Rehabilitation News

The MIG Takes Flight

Wed, 01 Sep 2010 13:47:00 GMT

(Be sure to reset your autopilot…)

The pun is intentional, even if the parallels are accidental.

The first MIG aircraft, the Model 1, was a low-wing monoplane of mixed construction with a taildragging undercarriage. It underwent a number of improvements before the last one was retired in 1944.

Sixty-six years later we have the Minor Injury Guideline with its $3,500 benefit maximum for non-catastrophic injuries – compared to the current limit of $100,000. Its introduction is anticlimactic, as it follows a protracted review that seemed to drag on without end, and it is receiving mixed reviews. As in the world of aeronautical design and construction, it is also a safe bet – indeed it is the stated intention – that someday this MIG will be superseded by the next best thing in the regulation and administration of auto injury benefits.

The MIG first saw the light of day as Section 40 of Auto Insurance Regulation 34/10 published in February of this year. In June further details were presented as Superintendent’s Guideline No. 02/10. Regulation 34/10 is one of six that resulted from the year-long review of Part VI of Ontario’s Insurance Act (see the articles Ontario Auto Insurance Reforms and Understanding Practice Risk in the Spring issue of The Health Professional) and will be in effect for accidents occurring September 1, 2010 and later.

FSCO states the objectives of the MIG as:

Speeding access to rehabilitation for minor MVA injuries
Improving the utilization of health care resources
Providing certainty around costs and payments for insurers and regulated health professionals
Providing immediate access to treatment without insurer approval for minor injury assessments and treatments

Within the $3,500 maximum, there is a pre-approved limit of $2,200 for assessments, treatments, supplementary goods and services (maximum $400) and discharge reporting, and is supposed to follow a prescribed service blocking and sequencing model. The pre-approval applies provided an eligible health practitioner prepares and signs the treatment confirmation using the new version of the OCF-23 form.

The MIG was controversial before it even got off the ground. The Health Professional does not intend to wade into the fairness or adequacy debates. However, this article will comment on the MIG’s many implications for patients and practitioners and it will outline how, in a MIG world, practitioners can still navigate care pathways in a way that lessens the probability of assessment and treatment disruptions for patients.

As the character who plays Robert McNamara in the movie 13 Days exclaimed to his trigger-happy, bow-shot-firing Navy counterpart, his precipitous act was “language” whose expression must be carefully considered to avoid misunderstanding of intent.

The MIG is powerful language indeed, and it leaves no doubt that the regulator continues to include within its purview and prerogative the dissemination of what it views as optimal clinical practice for the management of injuries covered under the SABS. Witness the Pre-Approved Framework Guidelines Project of 2007 during which FSCO commissioned at least one background paper and consulted widely with insurers and health professionals to gain a better understanding of best intervention, assessment and treatment practices for WAD I and II injuries.

The MIG sets additional precedents that cannot be ignored, and providers and insurers might justifiably interpret its language as intent to get into their respective backyards. Readers are strongly encouraged to read the Guideline.

In some important respects, the MIG is an extension of the PAF model beyond WAD I and II injuries. The regulation states that a minor injury means a sprain, strain, whiplash-associated disorder, contusion, abrasion, laceration or subluxation, and any clinically associated sequelae. The term “minor injury” is intended to apply to one or more of the following injuries.

Sprain: An injury to one or more tendons or ligaments or to one or more of each, including a partial but not a complete tear

Strain: An injury to one or more muscles, including a partial but not a complete tear

Subluxation: A partial dislocation of a joint

Whiplash injury or whiplash-associated disorder: Acceleration-deceleration injury to the neck that does not exhibit objective, demonstrable, definable and clinically relevant neurological signs and is not accompanied by spinal fracture or dislocation

The MIG, then, applies to the large majority of MVA injuries, possibly as many as 80%. The regulation further states that the OCF-18 (treatment and assessment plan form) can continue to be used to apply for benefits under the new $50,000 limit for serious injuries, but it sets out a major proviso, quoted verbatim below to ensure that readers understand its definitive language.

“Only in extremely limited instances where compelling evidence provided by a health practitioner satisfactorily demonstrates that a pre-existing condition will prevent a person from achieving maximal recovery from the minor injury for the reasons described above is the person’s impairment to be determined not to come within this Guideline. Exclusion of a person from this Guideline based on reasons or evidence falling short of this requirement is inconsistent with the intent of the SABS and this Guideline.”

What the MIG Means for Providers

Providers who were adept at navigating the regulations in the pre-MIG era in a way that brought them high adjuster approval rates and maximized fee revenue now have to reset their autopilots. Indeed, if they want to avoid in-flight adverse events and hard landings, they would be wise to assume that nothing will be automatic and to revert to what pilots refer to as visual flight rules in the best interests of their patients and the health of their practices.

Some insurers may not have the tools required to effectively administer decision rules for what constitutes a serious injury and the $50,000 limit that applies to such injurues. By the same token, in the absence of sophisticated internal claim adjudication rules and controls, some may well take the position that except for injures that are obviously catastrophic in nature, the Insurer Exam mechanism should be the final arbiter whenever an OCF-18 is submitted.

Differing definitions of “serious” are bound to complicate the assessment/treatment flow, and will likely expose some clinical practices to financial risk if services are performed for which payment is ultimately denied by insurers or their independent adjusters. Providers would be well advised to update their referral intake procedures to determine whether or not their patients have optional auto benefits coverage.

Providers who strongly believe that patients’ injuries fall outside the MIG and who can support their contention with credible evidence should also consult with patients’ auto claims adjusters to obtain pre-approval. Given the importance of patient service and assessment/treatment continuity, pending their negotiations with insurers they should also ensure that their patients fully understand what their payment obligations are for denied claims.

The SABS could be viewed as a public/private trust whose disbursements are for the benefit of claimants. Its moral, if not legal, fiduciaries are insurers, providers and Ontario’s financial services regulator. If standardization, consistency and equity are among the MIG’s stated and implied objectives, there is still work to do to ensure that, for claimants whose injuries fit the same profile, a consistent level of financial support is provided in practice as well as in theory.

Furthermore, though laudable, the $400 allowance for supplementary services and supplies included in the $2,200 pre-approved limit could be manipulated to cover additional (i.e. high margin) services instead of the supplies needed to promote the self-rehabilitation and functional restoration aims of the Guideline. Gross profit-taking on devices and supplies to the detriment of claimants also remains an issue, and one that could and should be controlled.

Change is at hand; the MIG is airborne. All stakeholders have a role to play to ensure that its course leads to its desired destinations. THP

The SABS could be viewed as a public/private trust whose disbursements are for the benefit of claimants. Its moral, if not legal, fiduciaries are insurers, providers and Ontario’s financial services regulator. If standardization, consistency and equity are among the MIG’s stated and implied objectives, there is still work to do to ensure that, for claimants whose injuries fit the same profile, a consistent level of financial support is provided in practice as well as in theory.

From the Heart: An OT in Haiti

Thu, 24 Jun 2010 18:36:00 GMT

At the end of January, Ruth Duggan’s client arrived home from work. She was standing outside chatting with a neighbour when suddenly the earth shifted and her house collapsed, instantly killing her father inside.

As a Canadian occupational therapist volunteering in Haiti, Duggan counts on creativity and cooperation to get clients through the calamities. Nine days after the earthquake Duggan met this woman, one of several people stumbling around in shock asking Duggan and her colleagues for help. She joined one of Duggan’s psycho-social support groups for survivors. “I’d ask people in the group, How many of you lost your home? Your job? Someone you loved? Every single person had experienced all of these.”

Ruth Duggan travels to Port-au-Prince several times a year with Team Canada Healing Hands (TCHH), a non-profit organization dedicated to providing rehabilitation services in countries of need. They are affiliated with the international agency Healing Hands for Haiti. Their rehabilitation clinic in Port-au-Prince crashed down the side of the mountain during the earthquake, accelerating effort to rebuild on flat land and employ greater numbers of newly trained Haitian recruits.Team Canada Healing Hand’s philosophy includes empowering local service providers and then stepping back. “As an occupational therapist, my job is to work myself out of a job,” said Duggan. Before the quake, the clinic was practically running itself. Local providers were doing assessments, making decisions on therapy, and carrying through so competently that the Canadian team had planned to move on to build a clinic in Belize this spring. But then they were needed in Port-au-Prince again.

There was a large influx of amputees and spinal cord injury patients, as well as people with peripheral nerve damage from being buried beneath debris for several days. Duggan’s work right after the earthquake included handing out crutches, teaching patients with prosthetic limbs how to move and training new community health workers – often people right off the street. Creativity was a key element in her work. So was compassion – a quality she also found to be abundant in the new recruits. “The biggest things people talked about were prayer and helping people. Doing this work gave them a purpose for their day, instead of just sitting and looking at the rubble.” Rather than providing prefabricated equipment that can’t be repaired if it breaks down, TCHH teaches rehabilitation techniques to clients using materials they have on hand. Duggan said that modifying tasks with local materials demonstrates to newly trained Haitian rehabilitation technicians how simple adaptations can make daily activities easier. “This challenges us to return to the roots of occupational therapy and explore our creative side. For instance, a local carpenter was taught how to make adapted spoons and cutting boards with available wood and cardboard.”

Thinking outside the box also applies to Duggan’s work in Canada. She runs Cornerstone Occupational Therapy Consultants in Halifax, holding educational sessions and consultations with employers and insurers, and meeting community-based rehabilitation needs for individual clients throughout Nova Scotia.Duggan’s earlier international work included three years in Kuwait, where she learned how to respectfully address cultural differences. “When I first went to Kuwait I was very naive. I thought that I could just go in and tell people what to do. But you can’t. You have to adjust what we’re doing to fit the culture. And you can’t just tell people, ‘Well, in Canada it’s this way and we should strive for that here.’ You have to work toward what’s right for that community. And that translates back to here in Nova Scotia, in finding what’s right for the individual client.”

As well as Kuwait and Haiti, Duggan has also worked in Trinidad and Tobago, and Vladimir, Russia. She traces her interest in international volunteer work to learning about the 2005 earthquake in Iran. “I remember hearing about it on the news: thirty thousand people died, their hospitals were damaged, and I thought, ‘There must be something I can do to help.’”

This article highlights exceptional work done by an exceptional health professional in the rehabilitation industry. Please send suggestions for future profiles to publisher@thehealthprofessional.ca.

Noreen Shanahan is a writing instructor and a freelance journalist. Her articles and essays have appeared in The Globe and Mail, the Toronto Star, Toronto Life, Reader’s Digest, Geist, CBC Radio and other places. She can be reached at nshanahan@rogers.com.

Interdisciplinary Team Working in Physical and Rehabilitation Medicine

Thu, 24 Jun 2010 18:30:00 GMT

Every medical specialty has to define its field of competence and improve professional skills and competencies. Physical and Rehabilitation Medicine (PRM) has been defined by the Section of Physical and Rehabilitation Medicine of the European Union of Medical Specialists (UEMS). The background as well as the skills and aptitudes and the role of PRM specialists in the rehabilitation process are described in the White Book on Physical and Rehabilitation Medicine in Europe.

The Field of Competence of PRM specialists is based on fundamental medical principles (establishing a diagnosis, functional evaluation, treatment plan and outcome measurement), models of body function and structure, activities, participation and contextual factors, and scientific results (evidence-based health care). However, professional practice of a single specialist is also influenced by other factors, e.g. the type of patients to be treated, the settings and the public health strategy of the country or region, the epidemiology of diseases and disabilities in that country, as well as the general health policy. Continuous evaluation and quality management as well as ongoing scientific work are factors improving the quality of professional practice in PRM. In order to describe and further develop the field of competence of PRM specialists, a series of position papers will be discussed both within the UEMS PRM Section (especially in its Professional Practice Committee) and with other national and international bodies. These papers will deal with PRM work in specific settings (e.g. acute hospitals) and for special indications (e.g. people with neurological disabilities). This paper is part of this activity and deals with interdisciplinary team work. It has been approved by the General Assembly of the UEMS PRM Section at the occasion of its meeting in Riga in September 2008. Publication at this stage is intended to generate further discussion and refinement. For that reason comments to the authors or editors are very welcome.

Introduction

PRM aims at optimization of activity, social participation and quality of life of people with acute and/or chronic health conditions. This involves empowering the individual to achieve autonomy and typically entails establishing a diagnosis, treating the underlying pathology where possible, reducing impairment, reducing the impact of impairment on activities, modifying context where possible to facilitate participation, and preventing and treating complications. PRM is necessary to reduce the consequences of disease and trauma in patients with severe and complex problems. These may include loss of employment following an insult to the brain or spinal cord, immobility following trauma, or reduced performance after myocardial infarction.

"For example, management of back pain may include education, advice to continue usual activities, medication, physical therapy and, rarely, surgery, as well as coordination of varied interventions to achieve agreed goals, and critical evaluation and revision of plans/goals to respond to changes in the patient’s health and function"

Additionally, impairments such as pain, nutritional difficulties, incontinence, communication disorders, mood and behavioural disturbance have to be addressed. Another key task in PRM is prevention of complications such as pressure ulcers and contractures and minimization of problems such as behavioural disorders in brain injury or mood disturbances associated with pain. The aim of this position paper is to review the rationale for interdisciplinary team working in PRM and describe optimal working patterns for such teams.

