Plan of Care for the Digital Clinic, Part 1

First, the Bad News

Would you spend thousands of dollars on a clinic expansion without seeing a detailed rendering? All you have is the contractor's word that you're going to get the space you need and that it will look the way you want. As far as the project's time frame, "That all depends," says the contractor. "We'll work on it for the next six weeks and then see how it goes."

If you're like me, you wouldn't invest that much time, energy or money on a project with so many unknowns. You just don't get that kind of work done without demanding a plan from the professional in charge.

Ironically, while we would never subject ourselves to this lack of planning, this kind of investment in time, energy and money without a plan is exactly what our patients do every day in our offices. They do it every time we define our plan of care as: "Three times a week for the next month, and then we'll see how it goes from there." Even though a plan of care for our patients is just good, sound chiropractic - and a legal necessity if we have Medicare patients - many of us don't even know where to begin when it comes to creating that plan. And it shows. Medicare is starting to figure it out and so are our patients.

I'd like to tell you how digital documentation, true electronic health records and digital efficiency can reform the way your practice meets this legal demand by prompting you to manage the patient better than you do now. It might sound like a challenge, but it actually will save you money, and it could boost your bottom line. Of course, your patients will be impressed as well, and really, it's what they deserve.

But perhaps I'm getting ahead of myself. Let's get back to the reality in a majority of chiropractic clinics and hash out why there's a deficiency in treatment plans - and how I could dare say such a thing. Once you understand where researchers of documentation and data flow like me are coming from, you will understand why I can see such a disastrous documentation climate, but still envision a bright future.

Two Problem Realities

There are two unfortunate realities occurring in many practices today: one, a proper plan of care isn't being made because, two, a deficient concept of a plan of care is being perpetuated in our profession. First off, I can't say for certain what's going on in every clinic, but if the 2005 report from the Office of the Inspector General (OIG) of the Department of Health and Human Services accurately depicts what's happening in our profession, many of us aren't fulfilling legal obligations - very explicit legal obligations.

The report reads: "Just 28 percent of chiropractic services were provided as part of a written plan of care, and only 23 percent of those plans included specific treatment goals and objective measures to evaluate progress towards those goals. ... The absence of specific goals was a strong indicator of unnecessary care."¹

To pare it down to what matters most, approximately 72 percent of chiropractors in the Medicare program aren't actually writing down what they intend to achieve with their patients. And of the minority that does, perhaps two out of 10 will actually include the necessary ingredients to a care plan, such as simple goals. Now, read that last line from the report again, and understand what the government is saying. I'll reword it for them: "If you can't take the time to write down goals for your patient's improvement, then you must not have any in mind, and therefore your care will be defined as unnecessary, and we'll refuse to pay you. If it isn't in writing, then it doesn't exist."

These very blunt words have gotten a lot of us active in trying to figure out where we've gone wrong as a profession. There's no room here to detail the responses from our official educational and political bodies. Suffice it to say, and as I've said in previous columns, things are going to have to change if they're going to get better, and I know I'm personally not waiting around to see where the chips fall. My whole interest in digital clinic management and what I do as a clinician has largely been in response to the need for better documentation in chiropractic practice, which began long before this OIG report. While it's a proverbial smoking gun that indicts our deficient documentation, the report only confirmed for us documentation junkies what we really knew all along: We, as a profession, just don't have a proper concept of what a plan of care is or what's required of us for documentation that will withstand third-party inspection.

What a Plan of Care Isn't

Listing how many weeks you will see a patient before a re-examination is not a plan of care. That may be what you learned in student clinic, but Medicare and other third-party entities aren't basing their standards on what your clinic doctor told you. Neither is a plan of care as your practice management guru defines it to be. Not every patient who walks through the door is going to have a level of functional severity or objective findings to substantiate giving them a three-by-12-visit schedule. If every new patient you see is getting the same treatment plan, then according to third-party standards, they'd all better be presenting with the exact same complaint.

A time frame is only a prediction of how long a patient will need to regain whatever it is they're seeking under your care. In fact, it may be changed on a week-to-week basis, based on your experience, outcomes data, and information obtained from the visit-to-visit encounters. If a time frame is all a treatment plan includes, it becomes easy to understand how a modification of that plan becomes difficult. Modifications are based on goals and objective observations; the kind of things you write down. Modifying without references to previous predictions becomes a kind of subjective exercise that's very confusing to the patient and hard to track on paper. It becomes too easy for the patient and third-party payer to imagine you're stretching things out in your own best interest rather than because of patient need.

Also, a plan of care isn't how many visits the patient will come into your office. It's how many times they are going to receive a certain chiropractic modality (e.g., flexion-distraction) for their presenting condition, based on your protocol of choice. It also includes any other therapy given by any other provider in your facility, and when, where and why that decision is being made. In addition to stating goals for the patient, a plan of care also should be a detailed game plan of how those goals are going to be achieved and how they will be evaluated.

What a Plan Should Be

Essentially, a plan is a road map of where you predict patient outcomes and how you justify your involvement with the patient. It's your declaration of intent, one that you say deserves reconsideration every time the patient substantially improves or makes a turn for the worse. It's your proof that you want what's best for the patient and identifies the standard you'll use to determine if they are responding to care in an expected way. It's your record that you are as good as you say you are and that chiropractic is as effective as you say it is.

A plan of care isn't just in our heads prompting us to clue our patients in when we think they're noncooperative. It exists in the world of flesh and blood, pen and paper, or as I prefer, binary code. It's been recorded, so according to third-party standards, it exists and cannot be a basis for which we'll be denied payments. It's evidence of your patient's progress and a tool to educate your patient about the objective ways in which chiropractic care has been effective for them, and how it could be effective for their friends and family as well.

A Plan Could Be Digital

So, how do you feel now? Are you excited about the possibility of what a plan of care could be? Or are you resisting these suggestions because you believe I'm overstating the problem, or because you think what I suggest is impossible when, as it is, we barely spend half our time in direct patient care? If you think I'm overstating the problem, I can't help you. We'll just see how the future unfolds.

If you think my ideas are worthy, but impractical, then I've got another aspect on what a plan of care is not. A plan of care is not limited by paper. To steal a phrase from a previous column, it's not limited by pen-and-paper physics. If the whole of your resistance to goal-setting and objective measures for each and every patient is that it's impossible under our current model, then I would say you're right. But the model is changing. Pen and paper are obsolete. What we can do now in seconds used to take minutes, and that goes for plan of care as much as anything else I've addressed in this venue, including authorization-of-care forms and improving informed consent.

This time, I've talked about the bad news when it comes to chiropractic practice and creating a patient plan of care. In my next column, I'll get to the good news. What's the good news? It's about how the digital clinic can help us do what seems to be impossible: manage our patients more effectively so we can get the most out of every clinic interaction. It's already happening in those few, but efficient, digital clinics of the future.

Reference

1. Chiropractic Services in the Medicare Program: Payment Vulnerability Analysis. Department of Health and Human Services, Office of the Inspector General, June 2005. OEI-09-02-00530, p.11.