INAPTA Central District Meeting

Maybe is not a wary word

Daniel J. Vreeman, PT, DPT, MSc
Assistant Research Professor, Indiana University School of Medicine Research Scientist, Regenstrief Institute, Inc
10.09.2012 dvreeman@regenstrief.org 2012

Why am I here?

photo via Sadie Hernandez

F or as long as I have wanted to be a clinician, I have also wanted to be a scientist and an information technology specialist.

If you care for your patients, dont you want to know whether your interventions really work? The only way we can know is through clinical trials with controls. In a very real sense, we, like other health care professionals, abuse the trust of our patients when we give the impression of knowing more than we do.

- Jules M Rothstein, PT, PhD, FAPTA

32nd Mary McMillan Lecture

No magical thinking!
photo via jdhancock

Physical therapy, by 2020, will be provided by physical therapists who are doctors of physical therapy and who may be board-certified specialists. Consumers will have direct access to physical therapists in all environments for patient/client management, prevention, and wellness services. Physical therapists will be practitioners of choice in patients'/ clients' health networks and will hold all privileges of autonomous practice. Physical therapists may be assisted by physical therapist assistants who are educated and licensed to provide physical therapist directed and supervised components of interventions. Guided by integrity, life-long learning, and a commitment to comprehensive and accessible health programs for all people, physical therapists and physical therapist assistants will render evidence-based services throughout the continuum of care and improve quality of life for society. They will provide culturally sensitive care distinguished by trust, respect, and an appreciation for individual differences. While fully availing themselves of new technologies, as well as basic and clinical research, physical therapists will continue to provide direct patient/client care. They will maintain active responsibility for the growth of the physical therapy profession and the health of the people it serves.

Vision 2020

Looking forward, I am profoundly uninspired by such a narrow, inwardly directed vision for our future as a profession. Today, Vision 2020 is neither bold nor visionary, and as Duncan stated in her 2002 McMillan Lecture, it sounds self-promoting and self-aggrandizing.
- Alan M. Jette, PT, PhD, FAPTA
43rd Mary McMillan Lecture

We need to shift dramatically our focus from optimizing parts to focusing on our role in the changing systems and society in which we practice.
- Alan M. Jette, PT, PhD, FAPTA
43rd Mary McMillan Lecture

The Future

Great Scott!
photo via JD Hancock

PASSreframed our traditional focus on the physical therapist and the patient/client to one in which physical therapists are an integral part of a collaborative, multidisciplinary health care team with the health care consumer as its focus.

First, therapists must become interested in data. Second, they must become skilled in the ability to devise solutions for the system problems that data and experience uncover. Third, the physical therapy profession must develop the ability to implement at scale - the ability to get therapists along the entire chain of care functioning in concert, in collaboration.
- Alan M. Jette, PT, PhD, FAPTA
43rd Mary McMillan Lecture

Frances Westley Brenda Zimmerman Michael Patton

1. Being distressed by a problem 2. Deciding something must be done 3. Getting to maybe 4. Understanding the system which led to discontent 5. Encountering powerful strangers 6. Rapid growth by finding the flow 7. Threatened powers fight back 8. Connecting with much larger forces
Frances Westley Brenda Zimmerman Michael Patton

Maybe comes with no guarantees, only a chance. But maybe has always been the best odds the world has offered to those who set out to alter its course...
Frances Westley Brenda Zimmerman Michael Patton

Maybe is not a cautious word. It is a defiant claim of possibility in the face of a status quo we are unwilling to accept.
Frances Westley Brenda Zimmerman Michael Patton

First, some introductions...

photo via komunews

increase in completion of overdue clinical tasks! (68% vs 18%)

4x

photo via martinak15

Complete, longitudinal information that follows the consumer

Care that is value-based and coordinated across settings

photos via meddygarnet and brykmantra

Health decisions made with information tools that assist and guide
Have you considered

Results
Fewer errors, waste, variations Consumer-centered care Lower spending

Healthcare is an information business. The quality, effectiveness, and efficiency of care depend on our ability to manage information. You just can't do it without EHRs.
Bill Tierney, AMIA 2011 Keynote

To do this, well need information systems that are WAY more than just electronic documentation.

Meanwhile, back on planet Earth

Fundamental challenge:
local systems have idiosyncratic ways of identifying the same concepts

Patients move faster and further than their health information

Only way to corral the innite indiosyncracies is with standards

photo via pfarrell95

What does this look like in the wild?

photo via bm.iphone

McDonald et al. Canopy Computing: using the Web in Clinical Practice. JAMA. 1998;280(15):1325-1329.

photo via nosha

The rain forest canopy is a seamless web through which arboreal creatures efficiently move to reach the edible fruits without any attention to the individual trees.
McDonald et al. Canopy Computing: using the Web in Clinical Practice. JAMA. 1998;280(15):1325-1329. photo via nosha

A Unied Patient Record

41%
of ED visits are for patients with data at another institution
Finnell JT, Overhage JM, Grannis SJ. All Health Care is Not Local: An Evaluation of the Distribution of Emergency Department Care Delivered in Indiana. AMIA Annu Symp Proc. 2011;:409-416.

Connectedness among IN EDs

Finnell JT, Overhage JM, Grannis SJ. All Health Care is Not Local: An Evaluation of the Distribution of Emergency Department Care Delivered in Indiana. AMIA Annu Symp Proc. 2011;:409-416.

