Tiny Town Clinic Case Analysis: Laurie Burke, Celia

Running Head: TINY TOWN CLINIC CASE ANALYSIS 1

Tiny Town Clinic Case Analysis:

Hybrid Delivery Model for Physical Therapy Services

Laurie Burke, Celia Dolinta and Harry E. Scher

Texas Woman’s University

Author Note1

Laurie Burke, The Houston J. and Florence A. Doswell College of Nursing, Texas

Woman’s University; Celia Dolinta, The Houston J. and Florence A. Doswell College of Nursing,

Texas Woman’s University; Harry E. Scher, The Houston J. and Florence A. Doswell College of

Nursing, Texas Woman’s University.

1 Alphabetical order

TINY TOWN CLINIC CASE ANALYSIS 2

Table of Contents

Tiny Town Clinic Placement in the Micro/Meso/Macro Systems Conceptual Framework………3

Services Needed for Tiny Town Clinic with Rationale………………………………………… 4 Finances…………………………………………………………………………………………..20 Current Revenue and Sources…………………………………………………………...20 Potential Funding Sources……………………………………………………………….21 Proposed Budget………………………………………………………………………...21 Current Workflow in Tiny Town Clinic………………………………………………………... 22 Measurable Outcomes from EHR, PT and Telehealth Services to Document Quality of Care... 23 Outcome A - EHR - Demographic Data Entry on 80% of All Patients ………………..26 Outcome B – Physical Therapy – Glycosylated Hemoglobin on Diabetics……………..26 Outcome C – Telehealth – Weight Loss and Glycosylated Hemoglobin………………..26 Decision Regarding Recommended Products and Rationale for Selection……………………... 28 Electronic Health Record………………………………………………………………..28 Physical Therapy Equipment……………………………………………………………30 Telehealth Equipment…………………………………………………………………...30 Project Management Plan……………………………………………………………………….. 30 Summary Document of Recommendations…………………………………………………........35 References………………………………………………………………………………………. 36


Appendices……………………………………………………………………………………… 42 Appendix A – Physical Therapy Advisement Form…………………………………….42 Appendix B – Physical Therapy Consultant Recommendations………………………..48 Appendix C - High Performing Clinical Microsystem………………………………… 53 Appendix D - Listing of Recommended equipment for Tiny Town Clinic…………… 54 Appendix E - Tiny Town Clinic Patient Flow Chart………………………………….. 55


Tiny Town Clinic Case Analysis: Hybrid Delivery Model for Physical Therapy Services

Tiny Town Clinic (TTC) is the only healthcare facility in Tiny Town. It is located

approximately 45 miles to the nearest clinic. The clinic serves a community of 2,818 and meets

the primary healthcare needs of the local population as well as those who are temporarily

relocated to the area for employment purposes. A nearby border patrol station brings illegals to

the clinic for medical clearance prior to their being sent to a holding facility. There are also

patients who obtain primary care services at the clinic as their primary care provider is located an

excessive distance from their homes in Tiny Town.

Tiny Town is an example of a microsystem. It provides front line health care services

to a significant number of people in the community. The clinic is part of a larger health system.

There is no business manager on site at TTC. Billing functions are facilitated at a remote

location. It is also known that a business/clinic manager is not listed as a clinic employee for the

clinic. (Handouts provided on blackboard regarding TTC). This clinic is also part of a

mesosystem, defined as when two or more clinical or supporting microsystems are joined

(Godfrey & Nelson, 2011). Front line health care facilities need a system for referral for the

patients who may need urgent care specialty care. These referral sites and specialty providers

then become part of the mesosystem that supports TTC. The individual departments and service

providers that are available for TTC fit into a larger organization known as a macrosystem, which

can be a hospital, a multispecialty group practice, or integrated health system (Nelson et al.,

2008). In the case of TTC, the macrosystem is likely to be a hospital or an integrated health

system.


Needed Services for Tiny Town with Rationale

Personal health portal. Jorch (2007) reports that the patient portal is a secure web site

that displays health records. Patient portals provide a direct communication link with doctors and

nurses. The use of a patient portal in TTC provides the clinic staff the ability to preregister

patients while providing access lab results, writing prescriptions, and billing for services rendered.

Jorch (2007) notes that the biggest challenge of implementing the patient portal is developing

secure communication so that sensitive medical information cannot be accidentally divulged.

MyChart from EPIC is one of the examples that has an integrated the patient portal. MyChart

gives patients controlled access to the same Epic medical records that providers use via browser

or mobile app (iOS and Android). EPIC (2014) noted that the self-serve online functions may

activate patients to improve their own health, reduce the cost of customer service and provide a

vital communication link to support accountable care. MyChart allows patients to access the test

results, view upcoming appointments and complete pre-visit questionnaires. It also provides an

interface that allows patients to schedule appointments, view paperless statement and pay bills,

upload photos, update medications and allergies, and refill prescriptions. A unique software

feature provides a secure messaging function that provides an electronic patient-to-provider

communication tool. While viewing medical records, MyChart provides documents on a wide

array of education topics. The software is also programmed to send patients electronic chronic

disease alerts that are triggered by electronic health record (EHR) data. TTC staff will have the

ability to make decisions on what information is displayed as a matter of course and what should

be available through direct provider-patient interactions.


E- prescribing. According to Centers for Medicare & Medicaid Services (CMS) (2014), e-

prescribing gives providers the ability to electronically send accurate, error-free and legible

prescriptions directly to a pharmacy from the point-of-care. Pennell (2009) notes that e-

prescribing has been described as the solution to improve patient safety and reduce sky-rocketing

medication costs. It is estimated that approximately 7,000 deaths occur each year in the United

States due to medication errors. Pennell (2009) states that these errors are predominately due to

handwriting illegibility, inaccurate dosing, and overlooked drug-drug or drug-allergy reactions.

There are approximately 3 billion prescriptions written annually, which constitutes one of the

largest paper-based processes in the U.S. (Pennell, 2009). This targets e-prescribing as a vital

element in improving the quality of patient care. CMS reports that adopting the standards to

facilitate e-prescribing is one of the key action items in the government’s plan to expedite the

adoption of the EHR and build a national electronic health information infrastructure in the

United States.

It is essential for TTC to integrate e-prescriptions in their EHR to improve patient safety

and overall quality of care. Since the mesosystem of TTC is a hospital 45 miles away, the

management of TTC should coordinate with the leaders of the hospital to provide resources such

as installation of high-speed internet connection, computers, and an EHR system, which includes

e-prescribing. One networking company that Pennell (2009) has recommended is SureScripts.

TTC may use SureScripts as it is the nation’s largest electronic prescribing network that provides

a true, seamless electronic connection between physician offices and pharmacies. This network

provides secure and reliable two-way transmissions between physician offices and pharmacies

(Pennell, 2009). TTC will realize several benefits if e-prescriptions are integrated in the EMR.

First, TTC will notice an improvement in patient safety and overall quality of care. The


illegibility from hand-written prescriptions provided by TTC providers will be eliminated,

decreasing the risk of medication errors and liability. The e-prescription system can also provide

an overall medication management process through drug utilization review (DUR) programs.

DUR programs perform checks against the patient’s current medications for drug-drug

interactions, drug allergy interactions, diagnoses, body weight, age, drug appropriateness, correct

dosing, contraindications, adverse reactions, and duplicate therapy alert (Punnell, 2009). Second,

TTC will notice a reduction or elimination of phone calls and call-backs to pharmacies clarifying

orders. Punnell (2009) reports that physician offices receive over 150 million call-backs from

pharmacies with questions, clarification and refill requests. These call-backs interrupt office flow

and reduce productivity related to chart-pulls and refilling, follow-up calls, and faxing

prescriptions. Third, e-prescribing will streamline the refill requests and authorization processes.

