All electronic outcomes measures are not created equal!  Valid, reliable, responsive and risk-adjusted outcomes data is important for accurately establishing your value as an efficient and effective clinician. The ability to show objective evidence of the quality of your care to patients, physicians and payers depends on the outcomes you use and the strength of the system measuring your outcomes.

To maximize your ability to show your service was effective and efficient, you need tools that are responsive to patient change. Although many legacy outcomes can be taken in electronic form, the tool is the same as the pen and paper version.  The psychometric properties of these assessments do not change just by using technology as the medium for administration. For example, the Oswestry Disability Index, the DASH, the Neck Disability Index, and the Lower Extremity Functional Scale (LEFS) can be completed on a computer or a tablet. All technology has done is saved a tree and saved your time scoring the responses.

What sets FOTO’s electronic outcomes measures apart from other electronically collected measures? 

FOTO’s “Smart” assessments use Computer Adaptive Testing (CAT). FOTO’s “smart” assessments are body part and impairment specific and are customized to each patient.   Each assessment begins by asking the patient about a functional activity that is of moderate difficulty and immediately adjusts what next question will be asked based on the patient’s previous question response. This means the patient only answers 4-6 relevant questions and it takes less than five minutes on average to complete and for the CAT to determine the patient’s functional level.  This makes the assessment much more efficient and meaningful for the patient.

What is the science behind the “smart” assessments?  How exactly do the CATs work?

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We are all taught the concepts and benefits of outcomes measurement in school.While most physiotherapists will agree that collecting outcomes is good practice, unless required, we have difficulty following through and implementing the practice of outcomes collection into our everyday clinic workflow. Why is this?

The obvious answers are that we are too busy, the patient says it takes too much time, or the front desk staff complains about the extra work.Does this mean that the pain is not worth the gain? If so, then what if we had a solution that decreased the pain and increased the gain? Let’s consider the benefits of electronic outcomes over the traditional pencil and paper method.

Benefits of FOTO’s Electronic Outcomes Measures

Electronic outcomes collection saves time for the clinic and reduces the patient burden. A single assessment takes 30 seconds to set up, 3-5 minutes for the patient to complete, and no time to score – that’s it! Plus, a report specific to each patient is automatically generated. Paper assessments tend to take about 5-10 minutes for the patient to complete plus the front desk staff or physiotherapist must manually score the survey and there is no report or summary- just a raw score.

The “smart” assessments are customized for each patient. The assessments are “smart.”This is called Computer Adaptive Testing, aka the “CAT.”Each assessment begins with a Each assessment begins by asking the patient about a functional activity that is of moderate difficulty and immediately adjusts what next question will be asked based on the patient’s previous question response. This means the patient only answers 4-6 relevant questions.

Individualized patient reports are based on the patient’s actual profile. The score the patient receives at the end of the intake assessment immediately translates to how the patient is functioning now.The risk-adjusted rehabilitation predictors give the clinician and the patient realistic benchmarks for the patient’s function at the end of treatment.This increases patient engagement and treatment compliance.The immediate results of patient improvement and satisfaction improves clinical decision making.

Risk-adjusted aggregate reports provide objective quality metrics. Risk-adjusted aggregate results of treatment effectiveness, efficiency, and patient satisfaction are automatically available in real-time reports that are easily viewed or shared. Risk-adjusted aggregate data is needed to objectively measure the quality of care.It allows for fair and accurate comparisons and gives the “big picture” over time of the value of care provided to patients.

Read more here about CAT and what sets electronic outcomes apart from legacy outcomes.

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Every morning, we look in the mirror while we comb our hair, brush our teeth, and ready ourselves for the day. Once we are satisfied with our reflection, we head out to face whatever the universe has in store for us. Sometimes we are satisfied with a clean t-shirt and a baseball cap, and we are on our way quickly. Other days, we need to spend more time on a more formal appearance. But no matter what the day, we all check the mirror at least once.

For as often as we do that with our personal appearance, how frequently do we reflect on our professional one? Of course, we know how to do this exceptionally well with individual patients. While the patients are with us in the clinic each day, we measure their range, their strength, use special tests and our evaluative skills, and of course, ask them how they think they are doing. We interpret the results of this information to determine if they are progressing toward the goals that we have agreed are appropriate.

