, operational and financial performance improvement.

As a Physical Therapist with an MBA in Healthcare Management, Darlene is a Rehab Management Strategist at MediServe, Darlene’s focus is to assist clients to utilize electronic documentation to its utmost potential in compliance, outcomes, revenue and efficiency. Working in rehabilitation medicine for more than 25 years, Darlene spent 12 years as a Director of Rehabilitation, with oversight of three post acute care service lines: acute rehabilitation, skilled and outpatient hospital-based services. She was instrumental in maintaining clinical adherence to IRF Federal Regulations and leading CARF and Joint Commission standards of practice. In addition, Darlene’s experience includes Quality Improvement Chair, Lean Healthcare training and serves as an active member of the Board of Directors for the Ohio Association of Rehabilitation. Darlene develops course content on federal guidelines for post acute admissions, level of care medical necessity, documentation, IRF PAI tool completion.

Darren is a Respiratory Care Clinical Consultant at MediServe. Darren is also a Registered Respiratory Therapist with 17 years of respiratory care experience in clinical, tactical and strategic management. Darren has spent the last ten years working extensively in clinical information systems and workflows, healthcare technology and change management.

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