Punnell (2009) explains that refill authorizations from the pharmacies can be a completely

automated process and refills can usually be generated in one click of the mouse. The pharmacist

generates a refill request/authorization that is delivered through the network to the provider’s

system. The provider then reviews the request, approves or denies the refill, and the pharmacy

system is immediately updated. Fourth, the compliance rate of TTC will increase. Punnell

(2009) noted that 20% of paper-based prescription orders remain unfilled by the patient. E-

prescribing systems expedite the filling of prescriptions at the pharmacy, and drug literature can

be printed and given to patients. E-prescribing will also increase the convenience for patients in

Tiny Town by reducing patient trips to the pharmacy as well as reducing wait time. Fifth, e-

scribing will improve Tiny Town’s formulary adherence. By checking with healthcare

formularies at point-of-care, generic substitutions and generic first line therapy choices are

encouraged, thus reducing patient cost (Punnell, 2009). Sixth, TTC providers will have full


mobility of prescribing anytime and anywhere. Seventh, the reporting ability of TTC will be an

improved query reporting system. This function will be helpful in identifying those patients who

are being treated with a medication that is has been recalled or discontinued (Punnell, 2009).

Office management software. Increasingly, providers are seeking software solutions,

such as integrated EMRs/Practice Management (PM) systems that accurately measure and reflect

clinical, financial, and quality improvements. This allows physicians and office administrators to

set performance goals appropriately across the practice. Integrated EMR/PM systems offer the

most comprehensive reporting of hard data and metrics to help manage issues such as population

health conditions, track provider performance, and identify first-time claims rejections. In

addition, less tangible analyses can be performed, such as staff scoring and patient satisfaction

(Hicks & Lieberthal, 2013).

Practice Fusion is a viable, affordable EMR software option for TTC. Practice Fusion is

the largest and fastest-growing healthcare platform, with a mission of connecting doctors, patients

and data to drive better health care practices and save lives (PR Newswire, 2014). Medical

professionals can sign-up for Practice Fusion online anytime and be live with their new EHR

system in just five minutes at no cost. PR Newswire (2014) noted that unlimited meaningful use

support and integration with local labs and imaging centers are included in Practice Fusion’s free

service. PR Newswire (2014) states that Practice Fusion’s free EHR is compliant and has been

certified as a Complete EHR by Drummond Group, approved by the Office of the National

Coordinator’s Authorized Testing and Certification Body (ONC-ATCB) to certify any complete

or modular EHR both ambulatory and inpatient, in accordance with the applicable certification

criteria adopted by the Secretary of Health and Human Services (HHS). PR Newswire (2014)

reports that in a 2014 survey, 83% of Practice Fusion users reported the company’s meaningful


use dashboard is excellent or above average, and only 29% reported that it is difficult to navigate.

The World Economic Forum recognized Practice Fusion as a technology pioneer for the year

2013. Practice Fusion has partnered as well with free clinics, nonprofits and community health

organizations throughout the country, including the National Association of Free and Charitable

Clinics (NAFC). This free software is an ideal implementation choice for TTC as it complies

with meaningful use requirements for reimbursement from Medicaid and Medicare.

Clinical decision support. Clinical decision support systems (CDS) are designed to

assist the clinician in making decisions about a specific patient. There are several tools including

computerized alerts and reminders to providers, clinical guidelines, condition-specific order sets,

focused patient data reports and summaries, documentation templates, and diagnostic support, to

name a few (HealthIT.gov). The intention is to increase quality of care, avoid errors and adverse

events while improving efficiency. The bottom line is cost effectiveness coupled with quality

patient care. One important consideration is determining the approach in which the system will

work with patients who have co-morbidities, confounding conditions, or other circumstances that

might affect a medically complicated patient (Hyman, 2012). Based on the population seen in

TTC, a beneficial function of CDS would allow communications that will alert the clinicians

about unusual data specific to a particular patient regarding encounters with other providers,

current medications, and tests that have been ordered at other facilities within the health care

system. One example of a clinical decision support tool that was developed by the Veterans

Health Administration (VHA) is called “Tool to Enhance Management of Symptoms (TEMS).

The CDS tool can be used in the EHR to adapt clinical strategies to the preferences, symptoms,

behaviors, and clinical histories of individual patients (Nader et al. 2009). In the VHA, TEMS

collects information on a portable electronic tablet (Panasonic model CF-08) that enables


respondents to answer questions by using a hand-held stylus similar to a pen, or alternatively by

touching the screen with a finger. After a patient has had vital signs measured, the medical

assistant registers the patient in the tablet-based survey application and remains with the patient in

order to help with any technical difficulties. The tablet queries patients about their symptoms by

using symptom questionnaires. The TEMS elicits symptom information at the time of check-in,

filters, and organizes that information into a concise and clinically relevant EHR note available at

the point of care, and facilitates clinical responses to that information (Nader et al., 2009). TTC

can also create a CDS tool to encompass a wide spectrum of information management necessary

for clinical care. These tools should synchronize with the workflow of a typical visit at TTC.

Health education documents for patients. Practice Fusion is a superior choice for EHR

as it is designed to fit any system. Practice Fusion (2014) notes that this system makes patient

education materials, discharge instructions, and drug information sheets easily accessible within

the provider’s workflow. Practice Fusion also ensures that the educational contents are

evidenced-based, easy-to-understand, and consistent with current medical practices and

guidelines. The content of Practice Fusion is peer-reviewed and updated four times a year by

medical professionals in common specialties. Practice Fusion (2014) reports that the educational

content is written at a 5th to 8th grade reading level to address the needs of the large percentage of

patients with low health literacy. Some of the educational materials are written at or below 4th

grade reading level and are marked as “easy-to-read”. The standards for easy-to-read materials

include creative use of color, subheadings, bullets, and illustrations to increase comprehension.

Practice Fusion also has video options that can engage patients at varying health literacy levels

using digital and animated graphics.


Provider order entry. Provider order entry in the EHR is a feature that allows providers

to efficiently enter orders into the record after developing the patient plan of care. As one might

expect, some writers refer to this feature as Computerized Physician Order Entry (CPOE).

Numerous articles have been written about CPOE as if it were merely electronic prescribing. As

stated by Hoyt, Yoshihashi and Bailey, (2012), CPOE is the actual feature that orders

medications, lab tests, x-rays, consults and other diagnostic tests (p. 67). Based on the fact that

the TTC has limited resources related to staff and clinical support, an EHR must be selected that

includes a provider order entry feature that is well-designed and comprehensive in scope. Errors

are one of the more serious concerns that plague both the inpatient and outpatient treatment

environments. With the appropriate software installation, TTC can utilize a CPOE system that

rapidly notifies the ordering provider of drug-drug interactions as well as medication dosage

errors. VHA has been using some form of CPOE for the last ten to fifteen years. With the

introduction of CPOE for medication ordering, illegible orders, non-existent hand-written drug

names, imaginary routes and nonsensical schedules were eliminated. A CPOE system that is

integrated with diet and diagnoses can alert providers of incongruent ordering scenarios such as

ordering insulin for a fasting (NPO) patient or a teratogenic drug for a pregnant patient (Dumitru,

2008).

A CPOE for TTC should also include a system of alerts. Alerts can be programmed to

assist the provider in numerous ways. Upon opening the EHR, providers can be alerted to

allergies as well as preventive health reminders and serious psychiatric issues. In the event a TTC

provider chooses to prescribe a medication on the patient’s allergy list, an alert would

immediately appear on the screen. This is an extremely helpful feature, as patients with low


health literacy often do not know the names or classes of the medications previously prescribed

that may have caused an allergic reaction.

In evaluating any EHR system, one concern to address is how different health care

systems effectively and efficiently shares patients’ medical information. For the patient who has

been referred to the hospital emergency department after presenting to TTC with an acute illness,

prompt access to the patient’s medical records at the hospital emergency department is crucial.

