O&P practitioners make decisions every day about patient treatment, and although new technologies and documentation requirements are changing the field, the goal of every decision remains the same: to help patients reach the best outcomes they can.
Evidence-based practice — defined by the Agency for Healthcare Research and Quality as “applying the best available research results when making decisions about health care” — can help practitioners to make better clinical decisions and support them, as well as to keep track of outcomes and evaluate the effectiveness of treatment. Although the extent to which evidence-based practice is used varies by O&P facility, its methods are becoming more common in the O&P profession.
“The O&P profession, as a whole, has increasingly made moves toward evidence-based practice,” Brian J. Hafner, PhD, associate professor in the Department of Rehabilitative Medicine at University of Washington, told O&P News.
Since 2012, entry-level O&P practitioners have been required to hold a master’s degree, and the new academic requirements include knowledge and skills in evidence-based practice, according to Hafner.
“That means graduates are more skilled in evidence-based practice than ever before,” he said.
Additionally, professional organizations like the American Academy of Orthotists & Prosthetists (AAOP) offer O&P practitioners continuing education courses and conference sessions incorporating the use of evidence-based practice. This allows practitioners who graduated before the 2012 academic requirement changes to gain knowledge and skills in this area, as well.
Also, “more practitioners are learning to use outcome measures in clinical practice,” Hafner said.
However, the field still faces hurdles to full incorporation of evidence-based practice.
“I suspect the barriers to adopting evidence-based practice in O&P are the same as those other professions have reported — limited time available to engage in evidence-based activities, limited access to evidence, limited familiarity or experience with evidence-based practice and perceptions of limited value in evidence-based activities,” Hafner said.
A major cause of the shift toward evidence-based practice is the change in patient expectations, according to Dennis Clark, CPO, president of the Orthotic & Prosthetic Group of America (OPGA).
“Over time, it has become more important that we be able to measure the value of the care that we provide,” Clark told O&P News. “As we live in this digital information world, [the ability of] patients to communicate with other patients on social media [and] to more easily communicate with other health care providers make it critical that they be able to say the care they received impacted their lives in a positive fashion and allows them to function more normally, stay healthier and lead a better quality of life.”
Clark said technology has allowed more people to see the strides made by amputees who accomplish great things. Increased media coverage of amputees has shown O&P patients that barriers can be overcome.
“This has created tremendous expectations for all patients that they can get back to a normal, functioning life after amputation,” Clark said.
Patient expectations need to be managed through empathy; the only way to help a patient meet personal expectations is to look at a situation through their eyes.
“It is critical that we not only measure from a prosthetist’s perspective, but also measure from the perspective of the patient,” Clark said. “We need to be able to measure … in a consistent way, how their orthotic or prosthetic care is impacting their life. Do they feel they can walk further? Do they feel they can [participate in] more of their normal activities of daily living? Are they impacted positively by the care?”
Measurement tools can allow patients to both keep track of and participate in their care. Marmaduke D. Loke, CPO, of Dynamic Bracing Solutions, said patient buy-in is crucial in producing positive outcomes.
“I am always listening to what [the patients] have to say — their needs, their wants — because that helps to drive the outcome,” he said. “Our job in orthotics and prosthetics is only to enable … to give them the best tools, the best knowledge to do it, but it is the individual who must obtain the potential outcome.”
Patients are not the only stakeholders in their care. Brian Gustin, CP, consultant at Forensic Prosthetic and Orthotic Consulting, Suamico, Wisc., said the advances in O&P devices have led to more stringent rules from the government and payers.
“Ten or 20 years ago we submitted a claim and we got paid, no questions asked,” Gustin said. “The cost of technology, in part changed all of that [so that] today we need data and objective functional science to prove the marketing claims by both the practice and the manufacturer of the technology.”
In addition, he said, different groups look for different types of evidence.
“The law enforcement side — the Department of Justice, the Office of Inspector General — does not really look at the clinical evidence. Their focus is more policy-related: Did you cross the ‘t’s’ and dot the ‘i’s’? … The payers, however, do care about [clinical] evidence, especially in the last few years given the Minimum Loss Ratio regulations … They want to make sure that they are paying to treat medical conditions and not for bells and whistles.”
Gustin said the most important goal in obtaining evidence for a payer is making sure the O&P service or device shows a functional difference in the life of the patient, particularly in affecting the patient’s activities of daily living (ADLs).
“The payer could [not] care less about biomechanical differences or metabolic efficiencies unless you can connect them to functional ADLs related to systemic medical conditions,” he said.
Scott Williamson Jr., CAE, president of Quality Outcomes, said the evidence used — and whether it is understandable and digestible to the payer — can make the difference in receiving payment for a device or service.
“When I go and talk to a payer, they have no idea what O&P is. They just do not get it. When we can go in there and show documentation of functional change, or improvement in the beneficiary’s quality of life, that at least gets them to turn their head and listen to us. It is a foot in the door,” he said.
Clark added, “What we [as O&P practitioners] are doing is measuring orthotic, pedorthic and prosthetic care with the goal of maximizing the patient’s function, health and quality of life. That is what we do. We do not make arms and braces for a living. We manage the care. If we do not start measuring and showing the value of what we do, there is going to be regulatory change that commoditizes our profession. We do not want that.”
Incorporating evidence into daily practice
Collecting evidence on an individual patient is just the first step in using evidence-based practice throughout one’s work. That evidence has to be used for a broader purpose. This is a shift in focus away from collecting information to applying that information, according to Hafner.
“The change that I see most is this: 20 years ago, the profession advocated that O&P practitioners conduct or produce research. Today, we most often see orthotists and prosthetists being asked to use or apply research evidence. The difference is subtle, but speaks to the need for practitioners to be educated consumers of evidence, rather than independent researchers,” he said. “I think this is a good change and one that better suits our current health care climate.”
