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Dynamic Chiropractic – January 29, 2010, Vol. 28, Issue 03

Shifting to a Functional Model in the Digital Delivery of Health Care

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

Chiropractic is structure and function, not just symptoms. How many times have you heard a similar phrase used by you or one of your peers? Chiropractors of all practice styles hold a strong conviction that chiropractic is ultimately about functional improvement, regardless of the diversity of ways in which we try to improve that function.

And in the near future, we're going to be asked to put our money where our mouth is and prove it to CMS, payer networks and even the federal government. But without adopting the latest technology in clinic management, we won't have the tools to show what we really can do, and that might permanently cut us out of the health care loop.

What am I talking about? Only the potential seismic shift in the way health care pays: from fee-for-service to outcomes-based pay, where successful case management is rewarded and redundancies in care lead to penalties. Every day is a step toward an outcomes-based model, and it's time for the chiropractic profession to get ready.

Back to the Medical Home Model

Last month I introduced you to the concept of the patient-centered medical home model (PCMH) or "the medical home." The medical home is one model of patient care delivery that's being explored in pilot programs across the U.S., often in partnership between third-party payers, hospitals and group practices. At least in certain areas, laws pertaining to the PCMH include doctors of chiropractic as medical home managers.

The medical home model is significant because it's a prime example of the way the health care industry is preparing to move away from a strict fee-for-service model or at least minimize its monopoly on reimbursement models. Right now, primary care providers are being enrolled to act as medical homes for their patients, becoming responsible for directing their total health care picture. The intent is to reduce unnecessary ER visits, expensive imaging, and costly procedures by making sure patients try conservative options before self-referring to expensive specialists. It's all about guiding patients through the maze of health care choices and in doing so, saving money by reducing waste. Plus, it involves patients becoming more responsible for their health care actions.

There is more work to be done in the development of the medical home model, and it remains to be seen where chiropractic will fit into this remarkable opportunity to encourage the use of conservative care. I invite you to revisit my column from last month to begin exploring the opportunity that is in front of us. The real key to success is having all of the patient's health information at your fingertips to truly manage the decisions in the delivery of their care.

Lower Costs, Better Outcomes

A major emphasis of the medical home model is not just cost-savings, but also the improvement of health care outcomes through a coordination of care enabled by real-time information exchanges. The idea is simple: Technology allows busy doctors to talk to each other, update patient notes, and actually manage a case across multiple providers. The sharing of all this data will create a unique opportunity for gathering evidence of what works and what doesn't across whole swathes of patient populations. And that means group networks, group practices, and private practitioners are going to be able to monitor who's providing the best outcomes for certain kinds of patients.

Not Just About Pain Anymore

Technology that allows the efficient mining of data for outcomes in general is the same technology that will encourage a shift toward functional assessment in particular. Visual analog scales or symptom-specific outcome assessments like the Neck Pain Disability Index may not be enough in the near future. Just as your care plan shouldn't just be focused on duration and frequency of pain, an outcomes-based health care model will go beyond the acute phase of patient symptoms, especially if the number of patients with chronic diseases continues to rise. Questions such as how have the patient's balance, posture, and endurance improved through care may be just as important in the chiropractic office.

While chiropractors have preached the importance of functional improvement for a long time, the task of consistently tracking functional changes has been hit or miss. First, there are often issues with patient compliance; unless you have clearly communicated a plan of action for improving your patients' activities of daily living, they often reduce their visits as pain levels drop. Second, there is the issue of practice workflow; helping patients meet functional goals means knowing how to measure those goals, before and after, and knowing what the best evidence is for meeting those goals. Third, there is the issue of time; every year, chiropractors feel increasingly burdened by documentation requirements and in doing so, often fail to chart their care plans and don't adequately document every patient visit. Adding more assessments to this situation wouldn't have been practical just a few years ago.

Technology's Solution

Practice technology, such as interoperable electronic health records (EHRs), will help chiropractors resolve each of the above issues and connect us to the new information exchange that will be able to demonstrate our patient outcomes. First, with digital clinic management, much patient instruction and communication for condition-based care can be automated. You'll have no excuse for patients dropping out in the acute phase of care. Second, a care plan that addresses patients' functional goals and quality of life can be created digitally with all the information you need to do it effectively, right at your fingertips. Third, with the interaction between diagnostic tests, SOAP notes, imaging and the EHR, these tasks should take moments. Expanding your functional assessment to prove your ability to manage chronic cases shouldn't add a burden to your day.

Imagining the Bigger Picture

The medical home model and other forms of health care reform are about preparing for new realities of American health. Chronic disease is rising, costs are skyrocketing, and it's becoming apparent that people need coaching on how to live a healthy lifestyle as much as they need access to primary care. Fee-for-service health care rewards providers for procedures, not for taking the extra time to consider the whole functional picture of the patient and their quality of life. Nutrition, exercise, balance, and coordination don't easily fit into the fee-for-service model, but they do when functional outcomes are emphasized. And when insurance reform rewards providers for managing the overall wellness of patients' health, the improved quality of care and cost-savings picture can become reality. These are areas that chiropractors already emphasize every day in their practices.

So, who is better qualified to lead a revolution in functional assessment of patients than doctors of chiropractic? If health care is going to be conservative, patient-centered, and empower patients to take responsibility for their health, then why shouldn't health care look to the profession that has been providing this kind of care for over 100 years? Weight loss, smoking cessation and anything that naturally increases mobility, prevents injury and reduces pain are going to be essential to the new model. Our health care delivery system is looking for the perfect health coach, and I daresay that we are it.

Making Your Clinic Functional for the Future

Real health isn't just about the freedom from symptoms; it's about improving the underlying function of the body. That has been the cry of many chiropractors for many decades. With the coming shift of the health care model from fee-for-service to one in which outcomes are constantly tracked, recorded and compared, chiropractors have an opportunity to shine, just so long as we can enter the data stream.

Interoperable EHRs and digital clinic management are already fueling the expansion of the medical home model at sites across the U.S. If chiropractic wants to have a part in this conservative, patient-centered care, then we need to join the data stream and show what kind of functional improvements are possible under chiropractic management. We all know the famous quote from Thomas Edison: "The doctor of the future will give no medicine, but interest his patients in the care of the human frame..." That future is approaching faster than you may have once thought.


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


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