Interdisciplinary care - Many of our patients need it and it can be economically and clinically rewarding. Furthermore, new evidence suggests that some MDs are open to it.So, why aren't more chiropractors doing it? From what I've seen in our profession, it's either that some DCs simply don't want to work with the allopathic community and wish to remain isolated or they lack confidence in their ability to generate co-care referrals from medical providers. More specifically, I believe it to be a lack of confidence in interdisciplinary communications with MDs. I also believe this lack of confidence comes directly from our discomfort over opening our clinic notes and patient-care plans to criticism. It has nothing to do with lack of skill or clinical competency, but rather how that competency is communicated. While chiropractic has survived for generations without widespread interdisciplinary cooperation, our isolation will become both unnecessary and a liability in the age of electronic health records (EHR).
Isolation due to poor interdisciplinary skills leads to something that health care policy-makers call "fragmentation of care." This fragmentation is one of the villains meant to be arrested by raising health care documentation standards through EHR. The sooner we understand that policy gurus are working to end fragmentation through the adoption of EHRs, the better off we'll be. Rather than just surviving in isolation, we'll find ourselves in the chain of health care exchange, seeing the benefits of better provider communication in things like co-care relationships and more medical referrals. Nothing less than a fully functional EHR will enable us to build the confidence we need to bring chiropractic successfully to an interdisciplinary team.
So, what makes me say all this right now? I'm constantly keeping track of trends that affect and influence decisions in chiropractic clinical management and EHR. And these past few months were particularly engrossing. For the sake of brevity, I'll limit our discussion to the following three factors: (1) a new law in Minnesota; (2) a new study in the Journal of Ambulatory Care Management; and (3) the growing interest in manual therapeutic approaches. While at first glance they seem unrelated, all three are pointing to a future of digitally based cooperation. Another key sign is that the U.S. Department of Health and Human Services is already offering bonus compensation for those providers who adopt the proper EHR; however, this point raises discussions for a future column.
Factor 1: Imposing EHR Via State Law
This column has been a resource for the latest developments in EHR policy-making and politics. Today is no different; the very thing we've predicted would happen seems to be one step closer to fruition - someone has finally put EHRs into law and set a date. State lawmakers in Minnesota have passed a law that all health care providers must be using electronic health records by Jan. 1, 2015. To grease the wheels of this great shift, Minnesota's governor has initiated an electronic health care grant program. State grants are now helping smaller medical facilities like nursing homes and community clinics move from paper to digital documentation. Will these grants include chiropractic facilities? Over the past two years, I've informed you that $77 billion would be saved if all providers moved to an EHR system. The U.S. government and state lawmakers have seen these data and projected savings. Therefore, the push toward EHR is moving from suggestions to mandates.
If you've read this column before, you know this development cannot be considered in isolation. While it's possible that Minnesota is acting alone to start a health care trend, the evidence says otherwise. First, 2015 is the same year included in President Bush's 2004 talking points on a possible federal mandate for EHRs. Second, the federal government has already initiated a kind of "back-door" EHR shift with claim-submittal policies for Medicare. As I have written elsewhere, any health care facility with 10 or more employees can only submit claims electronically to Medicare. Medicare is setting a kind of minimum standard for documentation and claims practices; this is a fact that shouldn't be taken lightly.
If I had more time, this would be a good place to recap all the EHR developments we've seen over the past year, like the attention placed on rules governing the use of EHR by the FCLB and state boards. It certainly would place this Minnesota decision in better context. The take-home message is for us to acknowledge once more that the future of EHR in patient care marches forward, whether chiropractic or individual chiropractors are on board or not. There is, after all, the problem of "fragmentation of care" to solve.
Factor 2: Studies Regarding Fragmentation of Care
Every few years, a new study is published that shows many chiropractors are professionally isolated from other health care providers. This research always seems to have a "dog bites man" quality to them (i.e., Why not study something we don't already know?). However, they also provide insight into reasons why this isolation remains. A new study from the Journal of Ambulatory Care Management is just such an article.1 It contains a few thought-provoking conclusions, such as both MDs and DCs agree what it takes to create positive interprofessional relationships. Agreement about basic issues is a start, right? These ingredients for co-care include improved communication between providers, improved patient interest, and openness to discussion. So what are the barriers? According to the authors, the MD and DC participants said there is less interdisciplinary cooperation due to miscommunications, improper understanding of chiropractic and a bias toward alternative medicine.
What I find most interesting about this study is the way communication between providers is identified as both a facilitator and hindrance to greater cooperation. A lack of effective communication also is a major component in the improper understanding of chiropractic and bias toward alternative medicine - a bias some believe is slowly eroding.
Factor 3: Manual Therapy Arrives
As far as MDs and manual therapy go, history seems to be repeating itself. Some of the original chiropractors were, in fact, eclectic medical doctors who wanted to learn the art of chiropractic adjustments to integrate into their various treatment regimens. Today, 94 percent of all manipulation techniques are performed by DCs. With that number on the decline, the trend could be changing. A groundbreaking course currently is being offered at Harvard Medical School for MDs on, what else, therapeutic manipulation. While it may not be chiropractic in aim, scope or application, it is manual medicine nonetheless, and this development has professional implications for chiropractors.