Interdisciplinary Team Work

As stated in a previous UEMS resolution, team working is considered essential for many reasons. These include the broad range of knowledge and skills required to diagnose and assess impairments, activity limitations and participation restrictions, and select treatment options, often from a diverse range. For example, management of back pain may include education, advice to continue usual activities, medication, physical therapy and, rarely, surgery, as well as coordination of varied interventions to achieve agreed goals, and critical evaluation and revision of plans/goals to respond to changes in the patient’s health and function.No single clinician is likely to have the necessary skills to achieve optimal results alone. The overwhelming view among PRM specialists who represent their nations at UEMS is that “interdisciplinary working” is the preferred pattern of team working. This means that PRM teams not only comprise members from many different professional backgrounds, but also work toward agreed aims and using an agreed and shared strategy. Since that UEMS resolution, scientific evidence has accrued to strengthen the case for team working in PRM programs. However, published studies to date have tended to use the term “multidisciplinary team” (MDT). As the exact nature of the relationship between team members is not always specified, this term is used in the following literature review. Studies have shown superior clinical outcomes in patients with a range of disorders treated by units with MDT working patterns compared with other settings. These data are summarized in Table I.

Evidence is particularly strong for cerebro-vascular disease (stroke), where MDT-based services also yield significantly better survival data. The Stroke Unit Triallists’ Collaboration have published data concerning 3,249 patients in Sweden, Finland, Australia, Canada and UK randomized to stroke units with MDT working or routine care. Among the latter, only 277 out of 1,346 participants were exposed to multidisciplinary PRM programs. Stroke units (with MDTs) showed better survival. Only 23.8% of those in stroke units died in the first four weeks compared with 27.8% of those not in stroke units. This difference was especially noticeable in those with severe stroke (Barthel Index less than 15/100 on admission); there were fewer neurological-, cardiovascular- or immobility-related deaths in those who received multidisciplinary treatment. The authors concluded this was not due to medication, and patients were less likely to need institutional care because they were less dependent. The authors proposed that this might be attributable to more encouragement and support for caregiver involvement in PRM programs by the MDT.

Organization within the Teams

The clinical literature provides limited guidance on what makes a good team. However, key features of successful team working in other situations have been utilized to provide guidance for PRM physicians in highly respected rehabilitation texts, such as that edited by DeLisa. These include:Agreed aims

Agreement and understanding on how best to achieve these (avoiding jargon unique to a particular profession)

Appropriate range of knowledge and skills for the agreed taskMutual trust and respectWillingness to share knowledge and expertise and speak openly

The team should work with people with disabilities and their families to negotiate and agree on appropriate, realistic and timely treatment goals within an overall coordinated rehabilitation program. These goals should be person centred, should not be imposed on the individual and should be endorsed by the team as a whole rather than by a single professional. Goals also need to be adjusted repeatedly as the PRM program proceeds.

Key Members of Interdisciplinary Teams in PRM, Their Qualifications and Roles

Successful teams will need to include a wide range of knowledge, aptitudes and professional skills, and members will primarily include:

PRM specialists
Nurses with rehabilitation expertise
Physiotherapists
Occupational therapists
Speech and language therapists
Clinical psychologists
Social workers
Prosthetists and orthotists
Dieticians

A range of additional clinicians may also be required, depending on the clinical field and specific needs and goals of each patient. On the other hand, for some patients and at certain stages in their PRM programs, only a few of the above disciplines, and sometimes only the PRM physician, would be involved. It should be noted that in many parts of Europe the decision to involve particular team members rests with the doctor, who also holds medico-legal responsibility for people under his/her care.

Elsewhere, such decisions (and legal responsibility) are shared among team members. Clearly, the method of working must be in keeping with each country’s pattern of medico-legal responsibility. Team members must be appropriately qualified. Knowledge and respect for the skills and aptitudes of the other team members is required. Each team member should recognize what particular knowledge and skills he or she can offer to the PRM program.In common with other interdisciplinary team members, PRM specialists have a duty to provide adequate information, training and support to others. However, each health professional has individual responsibility to uphold his or her profession’s standards. The following are some of the competencies typically associated with specific professions, although considerable overlap occurs in practice.

Physicians: Diagnosing the underlying pathology and impairments, medical assessment and treatment, setting up treatment and rehabilitation plan, prescription of pharmacological and non-pharmacological treatments and assessment of response to theseRehabilitation nurses: Addressing and monitoring day-to-day care needs, expertise in the management of tissue viability and continence problems, and providing emotional support to patients and their families

Physiotherapists: Detailed assessment of posture and movement problems, administering physical treatments including exercise to restore movement and alleviate pain, etc.Occupational therapists: Assessing the impact of physical or cognitive problems on activities of daily living, return to work, education and/or leisure activities, etc., and providing expertise on strategies that can be used by the patient and his/her family and environmental adaptations to facilitate independence

Speech and language therapists: Assessing and treating communication and swallowing disordersClinical psychologists: Detailed assessment of cognitive, perceptual and emotional/behavioural problems, and development of strategies to manage these with the patient, family and with other health professionals

Social workers: Promoting participation, community reintegration and social support

Prosthetists, orthotists and rehabilitation engineers: Expertise in the provision of technologies ranging from splints and artificial limbs to environmental controls to address functional limitations, for example, following limb loss, loss of independent mobility, loss of ability to communicateDieticians: Assessing and promoting adequate nutrition

Relevance of Medical Diagnosis for Therapy and Rehabilitation

Every clinical intervention has to address the health condition, impairments, activity limitations and participation restrictions. However, virtually every rehabilitation intervention has risks, which may be magnified if the underlying medical diagnosis, its severity or potential complications have not been properly evaluated. This is the case for both drug and physical treatments. Examples are manipulation of the spine in someone with undiagnosed spinal malignancy or aplasia of dens axis, rotation of the hip joint after total hip replacement, massage under the condition of anticoagulation, and attempted mobilization with artificial limbs in patients with inadequate cardiopulmonary reserve as a consequence of ischemic heart disease.

For this reason, a thorough medical diagnosis and assessment is essential prior to every rehabilitation intervention.

Safe Care Pathways

Patients will almost invariably need more than one rehabilitation intervention during their PRM program. Such interventions are likely to be delivered in different places by different PRM teams, and at different times in what is called the “patient journey” or the “care pathway.” This process has to be managed seamlessly. Networks, links with other specialists and clinical services also need to be well delineated, but fluid enough to respond to the patient’s changing needs.For PRM programs to function optimally, interdisciplinary members must understand their specific contribution to each patient’s care pathway. Other health professionals are trained to a high level of expertise to assess specific impairments within their fields. However, PRM specialists have a unique responsibility for providing an integrated description of an individual’s pattern of pathologies and impairments. People in whom complex problems are exerting a significant impact on functioning according to the ICF model are best served by carefully organized PRM programs under the direction of a specialist in PRM. This applies to both inpatient and ambulatory settings, as well as to private practice.

Conclusion

In summary, evidence from published scientific literature from larger trials indicates that PRM programs with multidisciplinary teams achieve better results in, for example, those with sub-acute and chronic low back pain and cardio-respiratory and neurological disorders than services that lack such PRM teams. Indeed, good team working may have a significant influence on survival. While there is limited evidence concerning what constitute the key components of successful teams in PRM programs, the theoretical basis for good team working has been well described in other settings. This includes agreed aims, agreement and understanding on how best to achieve these aims, appropriate range of knowledge and skills for the agreed task, mutual trust and respect, and willingness to share knowledge and expertise and speak openly. UEMS PRM Section therefore believes there is a very strong case for recommending this pattern of working. PRM specialists have an essential role to play in interdisciplinary teams; their training and specific expertise enables them to diagnose and assess severity of health problems, a prerequisite for safe intervention. Their broad training also means they are able to take a holistic view of an individual patient’s care, and are therefore well placed to coordinate PRM programs and develop and evaluate new management strategies.

This article has been published with the permission of The Journal of Rehabilitation Medicine (JRM). JRM publishes original articles from all over the world and has a high impact factor of 1.983. For more information about this non-profit international journal, please visit the website: www.medicaljournals.se/jrm.

* Abridged from The Journal of Rehabilitation Medicine 2009 2010; 42: 4–8Members of the Professional Practice Committee UEMS PRM Section: By Vera Neumann [UK delegate], Christoph Gutenbrunner [German delegate and Chairman of Professional Practice Committee], Veronika Fialka-Moser [Austrian delegate], Nicolas Christodoulou [Cypriot delegate], Enrique Varela [Spanish delegate], Alessandro Giustini [Italian delegate] and Alain Delarque [French delegate and President of Physical and Rehabilitation Medicine Section]

Toward a Paperless Office

Thu, 24 Jun 2010 18:16:00 GMT

To be more environmentally friendly, we all try to reduce our paper use, but for the rehab medicine office, it can have more than environmental benefits. It can also reduce the amount of paperwork done by both practitioners and staff, and save money in the long run.

Physiotherapist Heather King, co-owner of Active Life Physiotherapy in Vancouver, explained that she and her business partner (physiotherapist Sophia Sauter) deliberately designed their office to be as paperless as possible, but it has taken some time to get the system working as smoothly as they had envisioned.“All our therapists are responsible for tracking their own appointments, doing their own billing and handling their own administration,” said King. “We don’t have administrative support staff.”

Patients book their appointments online, and all files are kept online. There is some paperwork, as patients are given paper receipts when they pay for their appointments, but invoices for insurance purposes are issued online. Because many hospitals now store patients’ records electronically, if patients bring their CDs from the hospital, they can be uploaded to their Active Life Physiotherapy files. Paper files and X-rays can be scanned into their files, as well, so all records become electronic, eliminating the use of paper files in the clinic.“The patient is given an identity code based on their email address to access appointments, invoices and the treatment plan outline established on the first visit, as well as any notes the practitioner adds for the patient to read,” King said. “Each patient has one file that all the practitioners can get into using a unique password so notes can be added and shared.”

"The practitioners have put more than 300 exercise clips on a DVD for patients to follow at home, which eliminates the need for paper copies of the exercises"

Before the first visit, information regarding the patient’s current health status, health history and other relevant details can be filled in online and then automatically put into the patient portal. The treatment plan is available online and the practitioners have put more than 300 exercise clips on a DVD for patients to follow at home, which eliminates the need for paper copies of the exercises. It also allows patients to follow someone doing the exercise, so the maximum benefit is derived. More exercises are available on the clinic’s website.Another consideration in having a paperless office is the cost. All the systems geared to the various types of medical offices take time to implement, which has associated costs, and then there are the costs of training the clinicians. But while the start-up costs were significant, King figures that money has been saved by not having the extra support staff costs.

Active Life Physiotherapy is making good use of modern technology both before and after the patient’s first visit and any subsequent visits, thereby reducing paperwork and moving ever closer to the goal of becoming an essentially paperless office. The modern technology approach might not work if your clients and patients don’t have computers, computer literacy, and high-speed Internet access, said physiotherapist John Barratt, owner of the Napanee Sports and Spinal Centre in Napanee, Ontario. Having to meet extensive regulations set out by insurance companies, regulatory bodies and government agencies that require faxed copies of forms and charts doesn’t make it any easier to reduce the paperwork in the office, either.

Even so, handling appointments and at least some patient information electronically does make for less paperwork in the office. And as the technology advances, improves and becomes more accessible, we can look forward to the day when all offices could be very close to paperless.

Christine Peets is a freelance writer and a writing instructor. Her services include writing (or ghostwriting) articles for blogs, websites, magazines, newspapers and corporate reports. For further details visit www.CaptionsCommunications.ca.

Understanding Practice Risk

Thu, 24 Jun 2010 18:06:00 GMT

The International Organization for Standardization defines risk as “the effect of uncertainty on objectives.” If you are a health practice leader, owner or manager, having confidence in your ability to keep your organization out of harm’s way is an admirable leadership quality. Yet risk is insidious and being blind to it or ignoring it can have catastrophic consequences.

In business school we were introduced to the well-worn maxim, “If it ain’t broke, don’t fix it.” I was conflicted when I heard it then, and events since have helped me to understand why. Part of my unease stemmed from observing individuals’ risky behaviours in a variety of situations and their seeming disregard for the inevitable consequences. Why didn’t they recognize the risk, why didn’t they evaluate it when they did recognize it, and most troubling of all, why didn’t they manage it? Fortunately, some professionals make a point of being alert to risk. Early in my career, I took inspiration from an ad that featured sheep closely packed in a corral. The caption read, “That sense of everything going well is nothing more than the body temperature at the centre of the herd.” I framed the ad as a reminder not to be deluded into believing that if something is “going well” it will always remain so.

An “ain’t broke” state can be seen as a blessing of sorts for practice and clinic managers because the complexities and demands of running the business are stressful enough. Astute risk managers, however, are healthy skeptics who anticipate risk factors that have the potential to do harm and take the measures necessary to eliminate the possibility of harm or contain it within acceptable limits. What could be risky about the world of rehabilitation, one might ask? Demand for most services is high, as is employment, and the majority of provider incomes are funded by large creditworthy private and public sector institutions. Let’s look at the risk factors underlying what on the surface might appear to be a well-functioning practice to determine which factors are stable and which are not. In reviewing them and their implications, the management practices of some of our readers will be validated while others will realize the importance of resisting “comfort zoning” for comfort’s sake.

Risks can be firm-specific or systemic, such as a change in the personal injury benefits specified in insurance legislation that have global application. As we review both types of risk, readers are encouraged to assess the implications for their particular area of responsibility.

Service Disruption Risk

This risk category overlaps a number of others.First a true story. Several years ago, the CEO of a company called his sales VP at 6 a.m. one morning to announce, “Jack, the building is dead!” This CEO had a well-developed sense of humour, so Jack thought he was being pranked. Still half asleep, he chuckled reflexively in response. When the CEO didn’t laugh, Jack knew there was trouble.