Hopefully, a CPOE may be designed that will allow the provider to place an order that will result

in an immediate transfer of records to other health care providers or systems. While some may

consider the topic of EHR prosaic, it should be abundantly clear that their ultimate adoption and

full interoperability will prove fundamental to the future of medicine (Topol, 2012).

Interoperability with other entities. Interoperability, the exchange in health data

involving more than one medical facility, was cited more often as a barrier than as a facilitator to

EHR implementation in one study done in 2011 (McGinn et al.). Generally, inadequate

interfacing with other information technology systems (IT) was perceived as a barrier by users

and in some cases led to negative outcomes. For example, Ferris et al. (2009) found that when

there was no communication between medical offices and laboratories regarding test results, both

EMR and paper-based systems were required to manage test results. This issue can often lead to

increased time and man-hours required to manage test results that often includes scanning and

shredding documents.

An EMR will be beneficial to TTC only if the clinic system is well interconnected to

the hospital system. It is imperative that interoperability of the systems be such that health data is

available from outlying clinics, diagnostic facilities, and labs that all feed important information

into the system. To provide high quality care there needs to be sharing of data across the care


continuum and the multiple health care entities that are part of the mesosystem. EHRs can enable

a better quality of care if patients have essential health data accessible to their various providers.

Dr. Enriquez has indicated that her patient population has a large number of patients who have

chronic health issues being managed by other providers (Tiny Town, Texas, 2014). Efficient and

comprehensive care for TTC patients can be accomplished only when TTC providers have access

to outside records, diagnostic and lab results. This access would assist in preventing duplicate

services and create a more efficient healthcare system. A possible barrier to the provision of

efficient care is related to the interoperability with other EMR systems. Other healthcare entities

may be utilizing systems that do not effectively communicate with one installed in TTC. An

interesting perception noted when working with a high school population or one with low

education status reveals that patients often think that because their medical record is part of a

computerized system at one clinical setting, their health information is therefore available at other

facilities where a computerized EMR system is used. While that would be the ideal, it is not

currently reality.

Security. Yang, Lin, Chang, & Jian (2006) note that the protection of patient’s health

information is a very important concern in the information age. American Health Insurance

Portability and Accountability Act of 1996 (HIPAA) is a well-known model in the area protecting

patient information. HIPAA was enacted on August 21, 1996 with the goals of improving the

portability and continuity of health insurance coverage (Yang, Lin, Chang, & Jian, 2006). Yang,

Lin, Chang, & Jian (2006) presented two globally recognized principles in addressing health

information on privacy and security. During implementation of an EMR, TTC must facilitate

processes that assure that both privacy and security issues are addressed. First, the principle of

non-disclosure which states that covered entities may not use or disclose protected health


information (PHI), except as permitted or required by law. Secondly, when using, disclosing, or

requesting PHI, a covered entity must make reasonable efforts to limit protected health

information to the minimum necessary to accomplish the intended purpose of the use, disclosure,

or request. Yang, Lin, Chang, & Jian (2006) explain as well that with the privacy rule,

individuals have a right to access and amend the PHI. Each individual has the right of access to

inspect and obtain a copy of PHI about the individual in a designated record set; and the right to

have a covered entity amend the PHI or a record about the individual in a designated record set.

The covered entities can deny the individual request, and some PHI are exempted from the

individual’s access, such as psychotherapy notes; information compiled in reasonable anticipation

of, or for use in, a civil, criminal, or administrative action or proceeding; and health information

subject to the protection of the Clinical Laboratory Improvements Amendments of 1998 (Yang,

Lin, Chang, & Jian, 2006).

Yang, Lin, Chang, & Jian (2006) noted that HIPAA requires that all covered entities

that maintain or transmit health information electronically establish and maintain reasonable and

appropriate administrative, technical and physical safeguards to ensure integrity, confidentiality

and availability of the information. TTC will need to adopt security standards that are reasonable

and appropriate to maintain security such as: technical capabilities of record systems used to

maintain health information; costs of security measures; need for training persons who have

access to health information; value of audit trails in computerized record systems; and needs and

capabilities of small health care providers and rural health care providers (Yang, Lin, Chang, &

Jian, 2006)


Disaster back-up. Fahrenholz et al. (2009) identified two kinds of system downtime as

unscheduled and scheduled downtime. Unscheduled downtime is the time in which a functional

machine or system is not functioning properly or is otherwise unavailable to users. Scheduled

downtime is planned in advance for reasons including scheduled maintenance, system updates

and patches, and system upgrades. Unscheduled downtime is due to system or environmental

failures such as power outages; semi-planned downtime includes software or hardware upgrades

that the practice does not schedule itself but is scheduled by vendors to patch quickly to avoid

security vulnerability.

Planned and unplanned system downtime require policies and procedures that address

the same considerations: how the downtime and alternate processes are communicated; how

providers and staff document patient care; how charges are captured; how systems are brought

back up; and how downtime documentation is transferred to the EHR once the system is live

again (Fahrenholz et al., 2009). It is vital for TTC management to include a “System Back-up

Plan” when preparing to install EHR. Staff should be familiar with the policies affecting their

area to facilitate patient care and maintain clinic flow. EHR system training, which includes

downtime back up, should be mandated for all staff to with the goal of preventing patient flow

interruptions at TTC.

Plan for incorporation of legacy records. One of the advantages of EHR over paper

charting is the tremendous amount of space that is available when the paper charts are removed

from the clinic setting. One office that converted to an EHR eliminated four storage rooms on

site that were used to store paper charts (Harney, 2009). TTC is a small clinic and any space that

can be gained with elimination of paper chart storage will improve clinic flow and efficiency as

well as allow for maximizing use of available space. Space change recommendations with


implementation of an EHR will eliminate the current area of paper chart files. Eliminating the

chart files will open up space in the reception area that can be used for additional workspace. An

EHR will allow for provision of better patient care in today's milieu of meaningful use, shifting

government regulations, and changes in reimbursement.

Equipment. Didonato (2013) identified the following important considerations when

integrating medical devices in the office: how the new solution will affect workflow; how it will

affect the facility’s physical requirements; and how it can adapt to future infrastructure changes

and updates. TTC should consider the workflow and the physical structure before installing EHR

equipment. Rooms need to be carefully planned, with special consideration to placement of

equipment. Didonato (2013) suggests that patient exam rooms require several wall outlets and

network jacks to ensure that medical devices are always connected to the network and that data

are being transferred. Cable management is also important since some medical devices need to be

hardwired into the network (Didonato (2013). A facility such as TTC needs action plans that

include periods for network downtime. When considering the implementation of an EHR, a

focused analysis must be performed to determine what equipment is required for TTC. Any staff

member who accesses patient health information will need the ability to access EHR through

some type of platform such as laptop, desktop, or tablet personal computer (PC). Careful

consideration must be made in selecting a scanner that will allow TTC staff to integrate the paper

charts into the EHR. The clinic will require a large volume scanner capable of handling the

workload (Jimenez, n.d.). In addition to those costs, others that must be considered include

purchase of hardware and software licenses. Maintenance costs for software licenses, hosting and

technical support must also be considered (Fleming, Culler, McCorkle, Becker, & Ballard, 2011).

TTC will need a server in the event it implements the EHR as a stand-alone clinic rather than part


of a hospital system. When considering initiation of EHR, it is also important to remember that

Dr. Enriquez states that internet speeds are slow and sometimes unreliable (personal

communication, January 28, 2014). This may create challenging issues with reviewing patient

charts, writing notes, creating an encounter, and billing.

The installation of an EHR will have a definite affect on the environmental footprint. As offices,

clinics, and hospital systems convert to EHR, it will be intriguing to see how the conversion

affects the environment. A study done at Kaiser Permanente found decreased paper consumption

and reduced gas consumption from ambulatory visits that were handled with secure email

communications with patients. It was also found that there was decreased plastic waste, toxic

waste and water use by digitizing and archiving x-rays rather than printing them (Turley et al.,

2011).