While our knee-jerk reaction is to be suspicious of the Harvard program and decry the medical trespass on our turf, another outlook is more valuable. I don't believe that manual approaches to patient care is a zero-sum game, as in the world can only handle so many adjusting/manipulating physicians. If anything, this new interest by MDs in our work will only grow the cultural authority behind those who are already known for their expertise in moving joints and vertebrae: us. I believe the result is a positive-sum game, where there will be more patients open to manual approaches than there used to be. And this game will be all the more positive for chiropractors who have already demonstrated their ability for interdisciplinary cooperation, particularly with those medical doctors who have a growing interest in what we do. They will realize that we do it better.
The Missing Link
Wider EHR adoption, a growing concern for fragmentation of care and a new boom in the interest in manual therapies by MDs; what brings these new developments in our profession together? Simply put, they all point to a future where interdisciplinary care between health care providers is going to be the norm, not the exception to the rule. I believe that this cooperation must include chiropractors or our profession will face a growing cultural irrelevancy as the rest of health care is digitally streamlined without us. What we must accept to use these developments to our advantage, however, is that our ability to communicate with multiple providers is the chiropractic missing link. Once we finally "get" the importance of the clinical care-plan paper trail, the world of interdisciplinary co-management will greatly open up. And we finally have the ease of digital documentation with which to do it.
Signs of Communication
As I mentioned above, both MDs and DCs say that inter-provider communication can either help or hinder interdisciplinary care. Other evidence seems to be in agreement. Another study2 in the Archives of Family Medicine states the problem of chiropractic isolation succinctly: Both family practice MDs and DCs "believed that they did not receive enough information on adverse health outcomes or treatment plans for shared patients." And: "These findings indicate that care is fragmented between chiropractors and the general medical sector, with little information communicated between health care providers on issues with critical importance to quality of care." Of course, more study is suggested to figure out how to straighten out this fragmentation of care problem. I'm 99 percent certain that the answer to this question, at least in the mind of policy-makers, is to ensure that all health records are both electronic and portable. It's the only feasible way to overcome the physical limitations to greater interdisciplinary care like geographic distance and speed of communication. When the patient tells you they are seeing their MD today or tomorrow, do you really have time to formulate a report? Electronic documentation would allow you to send it over with just a click of a button.
EHR also is the only way to guarantee that chiropractors will actually expose their records and care plans to scrutiny, with the quality assurance offered by EHR embedded systems. I say this because EHR offers the best way to:
- review objective and subjective evidence with the patient and document progress as actively as it should be documented;
- create a custom patient record that's above third-party standards, and is immediately understandable to the patient's internist or general practitioner; and
- progress the patient through condition-based care into preventative care, while closing the active care plan.
This is a point I stressed in a previous column, where I went to great lengths explaining why PTs continue to get the lion's share of conservative care referrals from MDs. It is largely the PTs' ability to create and follow a detailed care plan, which includes a clear release of the patient from condition-based care. Why and how we're failing to make these plans is beyond the space allowed here, so you'll have to refer to the archives. The lesson to be learned from the PT/MD cooperation is that there is no veil of confusion over what the physical therapist provides, or what entails physical therapy, as the communication between providers is strong enough to overcome any interdisciplinary biases; there's no communication breakdown. This is the kind of communication that we need to overcome the other hindrances to cooperation found in the aforementioned study, like the medical confusion as to what chiropractic can offer, and what the application of chiropractic theories look like in practice.
Reaping the Benefits of Interdisciplinary Relevancy
For many DCs, interdisciplinary care remains the last unexplored frontier of their practice. I've been doing it for 10 of my nearly 20 years of practice and have seen firsthand the benefits of referrals. It also can offer the greatest rewards. It won't come, however, without establishing better rapport with other providers, and this rapport will largely rely on the chiropractor's willingness to open their documentation and plan of care to interdisciplinary scrutiny. This is the fastest way to improve communication while clearing other hurdles to greater cooperation, such as medical misunderstandings as to what chiropractors can provide their patients, and suspicions surrounding chiropractic case management.
The above developments - further advancements in EHR, recognition of a fragmentation of care and a growing interest in manual therapies - all point to a future where chiropractic is going to be digitally integrated to the health care team, or face increased irrelevance. While not every chiropractor is going to be solidly embedded into multidisciplinary practice, the digital clinic of the future will help us ensure that traditional chiropractic isolation will quickly become a thing of the past. However, with chiropractic in the mainstream, market share will increase, as well as the demand for chiropractors. This will result in a resurgence our profession has not seen in decades, but only if we communicate digitally.
- Allareddy V, Greene BR, Smith M, et al. Facilitators and barriers to improving interprofessional referral relationships between primary care physicians and chiropractors. J Ambul Care Manage, Oct/Dec 2007;30(4):347-54.
- Mainous AG, Gill JM, Zoller JS, Wolman MG. Fragmentation of patient care between chiropractors and family physicians. Arch Fam Med, May 2000;9(5):446-50.
Click here for previous articles by Steven Kraus, DC, DIBCN, CCSP, FASA, FICC.