The building and its entire service operation had “died” as the result of a local hydro blackout that had shorted out the inbound calls from customers, who required 24/7 access to assistance. There was no alternative power supply for the company’s 400 employee, single-facility operation. In direct and indirect financial terms, the impact, such as loss of brand equity, was major. But a split second before the lights, IT systems and phone switches died, everything was going well. It wasn’t broke.Disruption of service in a rehabilitation practice can be caused by a number of events – or risks. It could be a power outage. It could also be a default risk of your client service model. To illustrate, here are two questions of readers who operate multidisciplinary practices: 1. For your most profoundly disabled and needy clients, especially those with major cognitive deficits, have you designated backup professionals in the event the internal case manager can no longer provide service? 2. What would the ramifications be if, as a result, those clients’ current twice-weekly service interactions with your firm suddenly stopped?

Medium to large organizations spend big money and commit significant standby resources to developing, updating and activating elaborate business continuity and disaster recovery plans. Most rehabilitation practices do not have the resources to develop such plans. But here is the good news: depending on your size and complexity, you may not need that level of detail and resourcing. What you do need at a minimum is a plan that addresses such topics as:

The recovery plan’s owner
The plan’s executive sponsor
Evacuation protocols in case your facilities are rendered unsafe by fire, flood or other calamity
Recovery protocols for each of your business processes, including those you have so far considered to be strictly clinical in nature
Recovery plan leadership: role description and formal designation of the leader and the leader’s team
Client communications
Staff communications
External partner/supplier communications
Data/file access, backup, storage and recovery
Response phasing strategy, i.e. for interruptions expected to last less than one day, one to five days, more than one week

The plan should also identify contingency operating locations in case lack of access to service in the existing facility extends more than a specified number of days. Even without specific risk management strategies designed to prevent it, the probability of an adverse event requiring the activation of a formal disaster recovery plan is extremely low. Yet disasters happen, and the organizations that are prepared for them survive and continue to prosper. Indeed, business continuity planning can be a competitive advantage because it forces an understanding of the interdependencies of complex service operations.

Cascading Risk: The (not so hypothetical) Case of the Compound Systems Failure

Isolation of risk factors is a risk management strategy in its own right. When it comes to such strategies, necessity is the mother of prevention, which is why IT people have made lasting contributions to the classification and management of risk. They coined such terms as fault tolerance, failover and redundant array of independent disks (RAID). In ISO parlance, if one of your objectives in a clinical practice setting is data access, the uncertainty that has to be managed is availability.

Like all systems, IT systems have life expectancies. They also have components that are highly interdependent. A controller failure, a data drive failure or a failed internal power supply can each bring down an entire system. While there are accepted methods of assessing and preventing the impacts of such failures, they are beyond the scope of this article. What will be reviewed instead is systemic risk and how an adverse systemic event can trigger multiple internal failures.First, another real scenario to set the scene.Soon after assuming responsibility for a sixty-person financial services consultancy, the general manager conducted an informal audit of business continuity readiness. Several employees met in his office and they started going down his list. Q: How are we backed up in the computing room? A: We back up our data daily and store tapes off-site. Q: What happens if we have a power outage? A: Our phone switch has a backup that is rated at twenty minutes.

That was it. The only protection this firm had from a generalized power interruption was batch media and a twenty-minute line to the outside world. And these employees were conscientious, capable and dedicated people. When asked why they had not taken more measures to safeguard the operation, they replied that within recent memory, the maximum duration of a power outage had been about fifteen minutes. The manager immediately authorized the expenditure of $6,000 to purchase alternative backup power supplies for all critical data and voice system components – a small sum, given the stakes for this $8-million operation. Unfortunately, two weeks after the backup equipment was ordered, the organization was caught in the August 2003 power blackout. The equipment had been delivered but not installed, with predictable consequences: consultants could not do their work and therefore could not bill their clients, clients reached dead air when they tried to call the office, and there was no means of informing staff who were not in the building at the time about contingency and resumption plans without resorting to individual cell phones.

To briefly illustrate another example of cascading risk, let’s hypothesize the existence of a clinic called Zero Risk Rehab (ZRR), which has just three systems: a local area network, an inbound/outbound wireline PBX phone system and a diagnostic imaging machine. It was also caught in the same August 2003 blackout at the same level of exposure on all three systems.Since ZRR does diagnostic imaging, what would happen to patient and machine if the machine quits mid-scan? What if that has happened numerous times in the past? Will repeated outages cause total system failure? Without a secure power supply, will repeat scan attempts expose patients to excess radiation?

Patient/Client Diversification Risk

Diversifying one’s patient or client base is among the most difficult things to achieve for a manager because it involves strategic and tactical thinking and the application of a number of business disciplines. Yet we can all relate to its necessity. How many practitioners derive more than 50% of their fees from Ontario’s auto insurers for assessments and treatments? What percentage of their clients or patients fit the Minor Injury criteria described in new Regulation 34/10? If it exceeds 50%, the new regulation could just be their perfect storm.

Like all storms, this one starts with a gust or two, picks up in intensity, then hits with full force. If you have a well-developed sense of risk management, you would have felt the first gust last November with Minister Duncan’s announcement. Intensity built dramatically with February’s release of that regulation and five others that govern auto insurance in Ontario. On September 1, 2010 the storm front will be heading directly your way. Don’t be caught in the same position that some highly regarded organizations experienced when the WSIB consolidated its Labour Market Re-entry program several years ago.

Financial Risk

There are many types of financial risk, but there is a particularly insidious type to which just about all practices and clinics are exposed. First, another situation.Your monthly statements indicate that your practice is a picture of financial health. Period-over-period revenues are increasing at a rate exceeding your people costs. Your margin percentage on both micro (per unit of service) and macro (gross contribution after all variable costs are taken into account) bases is also healthy. You are showing a strong bottom line. Then your bank calls to ask how you want to handle this period’s preauthorized withdrawal by your payroll service provider, because your operating line has maxed out and thus you are technically insolvent. “That can’t be!” you sputter incredulously. “I am making money.” Barring outright fraud or misappropriation, you are both right. But in this case, your banker is more right than you are.

Make no mistake, if the first inkling of cash flow trouble occurs when your banker tells you that you have it, you have a serious problem. But there is hope, and there is a way to manage this risk to avoid a recurrence.To fix your immediate problem, first request a temporary extension to your limit. Next, assess the quality of your receivables. Is your services “cash-to-cash” gap (the lag from the time payment is made for your service costs to the time you are paid for those services) caused by people doing unauthorized work but invoicing for it anyway, the poor creditworthiness of your customers, or both? You need to find out, and quickly. Managing this risk requires the establishment of reliable service approval procedures, and account rating and collections management processes.

Most credentialed accounting professionals can help you, but be sure they have experience with your accounting software and can write basic bookkeeping and collections procedures for you and your staff.

Process Performance Risk

Another example will demonstrate process performance risk and support the contention that this risk lurks in the most unexpected places and can contribute to overall financial risk.This hypothetical situation is the same as the one above, but it is compounded by the fact that your revenue line does not correspond to the service activity you see going on around you. You have plenty of patients, and your invoicing controls appear to be working insofar as your service providers are booking their time and fees accurately right after patients are seen. You are at a loss to reconcile your perception of “everything going well” with the flat-lining of your reported revenues.Then you come across a drawer containing a pile of paper invoices. Lesson one: if it isn’t being invoiced, it isn’t revenue. This is a case of process failure because controls did not extend through the entire time/billing cycle. The good news about this risk is that if the average age of your WPUB (work performed but unbilled – distinct from WIP: work in progress) is low, your cash recovery rate for it should be the same as for the invoices that are being sent.

Errors and Omissions Risk

Errors and omissions risk is something that will probably increase for the rehabilitation sector as expectations of quality and objectivity increase on the part of clients, payers and the courts.

Readers who are active in the medico-legal field in Ontario would be well advised to become familiar with changes to the rules of civil procedure that took effect in January of this year. It would also be prudent to review the restrictions, if any, that have been set by your respective regulatory authorities on assessing and treating the same person. If you perform services for a third party, such as an insurer, also review the contract language governing your professional relationship with persons they refer to you.An act of commission or omission can happen as unintentionally as in the following example.A recently hired vocational rehabilitation consultant has been assigned an LTD return-to-work claimant file that was referred by the firm’s biggest life insurance customer. The claimant’s disabled life reserve is $2 million and her two-year “own occupation” period will end next month. So the consultant first performs an employability assessment, but does not have suitable supervision and as a result, the assessment is poorly done. Furthermore, he fails to follow the firm’s quality assurance protocol for peer review of reports.

The report is sent to the insurer by the consultant with a cover letter that states in part, “In my professional opinion, which is supported by the results of Ms. Claimant’s assessment and the lack of availability of any other suitable employment according to our employment market database, Ms. Claimant is unable to perform the duties of any occupation.”When the insurer rejects the findings and asks the claimant to undergo another assessment with another consultant, Ms. Claimant refuses. She supplies a copy of the email that had accompanied her copy of the report, which stated in part, “Acting on behalf of the insurer, I am informing you that based on the definition of disability contained in your group policy, I believe you are entitled to the indefinite continuation of your current benefits.”

Ms. Claimant refuses to undergo the second assessment. The insurer discontinues benefits for failure to comply with a contract provision requiring consent to undergo independent assessments as a condition of benefits continuation. Ms. Claimant engages a lawyer specializing in plaintiff LTD claims, who files a claim for unpaid benefits and interest, plus damages. The insurer then sues the rehabilitation firm that employed the consultant for negligent service performance.

Concluding Thoughts

It is the lot of the practice or clinic manager to be a risk manager at the same time. Risk management – or downside management – is admittedly unglamorous and can be unfulfilling, but it needs to be done to make patient rehabilitation upsides all the more probable.

Charles Spina is a management consultant who specializes in growth strategy and brand-aligned operations design and management. He can be reached at c.spina@sympatico.ca.

Collaborative Relationships: A Chiropractor’s Perspective

Thu, 24 Jun 2010 18:04:00 GMT

Offer services that complement those of other assessment and treatment professionals, keep patients’ health care teams informed and take the time to highlight the complementary skills and services you can offer patients in order to make your practice more appealing to the medical community.

1. Make yourself distinct from others

Offer services that complement those of other assessment and treatment professionals in order to make your practice more appealing to the medical community. Physicians vary in their familiarity with alternative and complementary medicine, but increasingly patients are looking for these types of treatments and family physicians are referring their patients to them.

For example, our chiropractic clinic also offers a range of related services, including medical acupuncture, laser therapy, physiotherapy, therapeutic massage and naturopathic medicine – all adding up to a multidisciplinary practice.The key factor that will distinguish you from your peers is your success rate. No matter which approach you use, if you can achieve better-than-average clinical results, then you will certainly increase the number of referrals you receive.

2. Foster open communication with others

It is important to keep patients’ health care teams informed, not only to help their health records remain up to date, but also to strengthen the relationship between you and the other health professionals involved in their care.

After the initial visit with a patient, I send a short note to the family doctor and any other medical or health care practitioners they may have seen about their chief complaint, such as a physiatrist, surgeon, naturopath, physiotherapist or massage therapist. This note briefly explains my diagnosis and the methods I am using to correct the problem. If this is the first time I have corresponded with them, I include a short biography so they can familiarize themselves with my skill set. I then follow with a short progress report at the two-week mark and again at the time of discharge. After I had been following this practice for a period of time, referrals from family physicians and medical specialists began to increase in number. Today I receive an average of two patient referrals per week from the medical community. Additional referrals to our clinic have come from physiotherapists, naturopathic doctors, registered massage therapists, reflexologists and other chiropractors. One of the best places to meet other progressive health professionals is at courses and seminars, where you not only improve your skills and techniques but also have lots of networking opportunities. These events have accounted for many of the referrals I have received from other rehabilitation practitioners. Knowing your peers can build relationships that are the source of new patients.

3. Make sure your curriculum vitae is current

When you strive to be the best in your field, you will get noticed. You must make a lifelong commitment to improving your skills and also practise the discipline necessary to make sure your curriculum vitae reflect those skills. I often send my CV to doctors who have extensive educational and clinical backgrounds, such as surgeons or pain specialists. This helps to highlight the fact that I am not only a chiropractor, but I am also certified in muscle release techniques and completed two years of acupuncture study at McMaster University, where I am now an instructor.Some of these additional specialties have greatly benefited the amateur and professional athletes who have come to our clinic. Once these players received the treatment and the results they were looking for, they started to refer other members of their team, and that component of our client base began to expand.

If you take the time to highlight the complementary skills and services you can offer their patients and can demonstrate success, physicians will see that you have skills that set you apart and they will be more likely to refer future patients.

Dr. Anthony J. Lombardi is a manual medicine specialist with a chiropractic licence. He specializes in the treatment of advanced musculoskeletal injuries in amateur and professional athletes who play in the Canadian Football League, the American Hockey League and the National Lacrosse League. In private practice at Hamilton Back Clinic since 2002, he became Senior Instructor of Contemporary Medical Acupuncture at McMaster University in 2005.

Practising What We Preach

Thu, 24 Jun 2010 18:04:00 GMT

Everyone wants patients to work in a healthy environment, but do you practise what you preach by making sure your own workplace is safe and healthy for your staff?

“We do the best we can,” said osteopath Natan Gendelman, director of the Health In Motion rehabilitation clinic in Toronto. “If the therapist isn’t comfortable, then the patient is going to sense that, and the patient will not be comfortable either.”