When considering the expense of equipment needed to set up an EHR system, the cost

for each provider license must also be considered. One study indicated that maintenance costs,

which began at implementation, was approximately $17,100 per physician/provider per year for

software licensing, hosting and technical support, and networking (Fleming et al., 2011).

Space. It is imperative that available space be used effectively. The first suggestion

includes dividing the current receptionist/chart space into two areas 10 X 6 with the addition of a

wall. These changes include moving the copy/fax machine to the wall where the charts are

currently housed. The plan would call for moving the area labeled “Nurses Office” on the Fire

Evacuation Plan to the area that is newly created from the division of the reception/chart area.

The area labeled “Nurses Office” would provide office space for an additional nurse practitioner.

Routers and other equipment needed to convert to an EHR will be placed in the storage area at the


back of the clinic if an area can be divided and secured. If that change is not feasible, a portion of

the reception area may require reconfiguration to serve that purpose.

TTC is part of a mesosystem in which other clinics/hospitals may be operating with an

established EHR in place. If that is the case, the computer system chosen and installed will be

Thin Client or Citrix, which are systems that are used remotely. They systems include

specifically designed software and hardware topology that provide performance of applications

over remote locations. There is one file server, which connects through digital modems to the

computers in other locations (MedFlow, n.d.). In this case, space concerns when implementing

the HER should not present any significant challenges. The following will be needed in the

conversion of paper to EHR: First, computer and monitors on the reception desk, in the lab, in the

triage area, and in both NP offices. The monitor screens will need screen covers to protect patient

information. The screen covers will not require any additional space. Second, printer in the

reception area and both of the NP offices for printing hard copies of prescriptions to be faxed or

given to patient and printing patient education materials if they are available on the EHR system

(Smith, 2003). Third, shredding bins in the reception area, triage area, and both NP offices.

Fourth, ergonomically appropriate keyboard height, mouse position, and monitor-viewing height

for any computers not at designated seated areas (Smith, 2003). This will affect the

monitor/computer in the lab area. Fifth, consider mounting the monitor in the lab area on a

movable arm attached to the wall so needed space is not taken from the lab counter. Sixth,

additional electrical and network wiring/cables will be needed (Smith, 2003). Seventh, a scanner

will be needed for scanning outside documentation into a patient’s record. The scanner may be

located in the reception area. Consideration needs to be given to placement of monitors if they

are hardwired in the exam rooms so that the provider is able to face the patient during an


encounter.

The advantages of EHR implementation include the elimination of clutter in numerous

areas of TTC including the reception desk, the reception area, the medical assistant’s office and

NP’s office. It will result in an reduction of lost paperwork/lab results/chart notes that may often

become separated from paper charts and get filed incorrectly. The implementation of the

electronic record system will lead to a more efficient use of limited space in a small clinic as the

hard chart filing system is removed and the work space is more effectively utilized. Conversion

to EHR in TTC will increase the amount of usable space in the clinic and will increase

productivity and work flow. A decrease in the amount of time spent searching, retrieving and

filing records will be realized.

Telehealth

Chronic disease management. Stephenson (1998) notes that healthcare professionals

who use telehealth improve delivery of medical care to medically underserved or isolated

Americans. The delivery of health related services and information via telecommunications

technology, that is called TeleHealth, can facilitate treatment in the remote rural regions such as

the TTC. Patients living in Tiny Town can benefit from specialized services in a timely fashion.

One example of telehealth that TTC can utilize is called the Turkcell TeleHealth System.

Ayyildiz et al. (2012) noted that the Turkcell TeleHealth System is designed to remotely track a

patient’s vital signs including weight, blood sugar/pressure, heart rate, and oxygen. Lee and

Harada, (2012) state that

The U. S. Department of Veterans Affairs (VA), in 2001, was one of the first health care

systems in the United States to implement home telehealth services, and by 2012 the VA

aimed to have 92,000 patients using telehealth services. The VA states that the “value


derived from telehealth is not in implementing telehealth technologies alone, but how the

VA uses health informatics, disease management and telehealth technologies to target

care and case management, thereby facilitating access to care and improving the health of

its patients” (p. 463).

This data of vital signs can then be securely transferred to the clinician who analyses the

information. Ayyildiz et al. (2012) state that chronic diseases such as diabetes, heart disease, and

chronic respiratory diseases are the leading cause of mortality in the world (p. 463). As TTC

integrates the concepts of telehealth, the remote patient monitoring will be an efficient and cost-

effective solution to monitor and treat chronic disease.

Clinic based physical therapy. The telehealth system being planned for TTC is one that

will allow a professional physical therapist to direct therapy sessions directly from the main PT

clinic at the hospital. It will allow TTC patients to participate in group or individual therapy

sessions. Outcomes of one study revealed that those patients who received PT through a

telehealth program achieved outcomes comparable to those of the conventional rehabilitation

group with regard to flexion and extension range of motion, muscle strength, limb girth, pain,

Timed “Up & Go” Test scores, quality of life, and clinical gait scores (Lee & Harada, 2012).

Interoperability with the planned Electronic Health Record

Didonato (2013) notes that the 2009 Health Information technology for Economic and

Clinical Health (HITECH) Act calls for hospitals to adopt meaningful use of their EHRs through

a set of objectives that a health care facility must meet to qualify for CMS incentive payments.

Medical devices can rarely be connected directly to the EHR to allow a free flowing exchange of

information. Didonato (2013) states that this is due to the differences in types of information

being transferred and the format in which this information is displayed. A medical device data


system (MDDS) has the ability to transfer, store or display medical device data. MDDS can

convert data into specific formats within preset specifications. MDDS is considered a Class 1

medical device, which the Federal Drug Agency (FDA) classifies as having the lowest risk for

patients and does not require clearance before marketing. Tiny Town management should be

aware that if the decision is made to create connectivity solutions, the facility should verify the

regulatory classification of any connectivity solution or service under consideration to avoid any

repercussions (Didonato, 2013). Connectivity solutions are available from a variety of vendors.

However, different vendors achieve integration in different ways. Some vendor solutions may

include both hardware and software components, while other vendors may provide only a

software solution. Solutions are based on characterizing the medical devices as either an episodic

or a continuous device (Didonato, 2013). Episodic devices obtain a single set of measurements

from a patient at a specific time. One such device is the vital-sign device. Continuous stand-alone

devices, such as ventilators, are used to monitor or treat a single patient over an extended period

of time, but are not networked to any vendor-supplied central server (Didonato, 2013). These

devices are similar to episodic devices and require a point of care (POC) component that is

stationed either in the patient’s room or attached to the medical device (Didonato, 2013).

Finances

As millions of people become newly insured in 2014, primary healthcare centers are

encouraged to implement EHR, including telehealth services, to remain viable sources of care.

For primary care providers, the move from paper to EHR and integration of telehealth services is

a challenging prospect-requiring investment of money, time, and expertise (Gebretatios, 2014).

Gebretatios states that cost continues to be a significant barrier to successfully implementing an

EHR system. The Medicare and Medicaid EHR Incentive Program provides incentive payments


to encourage eligible professionals to adopt, implement, upgrade or demonstrate meaningful use

of certified EHR Incentive Programs (Centers for Medicare & Medicaid Services, 2014).

Current Revenue and Sources

The budgeted total patient revenue of TTC in year 2013 was $373,247; the actual

expenses in 2013 were $387,443, showing a budget variance of $14,208. TTC has mixed payers

that include Medicare, Medicaid, private insurance, and self-pay. In the month of March 2013,

141 clients were seen with private insurance, 74 Medicare, 58 Medicaid, and 36 self-pay.