Consider this, though. How frequently do we step back, look at the combined results of all of our patient data, and assess how we are performing and give ourselves the “once-over”?

 It is easy to skim over it and think we are doing well, and move on. This is like the baseball cap and t-shirt appearance check. The quick assessment is especially likely to be true if the clinic is busy, referrals are coming in, and people seem happy. But for a moment, imagine something more. Imagine how much more information we could have if we looked deeper. If we gathered the data we collect from every patient doing what we do every day – and then organized it – we would have very remarkable information.

Acquiring that information by ourselves would take effort and a stack of spreadsheets. And most of us would prefer analyzing a gait pattern any day of the week over analyzing a spreadsheet.

So, how does this get accomplished? The solution is easy. FOTO.

For those who are using FOTO (Focus on Therapeutic Outcomes) for measuring outcomes electronically, the process for the desired and needed information is already in place. The collection mechanism is well-researched and validated, and the patient-specific reports generated by FOTO tell us a lot about the patient we are treating, before we even get in the exam room. But that is only the beginning.

A tremendous amount of data is right at our fingertips and FOTO does all the analysis for us.

For this to happen, though, an accurate reflection of our overall performance is imperative, and we must do the work and ask our patients to help us provide it. We all agree that excellent care for every patient is always our priority and we all believe that we are the best at providing that. Without the patients’ surveys, we have little to support our opinions about ourselves as providers of excellent care. If we

can’t prove it, then quite simply, we can’t prove it. It is essential then to make sure episodes are completed. That means not only capturing an intake when patients start care, but also inviting them to provide a status update every few visits while active during care. Explaining the value of their information to them encourages their interest in participation. Sharing report information with patients advances it even further. Additionally, catching the final status and closing the episode as close to the actual discharge date is a key element in accurately reflecting patients’ progress and satisfaction. Once the episode is completed and closed, it becomes part of the overall outcomes data, rendering it available for reflection both for the individual patient and for the overall dataset.

FOTO provides quarterly reports containing a vast volume of information gleaned from the overall dataset, covering everything from patient satisfaction to average number of visits and change score. All data is risk adjusted to offer a true “apples to apples” comparison. Comparing data from this year or quarter to previous years or quarters is simple with the FOTO report portal. We can also compare ourselves to national averages for effectiveness and efficiency, and compare our patients’ progress to predicted averages, as well. Reporting is available for the entire organization and can be separated for individual clinics and clinicians and by care type and region of the body.

Now, think of all the questions we might ask about statistics for our practices. What if we want to know the average improvement score for all shoulder patients? FOTO’s got it. What if we want to see which clinicians are showing the highest completion rates? Absolutely. How about satisfaction of neuro patients from the third quarter of 2016? No problem. What about the staff member who joined the group six months ago – might he benefit from a spine workshop? FOTO is great at identifying areas where someone may need to consider continuing education.

An ongoing and consistent effort is key for keeping the data coming and offering us valuable information. More completed episodes result in a larger number in the dataset, and therefore, stronger representation of our true outcomes in the reports. Consider if only 40% of our FOTO cases were complete and we were using this for research. Would we trust a study with a 60% dropout rate? Of course not. We look for studies with large volumes and little attrition to be confident in the results. The same applies to what we should expect from our outcomes. Therefore, it is up to us to gather the data on all patients, giving us a sufficient sample size, so we can continually evaluate our overall performance.

Reflecting on the data requires us to objectively evaluate it with an eye that sets the emotion aside and looks at the numbers as if they were someone else’s. We must understand what the report is telling us, because this is what our patients collectively are telling us. Consider what advice would be given to the practitioner whose data is being assessed. We must ask the difficult questions. Then we must answer them and celebrate or make changes accordingly.

We absolutely cannot miss the opportunity to give ourselves the “once-over” before we head out the door and make certain that we truly look the way we think we do. We can’t avoid looking in the mirror tomorrow just because we thought we looked good today.

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Evidence suggests for clinicians and instructors to learn from their clinical experience and years of training, they must be provided with optimal patient feedback about what they are doing right or wrong at the patient bedside. 