Gendelman added that it is sometimes difficult to ensure that treatment tables for physiotherapy, massage and other therapies in the clinic are a good fit for everyone because of the variety of body types and sizes using them. However, the tables are adjustable for the therapists to be as comfortable as possible while working. Space for therapists to lay their charts out with the day’s patient roster helps for a good work environment, too. “Knowing the schedule for the day means that therapists are not going to be stressed because they know exactly what is planned for the day,” Gendelman said. “This is as important as a safe physical environment – a healthy mental attitude in the workplace. That means better care for our patients.”

"It is sometimes difficult to ensure that treatment tables for physiotherapy, massage and other therapies are a good fit for everyone because of the variety of body types and sizes using them."

Treatment tables are adjusted for patients to get on and off easily, at the right height for the therapist to work, and positioned so the therapist can move around without difficulty. The main thing for patients who have physical or neurological difficulties, and especially for children, Gendelman indicated, is that the clinic rooms be a safe and pleasant environment. Therefore, they are large and brightly lit. Especially in a multidisciplinary clinic, another aspect of a healthy office environment is making sure there is a good fit among the staff. It is important that everyone respects other practitioners’ work and tries to understand the different medical modalities so they can refer appropriately, explained naturopath Sonya Nobbe, director of the Kingston Integrated Healthcare clinic.

“As clinic director, I have little say regarding ergonomics, because everyone provides equipment suitable for their practice,” Nobbe said. “However, I have worked hard to create an environment that is warm and friendly, and where co-workers actually work well together. An office space that can hold eight women who all get along is quite the balancing act, but it’s essential for health. Personality fit is a must in the clinic.” Professionalism and warmth were paramount considerations when the office was being designed last year in a space that had been a veterinary clinic. The wooden furniture complements the terrazzo floors; the stone wall in the waiting room is offset by soft lighting and muted tones on the other walls – all of which creates a warm and welcoming atmosphere for patients and staff. “Having our office manager at the main desk is also important, as that provides human contact and a safe, welcoming space for patients,” Nobbe said. What about patients needing care because of an unhealthy work or home environment? Nobbe indicated that only a small part of her practice is made up of that population. “As a practitioner, I recognize that 100 per cent of my patients have an environmental component to their health. Whether they recognize it and come to me because of it is another story. The environmental component could be social (e.g. relationships), or it could be toxins (e.g. exposure to heavy metals, solvents, allergens),” she said. “It could be ergonomic, and result in a more of a structural health concern, but for these I would refer the patient to either our massage therapist or our osteopath.”

Ergonomics is a misused word as far as Gendelman is concerned, because of everyone’s different body size, weight and height. “You can’t have the perfect office chair, the perfect seat in a car or truck, or the perfect space for everyone to work in,” he said. “You can make adjustments to come close, but everyone is going to have some issues.” So, how can you practise what you preach? According to these practitioners, by creating an atmosphere of mutual respect among practitioners themselves, between clinicians and patients, and by setting up the office to be warm, inviting and safe for patients, a healthy clinic environment can be created – one that will be beneficial for everyone.

Christine Peets is a freelance writer and a writing instructor. Her services include writing (or ghostwriting) articles for blogs, websites, magazines, newspapers and corporate reports. For further details visit www.CaptionsCommunications.ca.

Launching Your Practice – Choices, Choices, Choices

Thu, 24 Jun 2010 17:19:00 GMT

As they approach graduation, students starting their careers in rehabilitation face a number of daunting questions, including How am I going to get my practice started? As one RMT put it, “It’s not like graduating as a teacher or an X-ray technician where you know pretty well what your working environment will be – and how much you will be making…although that’s another story!”

For most regulated health professionals such as chiropractors, physiotherapists, naturopaths, psychologists, physiatrists, OTs, osteopaths or massage therapists, there are three basic choices: buy a practice, join a practice or start your own practice.For chiropractor Dr. Luke Winegard of In Motion in Sarnia, it was all about having clear values, a strong vision and considerable self-awareness. As an athlete, he wanted to live in a friendly small city with opportunities for outdoor activities, and Sarnia, where he also has extensive family connections, certainly fit that bill. Winegard knows himself well enough to realize that he wouldn’t be content for long playing on the second line in an established practice. “After a few months with someone else calling the shots, I would have had to find a way to do things my way, buy the practice and take over, or leave and start again somewhere else.”

"Like other regulated health professionals, physiotherapists are in high demand"

During his final year at CMCC Winegard developed a detailed business plan for a multidisciplinary clinic that could offer a wide range of services to his clientele. He was not content to just “hang a shingle” and operate a single-discipline practice working as a sole chiropractor. Instead, he wanted to offer both fitness and health care services under one roof.So began In Motion, opening in a Sarnia plaza after months of business development and down-and-dirty renovations that created a bright, welcoming multi-use clinic. From the day it opened, the business had a staff of eight – chiropractors, physiotherapists, personal trainers, massage therapists and nutritionists – which presented significant financial challenges for these young professionals at the beginning of their careers. But they never lost sight of the vision, and three years later, all eight practitioners have full appointment books, In Motion is a thriving practice, and Winegard’s thoughts are turning to possibilities of expansion.

"For most regulated health professionals, there are three basic choices: buy a practice, join a practice or start your own practice."

Dr. Carney Carney-Kilian wanted to be quite sure he would be heading in the right direction after graduating as a chiropractor in 2007, so he spent a year in a marketing job while he investigated his options. When a friend mentioned some good prospects in Red Lake, Ontario, Carney-Kilian took a trip up there to check it out. He was pleasantly surprised to find a prosperous community with a busy part-time chiropractic clinic available for purchase. He bought the practice, extended it to full time, and hasn’t looked back since. Both his professional and personal life have turned out just as he hoped: he has already bought his own building and expanded the practice to include a full-time massage therapist and a holistic health practitioner. As the only chiropractor within 3½ hours, his clinic is booked solid, and his work is highly rewarding. He does little advertising or marketing because word of mouth brings in most of his patients. Carney-Kilian also enjoys the lifestyle in northwestern Ontario, including the two-minute walk to the office from his downtown lakeside home, “Where I can fish right off my back deck,” he boasted cheerfully.In her final year of schooling, exams and licensing, naturopath Dr. Laura Gilpin considered a number of communities before settling on Guelph as the right place to start her practice. “It just feels like home,” she said. There she joined a like-minded group of chiropractors and massage therapists and was on the way to building a solid client base only a couple of weeks after she started practising. For Gilpin, qualitative considerations such as the right “feel” of the situation and compatibility with the rest of the team were paramount, and these days she couldn’t be happier in her comfortable Guelph office.

Given her focus on neurological/stroke rehabilitation, Dana Vanderaa graduated with a Masters in Physiotherapy in 2004 knowing she would likely work in a hospital setting. Like other regulated health professionals, physiotherapists are in high demand and according to Vanderaa, “You can find any kind of work you want in a large city.” She quickly landed a challenging and satisfying position in a Toronto hospital right after graduation. Since then she has started a family and has recently returned to her hospital job after maternity leave. Vanderaa also has a part-time position in a community clinic where she enjoys working with a broad variety of patients, most of whom need physiotherapy for orthopaedic conditions.After earning his diploma and membership in the UK Chartered Society of Physiotherapists in London, England, physiotherapist Ron Jolicoeur also practised in a hospital setting, first in his home country of Mauritius and later in Montreal and Toronto. After several years of developing his physiotherapy skills and rising through ever-more-responsible positions, Jolicoeur felt well prepared to launch his own clinic in Brampton, where he is the sole practitioner. That was almost 20 years ago, when only a few physiotherapists were in private practice and when there wasn’t a physiotherapy clinic “on every corner, as there seems to be now in Brampton,” Jolicoeur quipped. He believes it would be more difficult to start out his way these days, with so many private practitioners for clients to choose from.

"Massage On Wheels features mobile massage therapists who are hired for events, trade shows and workplaces in major cities across the country."

Massage therapist Kristy Cipolla always wanted to work for herself, but when she graduated with a diploma in massage therapy and completed her certification exams in 2004, she had to look for a job to pay the bills. After a couple of short-term positions – in chiropractic and athletic therapy clinics, as well as on-site for corporations and movie and television sets – Cipolla settled on a situation that suits her working style and lifestyle for the longer term. She did some advertising and marketing in her local area (“Because you don’t have your clientele handed to you,”) and has established a flourishing massage therapy practice in a multifaceted chiropractic clinic. She also has some corporate clients for whom she treats employees right in their workplace. This part of her practice is growing and has become very popular with employees. During her recent maternity leave, Cipolla had another RMT take over her practice temporarily, and now the two of them continue to job share and balance their work and home life.Ten years ago when the specialized service she wanted to provide didn’t exist anywhere, Carrie Rubel developed her own unique business model and founded what quickly became a very successful company. Billed as “Canada’s On Site Massage Specialists,” Massage On Wheels features mobile massage therapists who are hired for events, trade shows and workplaces in major cities across the country. The relaxing or energizing (depending on the purpose, the venue and the client’s needs) chair massages are extremely popular. At trade shows, the booth that has hired the Massage On Wheels specialists attracts line-ups and enthusiastic crowds – excellent traffic for the booth’s products or services. With the business going so well, Rubel is always looking for more RMTs to provide the superior customer service – consistency, quality and reliability – her company has come to be known for.

If there is one lesson to be learned from these practitioners, it is that although their training and skills prepare them for a variety of different practice models, graduates need to do some soul searching and have a clear idea of the kind of work they want to do. The ideal scenario is slightly different for everyone, and one’s sense of the ideal can change with experience over time. Starting out with defined values and a clear vision helps to ensure that each step along the way is the right one for the right reasons.

If soon-to-be or recent grads would like specific advice from any of the practitioners mentioned in this article, email editor@thehealthprofessional.ca and we will put you in touch with them. Also note that Dr. Anthony Lombardi (whose article on relationships with referral sources appears in this issue) offers guidance to new practitioners at www.facebook.com/hamback.

The World of Care and Rehabilitation Funding

Tue, 31 Aug 2010 19:24:00 GMT

“Complicated” best describes the rules and procedures governing the private and public funding of services, devices and supplies for the rehabilitation of persons recovering from disabling injuries and illnesses. Nonetheless, anyone involved in the assessment, treatment or administrative aspects of rehabilitation will probably agree that knowledge of third-party benefits – their types, claiming procedures, coverage limits and exclusions – is not only essential from a patient relations standpoint, but it has tremendous influence on a practice’s financial health.

This review will subdivide benefits into two broad categories: those that pay for goods and services (such as vocational counselling, physiotherapy treatments, medications and assistive devices) and those that pay income according to predefined schedules or formulas.Two associated topics will not be reviewed in detail: payment precedence (which party, plan or program pays first when a person has multiple coverage for the same risks) and subrogation (an insurer’s right to recover payments already made to an insured from another insurer or third party by virtue of that insurer claiming the insured’s rights to payment). The rules governing payment precedence can be contentious, and their application can pull the rug out from under an insured’s otherwise well-laid plans for security. To protect readers from the consequences of precedence rules and subrogation, I will make two broad recommendations.

"Every policyholder should consider the purchase of optional coverage for personal injury benefits to be a mandatory component of their financial security program."

The first recommendation is to own one’s insurance as a named insured where possible. Someone who has a policy of health insurance or disability income insurance that names them as the owner of the policy, the policy’s insured and its beneficiary can be virtually certain that, in the event of a disabling injury or illness, the benefits they receive under such policies will not be offset by the benefits received under any other program or policy. For example, in practice, if your client or patient has such a policy and qualifies for an income benefit according to the policy’s definition of disability and other payment conditions, they will receive one hundred cents on each dollar of benefit plus the income benefits of any other policy or program for which they qualify. The second recommendation pertains to auto insurance. Because personal injury benefit cutbacks under Ontario auto insurance policies will start to be phased in for all but the catastrophically injured starting September 1, 2010, it is more important than ever that insureds purchase the maximum optional coverage prescribed by new Regulations 34/10 and 36/10. Current optional benefits have not been aggressively marketed by agents and brokers. If by the end of the summer your broker cannot price or explain the new optional benefits, look for a broker who can and advise your clients or patients to do the same. Every policyholder should consider the purchase of optional coverage for personal injury benefits to be a mandatory component of their financial security program.

Every resident of Ontario can be assured of at least some protection from the financial consequences of disability and the costs associated with rehabilitation. Regardless of the cause of one’s disabling injury or illness, the first line of funded acute care is the local hospital emergency department. For medical care it is OHIP, although OHIP coverage is not automatic, and has a number of eligibility criteria. (See www.health.gov.on.ca/en/public/programs/ohip/ohipfaq_dt.aspx for further details.) For in-home services it is the Community Care Access Centre. Another source of funding is group insurance, or employee benefits plans, from which payments for health, dental and disability benefits exceed $20 billion a year in Canada. Members of a group – most commonly employees of an employer who sponsors a plan – who satisfy the waiting period and other qualification requirements of those plans will have coverage under the plan’s benefits schedule. Benefits can be for health services not covered by OHIP, such as physiotherapy, psychological counselling, chiropractic treatments, private or semi-private hospital accommodation, medications not administered in a hospital, dental services and income replacement benefits. Note that under these plans benefits are typically, but not always, paid only if the illness or injury is non-occupational.

"Yet, many providers spend much uncompensated time on this activity. An aspiring social economist might consider it to be a worthy topic for their doctoral thesis"

If a person is covered under two group insurance plans at the same time, for instance under their employer’s plan as an employee and as a dependant under their spouse’s plan, it may be possible to claim reimbursement for expenses not covered by their primary plan from their secondary plan under “coordination of benefits” rules. These rules and their corresponding claiming procedures are detailed in the benefits booklets issued to the members covered under such plans.

