Easing scheduling, minimizing documentation paperwork, integrating billing, maximizing efficiency, centralizing operations, increasing reimbursements, improving workflow, and reducing costs—there are a variety of reasons why the rehabilitation industry is using electronic documentation software. In any clinic, private practice, or hospital, this handy tool can help you with everyday business practices.

For the purpose of this article, we will feature four products that became the solution that addressed some of the issues mentioned above. Of course, you are not limited to these products only, so please review the sidebar below for additional company names and their contact information.

INFORMATION ORGANIZATON

Tracie Rodak, PT, works for Spartanburg Regional, a large not-for-profit hospital in South Carolina. She is manager of the outpatient pediatric rehabilitation program and treats the special needs population (young, early-intervention-type cases) that includes children with cerebral palsy, Down syndrome, and autism. Although the hospital has a large rehabilitation department, it uses software from Chart Links LLC (www.chartlinks.com) throughout it. "It is a rehab documentation system, so the entire medical record system is housed in Chart Links," she explains. Chart Links is headquartered in New Haven, Conn, and develops rehabilitation software that automates workflow for referrals, insurance authorizations, cross-discipline scheduling, documentation, charges, and more.

Problem/Situation: The hospital, as did the rehab department, wanted to move toward electronic documentation. "The paper chart system was archaic," she notes. "We used to have a big medical records room and all this filing. Records had to be hauled off to storage areas after so many years and catalogued."

Solution/Results: "Probably the absolute best thing about it is the fact that you don't have to go anywhere to look for information," Rodak says. "Before, we had to find the chart or track down the person who had it." Now, from any desk/computer, you can look up patient information. "As far as documentation—and we were told this up front—sometimes there's a misperception that electronic documentation is quicker," she stresses. "It might even be a hint slower, but it's the retrieval and the organization where you get your time savings."

Users will find reporting capabilities for managers who want to track productivity and attendance and see how many evaluations are being done. In addition, if you wanted to do some research on autistic children, for example, there's a way to designate a field, flag it, and pull out this information from a chart.

"Additionally, when a patient is checked in, our therapists automatically get a notification that says the patient is here. It creates an incomplete note and charge ticket," Rodak says. The therapists all have a list of how many notes they have left and how many evals and plans of care are due daily. "They are constantly working down their lists. Technically, they can't sign a file unless they've done all the parts," she says. "The nice thing is that they can't sign the note and forget to bill. The system won't let it happen.

"As a manager, I can see everyone's incomplete notes, where before, I wouldn't have any idea unless there was a problem. I'm able to manage better," she says.

ADHERENCE TO GUIDELINES

Elizabeth Lamb is director of Doctors Hospital Rehab Health Centers in Augusta, Ga. In the hospital-based OP clinic, her patients range from adolescent to geriatric. "We have a few specialties with our certified hand therapist and certified lymphedema therapist," she says. She chose Rehab Documentation Co, Nashville, Tenn (www.rehabdocumentation.com), not only because it offered an efficient system, but because she believed the company behind it had a solid commitment on adherence to CMS/Joint Commission guidelines. "It's also a nice benefit knowing that all this company does is focus on actual rehab documentation," she states. "The fact [it] solely focuses on one discipline—rehab—makes all the difference."

The Rehab Documentation Co helps PTs, OTs, and speech pathologists in all settings apply information technology to solve their clinical documentation, workflow, and business issues.

Problem/Situation: Increasing accuracy in billing, decreasing errors in documentation, increasing compliance in CMS guidelines, losing productivity due to handwritten documentation and the illegibility of documentation—these were some of the concerns the clinic faced. Was there something out there that was easy to use and could interface with their hospital system, reduce manual charge entry errors, and enhance revenue?

Electronic charting of patient information helps Todd Cadby, MS, PT, ATC, CGFI, (right) and his team work efficiently.

Solution/Results: According to Lamb, the software has rich clinical content built in the system specifically for PTs and OTs. "There's decreased documentation time," she explains. "As for paper notes, [it's] much faster, more efficient, and [we have] better productivity." In addition, Lamb sees increased accuracy in billing, and because of the interface, it automatically drops charges to bill directly from the therapists' signed notes. No manual entry is required. "We have been through many audits from The Joint Commission—Medicare, Medicaid, internal—and all auditors agree that this is the best documentation they have seen," she stresses. "Our physician referral relationships have been strengthened by the enhanced plan of care form and communication from therapists throughout the ReDoc system.

"The ReDoc software has been exceptional," Lamb continues. "Our notes are clean, consistent, and accurate. The system prompts you for those areas you might, in other circumstances, forget to include in your daily notes." Lamb says that Rehab Documentation Co is not just a business from which her clinic purchased a product. She views the relationship as a partnership.

"It's very easy to use. They have a tutorial, a testing database to ensure everything works properly, and a live customer support service team that is responsive to any of our needs," Lamb concludes.

