Measurement Concerns


The number of measurement tools available per body part creates difficulty in comparing results.

By Alfonso L. Amato, PT, MBA

The introduction of Functional Limitation Reporting (FLR) by the Centers for Medicare and Medicaid Services (CMS) requires the use of a functional measurement tool. However, CMS has no recommendation or endorsement of what functional measurement tool to use in the outpatient rehabilitation setting.

Rehabilitation has led the way in health care by developing the science of measuring and reporting outcomes. A multitude of functional outcomes measures are available through commercial and open-access sources for nearly every type of patient health condition seen in rehabilitation. Although variety is typically considered positive, for rehabilitation professionals, this variety leads to a problem. The number of measurement tools available per body part can create difficulty in comparing results between patients, or between practices.

A simple head-to-head comparison of functional change between measurement tools is impossible. Let us analyze a common scenario. Two therapists are treating patients who have knee pain. Each therapist chooses a different functional measurement tool to measure function. Therapist A uses the Lysholm Knee Rating Scale and Therapist B uses the Lower Extremity Functional Scale (LEFS). Both tools are valid and reliable functional measurement instruments; both use a higher score to report better function. The LEFS top score is 80 points; the Lysholm top score is 100. Each therapist will report the resulting functional score from each instrument.

The challenge arises when you want to compare the outcomes between these two patients. A score of 40 on the LEFS is not the same as a score of 40 on the Lysholm. You cannot compare a patient’s outcome measured by the Lysholm with a patient outcome measured by the LEFS. Even with two measures with the same scaling of 0-100, a score of, say, 47 does not mean the same thing as a score of 47 on the other measure. Even if the necessary sophisticated statistical analyses were performed to “link” or “crosswalk” the scores of one measure to another, any change in scores would not be comparable. That is, clinical and statistical interpretations of change— the minimum clinically important difference (MCID) and Minimum clinical difference (MCD)—would remain unique to each measure.

When reporting change in function between patients, measurement properties of the tool are just one aspect in the comparison equation. Patient characteristics must also be taken into consideration. Certain patient factors affect functional outcomes and need to be considered when making a direct comparison. The science of outcomes has evolved to equalize patients via risk adjustment. The main factors considered via risk adjustment often include gender, age, and acuity of the condition. To accurately compare effectiveness and efficiency of care, risk adjustment is required. When comparing functional change of “knee patients,” even with the same functional measurement tool, you cannot compare functional change of each patient because you do not know what other confounding variables have influenced the patient’s potential for change. Risk adjustment accounts for the variables that influence the patient’s ability to respond to treatment and allows for one patient to be compared with another accurately. Using more risk adjustment variables allows you to better account for as many patient differences as possible.

No one wants to be punished for caring for the patients who are sicker, more severe, more complex, more difficult to get better, but that can happen if reimbursement is using a system that does not take risk adjustment into account.

Functional limitation reporting utilizes a G code modifier, which does not specify the specific measurement tools used. Use of different measurement tools can confound the understanding of the functional improvement as a result of care. The G code functional limitation levels are broken down into 20-point increments of change on a 0-100 scale. The following example can show how the reporting of change in a G code level may not provide an accurate picture of true functional change:

Patient A’s functional score at admission places the patient at the bottom of a G code scale; Patient B’s functional score at admission is placed at the top of a G code scale. Both patients had 19 points of change, but one is reported to be in a higher G code and the other patient remains in the same G code. This issue may lead to a missed opportunity to fully understand the change in function the G code reporting process was designed to capture. G code reporting, or a system like it, will possibly be the basis for future reimbursement policies. There is the real possibility that the rehab provider may be paid differently based on the G code level change, rather than on the patient’s actual functional change.

In summary, functional outcome reporting is here to stay. It will become the common language for reporting efficiency and effectiveness in outpatient rehab. It will increasingly be the basis for reimbursement. How do we ensure that reporting functional change will accurately reflect the benefit the patient received from the rehab provider, and that the rehab provider is paid fairly and credited for their contribution to the patient’s welfare?