Group insurance income replacement benefits such as STD or LTD can be taxable or non-taxable, depending on who pays the premiums, and are normally expressed as a percentage of employment income. High income earners in low-risk occupations can be eligible for benefits of $25,000 per month or more. Benefits can be reduced directly by other disability income sources such as CPP disability benefits, employment income and partial disability income benefits, and indirectly by what is referred to as the “all-source maximum.” They cannot be reduced by income benefits provided by a personal disability policy.

An employee working for a non-exempt occupation or employer who is injured while performing the duties of his or her job will be eligible for comprehensive health, dental, income replacement, vocational and rehabilitation benefits under a provincial workers compensation plan. Unlike in the United States where workers compensation is in essence a private system in 46 of the 50 states, workers compensation benefits in Canada are the responsibility of provincial governments. Workers compensation benefits are extensive. (Particulars for Ontario’s WCB benefits can be found at www.wsib.on.ca/wsib/wsibsite.nsf/public/WSIBBenefits.)Workers compensation programs are always first payers for occupational injuries or illnesses. In cases other than death or permanent disability, the administration of claims and payment mechanisms is highly procedural and integrated. Non-income benefits tend to be paid directly to the providers of goods and services. An increasing number of these claims and payment mechanisms are web-enabled. Certain workers compensation loss of earnings and future loss of earnings benefits can be offset by CPP disability income benefits.

"Every resident of Ontario can be assured of at least some protection from the financial consequences of disability and the costs associated with rehabilitation."

If a person is injured as the result of a motor vehicle collision, they will have coverage under the personal injury benefits schedules of their auto insurance policy. Ontario’s benefits are described in the Statutory Accident Benefits schedule. SABS is first payor for some benefits. It is last payor for the Income Replacement Benefit, in which case, it is last payor. A summary of the SABS can be found at www.fsco.gov.on.ca/english/insurance/auto/drs/default.asp#d.Those who have satisfied the contributory and service requirements of the Canada Pension Plan and meet its definition of disability may also qualify for the CPP disability benefit. The monthly benefit is determined according to a formula and increases with the number of dependent children. Again, group insurance disability benefits may be offset by such payments depending on whether the group plan specifies no offset (rare), an offset equivalent to the recipient’s own CPP benefits (common), or a full offset for all benefits received for themselves and their dependent children (less common now, given precedent-setting court cases).

So much protection, so many options. In fact, it takes a fertile imagination to think of a scenario under which someone who becomes ill or is injured will not have at least some of their income replaced or costs of service paid for by a third party under one or more benefits programs. The worst-case hypothetical scenario this writer could come up with – and an admittedly morbid one at that – is an unmarried, unemployed, newly resident adult citizen of another country, with negligible liquid assets and no personal health or disability insurance, who fails to heed a “do not swim – dangerous undertow” warning posted on a public beach and suffers an incapacitating brain injury due to oxygen deprivation. Chances of a successful tort action are slim, so the insurer of the municipality that owns the beach is excluded as a potential, eventual source of funds for the person’s acute, convalescent and rehabilitative care and related income needs. In Ontario, no hospital would turn this person away for their acute care needs, despite their lack of qualification for OHIP. This person would also likely qualify for some combination of (ODSP) Ontario Disability Support and/or social assistance for some of their income needs. If they are a refugee claimant, they may qualify for comprehensive health benefits provided under a federal program. They would not qualify for services from a Community Care Access Centre, so discharge to alternative care might be problematic, particularly if they have no relatives in Canada. The most prominent gap would likely be associated with ongoing primary care and rehabilitation.

Complexity appears to be the price we pay for a diverse benefits landscape and for the coordination required to ensure that benefits from all sources do not exceed indemnified losses or actual costs associated with assessments and treatments. A certain amount of complexity is also the by-product of controls employed to prevent fraud, promote adjudication equity and manage costs. Nonetheless, despite some attempts at streamlining and pre-approvals up to set limits, and some insurers’ exemplary practices in those areas, claiming for benefits can be a cumbersome, complex ordeal. To anyone – such as this writer – who has managed such programs and heard the term “abusers” applied to some perfectly legitimate claimants who happen to claim more than others, it is not surprising that a guilty-until-proven-innocent attitude creeps into some organizations’ claims processes.

"For practitioners, a 'whole person' view should include knowledge of patients’ and clients' funding sources."

“For practitioners, a ‘whole person’ view should include knowledge of patients’ and clients’ funding sources.”For practitioners, a “whole person” view should include knowledge of patients’ and clients’ funding sources. Some individuals may not understand their entitlements, and their insurers may not have had success explaining them. Yet, many providers spend much uncompensated time on this activity. An aspiring social economist might consider it to be a worthy topic for their doctoral thesis.

Making Your Marketing Work for You

Thu, 24 Jun 2010 17:03:00 GMT

Health care professionals often have an "if we build it, they will come" attitude. Marketing is viewed as an unnecessary time-waster – until there are gaps in the appointment book. But there are ways of filling those unexpected gaps, decreasing patient attrition and attracting new patients, all with just a little sprucing up, online and off.

How Do Clinics Lose Patients?

In any business, getting new clients in the door is much more expensive than maintaining clients you already have. The first area to examine in any practice is patient attrition.

First Impressions

To evaluate the appearance of a clinic, enlist the aid of people who have never seen it before. Arrange for family, friends or, ideally, disinterested third parties to sit in your waiting room and evaluate the appearance and atmosphere of the clinic. Patient surveys are another great way to get anonymous comments on any aspect of a practice, including appearance.

"If the chairs are hard and the waiting area is cluttered or dusty, patients will leave the practice"

Once you have feedback, hire an interior designer to implement the suggestions. If your budget won’t stretch to a designer, implement as many ideas as you can using your own taste and preferences and perhaps getting free advice from building supply or design stores. But remember the basics: if the chairs are hard and the waiting area is cluttered or dusty, patients will leave the practice. Any improvement in the cleanliness and decor of the clinic will improve client retention.

Make Time for New Patients

In addition to any initial assessments you might do, new patients need extra time to get to know you and your staff, and to feel welcome in your practice. The more open and welcoming you are with new patients, the more likely they are to keep coming back [1].

Front Office

A study at the University of Pittsburgh [2] asked residents to take on front-office duties in order to better understand the pressures on their staff and the needs of the practice. This is a great example to follow: put yourself in the shoes of your staff for just a few minutes and you will better understand what needs to be done.You will also have a glimpse of how your staff deal with patients and what their standard practices are, allowing you to make improvements right away if there are any obvious issues. Patient feedback through surveys and email engagement will help in this area as well. The more valued your front-office staff feel in their day-to-day operations, the more likely they will be to treat your clients warmly and professionally.

Your Unique Selling Points

Your unique selling points are the things that make you stand out. Do you have certifications that others may not have? Does your office have longer hours than traditional practices? Take a few minutes to write down what you believe these unique selling points to be, and then have a look at your website. If you don’t list your unique selling points anywhere, make sure to do so in “About Us” and other relevant sections of your site.One local massage therapy centre offers appointments on Sundays. However, they do not mention this on their website. The Sunday appointments would be booked more quickly and further in advance if this unique feature were simply advertised on the website.

Online Image

If the same website design has been used for more than two years, it is time to evaluate it. The Internet changes rapidly, and changing with it increases the professionalism of your online image. Depending on your needs, a simple website redesign will cost $500 to $2,000 and will go a long way toward building client trust. Think about your own online journeys and bookmark sites that impress you; your own site can impress your clients with the touch of a professional designer.

While you are having your website redesigned, consider setting up an email newsletter service. (Dozens can be found online with a simple search.) This will allow you to stay in touch with your patients by email, which is a powerful tool to reinforce client trust.

Optimizing Your Website

Search engine optimization consultants are often inexpensive when compared to traditional marketing efforts. They help to optimize your online presence so your practice’s name comes up in searches related to your business. While any number of things can improve online presence, hiring an individual to handle your search engine optimization needs can ultimately be the most cost effective.To find such a specialist, look for “search engine optimization” or “web design” at any directory site. You will get the greatest value from someone local, who will put in face time with you and understand your business before trying to promote it online.

Appearance is Everything

Whether online or offline, the way your practice and office appear to a patient says everything about your practice. The actual services your clinic offers probably are not much different from your competitors’ because everyone in your profession does essentially the same thing. What can set you apart is your image, and a great image will make all the difference in keeping your current clients and getting new ones.

Angela West is a copywriter who specializes in website copywriting and social media through her business at www.workingwebcopy.com.

www.articlesnatch.com/Article/Early-Patient-Attrition---How-To-Detect-And-Handle/513817
www.med-ed-online.net/index.php/meo/article/viewFile/4471/4651

Ontario Auto Insurance Reforms

Tue, 31 Aug 2010 19:22:00 GMT

In the inaugural issue of THP we chronicled the first review of Part VI of the Insurance Act and summarized Finance Minister Duncan’s proposed changes to the Act that pertained to personal injury benefits. In that issue we contended that the changes could be subdivided into four buckets:

Benefit reductions
Benefit delisting
Claims cost control
Cost shifting

The rumblings of reform seem to be triggered by crises. Witness Ontario’s pension and workers’ compensation reforms of the mid-80s and mid-90s, respectively. The statutory device of the five-year review was introduced to bring some predictability and order to the auto insurance review process. It is a cruel irony that the first such review should have occurred during a firestorm of controversy surrounding medical/rehabilitation benefit costs and practices.

“….the first piece of advice for professionals who perform services for motor vehicle injury claimants is that if they have never done a strategic plan, or at least an assessment of risks, threats and opportunities, they should do one now."

We promised readers an update in this issue. Soon after our magazine’s distribution early in March, the Financial Services Commission of Ontario announced a number of new regulations and issued rate filing instructions to insurers to reflect the changes. These included pricing of an option to reduce the tort deductible to $20,000 from $30,000 and an option to purchase specified accident benefits that are being de-listed from the previous Statutory Accident Benefits Schedule. The rate filing deadline was April 15. The expectation is that the premium component for accident benefits will come down significantly owing to lower actuarial assumptions. On February 24 a number of regulations were made under the Insurance Act, all to be effective on September 1, 2010. Six of the regulations pertain in whole or in part to the personal injury benefits prescribed by the Act. They are:

Regulation 34/10: Statutory Accident Benefits Schedule
Regulation 35/10: Transitional rules for accidents occurring before September 1, 2010
Regulation 36/10: Option to reduce tort deductible; at-fault rating restrictions
Regulations 37/10: Unfair or deceptive acts or practices
Regulation 38/10: Disputes between insurers
Regulation 39/10: Definition of health care claims

In the lead-up to the latest reforms, none of the main stakeholders – claimants, insurers, providers or the regulator – was satisfied with the status quo. Claimants who made submissions to the review process complained about unfairness, complexity and inequity, while insurers cited the escalating cost of medical/rehabilitation benefits, particularly the spiralling frequency of assessments and the lack of provider accountability. Providers voiced concerns about complexity, lack of accountability with respect to missed deadlines, adjudication inequity, and waste. Through their industry group, OTLA, lawyers representing claimants in tort actions or facilitating their accident benefits claims took aim at fraud, abuse, complexity and the tort threshold.

Readers have by now seen a number of commentaries, analyses and reviews both during the protracted review process and since the release of the new regulations. Many of the personal injury law firms have published useful reviews, and some have done exquisite analyses, which in addition to their public relations value are also an important public service. The “Bulletins” section of the FSCO website is also useful: www.fsco.gov.on.ca/english/pubs/bulletins.The changes to the regulations are far-reaching and extensive, so the focus here has been less on the specifics of the changes than on their implications. To readers who consider themselves expert strategists, the start of the review over a year ago should have sent them a strong signal to dust off their business plans and the assumptions underlying them. Indeed, the first piece of advice for professionals who perform services for motor vehicle injury claimants is that if they have never done a strategic plan, or at least an assessment of risks, threats and opportunities, they should do one now. Their survival may depend on it.

Ontario’s system is sometimes called “no-fault,” but it is actually a no-fault/tort system and one that is often in a state of disequilibrium at that. Indeed, when it comes to auto insurance, reform and re-reform have been driven by the swings of the pendulum: cost escalation on the one hand and cries of insufficient protection on the other. Given that costs appear to have been the main driver behind the latest reforms, it could also be referred to as a cost-driven system, which helps to explain how a province of 13.5 million people can support almost 200 auto insurers. There have been so many changes to Ontario’s personal injury benefits regime during the past twenty years, including the introduction of an elaborate claims system (HCAI) for some of its prescribed forms, that provider and insurer alike could be forgiven for hoping that stability will reign for at least the next five years.

Post Head Injury Endocrine Complications

Fri, 16 Apr 2010 20:36:00 GMT

The greatest challenge associated with endocrine complications in individuals with traumatic brain injury (TBI) is early recognition of these subtle problems. Endocrine complications can produce significant impact on the progress and outcome of TBI rehabilitation. Prompt diagnosis and treatment of endocrine complications following TBI facilitate the rehabilitation process of patients with TBI.

The release of pituitary hormones, orchestrated by the neuropeptide signals from the hypothalamus, provides a tight control of hormone-regulated homeostasis. The pituitary gland is protected well within the sella turcica of the sphenoid bone; however, the pituitary stalk, connected to the anterior pituitary and hypothalamus, is vulnerable to the effects of TBI, especially in patients with associated facial fractures, cranial nerve injuries, and dysautonomia.

Pathophysiology

Autopsy studies in fatal traumatic brain injury cases demonstrate a fairly high prevalence of hypothalamic and pituitary abnormalities, including anterior lobe necrosis, posterior lobe hemorrhage, and traumatic lesions of the hypothalamic-pituitary stalk. Some variability is noted in studies. Anterior pituitary infarction has been seen to occur in 9 to 38% of patients, posterior pituitary hemorrhage in 12 to 45% of cases and traumatic lesions of the stalk in 5 to 30% of patients.

