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It’s designed to make documentation easy
Teams Rehabilitation System Inc. of Clear water, FL, first designed TEAMS REHABWARE with the idea of making it easy for rehab facilities to track their patients, schedule appointments, and analyze patients’ progress. So far, managers at Craig Hospital in Englewood, CO, have been pleased with the software’s success in each of those areas.
"One of the advantages of TEAMS is the way the software set-up allows us to customize it specifically to our patient population," says Scott Manley, senior vice president for the traumatic spinal cord and traumatic brain injury rehabilitation hospital.
Manley and Teams Rehabilitation officials describe some of the main features of the software this way:
1. Creates a standard for rehab processes.
The software permits managers to create forms that are specific to each discipline but can be integrated for the purpose of analysis. Craig Hospital, for example, created its own tools for each discipline. Therapists and clinicians will be able to fill in the various fields in those specific tools once they’re fully implemented. They can add extra notes if necessary, so the documentation suits their needs. The information from each documentation form on a particular patient can be integrated easily into the overall medical record, so other disciplines and clinicians can assess how a patient is doing in all areas.
"We will use that so when we’re in team rounds or patient conferences, we can pull that information up and look at it to make sure everyone is on target," Manley says. "This way we will be able to make sure the patient is actively participating in treatment and knows what direction we’re heading and what our goals are."
The team also can change goals easily according to the patient’s and family’s desires. All it takes is a few minutes on the computer screen and everyone can see what the new goals are.
2. Improves scheduling.
Scheduling, which always is a huge issue in rehabilitation care, can be centralized through the computer documentation program. Before using the computer system, Craig Hospital had a manual scheduling system in which therapists turned in their schedules to one person who handled the task. "We wanted to build on that, and now we’re paralleling that system with the computer scheduling," Manley says.
Making data changes is simple
If a therapy session is rescheduled or altered because of unexpected changes, then therapists simply enter the change in the computer and state the reason for it. Everyone quickly learns of the change.
However, the records can be made permanent. All transactions may be signed digitally and posted, and from the moment the record is posted by the clinician, that posting makes it permanent and unchangeable. It freezes the record from any permanent changes.
The computer system tracks every therapy event more efficiently, including when a patient is working on the parallel bars or when a patient is involved in driver’s training. The system coordinates everything on the patient’s schedule, and when the activities are confirmed through progress notes and other reports, it automatically generates a charge and estab -lishes billing documentation.
3. Makes it easier to track patients.
Immediately after a session, therapists and clinicians document what tasks a patient has completed, and the software provides a comparison of what was done vs. what the goals were. If the goals were not met, staff will know immediately and can intervene to correct the problem.
The software program also can provide weighted scores, which are numerical values calculated according to a patient’s current level of progress. Therapists and clinicians can track how the patient’s score compares with the expected score at any particular point in treatment, which is part of the necessary staff training and education.
Because the scoring system is automatic, it requires no extra documentation from clinicians. Plus, the computerized database can save storage space by holding decades of patient information. Physicians and therapists can track patient progress over long periods of time without having to dig up dusty files in a warehouse or, in the absence of historical paper documentation, rely on patients’ memories.
4. Provides framework for critical pathways.
Craig Hospital has a critical pathway for each discipline, including nursing. The pathways provide a template for patients and families, using a multidisciplinary approach to developing goals and specific tasks. For example, the pathways may describe what sort of treatment a patient will receive over a 60-day period and what the goals are for the patient’s outcomes.
"We had the pathways already but never sat down and developed them to be put in a computerized format so everybody could get a better idea of the integrated goals for each patient," Manley says. Instead, the staff had used the pathways on an intuitive basis without actually following them closely to make sure a patient’s care and goals matched what was outlined on the pathways.
By placing the pathways on the computer as part of the rehab software system, the hospital will be able to make sure everyone on the rehab team knows exactly which pathway objectives have been met and whether they were met within the desired time frame.
"The value of putting it in a computerized format is now we have a checklist," Manley says.
When patients are discharged, the therapy team can print out the patient’s pathway objectives as a checklist or teaching summary that shows the patient’s progress and continuing objectives to be met during follow-up care. It may include a bowel management program, for example.
5. Gives structure to billing information.
The traditional paper charge sheet is prone to many errors because it relies on a clinician’s ability to determine which charges are reimbursable, and it is dependent on a clinician’s memory of every task completed.
The rehab software provides a charge sheet automatically as soon as a therapy task is completed. It also will calculate the exact treatment time, assign the appropriate billing codes, and determine the therapy charge for submittal to the payer. It can be processed immediately and is recorded for auditing purposes.
One of the time-saving features of the software is that it will enable the hospital to bill different payers easily according to their specific documentation and reimbursement criteria, Manley says.
In addition, the software can create a summary of billable therapy services and will highlight incomplete areas. For example, if a therapy goal is not met, it will alert a clinician to the deficit so he or she immediately can modify the treatment plan and perform the service accordingly. That acts as a quality control, ensuring patients receive all of the therapy they need to achieve their outcome goals, and it allows the hospital to create billable therapy time that otherwise might have been forgotten or ignored. Also, therapists soon will learn to be meticulous in completing all therapy goals with patients because if they fail to do so, everyone who reads the computerized report will know that some tasks were left unfinished.
Hospital billing managers will be able to take a comprehensive look at the hospital’s expected costs of services and the charges generated and analyze trends that could show where therapists could be more efficient or where the hospital should focus to develop a future niche market. n
Adee Feinstein, President, Teams Rehabilitation Systems Inc., 5801 Ulmerton Road, Suite 201, Clearwater, FL 33760. Telephone: (888) 734-2292. Web: www.rehabware.com.
Scott Manley, Senior Vice President, Craig Hospital, 3425 South Clarkson St., Englewood, CO 80110. Telephone: (303) 789-8214. Fax: (303) 789-8219. Web: www.craighospital.org.