Nearly every ED in Indiana shares patients with every other ED in the state

A universal code system that facilitates exchange, pooling, and processing of results

A universal code system that facilitates exchange, pooling, and processing of results

Similar name, different meaning

photo via Caption Time

Similar name, different meaning

photo via Caption Time

meerkat meerkat mere cat meerkat

MEASUREMENTS R US
photo via puuikibeach

18,700+ users in 148 countries

How fast does my patient usually walk?

41959-8:Walking speed:Vel:1W^mean:^Patient:Qn:Calculated

photo via Ed Yourdon

photo via Ed Yourdon

photo via Ed Yourdon

ICF: walking short distances

photo via Ed Yourdon

ICF: walking short distances Walking speed: 1 m/s

6 min walk distance: 600m

Fall risk: Mod

photo via Ed Yourdon

ICF: walking short distances Walking speed: 1 m/s

41957-2:Walking speed 24 hour mean

6 min walk distance: 600m

64098-7:Distance walked in 6 minutes

Fall risk: Mod

NNN-N:More than 2 falls in last 1Y
photo via Ed Yourdon

d4500.1 mild difficulty with walking short distances with the use of assistive devices that are available to the person in their current environment

ICF: walking short distances Walking speed: 1 m/s

41957-2:Walking speed 24 hour mean

6 min walk distance: 600m

64098-7:Distance walked in 6 minutes

Fall risk: Mod

NNN-N:More than 2 falls in last 1Y
photo via Ed Yourdon

Now we have a powerful set of coded data that computers can operate on and exchange between independent systems in an understandable way.

2 Key Ways EHRs can Help Accelerate that Vision

Seamless web of data Decision support

photo via OiMax

2 Key Ways EHRs can Help Accelerate that Vision

Seamless web of data Decision support

photo via OiMax

Clinical Decision Making

Right info. Right time. Right format.

Evidence-based Practice
patients + evidence + clinical expertise

Everyone wants it. Nobody has time.

(so they say)

Jette DU, Bacon K, et al. Evidence-based practice: beliefs, attitudes, knowledge, and behaviors of physical therapists. Phys Ther. 2003;83(9):786-805.

How can EHRs help? Tools to help implement EBP at the point of care.
myEBP

EHR Decision Support

me

A computer-generated suggestion about care for an individual patient

The secret sauce of the EHR chicken soup

photo via liber

Wheres the evidence?

photo via paskukaru76

92%
of 154 studies

Odds Ratio = 1.79

95% CI 1.56, 2.05

Evidence for EHRs in Rehabilitation

1968!

This review suggests that EHRs have potential benefits for physical therapists.

Do PTs today really use EHRs?

good question...

APTA 2010 Member Survey

Got EMR?
1%
Yes, all electronic Yes, paper and electronic No Dont know

38%

28%

33%

EHR Satisfaction
Very satisfied Satisfied

APTA 2010 Member Survey

Neither satisfied nor dissatisfied

Dissatisfied

Very dissatisfied

10

20

30

40

50

60

Most common complaint?

anecdotal

Wheres the Rehab stuff???

Getting from here...

to there.
photo via janeandd

We can!
if we start doing some things were not doing now.
photo via lindaaslund

A journey. Not a destination.

What are we waiting for? Lets jump in.

photo via Justin Ornellas

Adopt interoperable Electronic Health Records, but be mindful of the complexity.

Resolved, that the American Physical Therapy Association supports the use of electronic health record systems (EHRs) and promotes the widespread adoption of interoperable EHRs in all physical therapy practice settings.

apta.org/EHR

apta.org/EHR

EHR Readiness Assessment EHR Selection Priority Worksheet EHR Evaluation Worksheet Implementation Checklist

Physical therapist education programs should incorporate core informatics competencies into their curricula.

Although most health professionals use IT daily in their work, few know how to adapt their roles and work processes to incorporate IT for the greatest benefit.

Stead WW, Searle JR, Fessler HE, Smith JW, Shortliffe EH. Biomedical informatics: changing what physicians need to know and how they learn. Acad Med. 2011 Apr;86(4):429-34. PMID: 20711055

We have frequently heard the opinion from both faculty and students that medical students already possess all the basic skills necessary to function effectively in an information-rich environment.

Silverman H, Cohen T, Fridsma D. The evolution of a novel biomedical informatics curriculum for medical students. Acad Med. 2012 Jan;87(1):84-90. PubMed PMID: 22104049

We have frequently heard the opinion from both faculty and students that medical students already possess all the basic skills necessary to function effectively in an information-rich environment. This is similar to assuming that a student proficient in the use of a word processing program knows how to write an award-winning novel.
Silverman H, Cohen T, Fridsma D. The evolution of a novel biomedical informatics curriculum for medical students. Acad Med. 2012 Jan;87(1):84-90. PubMed PMID: 22104049

photo via JOPHIELsmiles

Physical therapist education programs should partner with health informatics professionals in evaluating the efficacy of informatics interventions in physical therapist practice, education, and research.
photo via JOPHIELsmiles

photo via JOPHIELsmiles

Key Lesson for Today

photo via IMLS DCC

Human + Computer

Human

Closing Thoughts

What is your maybe?

The way will open

I didnt see it then, but it turned out that getting fired from Apple was the best thing that could have ever happened to me. The heaviness of being successful was replaced by the lightness of being a beginner again, less sure about everything. It freed me to enter one of the most creative periods of my life.

- Steve Jobs
Stanford Commencement Speech 2005

Tone is in your fingers

Tone is in your fingers

photo via scragz

Though Wooten's basses receive much attention, his most frequent and Tone is consistent response when asked by his fans about his equipment is in your that "the instrument doesn't fingers make the music ... you do".
photo via scragz

Tone is in your fingers

photo via scragz

photo via milos milosevic