The traumatic rupture of the pituitary stalk results in anterior lobe infarction because of disruption of the portal blood supply between the hypothalamus and the anterior pituitary. Ninety per cent of the anterior lobe is nourished by the hypophyseal portal veins, which originate from and follow the pituitary stalk. An alternative explanation is that post-traumatic edema of the pituitary gland within the bony sella turcica compromises the portal blood supply, resulting in anterior lobe ischemia/necrosis. Both mechanisms may contribute to anterior lobe dysfunction following TBI.

Anterior hypothalamic trauma is often observed on postmortem studies and may be associated with pituitary hemorrhage or infarction related to TBI. Anterior pituitary hormones (e.g. growth hormone [GH] 1, thyrotropin, corticotropin, gonadotropins) are released by the neuropeptide-releasing hormones from the hypothalamus. The posterior pituitary hormones (e.g. vasopressin, oxytocin) are produced by the hypothalamus and are carried by long axonal projections into the posterior pituitary; they are released later. The posterior lobe vascular supply is not affected by pituitary stalk trauma, because it is supplied by the inferior hypophyseal arteries, which arise from the internal carotid artery below the level of the diaphragma sella. Infarction of the posterior lobe is therefore rare, and the mechanism of the development of diabetes insipidus (DI) is by denervation-losing neural integrity with the hypothalamus2,3,4,5,6,7.

The most common endocrine complication after a TBI is a syndrome of inappropriate antidiuretic hormone (SIADH). SIADH causes a dilutional hyponatremia secondary to inappropriate renal water conservation. Relatively less common post-TBI endocrinopathies include anterior hypopituitarism (AH), DI, cerebral salt wasting (CSW) and primary adrenal insufficiency (PAI).The most common endocrinopathies associated with hypopituitarism, in descending order, include hypogonadism, hypothyroidism, adrenal insufficiency, hyperprolactinemia, DI, and GH deficiency. CSW and PAI are peripheral causes of hyponatremia after a TBI. SIADH, AH and DI have central endocrine etiologies.

History

Approximately 30 to 50% of patients who survive post-traumatic brain injury (post-TBI) demonstrate endocrine complications. Most post-TBI endocrinopathies do not have typical specific history patterns.

Diabetes insipidus (DI) is an exception, as it does have a specific history. DI most commonly is associated with severe TBI and basilar skull fractures with cranial nerve involvement, craniofacial trauma and postcardiopulmonary arrest. Delayed onset of DI is associated with a poor prognosis due to hypothalamic involvement causing permanent DI. Acute DI following a mild to moderate TBI indicates a posterior pituitary lesion with only a temporary antidiuretic hormone (ADH) deficiency.

Anterior hypopituitarism (AH) also has a specific history. AH is usually associated with moderate to severe TBI. With improvement of emergency and neurosurgical care for these patients, there are more survivors demonstrating AH. AH may present weeks to months after the TBI, typically in the acute or chronic rehabilitation phase. Any patient with unexplained malaise or a setback with regard to functional status should be examined and tested for AH or the other post-TBI endocrinopathies. In summary, risk factors for AH include relatively serious TBI (Glasgow Coma Scale score <10), diffuse brain swelling and hypotensive or hypoxic episodes.

A syndrome of inappropriate antidiuretic hormone is the most common TBI-associated neuroendocrinopathy causing hyponatremia. The incidence is reportedly as high as 33%.

Cerebral salt wasting (CSW) is a less-common cause of hyponatremia in the post-TBI population. These patients are dehydrated and lose weight.

Primary adrenal insufficiency (PAI) is rare and presents with the superimposed psychiatric symptoms of depression, confusion and apathy. PAI is associated with fatigue, weakness, anorexia and weight loss. These problems may present insidiously over a prolonged period. The acute presentation of PAI includes nausea, vomiting and hypertension.

Physical

Physical examination findings may be obscured by the altered cognitive status of patients who have had a traumatic brain injury. Common post-TBI findings, such as lethargy, fatigue and slowed mental processing time, also are associated with endocrine complications.
In extreme cases, hyponatremia can cause seizures, confusion and coma. Primary adrenal insufficiency (PAI) may present with acute psychiatric problems, such as psychosis, depression, apathy or a schizophrenia-like syndrome.
General physical examination findings may include myxedematous, addisonian-appearing or slowed mentation.
Vital signs include the following.
- Slowed pulse
- Hypothermia
- Orthostatic hypotension
Dermatologic findings include the following.
- Pale, soft, waxy skin
- Hyperpigmentation
- Decreased axillary and pubic hair
- Areolar depigmentation
- Decreased male facial hair
- Decreased sweating and sebum secretion
Neurologic findings include the following.
- Mental status changes (e.g. lethargy, confusion, slowed mentation)
- Muscle weakness (may be proximal due to endocrine myopathy)
- Hyporeflexia or areflexia
- Hypotonia

Causes

The most common post-traumatic brain injury (post-TBI) endocrine complications are as follows.

Syndrome of Inappropriate Antidiuretic Hormone (SIADH)

SIADH is the most common neuroendocrine complication following TBI, with a reported incidence as high as 33%. In the TBI rehabilitation setting, SIADH is the most common cause of hyponatremia.
Hyponatremia is often seen in the rehabilitation setting among survivors of either traumatic or non-traumatic brain injury (e.g. hemorrhagic stroke, brain tumours, CNS infections). This problem is associated most often with SIADH. Approximately 30% of patients who undergo neurosurgery demonstrate SIADH. SIADH also can be induced by medications such as carbamazepine, major tranquilizers and antidepressants.
Hyponatremia can cause several problems, including cerebral ischemia (by volume depletion), lassitude, seizures, confusion and coma.
SIADH causes renal water conservation, with a secondary hyponatremia because of dilution. In patients who are not dehydrated or using diuretics, the laboratory diagnosis is based upon a urine osmolality greater than serum osmolality. The serum osmolality in patients with SIADH is less than 280 osm/kg, serum sodium is less than 135 mEq/L, and urine sodium is greater than 25 mEq/L.
The treatment in most cases is fluid restriction and, in unusual situations, IV hypertonic saline.

Cerebral Salt Wasting (CSW)

Although most cases of hyponatremia due to brain injury are caused by SIADH, a less-common etiology is CSW syndrome. Peters and colleagues first described CSW in 195013.CSW is caused by impaired renal tube function that results in the inability of the kidneys to conserve salt. The etiology may be attributable to direct neural influence on renal tube function. Salt wasting with volume depletion is the hallmark of this syndrome. Clinically, patients manifesting CSW are dehydrated, lose weight, have orthostatic hypotension, and demonstrate a negative fluid balance. In cases of CSW and SIADH, the laboratory values often are the same for serum/urine osmolalities and electrolytes; however, elevated serum blood urea nitrogen (BUN), serum potassium and serum protein concentration are also supportive of the diagnosis of CSW. Additionally, serum uric acid is normal in patients with CSW and is low in persons with SIADH.
Treatment of this type of hyponatremia with associated dehydration consists of replacement of fluids and salt, which is best managed by IV normal saline or, in rare cases, by IV hypertonic saline. Rehydration significantly reduces the risk of cerebral ischemia or cerebrovascular accident.

Diabetes Insipidus (DI)

DI is rare, with an estimated one case per 100,000 hospital admissions. Post-traumatic DI occurs in 2 to 16% of all cases. The most common etiologies of post-traumatic DI include severe closed head injury, frequently with basilar skull fractures; craniofacial trauma; thoracic injury; postcardiopulmonary arrest; and intraventricular hemorrhage in neonatal patients. DI frequently is associated with cranial nerve injuries. The usual onset is 5 to 10 days following trauma.
Characteristic features of DI include polyuria, low urine osmolality, high serum osmolality, normal serum glucose and normal to elevated serum sodium. Urine output usually is greater than 90 mL/kg/d, with a specific gravity of less than 1.010 and an osmolality of 50 to 200 mOsm.

Anterior Hypopituitarism (AH)

AH, anterior hypopituitarism or panhypopituitarism, is not as rare a complication after a closed head injury; it usually follows moderate to severe craniocerebral trauma. With improvements in emergency and acute neurosurgical care for patients with head injuries, a greater number of severely involved patients are surviving than had previously done so. This subset of patients is most susceptible to the development of AH. The mechanism through which AH develops in patients with severe head injuries is an interruption of the major blood supply to the anterior lobe of the pituitary gland because of trauma to the unprotected stalk connecting the anterior pituitary to the median eminence of the hypothalamus.
Additionally, the hypothalamus secretes releasing and inhibitory hormones into the portal or stalk circulation, for controlling the release of the anterior pituitary hormones. Although the pituitary gland is well protected by the bony sella turcica, the pituitary stalk is not covered by dura mater and lies in the subarachnoid space. Severe craniocerebral injury may traumatize the stalk directly, or an anterior lobe infarction can occur due to impaired portal system circulation secondary to shock and cerebral edema.
The arterial blood supply of the posterior lobe of the pituitary comes directly from the inferior hypophyseal arteries branching from the internal carotid arteries. The posterior pituitary hormones are secreted by the hypothalamus.
Autopsy studies of 100 patients who died from craniocerebral trauma demonstrated pituitary lesions in approximately 60% of the group. Of those subjects with pituitary lesions, 59 demonstrated capsular hemorrhage, 42 demonstrated posterior lobe hemorrhages, and 22 revealed anterior lobe ischemic necrosis. Most patients (20 of 22) with anterior lobe ischemic necrosis died within the first seven days following injury because of the severity of the craniocerebral trauma associated with shock and severe cerebral edema. Clinical AH is so rare in association with closed head injuries because most of these patients do not survive secondary to the severity of their injuries. This clinical syndrome presents itself only when two-thirds of the anterior pituitary has been destroyed.
The syndrome of AH may manifest an insidious onset weeks to months after the original closed head injury. The patient may become progressively lethargic or anorexic and may demonstrate hypothermia, bradycardia or hypotension with hyponatremia. These symptoms result in a significant setback if they occur during the acute phase of rehabilitation of a patient who has sustained a closed head injury. Any unexplained onset of malaise and generally decreased vital signs with associated stagnation of the rehabilitation progress in a patient following closed head injury should prompt the clinician to suspect the presence of AH.
AH following TBI can be obscured by the cognitive impairment of the patient and can contribute to delayed progress in rehabilitation.
The endocrine workup for AH includes serum hormonal assays, such as cortisol (0900), testosterone, triiodothyronine (T3), thyroxine (T4), thyrotropin, follicle-stimulating hormone (FSH), luteinizing hormone (LH) and estrogen (for females). Insulin-like growth factor-I (IGF-I) is a screening assay for growth hormone (GH) deficiency. Advanced provocative GH testing may be necessary to confirm this diagnosis. Also perform a complete blood cell (CBC) count and serum electrolyte evaluation.
Treatment involves multiple hormonal replacement therapy, as well as monitoring of the patient’s serum levels and clinical response. The patient usually responds with improved vital signs, improved constitutional symptoms, and increased endurance for participation and progress in the rehabilitation program. The hormonal replacement therapy usually is required long-term.

Primary Adrenal Insufficiency (PAI)

PAI usually presents with the psychiatric symptoms of depression, confusion and apathy.
Additional features include self-mutilation, paranoia, psychosis and schizophrenic behaviours.
The mechanism of the psychiatric presentation is related to factors such as hypoglycemia, elevated exogenous endorphins, and axonal conduction changes.
Progressive deficiency of glucocorticoid and mineralocorticoid hormonal activity leads to hypotension, fatigue, anorexia/nausea, hyperpigmentation and progressive, generalized weakness. Diagnosis of PAI is difficult in patients with TBI, because these particular symptoms may be ascribed to the TBI itself.
The most common cause of PAI is autoimmune or idiopathic adrenalitis (in 65 to 84% of cases). The next most common etiology is adrenal parenchymal destruction secondary to tuberculosis, sarcoidosis, malignancy, acute sepsis (including systemic fungal infections) and acquired immunodeficiency syndrome (AIDS).
Acute adrenal crisis may result from bilateral adrenal hemorrhage from trauma, sepsis, surgery or acute burns. If this problem is unrecognized, acute adrenal crisis may lead to acute shock and death. Adrenal failure is usually permanent in patients who survive the acute phase of the adrenal crisis.
Several rare hereditary syndromes are associated with PAI, such as familial glucocorticoid insufficiency, adrenoleukodystrophy and adrenomyeloneuropathy. PAI results from a deficiency of glucocorticoid and mineralocorticoid hormonal activity, combined with a reduction of feedback to the anterior pituitary gland. The cortisol deficiency results in excessive secretion of corticotropin from the anterior pituitary gland and excessive secretion of corticotropin-releasing hormone from the hypothalamus.
The presentation of PAI may be acute, characterized by nausea, vomiting and hypertension. Alternatively, this clinical entity may present insidiously, with slow development of non-specific symptoms over a prolonged period. The most common features include fatigue, weakness, anorexia and weight loss. Additional findings include hyponatremia, hyperkalemia, skin hyperpigmentation and gastric motility impairment that leads to complete gastric stasis.
Physiatrists must be aware of PAI, even though it is rare, because the presentation of adrenal insufficiency can be similar to the presentation of TBI. The symptoms limiting rehabilitation of patients following TBI can be attributed to the brain injury itself or to deconditioning secondary to prolonged bed rest. Treatment of this underlying problem by mineralocorticoid and glucocorticoid replacement therapy can result in a significant improvement of rehabilitation progress and outcome.

