Charting in the electronic age
Charting is an essential component of a massage therapist's practice. Beyond regulatory record-keeping requirements, charting provokes a practitioner to listen attentively and analyze critically when capturing a subject's case history, measuring benchmark neuro-musculoskeletal and quality of life indicators and comparing these to post-session outcomes. Charting and forming a treatment plan provides the compass, keeping the practitioner on track toward realizing patient/client objectives.
Increasingly, massage therapists want and need to make the transition to electronic records. Many health-care providers (and their regulatory agencies) are pushing the transition. There is an increased need for security and privacy in an electronic environment – on top of making meaningful session entries, practitioners must observe and comply with regulations from multiple authorities: the regulatory body, Privacy Commission and government health agencies.
As useful a tool charting is for massage therapists, it also presents a challenge. There appears to be little standardization in charting observations or outcomes. While there are regulatory guidelines, what observation or assessment variables are measured and how outcomes are shown varies greatly among practitioners.
Alison Taylor, cofounder of JaneApp comments, "Creating a way to chart that is fast, convenient and customizable yet still in a format conducive to meaningful data retrieval is a huge challenge. Many associations and organizations are interested in outcomes-based charting and data mining to validate and promote their discipline, but the very first step is collecting the data in the first place." Taylor laments, "Few practitioners want to chart on prescriptive templates that take ages to navigate and click through, yet that's the best way to collect compile-able data."
When asked what benefits electronic records have over paper, Taylor replies, "Legible, searchable, ensures privacy, more accessible, cost savings over paper, storage in perpetuity, and no shredding required."
Daniel Ruscigno, creator of ClinicSense concurs on the point of outcomes-based charting. "The challenge for software providers is the lack of a standard charting template... there is a ton of variability among massage therapists when it comes to the detail they want in their notes. We have some users that are very detailed in their notes while others jot down a few bullet points. Much of (charting) behaviour is guided by regulations."
Ruscigno continues, "we provide our customers with a free form response to charting – meaning a therapist can type in their notes using their preferred terms/lexicon which our system then learns and suggests in future notes. Our customers highly value this ease-of-use and flexibility of format."
Add to the problem, practitioners work in a variety of settings with different populations and the multiple sectors served – spa, rehab, private practice, multi-disciplinary, human performance/athletic, and workplace wellness/mobile massage. Different populations express different desired outcomes, so the practitioner must adapt and chart accordingly.
Software developer Bryan Quesnelle, RMT and developer of ClinicWise describes the challenges of documentation without a common charting lexicon, and the difficulty of incorporating other disciplines into an integrated charting system. "Massage therapy is very individualistic in both clinical practice and record keeping. In my experience, the only common element in the documentation habits of massage therapists is the adherence to our regulatory requirements... many of which are vague or open-ended. As a result, we as a profession don't use a universal nomenclature when documenting, or even measure the same variables when we treat patients. This allows us to adapt to the needs of our target demographics, but the variability makes developing a standard set of rules and priorities – a requirement for building an intelligent and adaptable digital record keeping system – very challenging."
Quesnelle elaborates, "Many massage therapy clinics employ other types of health-care professions in addition to RMTs, and want a system that will accommodate all of their staff. Since many of those professions have similar variability in record keeping practices, the challenge has increased exponentially to meet the needs of those clinics."
Author, educator and physiotherapist Carla-Krystin Andrade makes a compelling argument in her book, Outcomes Based Massage, that practitioners need to consider beyond bio-mechanical/functional outcomes. Andrade describes measurable quality of life indicators: improved energy and sleep, better social functioning and family relationships, a sense of well-being, improved mood, relaxation and coping skills, mindfulness and greater life satisfaction, positive attitude and empathy toward others. To provide comprehensive care, practitioners need a charting system to help them qualify and quantify the full scope of a person's health and well-being.
J. Sarah Armstrong, founder of DigitalRMT agrees. "When you chart quality of life indicators, you open a discussion with the patient about their progress. (Without charting these indicators) we lose that opportunity to measure our success and lose the opportunity to discuss the small nuances of improvement arising from care."