It is fascinating to see how the patient’s self-report outcome data tells a story. I love being able to know whether I should confirm or change a patient’s intervention based on serial and optimal “patient” feedback assessments. 

Optimal “patient” feedback is: 

-Patient self-report objective assessments 

-Performed serially throughout patient’s episode of care 

-Risk adjusted to improve the meaningfulness of your interpretation of that feedback 

-A helpful compass for establishing patient rehabilitation prognosis 

-A guide for clinical decisions regarding optimal treatment strategies 

Unexpected results: 

Mr. B was a 55-year-old computer analyst with complaints of intermittent low back and left leg pains to the mid-calf. Mr. B loved to exercise in his home gym; physical activity appeared to make him feel better. But his pain pattern persisted, especially with prolonged standing and walking. 

If you are thinking unilateral stenosis, then you are correct. To me, Mr. B’s problem appeared to be a straightforward biomechanical case. However, my baseline psychosocial screening results were unexpected. 

While the patient appeared to be managing his pain fairly well, his StarT (Subgroups for Targeted Treatment Back Screening Tool) classification was high. Furthermore, his intake self-efficacy measurement scores for coping and managing pain were very low. 

Based on these baseline screening results, I augmented my treatment plan with a clinical cognitive behavioral approach (CBA). Pain neuroscience patient education, hierarchal & specific graded activity exposure, and patient problem solving are a few key components of CBA. 

At discharge, Mr. B had fewer visits and higher functional status than originally predicted. His psychosocial screening results were now good. If I had not thoroughly screened Mr. B’s biopsychosocial status at intake, my outcome results may not have been as efficient or as effective. 

The above example highlights the clinical utility of PROM data to optimize the patient’s voice and feedback regarding your treatments during the patient encounter. Listening and objectively measuring what the patient is telling you during the episode of care are important skills worth practicing to maximize the patient’s rehabilitation experience and treatment effectiveness. 

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After decades of collecting outcomes, I would like to share with you my clinical thoughts for enhancing treatment effectiveness and value by collecting and integrating patient self-report outcome (PRO) data to guide patient management during routine clinical practice.  

Whose Value do we measure? 

Although there appears to be growing consensus among stakeholders in healthcare that value is necessary for improving quality of care and controlling costs, whose value should we be measuring? Different stakeholders have different views for measuring value. For instance, the payer may define value as the fewest number of treatment visits, the employer describes value as an employee who forgoes sick time and continues to work full time/full duty, a physical therapist may document value as improved range of motion or increased muscle strength, or the patient may view value based on changes in his or her quality of life. Clinical practice guidelines, policy makers, and physical therapy associations have unanimously defined value using the patient’s perspective. Sackett’s operational definition of evidence-based medicine clearly prioritizes the patients’ perceptions to define value i.e., “integration of the best research evidence with clinical expertise applied to patient values to optimize patient outcomes and quality of life to achieve the highest level of excellence in practice.”² The bottom line is that the patient plays the central role in the delivery of care and is a driving motivation for clinical education and research. 

What Measures Should Physical Therapists Use to Demonstrate Value of Care?  

The most common outcome measures utilized by physical therapists during clinical practice to justify value of their treatments are impairment and physical performance data. A principle physical therapy treatment tenet focuses on the patient’s impaired movement & motor control which are responsible for limitations in patients’ physical function; optimal care addresses these impairments. If physical therapy interventions focus on resolving the patients’ impairment, then can it be assumed that impairment and performance measures should provide the best tools to document value and patient outcomes?  The evidence suggests otherwise. Both impairment and physical performance may not adequately capture the breadth of health concepts associated with a patient’s perceived functional ability, can be time consuming to measure, and/or are often associated with inadequate reliability/validity data. Despite the evidence, many physical therapists cite restoration of function as primary treatment goals, yet never measure function. Too often, impairment measures are used as a proxy to infer function for evaluating treatment and value of care.   

