Electronic Health Records: Rising to the needs of the complex patient

Depending on our individual area of expertise as a physical therapy provider, we may spend a great deal of time case managing complex patients. I specialize in pelvic floor dysfunction, treating both males and females with incontinence, chronic pelvic pain, bowel dysfunction, and post-cancer treatments. Similar to my colleagues in pediatrics, TMJ, and neuro rehab, I spend a great deal of my time outside of treatments communicating (rather trying to communicate) with other healthcare providers involved with a case. My ability to provide optimal care is dependent on my ability to convey my objective test results in a concise manner, store imaging and medical test results electronically, and to quickly fax out reports for quick turn-around, without lapses in approved plan of care.

Since making the change to electronic health records, this process has become exceedingly improved. bestPT electronic health records allows me to quickly enter in case diagnoses and produces a clean report format which is immediately faxed straight to the physician from my laptop. This clears up my front office from mundane clerical tasks and allows them to focus on scheduling patients and maintaining a more smooth running clinic.

The efficiency of this system became most apparent to me during the treatment of a new patient a few months ago. My patient was a 20 year old female present for physical therapy evaluation with a diagnosis of a hypertonic pelvic floor with secondary chronic constipation. For those not in the pelvic floor field, my patient was experiencing chronic constipation as a result of a non-contracting and non-relaxing pelvic floor. She had become so distended from the chronicity of the condition that she was experiencing significant stretching on the lower bowel with subsequent nerve damage to the bowel itself and surrounding pelvic floor. In the year prior to her visit with me she had been seen by a myriad of physicians. She had seen her primary care physician, two gastroenterologists, a general surgeon, and a gynecologist. She had undergone endoscopy, colonoscopy, ultrasound, and defecography. Furthermore, she had 3 more scheduled imaging tests and procedures scheduled for that month. I was essentially one of 5 chefs in her proverbial “kitchen.”

As many of us know, keeping track of medical reports and various health care providers in any area of physical therapy can be a daunting task. My patient had made it clear during the evaluation that in her twenty years on this earth that she had seen more than her share of doctors and had fired a few of them for poor responsiveness and failure to keep up with changes in her condition. Her surgeon had essentially volunteered my physical therapy services as her last resort before colon surgery, and I did not want to fail her.

What I have enjoyed most since my choice to utilize bestPT electronic health records is the customization provided to me in my specialty practice. Each practitioner is provided with the ability to customize settings for documentation according to the needs of their practice and individual specialty. This individualization of preferences is noticeable throughout the duration of the plan of care. This begins on day one with your patient. Check in of the patient described was expedited as my front office staff was able to scan in the patient’s driver’s license, imaging reports, clinic forms, and outcome measures upon her arrival.

Furthermore, a sub-category for imaging and other test results within the electronic patient chart made it easy to view them throughout the subjective interview portion of the evaluation. On the initial evaluation I was able to quickly select the patient’s diagnosis from searchable customized database of codes. I was also able to readily enter in objective data throughout the evaluation on my laptop.  Following the first appointment I faxed the evaluation off to the referring physician and other pertinent health care providers involved in the patient’s care, receiving a signed plan of care from the referring physician soon after.

X-Ray Report2

An example of the imaging report screen

Consistency and ease of use reigned throughout the complicated plan of care. The patient required several visits spanning across several months. The neurological damage to the bowel and pelvic floor were prolific unfortunately, however the patient made progress. As she underwent further testing and imaging, data was scanned into the system. My treatments including manual therapy, therapeutic activity, neuro re-education, and biofeedback, and were documented and coded appropriately. The “Quicklinks” section in the system allowed for  easy access to the most commonly utilized applications of the system. Toggling through these features including billing and scheduling was quick and easy.

Alerts pertinent to the patient’s insurance requirements and documentation popped up upon each visit check in. The checks and balances within the system allowed me to easily track due dates for progress reports which prevented lapses in the approved plan of care. Furthermore I was able to communicate with technical and billing staff via the ticketing system if questions arose. I could even use it to communicate necessary information regarding treatment room setup for the patient with my front office staff. Often times the rush of the clinical flow throughout the day inhibits my ability to share details with staff regarding individual patient needs, and the ticketing system assisted with this. I could ensure that a sterile bedding and drapery were set up prior to patient arrival, or request reordering of gloves and other equipment.

Reimbursement for my practice became substantially quicker once I began billing straight from the bestPT electronic health record system. Instead of having to thumb through pages of documents to track the eligibility and services covered by each individual insurance provider, the organized system assisted in this process, freeing me up to provide more focused care. I was able to determine immediately that the biofeedback training so desperately needed by this patient was covered. And billing was submitted immediately following each visit.

After three months, the patient had began to plateau in progress. She had progressed significantly in functional abilities and her pain had decreased. It is common for patients with this diagnosis to panic at the thought of being discharged from physical therapy care, and though she was largely independent, she was hesitant to be set free and completely independent, worrying that she would relapse. We arranged for her to trial a three week period of independent self management. At the end of three weeks I called her to check in and we would proceed according to her needs. After three weeks, I called and indeed she was doing well. I was able to write a discharge note after our phone call and fax the discharge to her physicians. The documentation system supported us both throughout her treatment.

Disclaimer: For HIPAA compliance, all characters appearing in this post are fictitious. Any resemblance to actual persons or actual events is purely coincidental.

-Amanda Olson, DPT

Doctor of Physical Therapy