Summary

Approximately 30 to 50% of patients with moderate to severe head injury demonstrate endocrine complications. These problems may not present in a classic textbook fashion in persons who are severely impaired following TBI. The only clue to determining endocrine complications may be an unexplained failure to progress or a setback in the TBI rehabilitation program.
The most common endocrine abnormality is SIADH, followed by DI.
SIADH is the most common cause of hyponatremia; however, other causes include fluid overload or extra-cellular fluid depletion from GI or renal loss of sodium. Criteria for diagnosis of SIADH include low serum osmolality, hyponatremia and inappropriately concentrated urine (with urine sodium >25 mEq/L).
Hyponatremia that remains unresponsive to standard treatment for SIADH should point the clinician to other causes of hyponatremia.
Another clue to recognizing adrenal insufficiency is hyperkalemia associated with the hyponatremia secondary to a loss of mineralocorticoid activity at the kidney, causing urine sodium loss, impaired excretion of potassium, and hydrogen ion retention.
Azotemia may also be associated with adrenal insufficiency.

Surgical Intervention

Endocrine complications following traumatic brain injury (TBI) are treated by medical management and usually do not require surgical intervention.

Consultations

Endocrinology subspecialty consultation may be needed following traumatic brain injury (TBI) in patients who demonstrate subtle findings of underlying endocrine abnormalities, as evidenced by a slowdown or complete halt in the progression of a TBI rehabilitation program. This group of patients includes those who have a growth delay (pediatric patients) or unexplained constitutional symptoms of lethargy/poor appetite following TBI, and young female patients with amenorrhea following TBI.

From the endocrinologist’s perspective, patients with vital endocrinopathies such as diabetes insipidus, secondary adrenal failure and secondary hypothyroidism should be promptly treated with hormone replacement therapy (HRT). Secondary hypogonadism and severe growth hormone (GH) deficiency should be considered later, after replacement of other deficits and after retesting. Patients who are severely involved in a persistent vegetative state would not likely benefit from HRT for secondary hypogonadism or GH deficiency. GH replacement therapy outcomes include increased muscle mass/exercise tolerance and improved quality of life/sense of wellness.

Post-TBI patients functioning at a very low level who are institutionalized should receive HRT only for vital endocrine hormones, including hydrocortisone, vasopressin and T4. All patients with moderate to severe TBI should receive a baseline pituitary hormone deficiency evaluation, especially if they were hospitalized for at least one day post-TBI.

Medication

The goals of pharmacotherapy are to reduce morbidity and prevent complications.

Hormone Replacements

Because most endocrinopathies following traumatic brain injury are due to failure at the anterior pituitary level, treatment involves hormonal replacement. Individual hormonal replacement is also indicated, depending on the specific endocrine gland involved. Posterior pituitary failure is also treated by replacement therapy.

Levothyroxine (Levoxyl, Synthroid)

In the active form, this drug influences growth and maturation of tissues. Involved in normal growth, metabolism and development. Primary use is for synthetic thyroid hormone replacement. Secondary use is for suppression of pituitary thyrotropin for management of thyroid carcinoma or thyroid nodules. Titrate to degree of hypothyroidism.

Desmopressin Acetate (DDAVP)

Synthetic analogue of hypothalamic/posterior pituitary hormone 8-arginine vasopressin (ADH) for treatment of central DI. Not for treatment of nephrogenic DI. Dose should be titrated to plasma/urine osmolality and urine volume.

Testosterone (Andro-LA, Androderm, Depo-Testosterone)

For treatment of primary hypogonadism or hypogonadotropic hypogonadism.

Hydrocortisone (Cortef, Solu-Cortef)

Used for treatment of primary or secondary adrenocortical insufficiency.

Used short-term to treat flare-ups of rheumatologic conditions. Used for prolonged maintenance of collagen diseases (e.g. systemic lupus erythematosus, polymyositis/dermatomyositis). Also used for dermatologic (e.g. pemphigus), allergic (e.g. atopic dermatitis) and respiratory diseases (e.g. sarcoidosis).

Pediatric growth and development may be suppressed and should be monitored.

Follow-Up

Further Inpatient Care

The clinical response of the patient after treatment has been instituted is the most important factor in determining the necessity of additional treatment. Follow-up endocrine studies (i.e. hormonal levels) are necessary at least weekly until homeostasis has been achieved. Serum electrolytes, BUN and creatinine levels need to be assessed at least daily until normalized, and then these levels should be monitored at routine intervals.

Further Outpatient Care

The outpatient follow-up care of these patients is individualized, depending on the endocrine problem under treatment and the patient’s metabolic stability.

Inpatient and Outpatient Medications

As stated previously, medication management consists primarily of hormone replacement until clinical response and normal serum levels have been achieved. In most cases, the HRT continues on a long-term outpatient basis. Most inpatients with associated electrolyte disorders are stabilized with intravenous electrolyte therapy before hospital discharge, and no further medication management is necessary.

Deterrence

No deterrence/prevention program exists for endocrine complications following traumatic brain injury. Early recognition of these problems through a high index of suspicion, close monitoring of serum electrolyte balance and prompt corrective treatment minimizes any negative impact these complications have on the rehabilitation outcome.

Complications

The most significant complication is failure to recognize these treatable endocrine complications, ultimately prolonging the rehabilitation program and decreasing the patient’s functional outcome following traumatic brain injury.

Osmotic demyelination of the CNS, caused by an excessively rapid correction of hyponatremia with IV hypertonic saline, is an unusual complication of TBI, albeit a serious and sometimes lethal one.Prognosis

The prognosis for the patient with endocrine complications following traumatic brain injury is good to excellent, assuming these sometimes subtle problems are diagnosed and treated promptly. Failure to recognize and treat these problems negatively affects the rehabilitation progress and eventually the long-term functional outcome17,18.

Patient Education

Depending on the level of patient cognitive impairment, the patient and his or her caregivers/guardians are advised to be aware of any changes exhibited by the patient, such as unexplained lethargy, decreased tolerance to activity or cold intolerance. These particular problems require immediate notification of the attending physician. The patient should undergo physician re-evaluation and, if necessary, an endocrine workup. Rapid corrective hormonal replacement therapy then can be initiated and monitored at a follow-up session with the treating physician. For excellent patient education resources, visit eMedicine’s Endocrine System Center. Also, see eMedicine’s patient education article Anatomy of the Endocrine System.

Medicolegal PitfallsThe most significant medical/legal pitfall is delayed diagnosis or failure to diagnose neuroendocrine abnormalities following traumatic brain injury (TBI), especially in a patient with severe cognitive impairment. Should this problem remain untreated, the progress and eventual outcome of the patient’s rehabilitation may be significantly compromised. Non-reversible loss of function would be costly in terms of patient care needs and, more importantly, the patient’s quality of life.

About The Author

Milton J. Klein, DO, MBA, is Consulting Physiatrist, Sewickley Valley Hospital, Allegheny General Hospital, Harmarville Rehabilitation Center, Ohio Valley General Hospital, and Aliquippa Community Hospital. Reprinted with permission from eMedicine.com, 2010. Available at http://emedicine.medscape.com/article/326123-overview.

Ontario ePrescribing Takes Utilization Review to a New Level

Mon, 19 Apr 2010 14:31:00 GMT

They may not have known it, but for a number of years most employees covered under pay-direct (a.k.a. drug card) plans have had their prescriptions captured and monitored by real time drug adjudication systems that incorporate sophisticated control, security and safety logic. These controls have collectively been referred to by the employee benefits industry as DUR, for Drug Utilization Review. DUR systems check a patient’s current and newly prescribed medications for drug-drug and drug-allergy interactions, multiple doctoring, quantity restrictions and internal plan cost controls such as those for mandatory generic substitution, reimbursement limits, co-payments and maximums.

Enter ePrescribing. ePrescribing is a process that electronically generates, authorizes and transmits prescriptions from doctors to pharmacists. ePrescribing takes DUR to a new level of sophistication in the areas of safety and efficiency. eHealth, the electronic health record deployment entity of Ontario’s Ministry of Health and Long-Term Care, has committed $2.1 billion to the rollout of the ePrescribe system. A key component of eHealth Ontario’s Medication Management strategy, the plan is to have the electronic health record in place in all Ontario health care offices by 2015. Paper prescriptions are soon to be history.

To put the ePrescribing stakes in perspective, one U.S. source claims that paper prescriptions generate 900 million callbacks a year by pharmacists who can’t read physicians’ writing or who question the need for the drug being prescribed. That represents a staggering 30% of the annual prescriptions written in the United States. Extrapolate those numbers to Ontario alone and it becomes a lot clearer why medication morbidity and mortality should command more of our attention as consumers of medication. One estimate is that every year almost 400,000 Ontarians suffer a preventable reaction to medication.As is often the case with innovation, it took the public sector’s legislative and funding clout to champion a better solution. This is the good news. The bad news is that it took so long to do so in the face of compelling statistics and the availability of the prerequisite technologies and telecommunications infrastructure. Canada’s $30-billion employee benefits industry, for instance, has also taken limited steps along the ePrescribing path. Dominated by giants Sun Life, Manulife and Great West Life, whose collective market share approaches 70%, and their sub-contracted drug claim adjudicators, such as Telus Health Solutions, the industry has made some progress in getting ePrescribing functionality out to physicians. Perhaps market concentration can go hand in hand with innovation after all.

In fairness to our policy makers and private industry, the benefits of ePrescribing as a standalone capability pale in comparison to its benefits when it is integrated with the EMR (electronic medical record) capability. Here’s where ePrescribing works its magic. Reliance on EMRs to enhance the DUR function means that more information about the patient can be referenced in real time. Physicians and pharmacists can check diagnoses, body weight, age, drug appropriateness, correct dosing, contraindications and adverse reactions, and detect duplicate therapies in the doctor’s office or at the pharmacy counter before the drug is prescribed, and certainly before it is dispensed. The ePrescribing Demonstration Project is in the first trial implementation, in which two family physician practices were selected to pilot the system. Outcomes are expected to provide valuable lessons for a broader rollout. The project will provide pharmacists with access to electronic medical records to view pending prescriptions and a subset of clinically relevant information, as well as validate key electronic prescribing outcomes at the two sites.

The two sites selected for the project are the Group Health Centre in Sault Ste. Marie and the Georgian Bay Family Health Team in Collingwood. Both are advanced EMR users. During the trial, eHealth Ontario will examine workflow, change management requirements, regulation guidelines and the impact on physicians, nurse practitioners, pharmacists and patients. Participants include 16 general practitioners, five specialists and seven nurse practitioners from Group Health Centre and 24 general practitioners and four nurse practitioners from Georgian Bay Family Health Team. On the dispensing end, 22 pharmacies in Sault Ste. Marie and 17 pharmacies in Collingwood, Wasaga Beach, the Blue Mountains and Clearview (which includes Stayner, Nottawa, Duntroon and Creemore) are participating.

Each site will define an agreement procedure to manage patient consent to participate. The College of Nurses of Ontario, the College of Physicians and Surgeons of Ontario and the Ontario College of Pharmacists have been consulted regarding secure prescription authentication and patient choice, and have issued a joint letter of support for the project.

Practice Management Software Selection Rule 1: Understand Your Requirements

Tue, 13 Jul 2010 19:09:00 GMT

Whether you are a physician, a psychologist, an occupational therapist, another type of health professional or an administrator, the complexity of managing your office and vital patient functions tends to go hand in hand with the diversity of your practice model. That applies especially to multidisciplinary practices and those assessing or treating patients covered under more than one plan or program.

In the multi-faceted world of health services delivery, secure automation of “front clinic” and “back office” processes has never assumed greater importance. That is where practice management software can either help you or hinder you. When purchasing and implementing practice management software (PMS), you will be doing far more than simply loading a disk in your DVD tray and clicking the install icon. Furthermore, when you make the decision to purchase one product over another, you will reap what you sow in terms of patient management, productivity, compliance and financial management. To use what is perhaps a clumsy analogy, a little analysis and pre-planning will ensure that your harvest is weed free.

The PMS world is a crowded one. Claims abound as to products’ functional integration, automation, performance, pre/post installation support and technology compatibility. Truth be told, unless you have the scale and resources to build your own, the software you adopt will necessarily be a compromise among competing factors. If the lowest cost is your driving criterion, you may be trading off support, performance, integration or the automation of a critical process or function. That is not a bad thing as long as the trade-off is a conscious one based on sound assumptions about your needs.Whether they are large or small, public or private sector, every health practice contemplating making a PMS purchase should conduct a well-considered analysis of requirements. This rule applies whether you are going to build your own system or buy a package from a system vendor. Knowing what you need in objective terms will ensure that your purchase is an informed one. Make the purchase based solely on a gut feeling or the allure of the vendor’s claims for his or her product and you will pay a big price in practice disruption and crisis management.

In this article, we provide a simple step-by-step approach to determining your requirements. However, we would advise that “enterprise scale” practices of 200 or more staff should engage a competent IT professional who has experience with a conventional systems development methodology.

Step One: Define your facility’s current patients and clients

Perhaps it is human nature, but many clinics describe their patients in program or funding source terms: he or she is an “LTD,” “OHIP,” “auto insurance” or “WSIB” patient or client. Though it is critical from a management perspective to know where your patients or clients are coming from and to master the procedures you might have to follow when making treatment recommendations to third parties, or billing for your services, let’s agree that a patient is first and foremost a unique person. And persons have names, genders, conditions, medical histories, relatives and locations. It sounds pathetically simple, but we need to state the obvious sometimes because we lose sight of it.