Williamson said that although any practitioner is able to learn and gain the skills needed to use evidence-based practice, it has to become a priority for the facility and the practitioner to provide benefits.
“The biggest thing is commitment,” he said. “The biggest hurdle we have to overcome is [the idea that] ‘I am not getting paid for that.’ Practitioners are busy, the paperwork burdens are tremendous,” and evidence-based practice requires even more time and energy.
Practitioners, according to Hafner, “need to [be] able to identify when evidence is needed, locate appropriate evidence, critically review that evidence, apply that evidence and evaluate the effectiveness of the decision and revise it, if necessary.”
To ensure that their facility as a whole uses evidence-based practice, O&P business owners need to make sure they are “helping staff to acquire the above skills, through professional education, attending conferences, etc.; giving staff the time to engage in evidence-based practice activities, such as performing literature searchers and collecting outcomes data – during their work hours; and creating a culture that supports and values evidence-based practice.”
Many practitioners utilize technology to further their evidence-based practice. Loke recommends the use of video documentation and a 3-D walkway to gather information.
“Every picture is worth a thousand words. Well, there are 1,800 pictures per minute and 30 pictures per second [on a video],” he said.
Loke, who began using video in his patient exams in the 1990s, said using video allows him to examine a patient’s gait and other measurements repeatedly and from multiple angles.
“I thought I was a good clinician until I started studying video, and it took me to a whole other level. It is very powerful to me … My worst video is better than anyone’s best progress note,” he said.
Williamson, meanwhile, finds value in electronic documentation tools.
“The challenge with video documentation is that you cannot mine that for data. My strong argument is for software,” he said. “The whole concept of electronic medical records is accepted now by traditional health care. We tend to follow traditional health care by 5 to 10 years … so it is only a matter of time before we are forced to change. I recommend that O&P business owners find a software solution for practice management.”
The use of specific technologies should be evaluated on a case-by-case basis to determine whether they fit the goals of the facility and its abilities, according to Hafner.
“I ultimately think use of these types of technologies comes down to a question of value. Do they provide value to practice?” he said. “For example: Does it help the practitioner make better clinical decisions? Does it enhance understanding of the patient’s condition? Does it enhance communication with the patient, their family, other rehab professionals or payers? Does it demonstrate a level of professionalism that is important to the practice? These are all questions that the practitioner or practice needs to ask when adopting these types of technologies.”
Creating results through consistency
Clark believes the consistency of data is much more important than the method used to obtain the data.
“We keep getting ourselves wrapped around the axle of specific technology,” he said. “I do not care how we get the data, as long as we get it consistently across the board. As long as the process of achieving and garnering that data does not take too much time or cost too much money, we have to weave data collection into our normal practice.”
Consistency among the measures used and the data gathered will take evidence-based practice beyond the individual facility.
“Consistency is key,” Williamson said. “If we have 50 practitioners out there collecting evidence and they are using 50 different measures, then they have not gained anything.”
“No one clinician can rely solely on their own data and their own data collection,” Clark agreed. “If we only use our own data, then we are limited by ourselves. Each one of us is going to be just a little bit slanted in how we view the care that we provide. It is important to be part of a larger data collection network, and that that larger data collection network gives us a way … to make decisions that can keep our patients from getting in trouble.”
Technology can be used for everything from functional assessments to the way data is recorded, Clark said, but he finds the most promise in its capabilities for data collection, storage and analysis.
“I think the more important aspect of technology utilization is [the development of] universal data collection points and the ability to share that data in a way that can help all ships rise,” he said.
Gustin said consistency throughout data collection would allow practitioners to make better choices for patients, based on the results collected from an entire patient population.
“[A practitioner] should be able to demonstrate over time how an individual patient is performing with the level of service provided, and they should be able to demonstrate how the population of patients is performing in aggregate,” he said. “We all have strengths and weaknesses, so why not leverage the strengths and minimize the weaknesses to improve the patient experience and lower cost. All of this will require the re-engineering of O&P culture into definable and repeatable processes. These processes then need to be coordinated between the administrative, clinical and technical aspects.”
The creation of practice standards would lead to the development of metrics that can be used across the board, according to Gustin. Practice standards should be applied to all processes, asking questions such as: Who does this process? When do they do it? Could someone else do it? How much does it cost? Does it need to be done?
Coming together to share value
Pooling data among all practices across the United States could be the quickest way to begin showing the value of O&P and its importance in health care, Williamson and Clark said.
“There are two ways to go,” Williamson said. “One is that we digress as a profession even more into the supplier category and ultimately competitive bidding comes into play … The other is that we come together [and] start documenting. We have the opportunity now to establish ourselves as clinical professionals.”
Clark said the essential component to implement evidence-based practice on a nationwide scale is leadership.
“We need great leaders to carry the message,” he said. “We need great leaders to convince third-party payers that the evidence and the value [of O&P] are as important as cost. We need education to show how a whole new generation of clinicians can utilize this data not just for turf protection but for the greater good of the patients we serve.”
Providing optimal care to produce the best outcome for the patient is still the goal, Clark said, but it cannot stop there.
“The bottom line is, our practices need to not only provide great care but to provide the data that supports that care and then share that data in meaningful ways with all the payers and providers across disciplines, so that we know that this combination of care achieves maximum function, maximum health and maximum quality of life,” he said. – by Amanda Alexander
- Glossary of Terms: Evidence-Based Practice. Agency for Healthcare Research and Quality. Available at http://effectivehealthcare.ahrq.gov. Accessed July 6, 2015.
Disclosures: Hafner, Clark, Loke, Gustin and Williamson report no relevant financial disclosures.