Practitioners are looking for ease and efficiency of recording comprehensive notes, remaining in regulatory compliance, with simple storage, and perpetual access. Armstrong shares, "Practitioners want to transition (to electronic records) but are fearful that, come next peer assessment, their records will be found non-compliant. It is a new medium and practitioners are unsure how big the learning curve will be, especially if they're not tech savvy. The reality is that in 10 years, most health professionals will not be using paper."
Armstrong describes how relying on paper as a medium for record-keeping can allow standards to degrade. "One of our users admitted she was concerned about the completeness of her notes. Once she switched to electronic records, she reports happily her records are completed every day."
Armstrong has spoken to recent graduates of massage therapy programs on their recollection of required case history variables to screen for. She found many of the graduates were missing key information. "Just out of school, this information should be fresh" she proclaims.
She states compliance and completeness can be built into software, where electronic records will not permit storage without required fields filled in. "There is a fail-safe in DigitalRMT that will not allow the record to save if record-keeping requirements have not been met."
Mary Ellen Logan, director of academics at Ontario College of Health and Technology, explains her motivation in developing SoapVault with partner Nick Gabriele. "We started SoapVault for two reasons. First, Nick had practiced as a RMT for more than 20 years and dreaded the onerousness of charting. He was technologically inclined and just wanted to easily click options to make effective notes. We also knew that peer assessors (employed by the College of Massage Therapists of Ontario under the Quality Assurance program) are concerned when they review RMT notes and observe the simplistic 'See Previous Treatment.' They want more specific detail in each record.
The second reason was because of the development in our student clinic. Sometimes we have upwards of 40 students in clinic per semester, many who treat the same patients. Legibility is an issue, as is storage space for all those files. Our teaching clinic supervisors needed a consistent and easy way to review charts that were web-based for our oversight. We started with just our teaching school clinic and now we have more than 600 clinics worldwide that use the program."
Admittedly, the standardization of charting will require practitioners to come together and evolve the lexicon, variables measured and conceive of ways to incorporate evidence-based practice. Jim Shedden, director of business development at mindZplay Solutions Inc., views electronic charting for RMTs as an evolutionary and continuing process.
"When we first introduced electronic charting in our practice management software, some 14 years ago, practitioners had quite different usage expectations with respect to charting in general. In lieu of an accepted industry standard, we based the charting system on the latest paper systems and adherence to various regulatory bodies' requirements and recommendations. From there, we listened to our subscriber base to evolve, fine tune and enhance its functionality."
Shedden continues, "Consider the differences in large scale public health versus private health electronic medical record systems (EMR). The initiatives required to create the system specifications and the programming efforts in the public health system took years of collaborative effort amongst the stakeholders. Stakeholders include various taxpayer financed bodies representing health-care professionals, privacy authorities and system developers."
He cautions, "This level of funding initiative and stakeholder collaboration has not been available in the more fragmented and price-sensitive allied health-care field. This does not mean we cannot all get there from here. It is possible that future collaborations could lead to functional specifications for more advanced electronic charting development. It will then be up to individual industry developers to determine if the business case makes the development investment worthwhile. In the meantime, we continue to listen closely to our loyal customers' suggestions and many of our systems enhancements in Massage ManEdger come from their thoughtful input."
Software developers and massage therapists collectively have a partnership opportunity here. In addition to helping the massage profession enhance its capture, recording and analysis of practitioner findings, developers can help propel the massage profession in its efforts to evolve the scope of assessment and lexicon in the field. Data collection necessary to accurately examine our patient/client populations can be extrapolated (see PatientsLikeMe.com) to examine trends while preserving individual patient privacy.
With proper collaboration we could see the beginnings of reporting massage therapy efficacy while more specifically crafting our public/media campaigns to the populations we serve. Indeed, software developers could provide the catalyst to positive public/media attention and government/insurer/gatekeeper credibility we've been looking for.
The age of electronic record-keeping has arrived and massage therapists face a learning curve in adapting and transferring their charting practices to software applications. Software developers are looking for guidance in designing the features of their software while providing an essential catalyst in helping practitioners improve the efficiency, relevance and compliance of their charting and related business functions. Working together, there's an opportunity to launch massage therapy into a more prominent position in the public/media eye while learning more about the populations we serve.
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