Potential Funding Sources

The Economic Stimulus Act of 2009 includes $19 billion in grants and loans for

infrastructure and incentive payments under Medicare and Medicaid for physicians who adopt a

certified EHR system (Mevis, 2014). Mevis also reports that grants and loans totaling $17 billion

are slated for incentives, with $2 billion allotted to jump-start HIT adoption. The Economic

Stimulus Act provides funding for physician practices to receive incentive payments totaling

$44,000 per physician over a five-year span. TTC, located in an underserved rural region, can

receive additional funding as well (Mevis, 2014). Lynn (2009) reports that 18 grants tallying

more than $22.6 million will support EHR implementation. Grants totaling more than $2.6

million will help implement a variety of HIT installations; whereas, five grants totaling over $2.5

million will fund health centers devising plans to use EHRs to improve patient outcomes (U.S.

Department of Health, 2014).


Table 1

Tiny Town Clinic - Revenue 2013

Total operating revenue 2013

(actual expenses)

$387,455

Total operating revenue 2013 (budgeted) $373,247

Total operating revenue variance 2013 $ 14,208

Table 2

Tiny Town Clinic - Proposed Budget

Proposed Expenses 2014

Telehealth 25,098.81

EHR 77,435.00

Total 102,533.81

The grant that fits the needs of TTC is the State Government Electronic Records that is

listed in grant.gov (grant number 201412, with an estimated amount of $600,000). Submission of

the grant application by TTC management should be done before the deadline of December 2014.

This grant money is estimated to be sufficient to cover the expenses of EHR and telehealth

implementation at TTC.


Current Workflow

Measurable Outcomes for Quality of Care Assessment

President George W. Bush formally initiated Health information technology (HIT) and

EHR in 2004 in his State of the Union Address. President Obama passed legislation that put into

effect an incentive-penalty system when he signed the American Recovery and Reinvestment Act

of 2009 (ARRA), commonly known as the stimulus bill. Part of this legislation contains the

Health Information Technology for Economic and Clinical Health Act (HITECH) that has the

goal of improving health care delivery through investment in health information technology. The


HITECH act provides the U. S. Department of Health and Human Services with the authority to

establish programs to improve health care quality, safety, and efficiency through the promotion

and adoption of EHRs, advanced information technologies, and private and secure electronic

health information exchange. Through these incentive programs, hospitals and providers can

qualify for reimbursement through Medicare and Medicaid services when they initiate EHR and

follow the guidelines for use (Reilly & Polifroni, 2012).

Meaningful Use is the Medicare and Medicaid incentive program that is in place to

encourage providers to use electronic health records to improve quality of patient care. There is a

set of criteria that must be met to quality for reimbursement funds. It has been implemented in a

phased approach over a series of three stages. Stage one is adoption of EHR and data gathering

with stage two emphasizing care coordination and exchange of patient information. Stage three

involves improvement of healthcare outcomes. Providers qualify for Meaningful Use when their

patient population includes Medicare or Medicaid patients. TTC qualifies based on their patient

cohort and their status as a Federally Qualified Health Center (FQHC) FQHCs may participate if

they are a rural health clinic and have a 30% needy individual patient volume (CMS.gov, n.d.).

Implementation of stage one requires reporting on all of the following core measures and

five menu measures. The core measures required are: Computerized physician order entry

(CPOE) which requires entering at least one prescription order for more than 30% of all patients

seen; drug interaction checks; maintenance of problem list which requires at least one diagnosis

for more than 80% of all patients seen; e-Prescribing which requires sending more than 40% of

prescriptions electronically (TTC may qualify for exclusion if the one pharmacy in the

community does not accept e-prescriptions); an active medication list with at least one medication

listed for more than 80% of all patients seen; medication allergy list with at least one allergy


entered for more than 90% of all patients seen; demographics of date of birth, sex, race, ethnicity,

preferred language recorded for more than 50% of all patients seen; blood pressure (BP) for

patients over age 3 (TTC sees patients beginning at age 2) and height and weight for all patients;

smoking status for more than 50% of all patients age 13 and older; one clinical decision support

rule; patient electronic access to health information for more than 50% of patients; provision of a

clinical summary to more than 50% of patients within three business days; and protection of

electronic health information with security risk analysis and implementation of security updates

as needed.

Five menu measures must also be reported, one of which is a public health measure. The

menu items include drug formulary check, clinical lab test results, patient lists (lists of patients

with specific diagnosis), patient reminders, patient-specific education resources, medication

reconciliation, transition of care summary (pertains to patients referred or transitioned from the

practice), immunization registries data submission (public health measure), and syndromic

surveillance data submission (public health measure).

Implementation of EHR at TTC requires Meaningful Use to begin by July 1, 2014, to

avoid Medicare penalties in 2015. The clinic will have two years to implement stage 1 before

transitioning to stage 2. During the first year the criteria is to be fulfilled over a 90-day reporting

period. After that, they will have a full calendar year. Starting in 2015, providers who are

eligible for Medicare Meaningful Use program but don’t demonstrate it will be penalized. As a

provider starting in 2014, TTC will avoid a 2015 penalty if they begin their reporting period by

July 1, 2014 and attest by October 1, 2014. Maximum payout for TTC beginning stage 1 will be

$12,000. If they wait until 2015, they will be penalized 1% (Practice Fusion, 2014).


Physical Therapy services are reported differently than medical services. The system for

therapy is reported with G-Codes. These are functional reporting codes required by Medicare

starting July 1, 2013. They are reported at the outset of therapy on the initial date of services and

at least every ten-treatment days (or 30 days). They are also reported anytime an evaluation or re-

evaluation procedure is submitted. Discharge reporting is required, except for those cases where

therapy services are discontinued by the patient prior to the planned discharge. G-Codes are

categorized by mobility, self-care, and other functional limitations. These codes are included in

the medical record and are accompanied by rationale on determining severity. Currently

Medicare requires this coding and third party payers are adopting the same policies and putting

into their contracts that they are following Medicare policies. If the functional reporting is not

done monies may be taken back from the therapy provider. Software in the TTC EHR system

will need to have a program that allows the therapist to chart plan, progress, and goals in the

existing chart for patients participating in the physical therapy component of services offered at

the clinic.

Outcomes of EHR. The outcome in EHR to be measured in the first stage of meaningful

use will be that of data capturing for TTC. This will be measured by running the data on the

number of patients entered into the system with the onset of the Go-Live date. Patients will be

entered into the new system at check in and demographics will be recorded. Email addresses will

be noted if the patient has an active email account. Eighty percent of the patients seen will need

to be entered into the system and the data will be run at the end of the first quarter period in which

the EHR is in place as mandated by the government. The reporting period must be started on July

1, 2014 and the first attestation deadline is October 1, 2014 (CMS.gov, n.d.).


Outcomes of physical therapy. The physical therapy (PT) component will be initiated to

focus on the community health risk factors of weight loss, increasing functional strength and

improving cardiovascular fitness. Outcomes may be monitored by measuring glycosylated

hemoglobin (HgbA1C) levels that will be drawn at the outset of physical therapy interventions.

After three months of therapy, diet changes, and instruction by the physical therapy providers

both in the clinic and through the telehealth program, Hgb A1C will be drawn and levels will be

compared with the initial values. These values will be entered in the EHR system and the

national database will provide a summary of results. This will alert the therapist to any trends that

have occurred during the course of the therapy. Noting trends will provide feedback that can be

analyzed and used to determine changes that may need to be made in individual treatment plans.

Utilizing this data in EHR allows patient specific plans to be formulated that will improve quality

of patient care and the delivery of services.

Outcomes for telehealth. Telehealth will be utilized in this setting to review previously

taught diet changes, recommended activities for strength training and improving cardiovascular

health. Telehealth will be instrumental in maintaining continuity of care in this rural population

with limited financial and transportation resources. Patients will be individually instructed during

their initial evaluation face-to-face in the clinic with the therapist and will be given a plan tailored

to their specific health needs and goals. The telehealth sessions will be utilized to review teaching

points as well as to evaluate progress in strength training and increased activity goals. Telehealth

outcomes will be monitored by the ongoing evaluation of individual patient goals and the

comparison of weight changes as well as the above-mentioned HgbA1C results. This information

will be entered into the patient’s record and tracked.