All types of PMS allow you to record client information somewhere or other. In a requirements definition context, though, the key message at the outset is that the patient as a person is a distinct entity that is independent of any program, funding source, invoicing procedure or referral source. Purchase a system that ties the definition of patient to any of those other entities, processes or functions and you will have inadvertently chosen a path that has a dead end and no means of returning to “GO.” Canoeists refer to this condition as being up a creek without a paddle.

Step Two: “Map” your patient relationships in functional terms

Find yourself a flip chart. Draw a stick person or circle in the middle of it, then draw eight radiating arrows away from it and write the following headings at the ends of the arrows, one for each arrow.

Providers
Scheduling
Goods, Services and Fees
Referral Sources
Documentation
Service Activity
Payers
Management Reporting

Step Three: Draw arrows from your headings to sub-headings

Do this for each of the headings in a way that defines the headings. For example, Goods, Services and Fees sub-headings could be Assessments, Tests, Devices/Appliances, and Fee Schedules. Payer sub-headings could be Patient Pay, Insurer EHC, and Legal. Notes, Reports, Correspondence, and Forms could be Documentation sub-headings and Service Activity sub-headings could be Time Units, Service Units, Dates, and CCI Codes.

Either beside or inside the stick person or your circle list all the information that defines “patient” or “client” that does not already fall under any of the headings above.

Step Four: Under each functional heading or sub-heading, list different types

System data analysts call these “instances.” We’ll just call them examples. When listing them, don’t limit yourself by the typical patient or your own experiences alone; rather, list all the possibilities based on your current practice model. Think globally, generically and objectively.

Under Providers, for example, list the practitioner types (e.g. MDs, OTs, Vocational Consultants) and other staff roles that could have a direct interaction with a patient, such as Referral Intake Coordinator. In addition, under the Provider heading only, place the letter I (for Internal) beside the types that are formally employed by your practice, either full or part-time, and an E (for External) beside those that are external to your practice but perform services for your clinic’s patients on your clinic’s behalf.

Under Management reporting, start with “Patient listing,” “Services performed,” “Services- performed-but-unbilled listing” and “Aged receivables listing.”

Step Five: On a new sheet, map “objects” to your basic business processes

Create a ring of evenly spaced circles and label them as follows:

referral sources
patients/clients
appliance/device suppliers
payers
sub-contracted staff or service providers
one circle each for external systems with which you must interface for transactional or document transmission purposes, such as HCAI, WSIB, OHIP

Then draw a circle in the middle of the ring and label it “practice hub” or “clinic hub.”

Draw lines between the inner circle and the outer circles to represent the following flows, using different colours or line hashing for each.

invoicing
assessments/tests/treatments
activity and other management reporting
document transmission and receiving
applications and claims for funding
payments and collections

Step Six: Visualize your future practice

Review your two pages again and add, modify or delete any of the items you expect to change over the next five years, using a different coloured marker for each of the three revision types (addition, modification, deletion) noting the year in which the change is expected to occur or in which you plan to make it effective. Do not erase any of your original items. Step Seven: Map your internal and external staff

to their locations by role typeFlip the current page over. On a new sheet, draw a box in the middle of the page. Label it “Administrative Hub.” Identify all the roles that work inside the hub, enclosing them in a circle if they are administrative roles, and boxes if they are health service delivery roles (e.g. OTs, physios, etc.) Do the same for the roles that fall outside the box, such as for home offices. Then draw lines between the roles that interact with each other electronically, whether for file transmission, email messaging or document management purposes.

Step Eight: List your performance and service expectations

Now flip the current page over. On another new sheet entitled “Expectations,” print a heading for Features, one for Performance and one halfway down the page for Service. Under Features, list specific requirements that have not been addressed elsewhere. Examples could be “pre-formatted claim form libraries,” “HCAI integration” or “statistical and financial reporting.”

Under Performance, list “Reports” and “Maximum No. Concurrent Users.” Under Service, write the words “Pre-Installation,” “Installation” and “Post Installation” from left to right, evenly spaced. Draw right-tipped arrows between the first and second, and the second and third words. Under Pre-Installation write “data analysis” and “conversion mapping.” Under “Installation,” write the words “data conversion” and “training.” Under “Post installation,” write the words “upgrade policy” and “service desk access.”

Step Nine: Create a blank space to illustrate an end-to-end patient life cycle walkthrough

Flip to a new page. Write the word “Scenarios” at the top. Leave this page blank below the heading.

Congratulations. Only five pages! You cannot call yourself a system analyst yet, but if you’ve come this far, you are certainly entitled to consider yourself expert in the way your practice operates.

You are now ready to invite prospective vendors in for a meaningful discussion of your requirements and learn how they propose to address them with their systems. At some point in the discussion, the vendor should ask you to describe a patient’s life cycle from start to finish. If they don’t, page five is your prompt to bring it up. When it becomes a point of discussion, think of the most complex hypothetical case, as in severe, multiple conditions, multiple payers, multiple representatives and agents. Do not base your hypothetical case on a typical patient; PMS systems succeed or fail on their ability to support variability.

When painting your scenarios for vendors, think in sequential terms, starting with the first time a referral source calls to discuss the particulars of a prospective patient or a prospective client walks into your clinic to inquire about service, and ending with the closing of their file as an active patient. Hence the expressions “life cycle” and “end-to-end.” In the functional, role and locational context you have painted on your first four sheets, you want to know how a vendor’s system supports that life cycle and where it leaves gaps. These gaps, or trade-offs, may be acceptable to you insofar as you are able to handle them with a “work around” that you can live with…or they may not.

Parting Tips

Listen attentively and take detailed notes. In your dialogue with the vendors, the following expressions should gain them points.

“We built our system using an open architecture”
“The system is integrated”
“Please tell me how your practice operates today”
“Many of our fields are user definable”
“Where possible, we have incorporated features that require you to input frequently used information only once”
“We are open to customizing your requirements”
“Single point of entry”
“Location-independent access”
“If you have special reporting needs we will only charge you for our time required to build it using our report writer”
“Our system is based on an SQL database manager”
“Our system has multi-level permissions”
“Our system is fully HCAI, WSIB compliant”

Comments that should prompt you to ask further questions:

“We upgrade our system according to a fixed schedule”
“Once you sign on, we will analyze your practice”
“We use an Access database”
“We do not customize, but will provide you with the source code”
“I know the system well because I created it and do all the enhancement myself”
“We will have to get a programmer to develop your customized reports for you”
“Your users must be connected in your office in order to use it”
“To create an OCF-21 or other invoice, you simply pull up the form and input your time and fees”
“It’s pretty fast up to 10 users”

The number of PMS vendors offering their product in Ontario has mushroomed, particularly since the advent of the HCAI system for auto insurance personal injury claims. Given that fees generated by auto insurance medical/rehabilitation benefits are about $2 billion per year, and the fact that 25,000 providers will have to sign up, it’s easy to see why Ontario has suddenly become an IT product manager’s dream. There is lots of competition, and significant investment is being made to build and enhance systems. We have listed a number of PMS vendors below. Most of them have websites.

Antibex Software
Clinicmaster
Clinic Server
Copen Computer Consultants
Healthlink Technologies
MSF Computing
Ontario Chiropractic Association (Patient Management Program)
SmartSimple

About The Author

Charles Spina is a management consultant who specializes in growth strategy and tactics, and brand-aligned operations design and management.

Cognitive Behavioural Therapy Can Aid Chronic Pain Sufferers

Tue, 13 Apr 2010 16:34:00 GMT

For many of the thousands of Canadian men, women and children who suffer from chronic pain, medication and physical therapy are simply not enough to help them successfully manage the daily discomfort they experience. Yet that is often the extent of their treatment, and so they are made to endure their pain, often feeling hopeless and emotionally distressed about their never-healing condition. Their treating physicians’ exhaustion of known treatment modalities often contributes to their despair, leaving them to suffer in silence and feeling ignored.

People who have suffered from motor vehicle accidents, in particular, often find themselves faced with seemingly untreatable chronic pain. In many cases the severity of the physical pain can trigger debilitating emotional and psychological pain as well. In addition to asking, “How can I manage or get rid of my pain?” they may also wonder, “Why do I feel as if my whole world is spinning out of control since my car accident?”

Chronic pain sufferers commonly experience intense feelings of stress, anger, frustration, anxiety and depression. The suddenness of a car accident means that your life and comfort level can change in a flash, transforming you quickly from a successful, confident and social person to someone who is insecure, anti-social and depressed. The inability to perform one’s social, vocational and domestic activities may result in increased isolation and negative feelings.

The more someone spirals downward toward depression and despair, the less likely it is that he or she will be able to overcome chronic pain. After all, stress, anger, frustration and anxiety can increase muscle tension, prolonging recovery in many cases.
Cognitive Behavioural Therapy (CBT)

Chronic pain sufferers should know that cognitive behavioural therapy may be a solution. The connection between depression and physical pain is strong, so it follows that these two experiences will improve and worsen together. Treat one, and the other will follow suit. Neglect one and your physical and psychological pain will last longer.Cognitive behavioural therapy is a skills-based treatment that employs different pain management techniques, such as muscle relaxation, visual imagery and diaphragmatic breathing. These practices reduce muscle tension, allowing otherwise tight and wound-up muscles (that are unable to heal) to loosen, unwind and, ultimately, heal. Other coping mechanisms that are taught in CBT include stress management, sleep hygiene and pacing of activities.

The “cognitive” element of CBT requires therapists and clients to work together to understand how negativity and depression are not only a result of pain, but actually contribute to and exacerbate chronic pain. Psychological assessments and therapy can supplement other rehabilitation treatments and therapies such as those performed by chiropractors, physiotherapists and massage therapists.

About The Author

Ilya Gladshteyn, MA, C. Psych. Assoc., has a practice in Clinical and Rehabilitation Psychology and is a member of the College of Psychologists of Ontario.
He can be reached at office.gppc@gmail.com or 416-479-0022x203
Website: http://www.gladshteyn.ca

Rehabilitation News

The MIG Takes Flight

FSCO states the objectives of the MIG as:

From the Heart: An OT in Haiti

This article highlights exceptional work done by an exceptional health professional in the rehabilitation industry. Please send suggestions for future profiles to publisher@thehealthprofessional.ca.

Noreen Shanahan is a writing instructor and a freelance journalist. Her articles and essays have appeared in The Globe and Mail, the Toronto Star, Toronto Life, Reader’s Digest, Geist, CBC Radio and other places. She can be reached at nshanahan@rogers.com.

Interdisciplinary Team Working in Physical and Rehabilitation Medicine

Introduction

Interdisciplinary Team Work

Organization within the Teams

Key Members of Interdisciplinary Teams in PRM, Their Qualifications and Roles

Relevance of Medical Diagnosis for Therapy and Rehabilitation

Safe Care Pathways

Conclusion

Toward a Paperless Office

Christine Peets is a freelance writer and a writing instructor. Her services include writing (or ghostwriting) articles for blogs, websites, magazines, newspapers and corporate reports. For further details visit www.CaptionsCommunications.ca.

Understanding Practice Risk

Service Disruption Risk

Cascading Risk: The (not so hypothetical) Case of the Compound Systems Failure

Patient/Client Diversification Risk

Financial Risk

Process Performance Risk

Errors and Omissions Risk

Concluding Thoughts

Charles Spina is a management consultant who specializes in growth strategy and brand-aligned operations design and management. He can be reached at c.spina@sympatico.ca.

Collaborative Relationships: A Chiropractor’s Perspective

Practising What We Preach

Christine Peets is a freelance writer and a writing instructor. Her services include writing (or ghostwriting) articles for blogs, websites, magazines, newspapers and corporate reports. For further details visit www.CaptionsCommunications.ca.

Launching Your Practice – Choices, Choices, Choices

The World of Care and Rehabilitation Funding

Making Your Marketing Work for You

How Do Clinics Lose Patients?

First Impressions

Make Time for New Patients

Front Office

Your Unique Selling Points

Online Image

Optimizing Your Website

Appearance is Everything

Angela West is a copywriter who specializes in website copywriting and social media through her business at www.workingwebcopy.com.

Ontario Auto Insurance Reforms

Post Head Injury Endocrine Complications

Pathophysiology

History

Physical

Causes

Syndrome of Inappropriate Antidiuretic Hormone (SIADH)

Cerebral Salt Wasting (CSW)

Diabetes Insipidus (DI)

Anterior Hypopituitarism (AH)

Primary Adrenal Insufficiency (PAI)

Other Post-TBI Endocrine Complications

Summary

Surgical Intervention

Consultations

Medication

Hormone Replacements

Levothyroxine (Levoxyl, Synthroid)

Desmopressin Acetate (DDAVP)

Testosterone (Andro-LA, Androderm, Depo-Testosterone)

Hydrocortisone (Cortef, Solu-Cortef)

Follow-Up

Further Inpatient Care

Further Outpatient Care

Inpatient and Outpatient Medications

Deterrence

Complications

Patient Education

About The Author

Ontario ePrescribing Takes Utilization Review to a New Level

Practice Management Software Selection Rule 1: Understand Your Requirements

Step One: Define your facility’s current patients and clients

Step Two: “Map” your patient relationships in functional terms

Step Three: Draw arrows from your headings to sub-headings

Step Four: Under each functional heading or sub-heading, list different types

Step Five: On a new sheet, map “objects” to your basic business processes

Step Six: Visualize your future practice

Step Eight: List your performance and service expectations

Step Nine: Create a blank space to illustrate an end-to-end patient life cycle walkthrough

Parting Tips

The more someone spirals downward toward depression and despair, the less likely it is that he or she will be able to overcome chronic pain. After all, stress, anger, frustration and anxiety can increase muscle tension, prolonging recovery in many cases.
Cognitive Behavioural Therapy (CBT)