If traditional impairment tools may not be optimal for measuring the patient’s function; what measures should we be using during every day care? There is strong support in the literature for using PRO measures. PRO is now considered a gold standard for measuring patient outcomes during routine clinical practice and are endorsed by World Health Organization, Centers for Medicare and Medicaid Services, National Quality Forum, Institute of Medicine, and other policy makers, payers, professional associations, and clinical practice guidelines. PRO data play a key role in providing best research evidence from randomized control trials and well-designed observational studies. Clinically, PROs are objective measures capturing a wide range of a patient’s health concepts and physical abilities in short amount of time. 

As healthcare changes from a volume based to value based focus, physical therapists will need to reconsider their traditional focus on impairment. Physical therapists will need to consider how to easily report patients’ function and quality of health without increasing burden and costs. Outside stakeholders will be requiring proof of value of the services provided. Since the patient is the one centralized component of the service, PRO is the solution. 

This post originally appeared in the 2016 issue of Advance for Physical Therapy and Rehab Medicine, 27 (3), 6-7. 

References: 

1. Porter, ME. (2010) What is Value in Health Care? NEngl J Med, 363 (26), 6-7. doi:10.1056/NEJMp1415160. 

2. Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS. (1996) Evidence based medicine what it is and what it isn’t. BmjClinRes Ed, 312, 71-72. http://www.bmj.com/content/312/7023/71.full. 

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Physiotherapy is supposed to add value to the healthcare system, not be a drain on it. Value can be defined as improving our patient’s quality of life and function (i.e., effectiveness) while minimizing treatment costs and healthcare visits (i.e., efficiency).¹ 

After decades of collecting outcomes during routine clinical practice, I would like to share with you my clinical thoughts on ways to achieve efficient and effective patient outcomes.  

Being effective is important 

Decades of discussion have gone into what makes a physiotherapist “effective.” Some believe further education, while others (like myself) have found research suggesting that years of clinical experience, continuing education courses, and specialty certification(s) may not be as important as traditionally thought.  

To me, being effective means adding value to patient care. That means being able to measure what you’ve done so that you can use that information and learn from it.  

My focal area of clinical interest lies in managing patients with cervical and lumbar impairments from a biopsychosocially-informed perspective. In that realm, I share an unrelenting passion for collecting data and multi-domain outcomes. I do this by using psychometrically sound measures during every day clinical practice to guide patient management.  

What you need to know about being effective 

So, being effective means being able to measure what you’ve done so that you can use that information to learn from it. The functional status scores from patient self-report outcome measures that physiotherapists typically collect during routine care are observational data.  

Common challenges associated with being effective 

Differences in outcomes between your patients and other providers may be due to the fact that your patients received superior treatment. It may also be simply due to the differences in the characteristics of the patients you are managing.  

The majority of physiotherapists do not have the capability to apply sophisticated risk adjusted analytical methods to strengthen the validity and interpretation of their patient outcomes. We chose FOTO to manage and risk adjust our outcomes; this allows us to compare apples to apples.  

Another challenge our research group learned from using observational data for improvement was that it takes time to understand how to integrate patient self-report data into daily practice. Analyses of providers’ performance using FOTO data between 2010- 2014 taught us that it takes about one to three years of practice to enhance your outcome performance skills.  

The point is: don’t be discouraged when you first start to systematically incorporate patient outcome data into your practice.  

Potential consequences of not using effectiveness in your practice 

The short version of not using objective patient self-report data in your practice is that you won’t be as an effective physiotherapist as you could be.  

That applies to both choosing what observational data to collect and how you analyze it.  

Three things you can do right now to make your clinical practice more effective and efficient  

• Understand how to integrate these data to guide your patient management. I don’t believe this concept is emphasized enough at university or postgraduate educational levels. Can you remember an instance when a clinical instructor shared their patient self-report outcome data to support the value of interventions being touted as evidence-based?  
• Choose efficient measures. When getting started, using efficient measures means a reduced time for patients to complete and physiotherapists to score. Saving time during fast-paced and often hectic outpatient environments is a strong clinical advantage for collecting data at the patient’s bedside.  
• Make a plan to incorporate observational data into your practice today. Start with small steps and within a few weeks, you’ll start to have valuable data to improve your patient care.  

References: 

1. Porter ME. (2010) What is Value in Health Care?  N Engl J Med, 363 (26), 2477-2481. DOI: 10.1056/NEJMp1415160. 

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