New rehabware’ software improves record keeping

Software handles reports, billing, scheduling

(Editor’s note: Rehab Continuum Report offers you this quick look at a new billing, report, and scheduling documentation software program designed for rehabilitation providers. The newsletter will bring you information on various new software packages as part of our efforts to report on the latest innovative software tools designed to make it easier to operate a rehab facility.)

The average patient’s medical record at Craig Hospital is more than 1,000 pages long, compiling several years’ worth of data about the brain or spinal injury and how it has been treated. This cumbersome paper database is difficult and time-consuming for the staff at the Englewood, CO, facility to review. It’s especially troublesome when clinicians want to review a longtime patient’s progress.

Typically, hospital staff have had to search through the paper record at the nurse’s station and wade through the pile of information. The hospital, which treats only traumatic spinal cord and traumatic brain injury patients, has been working toward solving that problem by implementing a computer software program that promises to take much of the hassle out of documentation and record reviews.

"Like most hospitals, we have a sophisticated billing and data tracking program in place," says Scott Manley, senior vice president of the 93-bed rehabilitation hospital.

The hospital has been refining and installing a computerized system that will permit staff to access records from anywhere within the hospital, even in patient rooms and the gym.

Finding the right type of software has taken some time and considerable effort. "We had hoped to use the software of a large provider, but it was more for nursing and acute care services and didn’t meet our needs as a rehab provider," Manley says.

About two years ago, Craig Hospital administrators found a software package that appeared to have everything they needed in a computerized documentation system. Called TEAMS REHABWARE, the integrated management software is easily adapted to a particular rehab facility’s needs. In fact, Craig Hospital worked closely with the company that owns the software, Team Rehabilitation of Clearwater, FL.

Hospital managers were able to customize the software specifically to suit the patient population, developing their own goals and treatment plans, Manley says. "It gives you a very focused, very wide ability to develop what you want."

Hospital wanted to improve communication

The hospital’s chief objective was to improve communication among team members and patients, and then to consolidate the recorded information to focus toward a payer’s documentation requirements, he adds.

"We will be able to customize the output of all the data into different formats for the different payers," Manley explains. "Currently, we gather everybody’s notes at the end of the week, roll them up in a package, and mail them back to the payer."

While it’s too soon for the hospital to realize any cost savings from the switch to the computerized system, managers are pleased with the other benefits, he says. For example, the computerized system should decrease the amount of time staff spend on documentation, and that in turn will give them more time to spend with patients.

Of course, even that benefit takes time to realize because staff have to spend additional time in the beginning as they learn how to use the software system. "That’s a process of learning, and it takes time to learn to work through a computer system and the different screens," Manley says.

The other major benefit is that the rehab software program integrates information in a way that makes it easier to follow patients over a lifetime of follow-up care. Clinicians will type in new patient care data as they treat patients, and the system will maintain a database with the information for more than 25 years. Plus, the software is capable of integrating any historical data that already have been put in computer files.

"We can get years’ of data on a patient and compare it with previous data in the system," Manley says. "For example, we could collect information on bladder management and get a much broader perspective over five years, instead of dealing with thousands of pages of information."

Teams Rehabilitation Systems decided in the mid-90s to create a software program for rehab facilities. "Our company identified a need for a documentation system in the field of medical rehabilitation, but we ended up developing something far more complex and complicated," says Adee Feinstein, president.

"Our approach is that regardless of the discipline of treating patients, the treatment model is very similar," Feinstein adds. "Regardless if you’re an OT, PT, or ST, or 10 or 11 other disciplines in rehab, you’re basically dealing with planned encounters with a patient using a goal-oriented approach, and you’re typically generating costs and charges for that particular session."

Based on that philosophy, Teams Rehabilitation created a system with a series of transactions that allows clinicians to enter a small set of data information and then track patients and pull up a variety of analyses.

"Our contention is that all patients are different, but all processes are the same," Feinstein explains. "So it’s not a difficult thing to reduce interventions into a standard predetermined set because the clinician knows what they’re going to be doing with a patient even if they don’t know who the patient is."

Unlike acute care hospitals, rehab facilities have a very high level of integration in their treatment teams, and they all use the same goal-oriented approach with scheduled interventions, he adds. Plus, there are common treatment practices that are required by regulatory and accreditation agencies, and all of those factors help to make the processes standard with a similar model and language.

For example, the software refers to one-on-one planned therapist-patient encounters as events. It allows therapists to plan goals at the simple event level, such as "patient transfers self from bed to chair with moderate assist." Then the software system pulls a summary of all of those types of goals and whether they were met.

Tracking patient status

While most clinical observations are subjective, rehab facilities can easily train and educate staff on how to use objective standards and terminology to determine a patient’s functional status. Already, many facilities use functional improvement measures that have standardized the observations into a numerical scale system, Feinstein explains.

