As the chief clinical officer and lead physical therapist for a digital healthcare company, I have the privilege of regularly speaking to my fellow PTs regarding the trends in physical therapy and overarching healthcare changes that impact our profession most. While it’s always a pleasure to talk shop with my peers, I will attest that many of these conversations leave me a bit concerned.
As the healthcare industry reshapes its infrastructure to pave the way for more collaborative, affordable, and standardized medicine, healthcare providers are evolving in an effort to get ahead—by way of digital technology, cognitive assistants, or practice management changes. And they are doing so quickly—with the exception of PTs. In other words, there’s a huge adaptation lag within our profession. In fact, there seems to be a strong, unyielding resistance to it—due to fear of either losing autonomy or being replaced. But, I believe this is the wrong mindset to have. If anything, I’d argue that we’ve reached a point at which we must:
- become even more receptive to change,
- rethink the status quo, and
- redefine our approach within a more coordinated, increasingly digital healthcare environment.
Go beyond “hands-on.”
Traditionally, our profession has been defined by our manual therapy and biomechanical expertise. Our hands-on approach to assessing and treating an individual’s functional performance sets us apart from everyone else in the healthcare community. But considering the current, highly transformative healthcare environment, I believe our value actually far exceeds what we can do with our hands during a one-hour visit. Instead, I believe our future success hinges on our willingness to use meaningful data to enhance our clinical decision-making skills and effectively manage our patients when they are not in our presence.
The idea of treating a patient “globally” forms the very core of our profession. But, let me ask you this: when patients are home, can you quickly and objectively determine whether the activities they are engaging in are making them better or worse? Are you able to develop a concrete understanding of a patient’s condition—and the potential factors that may affect that condition—when he or she is at home? Or, are you forced to treat the condition based on what you see in person and what the patient tells you at that moment in time? When you give a patient a home program of four to five exercises, how do you know he or she is really doing it? More than that, how do you know the patient is doing the exercises correctly? Could he or she potentially do more? Does he or she need additional in-person attention? It’s tough to know.
What we know very well is that our expertise in rehabilitation has a dramatic impact on our patients’ quality of life. As studies prove, their success depends on both our intervention and their adherence to the in-home regimens we provide. But, we have to concede—or at least bring into question—the possibility that our impact is significantly less powerful when the patient finishes an in-person visit and goes home.
Look at it in the context of a week. For a typical PT prescription, the patient will only receive our intervention for two to three hours of the 168 hours in that week. That’s only 2% of the time in a week, which begs the question: what is our impact during the 98% of the time the patient is not under our supervision—when he or she has only a paper handout of exercises? Can we quantify that progress? Can we prove with objective certainty that he or she has been adhering to our plan? Is it feasible that a patient’s recovery from knee replacement surgery, for example, was more of a result of him or her simply doing more around the house (thus exceeding our exercise prescription)?
Chances are, we don’t know. It’s very difficult to make such assertions with certainty, as we’ve traditionally never had true insight into what the patient is doing or not doing in between PT appointments. When patients are recovering, they are without our supervision most of the time. And yet, they are still expected to adhere to our home exercise prescriptions. Perhaps this is what makes it difficult for referring providers and insurance companies to determine the true impact of our intervention. Our clinical effectiveness is currently only measured by the in-person visits we conduct.
Now, I am in no way implying that we have limited impact. Our skills in musculoskeletal rehabilitation are second to none. But, imagine what we could achieve if we increased our influence on the patient and took our intervention beyond the four walls of the clinic. We could maximize the efficiency of our practice and even get patients better, faster. We could potentially figure out which patients were having more difficulty at home—and then bring them in sooner for additional intervention. Maybe we could objectively identify our most compliant patients. If they perform well without complications, maybe we could give them more exercises and let them remain at home while we remotely track their progress.
Now, I’m guessing the previous sentence led you to form a rather critical opinion as to the legitimacy of this idea. We all know the elephant in the room: most PTs and private practice owners are paid via fee-for-service. And who would dare consider the idea of decreasing the amount of time patients see us in person? Furthermore, we pride ourselves on quality—and we rely on the human touch to provide it. But, let’s look at this under a different light. First, regarding quality, we have to admit the manner in which we perceive it can vary widely from PT to PT. Second, keep in mind that reimbursements are decreasing as hospitals, government agencies, payers, and doctors pay closer attention to where patients go in the post-acute setting. Not to mention, the utilization of this setting is becoming increasingly dependent on cost, measurable outcomes, and standardized practices that can easily be understood by the referring party.
If this is the case, then we have to start developing new ways to manage a patient population more efficiently while simultaneously delivering results that are both meaningful for patients and measurable for the rest of the healthcare community. Technology can help us achieve that.
Incorporate technology and intelligence-based practices.