Request for Proposal

Gebretatios (2014) reported that purchasing and implementing an EHR system is a

complex process that requires an organized approach. TTC will adapt Indiana Family Health

Council (IFHC) as a model in purchasing and customizing EHR. The first step is to establish a

project team. The team should include a representation from a clinical and an administrative

staff. The second step is to arrange a meeting between the TTC EHR team and the Indiana Health

Information Technology Extension Center (I-HITEC) to deliberate “meaningful use” of the EHR

and telehealth program. The meeting will also include discussion of strategies on negotiating

discounts with vendors and creating a project timeline (Gebretatios, 2014). The third step is to

select a vendor. Gebretatios (2014) said that I-HITEC would manage the task of researching EHR

system and compile recommendations that would be good fit for the IFHC network. The

following questions should be considered when evaluating the software vendors according to

Gebretatios: Is the EHR system designed specifically for primary health care clinic; can data

fields be customized and what are the functionalities; what training and support is offered; what

types of reports can the system generates; what acquisitions, implementation, maintenance cost;

and any recurring and non-recurring cost?

Recommended Products and Rationale for Selection

TTC will use Practice Fusion software for their EHR. Practice Fusion is the largest and

fastest-growing healthcare platform, with a mission of connecting doctors, patients and data to

drive better health care practices and save lives (PR Newswire, 2014). Medical professionals can

sign-up for Practice Fusion online anytime and be live with their new EHR system in just five

minutes at no cost. PR Newswire (2014) noted that unlimited meaningful use support and

integration with local labs and imaging centers are included in Practice Fusion’s free offer. PR


Newswire (2014) reports that Practice Fusion’s free EHR is compliant and has been certified as a

Complete EHR by Drummond Group, an ONC-ATCB approved to certify any complete or

modular EHR both ambulatory and inpatient. This is in accordance with the applicable

certification criteria adopted by the Secretary of Health and Human Services. PR Newswire

(2014) reports that in a 2014 survey, 83% of Practice Fusion users reported the company’s

meaningful use dashboard as excellent or above average, and only 29% reported that it was

difficult to navigate. The World Economic Forum recognized Practice Fusion as a Technology

Pioneer for 2013. Practice Fusion has partnered with free clinics, nonprofits, and community

health organizations throughout the country, including the National Association of Free and

Charitable Clinics (NAFC). This software is ideal for TTC because of the free cost and

meaningful use application.

EHR

Health information technology has the potential to improve health care quality, prevent

medical errors, and increase the efficiency of care provision (Lynn, 2009). The health care

providers of TTC must demonstrate “meaningful use” of electronic health records to be awarded

Medicare and Medicaid incentives under the Obama administration’s stimulus package and the

Affordable Health Care Act (Horowitz, 2010).


Table 3

EHR System Purchase Order

IT Contractor

1-HITEC $3,750

Hardware-Health Dynamix

Desktops, Laptops $10,950

Tables, rolling tables, docking stations $ 20,813

Routers $1,690

Firewall $10,950

Scanners $5,739

Printers $4,141

Hardware installation $ 8,402

Software – Practice Fusion Free

Customization, training $11,000

Total $77,435

PT Equipment

Initially, PT services will be offered to patients diagnosed with some strength and balance

problems. Ambulation and gait training will also be offered. As the clinic’s PT practice becomes

larger and the demand for services increases, additional equipment may be purchased if the clinic

budget can accommodate the cost. A listing of proposed PT equipment to be purchased may be

found on Addendum D. Most of the items listed there are crucial for evaluating and treating

patients with physical challenges related to muscle strength, ambulation and balance.


Telehealth Equipment for Physical Therapy Treatment Sessions

The Cisco telehealth monitor EX 9 has been selected to televise and monitor PT therapy

sessions remotely from the main hospital. This equipment has been chosen due to its

comprehensive design and integration of speakers and a microphone. This Cisco product requires

that users receive minimal training in order that they may use it effectively.

Project Management Plan

This project is projected to take approximately 18-24 months from initiating the process of

adding EHR to successfully completing the addition of the telehealth physical therapy component

in TTC.

The first step of the project is implementing the EHR system. The first question to be

addressed is whether TTC is part of a larger system that has an EHR in place. If that is the case,

budget can be established based on the projected cost to add TTC to the larger system. This will

be more cost effective than instituting a system that is isolated to the clinic because there will

already be templates and an IT vendor in place. This will also eliminate bidding for contracts and

the time involved in searching for products and services. Time will have to be built in to allow

for training of staff. This initial training will slow down the clinic flow and will necessitate a

lighter patient load until staff is comfortable working with the new system.

Current hard charts will need to be secured and transported to an off-site storage facility

that is secure and HIPAA compliant. This will take place as pertinent portions of chart records

are scanned into the new EHR system. If TTC is part of a larger hospital system, this transition

will be smoother as there will be a system in place for the charts to be archived. If TTC is

responsible for storing the hard charts, a secure location will need to be acquired and the


appropriate guidelines followed for transporting and storing the charts. Storage facility costs will

need to be built into the budget.

After the EHR system is determined, the next step is fitting the system into the existing

clinic. This entails rearranging the clinic to make maximum use of available space. Space

recommendations have been addressed in an earlier section of this proposal. (See page 16).

When the EHR system is in place, the next step is implementing the hybrid telehealth

physical therapy component of the project. This part of the project will entail acquiring the media

equipment needed to provide the telehealth portion of the therapy as well as the PT equipment

needed for the actual therapy sessions. In reality, this is two projects. See appropriate sections

outlining equipment needed. Staff will need additional training to oversee the therapy/exercise

and record the appropriate notations within the chart.

Timeline for initiation of EHR:

Nine to 12 months before Go-Live for EHR

Investigate if possible to connect with larger hospital system

If Tiny Town is independent, review proposals and select vendor

Determine go-live dates

Schedule vendors (if needed), trainers, consultant

Six to nine months before Go-Live

Determine workflow for check-in, encounter documentation, lab results,

medications, etc.

Review database

Conduct site assessment


Identify top 20 medical visit codes and most frequent assessments done in the

clinic

Identify hardware needs

Three to six months before Go-Live

Install hardware

Customize to clinic

Evaluate readiness of staff and schedule staff training

Make decisions about scanning documents needed for continuity of care

Verify installation timeline with vendor

Begin to educate patients about new system and explain benefits of EHR

One to three months before GO-Live

Build interfaces with lab, e-scribe/eFax (if available), imaging, hospital (if part of

the larger system)

Test go-live: begin building patient records

Adjust patient schedules-allow more time for visits and charting

Go-Live to one month out

Customize templates

Keep patient load reduced

Assess, recheck

Monitor staff and reward

30 days out to 120 days out

Continue to customize templates

Add charting phrases to expedite charting


Call vendor with any problems

Timeline for Initiation of Telehealth/Clinic Physical Therapy

Four to Six months prior to GO-Live

Consult with PT providers to determine needed space and equipment for therapy

Determine software needs to add PT to clinic

Determine go-live dates

Determine space allocations for conducting the PT in the clinic and begin planning

for in-clinic PT sessions as well as telehealth sessions

Reorganize current space as able to accommodate clinic PT sessions as well as

telehealth sessions

Contact vendors for pricing of physical therapy equipment.

