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Dynamic Chiropractic – September 9, 2009, Vol. 27, Issue 19

Definitive, Evidence-Based Clinical Decisions at the Point of Care? Just Point and Click

Technology Speeds up Clinical Decision-Making, Improves Patient Relations

By Steven Kraus, DC, DIBCN, CCSP, FASA, FICC

We've all heard about best practices, but how do they apply to our day-to-day business? When industry-best solutions, interoperability and patient history are rolled up into one tool, both DCs and patients gain an increased level of confidence in the clinical decision-making process. This type of technology serves the practice well in the short term (through efficiencies) as well as the long term (to chart a visible action plan for necessary ongoing treatment).

As you know, when you're at the point of care, time is precious. You have a limited window during the patient encounter in which to complete tests, analyses and range-of-motion assessments to determine the patient's diagnosis and prognosis. Do you need to devise a new treatment plan or course of care, or continue with an ongoing, already-established plan? Do you make a decision to end care and refer the patient out? Does the case require advanced diagnostic testing such as an MRI? Does the case present a new set of conditions since the previous appointment? That's the time to make decisions, clinically, about what's best for the patient. Believe me, you want technology on your side - to have your back, so to speak.

There is a certain volume of patients you need to see each day for business viability. You probably know exactly what that number is. If you don't, you should. As there are also only a certain number of hours in a day, something's got to give if you are to increase the number of patients you see and therefore increase your bottom line. Your level of patient care obviously cannot slide, so streamlining the administrative side of the equation seems to be the solution.

I've been speaking at seminars and conventions during the past several months, and have had a great number of sidebar discussions with chiropractic physicians. You should not be surprised that most involved the economy. The consensus - and this is from DCs across the United States - is that over the past five years, overhead has gone up and revenue has stayed flat or declined for most. Profit margins are smaller. Reimbursement is tighter and more restrictive.

Naturally, our industry is not alone in this boat. Regardless, you don't have to jump ship. The solution to improving your bottom line rests in how you utilize technology. Now, you've heard some of this before. We've acknowledged that technology can make your practice more efficient and profitable. But what does that mean for the ultimate judges of success - your patients? If the patient experience is negatively affected by any of the issues we've discussed to this point, you are at risk of losing them. They will either move to another practitioner or worse, altogether discontinue care they may need.

Technology can have a direct, positive impact on the patient. True EHR creates efficiencies for the office - and that's nice - but it can also provide immediate information to help you decide if a patient is making progress right at the point of care. You won't have to use office time to review charts. And let's be honest, when you see 25 to 45 patients today, what's the likelihood you will actually sit down and review all of their charts tonight?

Why wouldn't you want all of the information you can get, immediately accessible at the time you're making a clinical decision? True EHR allows you to instantly plot a graph of several visits. You can demonstrate pain scores, ROM findings, etc., in chart format from a patient's first visit up to their progress exam, whether that represents eight visits or 15. Then, following your progress exam and upon comparing prior visits to measure level of improvement, you can determine continuation or change in treatment plan, create new exercises, employ a different adjusting technique or involve another health care provider - on the spot.

I have previously written about how too much technology at the front desk may take some of the personal touch out of the patient relationship. But if you think about it, when you use technology with patients, how much more attention will they feel they are getting, when you can immediately produce a chart of their progress and make a confident recommendation about what's best for them while you're both still in the room?

Right now, more than a few DCs may be relying on nothing more than recollection to determine patient progress at the point of care. And flipping through pages and pages in a folder does not impart the greatest levels of confidence or personal interaction. In some cases, it may seemlike patients are not improving. What they're saying might lead you to think they're not improving. You know how it is - "I'm not sure I'm getting better, doc!" Or the opposite - "I'm back to normal," even when the patient still has numerous objective and assessment findings demonstrating otherwise. But using technology to create a graph showing progress, or lack thereof, demonstrates reality. EHR software can score patients' current outcome questionnaires and then compare them to original questionnaires to direct future care.

Let's talk a bit about a patient's potential concern with sharing health records externally. A health information exchange (HIE) represents one EHR communicating with a repository of information from other EHRs (it's an EHR hub, if you will) about basic patient history - allergies, medications, health problems, significant health events - test results or diagnostic reports. Many people have paranoia about "Big Brother," worrying that others can grab whatever information they want, whenever they want it. That is not what is happening.

It's important to remember that an EHR puts out a request for pertinent information and then sends it back. All of this is with patient authorizations according to HIPAA guidelines. Not every state has plans for an HIE - they are new and not fully established. Maryland and New York are paving the way, but processes are in place throughout the United States and exchanges will be more prevalent shortly. They simply act as a switchboard for connecting two parties. An HIE is not a government warehouse of all documents from EHRs; it's just the basics as described above. Patient records will still be in their doctor's office computer server or in the patient's own online personal health record (PHR) .

That's external interoperability; an example of internal interoperability is an office communicating with its own digital X-ray machine or inclinometer. Having both external and internal interoperability equals a speedy information exchange. Patients don't always remember the name and nature of all of the tests they've had done. Through an HIE, you may discover that a certain test has been performed on a patient just six months prior.

It all adds up to delivering better quality care, preventing mistakes, avoiding redundant tasks and eliminating repeat testing. You have access to complete data immediately, instead of having to wait a week or thumb through 50 pages of notes. You can also look at records objectively - through the use of graphics as well as information on best practices.

A major advantage of using technology is immediate access to evidence-based protocols. More and more treatment guidelines exist each year and they are rooted in evidence demonstrating the effectiveness of treatment options. Additionally, a component of the drive for national health care reform is rewarding and using what works. In other words, determining what the best treatments are and paying for them and only them. Like it or not, scientific study is establishing protocols our industry knows to be effective in getting consistent, reliable outcomes. (An example is the NCQA Back Pain Recognition Program.)

As the world of health care becomes more complex, technology keeps us in the know - and that's the only place we can afford to be. When it's decision-making time, if there's a guideline, we need to be aware of it. We need it to pop up in front of us at the point of care, telling us: "Here are evidence-based options for this diagnosis or presenting condition."

If you follow an evidence-based, best-practice plan, the patient is more confident because you're relying on universally accepted guidelines recommended by panels of experts. This also means the patient is more likely to comply with treatment. In more advanced EHRs, patients and doctors can review medical guidelines through videos, as well as materials that can be printed with one click.

When you share information directly with patients and print it out for them to take home, their buy-in, as well as that of their spouse and family, can be significantly increased. Practice management experts will tell you one reason patients discontinue treatment is because their spouses discourage it due to a bias toward chiropractic care. If patients have information about their plans that demonstrates solid evidence, they are armed to rebut any negative influencers. It effectively spreads the positive word about chiropractic care and your role in it outside of your office walls, with new audiences.

This will not only lead to increased patient satisfaction, but also increased patient numbers. Patients tell others when they receive an extraordinary experience. EHR technology can progress our profession at the point of care, resulting in greater exposure to more patient market share.

Click here for previous articles by Steven Kraus, DC, DIBCN, CCSP, FASA, FICC.

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