A COMPREHENSIVE SYSTEM

Todd Cadby, MS, PT, ATC, CGFI, is an 18-year physical therapy veteran in private practice at Rebound Physical Therapy & Sports Rehab/Rebound Golf Performance in North Scottsdale and Carefree, Ariz. His specialty is outpatient sports medicine and rehab, which includes post total joint, post orthopedic surgery rotator cuffs, chronic back pain, and acute sprains and strains. "We have a collage of patients from grade school to 90-year-olds," he says.

Located in Tempe, Ariz, SpectraSoft (www.spectrasoft.com) offers scheduling, documentation, and billing software that helps document cases and capture billing codes.

Problem/Situation: Cadby has been charting since 1994, but electronic documentation wasn't applicable back then. "It had more to do with developing outcomes," he says.

Solution/Results: "Currently, I use electronic charting because of its ability to work from one common database. Everybody has access to patient information through the computer, as all files are kept on a server," he says. "It's very efficient because you input data as you go," he explains. "I don't have to go through dictation, a transcriber, and then come back with corrections and go back again.

"The other thing is that electronic documentation creates more thoroughness," he notes. "I like SpectraSoft because it was written by physical therapists. That's number one." Cadby mentions that it promotes the completeness of an evaluation through a pick-list of tasks that you can do such as a particular type of exam or something you might otherwise not remember. The software also helps with billing in terms of rejection. There's a better chance of reimbursement because the notes are more complete. Documentation always matches billing; all billable treatments are captured.

Cadby uses this analogy to stress more benefits of using SpectraSoft. "You're working from one central organized pot, and everybody can look into the pot and see that it's spaghetti tonight. Everybody can see what's going on with the patient. They can see special notes, so it's easy to problem-solve across all dimensions—the biller, front office, tech, therapist, and scheduler."

BILLING MADE EASIER

Jennifer Beal, PT, CLT, owns a small private practice in West Palm Beach, Fla, that has been open for 2½ years. She has a full-time PTA, a salaried DPT, a per diem massage therapist, and an OT on staff. There is also a full-time receptionist (patient service rep) and an office manager. Beal, as well as the DPT and LMT, are certified lymphedema therapists. "Previously, I was manager at Martin Memorial Med Center South outpatient rehab center for 8 years, where we used TherAssist (www.therassist.com), and I became familiar with that system," she says. "That is why I decided to use it in my practice, especially since they added the billing component to the system." TherAssist Software LLC is located in Highland Park, Ill, and provides document and management solutions for therapy, rehabilitation, and medical practices.

Inputting treatment data on the spot reduces the need for dictation and transcribing.

Beal's patient load is varied and includes back and neck pain, vestibular and balance issues, postop shoulders, joint replacements, hands, oncology, and lymphedema patients.

Problem/Situation: When she started her practice, Beal had only a part-time PTA on staff. She wanted to use a Web-based system so that she would not have to worry about having a modem or the storage space necessary for the daily treatment notes.

Solution/Results: With TherAssist, less space for storage of old medical records is needed as it is all online and always available to download. "Therefore, I only keep on-site a file of the signed POCs and documents signed by the patients," Beal explains. "It also gives me the flexibility of doing my notes from home without having to worry about transporting medical records," she says. It allows Beal to customize her setup of objective groupings specific to her patient load, including a group of specific vestibular tests as well as groups of lymphedema measurements. It makes it very easy to compare measurements at evaluation to follow-up visits.

"It is very user-friendly if it is set up correctly from the beginning," she notes. You can even make specific phrases or measurements "mandatory" so that all important data are present in the evaluations or subsequent notes. It must be set up initially to use phrases (or "quick-picks") that are what you specifically want to make sure that the therapists address on a regular basis. "One of the things that I feel it has over other products that I have looked at is that it now has a billing program that we use, so that we no longer have to be concerned about interface problems [we had with a different product].

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"TherAssist has excellent reports that are user-friendly and very useful in tracking stats, weekly or monthly, using whatever parameters you choose. The support staff will gladly set up any additional reports that are requested, so that is what made me feel totally comfortable with choosing this program for both documentation and billing as my practice continues to grow."

It has been suggested that having the right practice software can make or break a rehabilitation department or clinic, and that how well your therapists complete their paperwork is a key to financial success. So if you're looking for better ways to make more informed management decisions, and maximize efficiency, productivity, and quality of care, it's probably time to consider electronic documentation software. Tighter reimbursement rules and the need for therapy-based systems have also been driving forces in the development of cutting-edge rehab practice technology. Practices of all sizes, as well as hospitals with single- and multisite operations, can manage departmental goals while giving clinical staff a documentation system that allows them to spend more time with their patients and less time handwriting their notes. Documenting every visit and treatment, and matching billing to the documentation, are some of the tasks that can be done with the click of a button. The result just may be an increase in your billings and collections, and a reduction in your insurance denials.

Nina Silberstein is a contributing writer for Physical Therapy Products. For more information, contact .