Two to Four months prior to Go-Live

Purchase additional laptop and rolling stand for PT to utilize while in clinic

Purchase physical therapy equipment

Purchase media equipment needed for telehealth sessions

Determine what space will be utilized for physical therapy sessions held in clinic

Determine what space will be utilized for physical therapy sessions conducted by

telehealth in real-time/synchronous

One to two months prior to Go-Live

Determine clinic schedule for in-clinic PT sessions

Plan patient scheduling for PT sessions in clinic with therapist

Plan patient scheduling template for in-clinic PT sessions with therapist

Determine billing for services and reimbursement of therapist


Determine schedule for in-clinic telehealth PT sessions

Plan patient scheduling template for telehealth sessions

Educate patients about both in-clinic with therapist and in-clinic with telehealth

options

Educate staff that will be conducting telehealth sessions

Go-Live to one month out

Evaluate both PT sessions and telehealth sessions

Keep patient scheduling light

Evaluate patient response and participation

Assess and recheck

Summary Document of Recommendations

The Tiny Town project includes initiation of EHR and meaningful use followed by the

addition of physical therapy services through a hybrid program of on-site and telehealth delivery.

This project will start with assessment of current space and best utilization of space that will

become available when the hard charts are removed from the premises and a significant amount

of usable square footage will become available for alternate use. Reorganization of the reception

area will allow for movement of staff and reassignment of current space utilized for the licensed

vocational nurse (LVN) and the medical assistant (MA). It is recommended that EHR be

researched and implemented before July 1, 2014 to allow for Stage One of Meaningful Us to be

instituted so the clinic is not penalized by CMS for noncompliance with the federal mandate.

Implementation of EHR will take place following the timeline discussed earlier in this

paper and will take approximately nine to twelve months to complete from scheduling vendors to

implementing the conversion to electronic records as the patients are seen in the clinic setting.


After the electronic record conversion has been completed, plans for a hybrid on-site physical

therapy with a telehealth component will begin. This will involve an estimated time frame of

approximately four to six months beginning with consultation with PT providers to determine

needed space and equipment for therapy culminating with provision of on-site physical therapy

services combined with telehealth follow up in between on-site visits.

Benefits of initiating EHR include monetary reimbursement from CMS for compliance

and timely installation, as well as the ability to track changes in patient health status and data

trends such as compliance with medication and diet changes. Other benefits include enhanced

quality and convenience of patient care as well as increased patient participation in care. It will

also increase accuracy of diagnoses and health outcomes as well as improve care coordination.

Evaluation of EHR will be accomplished by data tracking in the system. Historically there

is an increased use of ICD codes with implementation of HER, which in turn translates into

billable gain (Holt, Warsey, & Wright, 2010). This will be evident when the budget is reviewed

and the numbers are compared to previous fiscal years.

Evaluation of the physical therapy component of the project will be tracked in EHR with

criteria discussed previously concerning HgbA1C levels and evaluation of strength training and

weight gain/loss. An additional element that can be tracked through data mining in EHR is

cholesterol and triglyceride levels if the provider chooses to follow those numbers when

evaluating physical therapy outcomes.

Installing an EHR system in TTC has many positive repercussions in the improvement of

delivery of quality healthcare services. It also has the potential of engaging the patients in their

health care and empowering them to take ownership of their current health issues and strategies to

manage their medications, activity, diet, and ultimate improvement of quality of life.


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Appendix A

Physical Therapy Advisement Form

Request for Proposal for Physical Therapy

• Tiny Town Clinic (Community context)

The Tiny Town clinic (TTC) is located in a rural community in Texas that is

underserved. The population in 2011 numbered 2,818. It is the only medical facility

within 45 miles and there are currently two nurse practitioner (NP) providers. The

estimated per capita income in 2009 in Tiny Town was $14,304 and the ethnic makeup is

primarily Hispanic. Over half of the residents speak English as a second language. The

average age of residents in Tiny Town is 33.9. There are approximately 500 residents

over the age of 60. Thirty one percent of the population is illiterate and 34 % of families

live below the poverty level.

The average number of patients seen during a typical day is 20-30 with 4-5 new

patients, mostly due to those who are temporarily in the area working. The age range of

the patients is from 2 years old and up. There is a Border Patrol Station that brings illegals

for medical clearance before they are taken to a holding facility prior to deportation.

Many patients use the clinic as a primary care facility due to the distance to the nearest

hospital and difficulty getting appointments with their doctors.

There is one pharmacy in the town to fill prescriptions. There are limited

medications dispensed from the clinic and there are no narcotics offered on site. There is

a problem with medication compliance for many reasons including cost of clinic visit, cost

of medication, lack of time off to visit the clinic, and lack of transportation. Some of the

patients walk to the clinic.


Description of types of patients

Given the types of patients, illness, and injuries that TTC sees on a regular basis,

what needs do these patients have that could be addressed with physical therapy in the

assigned delivery model?

The demographics of the population indicate there is a problem with obesity,

diabetes, hypertension, heart disease, and hyperlipidemia. Many teens are seen in the

clinic for these chronic health issues and there is a growing problem of obesity in the

children. Many patients are seen in the clinic with extremely high blood sugar and blood

pressure and are unable to go to the Emergency Room for treatment. They are also unable

to purchase the medications they require to manage their chronic health issues. Ancillary

services such as occupational and physical therapy are often not realistic for this

population because of transportation and funding issues. It is often difficult for many of

the patients to travel several times a week the 45 miles required to obtain these services

• System analysis

TTC is an example of a microsystem as it provides front line health care services to a

significant number of people. Without knowing answers to whether the clinic is part of a larger

health system, it is posited that this is the case based on the notation that the billing office is at

another location and there is no specific area noted on the fire evacuation plan that there is an

office for a business/clinic manager. It is also known that a business/clinic manager is not listed

as a clinic employee for the clinic (Handouts provided on blackboard regarding Tiny Town).

This clinic may also be part of a mesosystem, defined as when two or more clinical or

supporting microsystems are joined (Godfrey & Nelson, 2011). First line health care facilities

need a system for referral for the patients who need additional care or diagnostic services. These


referral sites and specialty providers then become part of the mesosystem that supports Tiny

Town. The individual departments and service providers that are available for Tiny Town fit into

a larger organization known as a macrosystem, which can be a hospital, a multispecialty group

practice, or integrated health system (Nelson et al., 2008). In the case of Tiny Town, the

macrosystem is likely to be a hospital or an integrated health system.

• Current Work flow

Patients are seen on a walk-in basis and do not make appointments to be seen in

the clinic. They arrive at the clinic, sign in and wait to be seen. A nurse calls them back,

takes vitals, and puts them in a room where they will be seen by the provider. There are

three exam rooms and a small lab area where vitals are taken. When the visit is completed,

the patient goes to the front to pay the bill and check out.

Group two is investigating initiating a hybrid PT program for the patients of TTC.

The delivery model in this plan is one day a week on-site PT with the remainder of

additional PT services done by telehealth. The clinic has limited space. Currently space

appears to be well utilized with the exception of the area in the back that is used for

storage. It might be possible to reorganize the storage area and designate a portion of that

space for PT. If that is not feasible, the only other option may be to allocate an area in the

waiting room as the PT site. This is dependent on the amount of space needed and

specific equipment required for customary treatment plans.

• Infrastructure

The clinic will be transitioning to an electronic health record system that will allow

for some changes to be made with space that is currently used for hard charts. Removing

the chart racks will open up space in the current reception area. It may be possible to


consolidate the clerical area and use the newly opened space as the nursing office, moving

the additional, newly hired NP to the current nursing office.

Space change recommendations with implementation of EMR

• Eliminate the current area of paper chart files

• Divide the current receptionist/chart space into two areas 10 X 6 with the addition of a

wall

• Move the copy/fax machine to the wall where the charts are currently housed

• Move the area labeled “Nurses Office” on the fire evacuation plan to the area that is

newly created from the division of the reception/chart area.