Sure, we want to continue educating and developing ourselves as therapy providers. That said, insurance companies, doctors, and hospitals will pay little credence to whether or not we apply the Sahrmann, McKenzie, or any other movement system method. Instead, we will be judged on our ability to control costs and resources while we simultaneously help patients achieve their desired outcomes—that’s it. This means standard prescriptions will change, and the traditional protocols requiring two to three visits per week for four to six weeks for the majority of patients will gradually fade.
This is where technology plays a vital role. Digital tools such as telehealth platforms are improving at such a rapid rate that clinicians are able to gather valuable insight into the patient’s home and act on it almost immediately. Surgical techniques are improving dramatically as well—resulting in clinical pathways that are much more streamlined and far less stop-and-go. Take same-day orthopedic surgeries as an example. These are slowly becoming the norm for procedures such as hip and knee replacements. And the pathway that follows now enables patients to leave skilled nursing facilities earlier and go directly home for the remainder of their recovery. Not only is this transformation creating more opportunities to decrease utilization and cost, but it also is increasing demand for clear and measurable outcomes that can justify clinical use. And as technology platforms continue to improve, the need to deliver outcomes will be the force that fundamentally reshapes health care.
It is essential, therefore, that we become receptive to a form of PT that is more coordinated and technologically integrated. While we currently preach the idea of evidence-based practice, perhaps it’s time to consider applying the approach of intelligence-based practice, where insights gained from new data and technology can drive more accurate clinical decision-making and produce outcomes that satisfy patients.
So, what could this look like?
In physical therapy, the concept could be as simple as understanding the patient’s rehab therapy while he or she is in the comfort of his or her home. With innovative technology at our disposal, we can monitor and adjust a patient's treatment course remotely, with minimal effort. This might include monitoring range of motion, strength, swelling, level of function, exercise performance, length of time exercising, and adherence to home exercises. We can even go further and potentially measure gait speed, steps, or stairs climbed—all from the patient’s home. And based off these findings, we can learn trends and gain actionable insight while we use our clinical judgement to make the necessary customizations to the patient’s care. As a result, we can quickly determine:
- what exercises and protocols would maximize the patient’s recovery at home;
- which patients can stay home and progress with remote guidance;
- who will require more manual therapy; and
- who will need immediate referral to a physician.
In taking a clinical management approach and adopting intelligence-based care, our clinical decision-making capabilities become the main strength of our practice. In my view, this would somewhat mirror the practice of a physician: the clinician analyzes the data presented, establishes a diagnosis, formulates a prescription, and creates a set of instructions so the patient and the supporting team can follow them. The specialized manual intervention is therefore reserved for patients who have a confirmed need for that type of care. Think of it in a much broader context: not all low back patients receive spinal surgery, and not all cardiac patients receive triple bypass. Do all PT patients need manual therapy all the time?
Get over the fear of being replaced.
Mentions of healthcare policy, standardized practice, and digital technology strike right at the heart of PTs—and bring out our fears of being replaced and losing autonomy. To me, these are assumptions that we too often cling to with unquestioning certainty. Yes, healthcare services are utilized much differently than they were in the past. But, if the overall goal is to decrease healthcare costs while producing value for patients in rehabilitation, then our profession is well positioned to achieve it. However, we have to be willing to apply a new approach.
Sure, much of digital technology is novel in nature, and implementation of it requires clinical structure, precedent, or standard operating procedures. But, we have to take into account a few things. First, studies are already being conducted to establish the clinical value of these new tools. Second, with our skills and knowledge, we have an opportunity in our profession to set these standards ourselves and determine best practices for implementing technology and practice management principles that will achieve the low-cost, high-value outcomes the industry is seeking.
It was disheartening to read WebPT President and Cofounder Heidi Jannenga’s post on her experience at HIMSS. As Heidi wrote, thousands of healthcare professionals attended this conference to discuss collaborative medicine and the use of technology in all areas of health care—including those involving musculoskeletal conditions. However, there was little representation from our peers in PT—which made it tough for us to assert how we play a determining factor in patient success. It was even more disheartening to learn these presentations did not even mention PT. I agree with Heidi’s argument that we have to be at the forefront of these conversations and demonstrate that our profession cannot be ignored if the healthcare community truly wants to achieve the overarching goal of delivering the right kind of care to patients.
When it comes to assessing the nature of technology and clinicians, a colleague of mine put it very succinctly: in no way can physical therapists be replaced by technology. If a physical therapist were to be replaced, it would be by another physical therapist—one who can leverage technology and who understands how to work in an integrated and coordinated health care environment. A therapist who can align with other providers in that sense is far more likely to be sought after by hospitals, doctors, and insurance companies.
It’s clear to me that the physical therapy profession is at a crossroads. Will we be able to make the necessary adjustments to our practice and turn the tide in our favor? Or, will we remain right where we are—struggling for a seat at the decision-making table, longing for a time too far gone as the rest of the healthcare community evolves?