"It paints an automatic, real-time picture of what are the patient’s gains and efficiencies on the road to functionality," he says. "We’re taking information that is documented and using it for ongoing analysis, which the system does automatically."

Progress notes, outcomes scales, and other data that therapists collect are reduced to low-level components the software program can analyze and track.

In the traditional documentation model, therapists sit down and write extensive documentation. It’s hard to take that information and build a picture of where the patient is in achieving functional independence, Feinstein says. The computerized system makes it easy to see the whole picture.

Generally, clinicians welcome the opportunity to reduce paperwork, so they will quickly adapt to using the standardized computerized report, he adds. However, the software does permit therapists to write long notes about a particular patient. If they prefer to put their extra notes on paper, the rest of the rehab team still can obtain a clear view of how a patient is doing by looking at the computerized reports, which contain all of the patient’s goals and interventions and whether they were met.

Clinicians and therapists across the entire continuum of care also can easily take a look at any patient records within the system. For example, when a patient has progressed to the point that he needs only low-level outpatient treatment, clinicians can look at the computer screen and review the intake evaluation notes and every other piece of documentation provided during rehabilitation care, collected since the patient began treatment, he says.

Teams Rehabilitation released its first version of the software in 1998 and pilot-tested it at the University of Utah in Salt Lake City and the rehab department of the University of Utah Hospital. In 1999, the company released its latest version, which is being used by Craig Hospital. The company continually upgrades its system and works with each user to fit the user’s clinical needs and goals. A facility might spend six to 12 months working on adapting its forms to the software before the system is fully implemented.

Typically, clinical managers of the various disciplines will work on adapting the rehab facility’s own forms into the software system, Feinstein explains.

"Since the forms are drag-and-drop [on the computer] and easy to manipulate, we push for the implementation committee and managers of disciplines to work on this with us," he says. "Nobody knows better than they do how a form should work."

The process also gives managers an opportunity to clean up their outdated forms and eliminate redundancies and unnecessary information.

Rehab facilities want their own report forms

The company’s first try at creating rehab documentation software quickly ran into a major problem. The system had 600 predefined forms designed by a clinical team, but those were not adequate to meet the needs of most rehab facilities, Feinstein says.

"We very rapidly recognized that we could have 10,000 forms, and it’s still not good enough because everyone collects data differently," he explains. "The only way around this problem was to scrap our forms and design a user-defined engine that allows everyone to design their own forms."

The new and more flexible system has goals and tools specific to all rehab disciplines, including psychology, speech and language pathology, physical therapy, and occupational therapy. Some of the goals may be shared, while others are discipline-specific. The rehab facility decides how many different forms will be used during the implementation process. (See story on the features of the software, below right.)

Customizing what’s needed

The computer forms have easy-to-use software prompters that help administrators and rehab technical assistants set up the system, placing in it the specific features they need. Those are similar to the prompters that ask for specific decisions when loading new software on a home computer. Once a user designs a rehab tool, the system automatically creates databases to store the information put into it.

Computer experts help administrators set up the tools, educate their staffs, and provide other technical support.

Feinstein says the TEAMS software price is based on a facility’s number of active patient records and the acuity level of patients. For example, for a 40-bed facility with 200 active outpatients, the one-time licensing fee would be about $250,000. Plus, there is an annual support and maintenance contract that provides for continued upgrades to the system and ensures the software is enhanced to accommodate all regulatory changes.

The system’s cost benefits include a reduction in the amount of time clinicians spend documenting patient care, increases in productivity due to more precise scheduling capability, and a reduction in the amount of treatment that is not billed due to staff failures to document appropriately, Feinstein says.

While some rehab facilities may choose to start from scratch, creating their own documentation software, there are some disadvantages to taking that approach, he adds. For instance, rehab facilities that create their own documentation software will miss out on the improvements and upgrades a commercial software company can provide.

"When you do your own system, you are shutting the door on getting feedback from the industry on enhancements and improvements," he says. "A commercially available system, because of market constraints, is constantly being upgraded."

For example, the TEAMS software already incorporates the MDS-PAC forms, even though they will not be the industry’s standard until Oct. 1, 2000, when the prospective payment system (PPS) is implemented. These are being upgraded as the Health Care Financing Administration releases new versions of the form.

Feinstein estimates that when PPS begins, rehabilitation facilities will have to hire additional staff to handle the paperwork generated by MDS-PAC.

"It is our estimation that MDS-PAC will cost one full-time-equivalent per 20 inpatients, so if you have a 40-bed facility, our estimate is that you’ll need two people dedicated to collecting this information," he says.

Without the extra staff, a rehab facility runs the risk of having increases in the number of denials due to inaccurate or incomplete documentation. Another solution is to use a software program that provides a simple tool for collecting the data; with that, there will not be a need for additional staff, he adds.

As the MDS-PAC forms are changed multiple times over the course of the next year, the company will revise and update them within the software, Feinstein says.