• Use the area labeled “Nurses Office” for the second nurse practitioner

• Available space for physical therapy

• Preferred and potential spaces available for PT use

It would be ideal to have a permanently designated area for PT. PT could be done

on site in that area as well as through a telehealth program. Telehealth will allow patients

to come to the clinic to participate in therapy if they do not have the transportation to

travel the 45 miles to the nearest PT facility in a hospital setting. The ideal location for

on-site PT might be the current storage area or part of the waiting area. If the storage area

can be reorganized a portion of the room could be designated as the PT space. There will

need to be an area where the physical therapist can chart so space will need to be

configured to allow for a computer on a rolling cart.

• Tentative budget

The budget will need to be determined to allow for an additional laptop for the

therapist to use, software for the PTs to work from and access handouts for the patients,


and any equipment the therapists need to accomplish the therapy. There will also need to

be chairs for the patients to sit in when they are between therapies or waiting. There will

be a need to establish a method for billing for time and therapy services provided. An

important consideration for the software will be interoperability with the system in use

from the therapists’ home site so that the telehealth system will be feasible.

Estimated cost for EHR: $155,235 total cost for first year including IT contractor,

desktop, tablets and docking stations, routers, firewall, scanners, printers, hardware

installation, subscription to software, training and customization.

Physical therapy equipment: Equipment necessary to perform basic therapies

offered in a typical physical therapy program are targeted at therapy related to strength

training, balance training and back pain. The listing of the necessary equipment may be

found in appendix D.


Appendix B

Consultant Recommendations

Proposal for Provision of Physical Therapy to Tiny Town

Group 2 is to investigate initiating a hybrid PT program for the patients of Tiny

Town. Part of the time PT will be done on site in the clinic and part of the time PT will be

accomplished through telehealth. Can you tell us what we need to be thinking about for

this project?

MH: The number one thing that comes to my mind at this point is cost. What

resources do you have available to you as far as funding goes? Is this a project in

which you have unlimited funding or do you have a budget you need to stay

within?

RD: We haven’t had any exposure to telehealth. I think it might be possible, in a

limited fashion for PT. It’s very “hands on”, but could be modified with telehealth

maybe every other visit.

I am speculating that we need to look at space available in the current clinic to determine

where on-site PT can be done as well as consider what needs to be available for the

telehealth part of the project.

MH: Yes, space is certainly an issue. You will need enough space for some cardio

equipment, high-low tables, and an area for resistance training. This does not


include space that you will need to hold general equipment and supplies for

modalities.

RD: You could get by with a treadmill, maybe an ergonomic bike, set of hand

weights, TheraBands (easy to store), large wall mirror (3x5 ft). A hi-lo mat would

be helpful, but is also very expensive. I assume you would have a padded table for

medical exams; it most likely would work for PT also. The other equipment could

be added in later, as funds allow.

Have either of you been involved with a rural setting where the patients are compliant about

50% of the time?

MH. In my limited experience with treating patients, I would say that as far as PT

goes, geographic location is not the primary factor affecting compliance, but more

so, it is patient motivation/disease type/pt. personality. This has held true for me at

urban clinics and rural clinics.

RD: As I said, I grew up in a small town, so I understand the mentality! I would

see the #1 obstacle as resistance to change. So many of the PT problems we treat

are directly tied to obesity. I see the evidence in every culture across Texas, but,

having recently moved to Dallas from Corpus Christi, see a HUGE issue in the

Hispanic community. Education is the key, and changed need to be made at every

generational level.


Have either of you participated in telehealth and, if so, do you have suggestions for what

needs to be done from our prospective?

MH: I do not have any personal experience with telehealth but it would definitely

be beneficial for your patient to have a large screen to view exercises/receive

instruction from. There will also need to be in office equipment for filming the

patient as they perform their therapy. This will allow DPT can offer feedback and

suggestions on their performance. Physical therapy is an extremely “hands on” - I

think that it will be very challenging to utilize telehealth and have the patients still

receive the same quality of care.

RD: I have no exposure to telehealth. I agree that a large screen TV would be

helpful. The initial treatment with PT would have to be done by a PT. Carrying out

the exercises could be monitored by a tech, but exercises are only effective if done

correctly, with no muscle substitutions. Therefore, say, session 2 might be possible

by telehealth, with a PT progressing the program, and a tech instructing. This

would only work with orthopedic patients. Neurology patients have far too many

variables.

Do you typically use EMR for your charting?

MH: You mean electronic medical records, yes? If so, yes, but I find that in more

rural settings, paper charts are still the norm.


RD: EMR would be easiest for telehealth, not only convenience of practitioners,

but billing and charting.

We will have to consider how that works from the telehealth prospective. I speak for myself

only when I say I have no experience with telehealth.

• Needed equipment (Consider minimal and “it-would-be-nice” scenarios)

What equipment do we need to have in the clinic?

This list includes the basic equipment need to start the physical therapy program.

• 1-2 high low tables could use 1 padded standard exam table

• Treadmill agreed

• Nu-Step

• Arm Bike Ergometer YES!

• Set of free weights yes

• Set of therabands yes

• Total gym

• BOSU balls/balance equipment BOSU and Swiss balance ball

• E-Stim kits (great to have, could be purchased later)

• Therapeutic Ultrasound equipment

• Implications for infrastructure changes (i.e. EHR)


• What computer access do we need?

MH: If you’re wanting to do telehealth, you’ll need high speed internet. Probably at least one

laptop and one desktop. The desktop should be connected to a large monitor - like what we have

in the breakout rooms here. You’ll obviously need excellent sound equipment. Remember - your

patients will probably be older and may have difficulty with vision and hearing.

RD: Agreed. Also printer for handouts/exercise print-outs.


Appendix C

Graphics of High Performing Clinical Microsystem

The graphic shown below depicts the integration of the systems as they affect Tiny Town.


Item Function Model Information

Cost

Plinth Table Multi-treatment table

Hausmann Hi-Lo Power

2,095.59

Ultrasound machine Pain management Intellect Legend US

3,254.55

Electrical Stimulation machine

Muscle strengthening

Richmar Winner ST4

2,729.00

Walker/wheels/folding Improve gait Nova 409DW5

40.00

Walker Standard/Folding

Beginning Weight bearing

Invacare 6291-1

55.00

Walker/Rollator Wheels/Seat

Prevent falls Provide support

Nova 4010

168.00

Cane/Straight Single point

Balance re-education

ConvaQuip 835-700

73.89

Cane/small base 4 point

Balance Re-education

Drive Medical 10312FP-1

38.99

Crutch Forearm

Prevent weight bearing

Carex Adult FGA985C00000

115.99

Crutch Under axilla

Prevent weight bearing

Carex Adult FGA976000000

57.89

Gait belt For spot walking during ambulation

Invacare Gait SPTB054

17.85

Aerobic steps Step training Escalade F1028

53.06

Stationary bike Progressive exercise GX 5.0 599.00 TENS Unit Pain management Ultama 5 29.99

Cisco Telemonitor with camera/speaker/mic

Physical therapy telehealth

EX 9 15,800.00 (2 units)

Treadmill Exercise US Medical 2,199 Theraband set Muscle

strengthening US

Medical

126.73

Appendix D

Recommended Equipment for Physical Therapy Treatment Program


Appendix E

Patient Flow Chart

Pa#ent'in'the'system?'

!

Tiny%Town%Clinic%

Nurse''Available

?'

! !

!

Take''BP,'pulse,'weight,'urine'

Decision

Pa#ent'needs'to'complete'paperwork'

Wai#ng'Room' Pa#ent'with'NP'

Process'

NP'Available

?'

Need''labs'&'

Referrals'

Need''FollowDup?'Wai#ng'Room' Make'followDup'

appointment'

Process'Referrals'Order'labs'

!

Indicates%placement%of%computer%terminal%

Provide'Med'Reconc'&'Educa#onal'Printouts'

Documents

Tiny Town Clinic Case Analysis: Laurie Burke, Celia