Eli's Rehab Report

Documentation software can be your best friend -- or a thorn in your side

If you've considered purchasing documentation software for your rehab clinic, you have a lot of potential to bump up your productivity and maintain stellar records. Not to mention, you're right on track with the direction major payers are going.

But before you buy, take some time to ask yourself these five critical questions. Their answers could mean the difference between a good and a bad investment.

Ideally, documentation software will make life a lot easier and your therapists more productive, but beware that you're apt to lose productivity initially. "You're not only investing in the software, but in setting it up for your practice and training your staff," says Mitch Kaye, PT, director of quality assurance for PTPN in Calabasas, Calif.

That means you'll need to allow for extra time to get your therapists trained. But your vendor should be willing to help.

Good idea: When you're in the purchasing process, see if the vendors you like have good tutorial programs and a reliable technical support team. And it never hurts to ask your industry colleagues or the vendor approximately how long it takes to get your practice up to speed.

Many software products exist that tailor differently to every provider, so you'll want to consider things such as: What is my setting? Who will be using the software? What am I looking to improve in my documentation and record-keeping practices? Will I be able to add my old paper records to the program? What type of reports will I be able to generate? Will it interface with my current billing system? Understanding your reasons for wanting documentation software will steer you toward a more appropriate product.

Reality: Just remember that in a departmental setting like a hospital, "there is not one system that meets the needs of all departments: medical records, billing, nursing, therapy, etc.," says Denese Estep, OTR, with DE Consulting LLC in Atlanta. And interfacing between systems can be difficult.

So with that in mind, prioritize your department's (or practice's) needs, and that overwhelming list of vendors and products will start to narrow down.

Once you've established your basic needs, it's time to sort out the finer perks you need to make your software investment worthwhile. For example, "if you have a practice that focuses on a particular rehab specialty, you may want to make sure the program's evaluation forms meet your needs or that you can add your own forms to the program," Kaye says.

You may also desire the ability to conform to each therapist's evaluation methods. For example, if Therapist A evaluates knee's patients by measuring the knee's circumference, one inch above the knee, and one inch below; and Therapist B measures the knee's circumference and three inches above and three inches below the joint, each therapist may want their own customized forms to accommodate, Kaye says. "Some programs will allow for that, and some programs will have strictly one evaluation form."

Another thought: If you're of a statistical mind-set and want to examine your operations more closely, you may want a product that offers statistical analyses, such as how many patients a specific doctor has referred to your clinic, how many hip-replacement patients you have seen, patient outcomes for a particular therapist, your percentage of Medicare patients, etc., Kaye says.

This may seem like an obvious question, but when you're faced with purchasing site licenses for multiple therapists in a large practice, access is an important consideration. Ask the vendor if you'll have to pay for each therapist using the software, Kaye says. Don't forget to ask about assistants and aides usage too, he adds. "You should also ask what happens when temps or registry people need access and they don't have a license to use the particular product."

Don't miss: This is also a good time to ask about security features. You should have safeguards as to who is able to access patient charts. "Some programs offer different levels of access for different people or allow the practice owner to decide each staff member's level of access," Kaye says. The program should also have measures to protect each therapist's electronic signature.

Buying an expensive software license can do wonders, but it's not like waving a magic wand. "People need to realize that an electronic documentation system is only as good as the people using it," Kaye says. And some systems can allow you to get pretty lazy. Kaye recalls one product that shows the therapist the treatment given on the previous visit and allows the therapist to accept that as the current treatment. Then during a chart review, "there's a month of the same note being repeated day in and day out, with no progress documented," he says. And that's not going to help you get paid.

Good idea: Some programs make certain fields mandatory -- or that at least allow you to program mandatory fields. For example, "a program might require that for Medicare patients, you document the minutes you spent providing timed CPTs and the total treatment time before continuing to the next field," says Rick Gawenda, PT, director of physical medicine and rehab at Detroit Receiving Hospital and owner of Gawenda Seminars, "which may help with reimbursement," he adds.

Note: See the next issue of Physical Medicine & Rehab Coding Alert for important shopping tips.