A functional reporting system that has the following attributes will be the best opportunity to accurately measure and report functional outcomes, and become a basis for future reimbursement policy:

  • The industry settles on a functional outcome measurement system used by all providers.
  • The measurement system provides for the most accurate risk adjustment available for valid comparison of providers and treatments.
  • The measurement system has psychometric properties that ensure high responsiveness, validity, reliability, and precision of measurement.
  • The required G code method of reporting functional limitation allows for accurate reporting of change that captures true patient improvement.
  • The measurement system has risk-adjusted predictive analytics that most accurately predict discharge functional level.

These five attributes of a functional outcomes reporting system will provide the basis for a fair and accurate process to fully understand patient change, better inform policy initiatives, and guide evidence-based practice. 

Alfonso L. Amato, PT, MBA, is the president of FOTO, a private outcomes management and reporting company. He can be reached at

The Promise of Patient Registries


Clinical quality improvement beyond benchmarks.

By Chris E. Stout, PsyD; Grace Wang, BA; Julie Roper, PT, DPT; and David Nelson, MBA

As health care in the United States becomes increasingly patient-centric, hospitals, clinics, and other health care practices must strategically adjust their business models to focus on patient experience, and more specifically, patient outcomes. More than ever, health care professionals must know what works for which patients and why. Evidence-based medicine and evidence-based practice are more important to clinicians than ever before. While an evidence-base is predicated on having a robust literature from which to base reviews and consensus guidelines, generally only studies with positive findings pass peer review muster.1 Thus, studies that should be helpful and guiding are often of little practical value. An approach that may address this concern is the increasing use of patient outcomes registries, which, when designed and applied suitably, can provide clinicians and other stakeholders with a real-world picture of treatments and their efficacy.2

Streamline & Simplify Practice Management for Increased Productivity


The “5S” method helps to overcome the management and organizational challenges that private practice physical therapy clinics face every day.

By John Carpenter, CPA and Larry Briand, MS, PT, ATC

As both a clinic and a small business, private practice physical therapy clinics face management and organization challenges every day. Since most aspiring physical therapists go to college to focus on becoming clinicians and not businessmen and women, it can be difficult to effectively run all aspects of a private practice while still being able to spend the most time where it counts—with patients.

It is important to realize that although we may be clinicians, we still have to develop our management arm. Many aspects of our clinic are affected by management—both good and bad—and being able to effectively manage a clinic can either make or break you.

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“5S” is the name of a workplace organization method that uses a list of five Japanese words as a guide: seiri, seiton, seiso, seiketsu, and shitsuke, which translate, respectively, into sort, straighten, shine, standardize, and sustain. This method, intended to enhance operations and efficiency on a daily basis, uses simple and easily implemented ideas to achieve high levels of quality, safety, and productivity. By organizing both your mind and workspace, you will be able to spend more time on patients and less on all the other things.

HIPAA-Compliant Sharing Solutions for Physical Therapists


With the right tools, you can use text messages, emails, and cloud-based file-sharing services to help you share and manage patient information—without violating privacy regulations.

By Asaf Cidon

Physical therapists today have more ways than ever to communicate with colleagues, other health care providers, and patients.

Consider a hypothetical case that happens all the time: A patient’s regular physical therapist cannot make an appointment, so the therapist text messages her colleague some details about the patient’s case, including a list of his medications. This colleague makes progress notes on her iPad during the session, and the document is automatically backed up to a file-sharing service the physical therapists use to store patient files and other information. When she returns to work, the regular therapist reviews the notes on her laptop, and then emails them to the patient’s primary care provider.

The possibility of a data breach is particularly troubling for smaller practices that all too often ignore security—thinking that their practice is unlikely to be audited. But they do so at their own peril. Any medical professional who stores or transmits patient information online must comply with HIPAA security rules or face steep fines. Even a single lost client record can expose providers to liability.

Here are a few tips to keep in mind for each way you might share Protected Health Information (PHI).

Secure Text Messaging

Secure text messaging will not help you store and manage large numbers of patient files, but it is a must-have if you use texting to communicate about patient care.

  • User experience. Do not skimp on the user experience. The best secure text messaging apps replicate the texting experience.
  • Message storage. In order to mitigate the risk of a breach, ensure that your provider stores messages on its servers—not your phone. Look for solutions that encrypt data at rest and in transit to minimize risks associated with hacking. Because the PHI-laden messages are not stored on the therapists’ phones themselves, a lost or stolen phone would not result in a data breach—or a violation. You should be able to set preferences for messages to be automatically deleted either after a set time period or once they have been read.
  • Control forwarding. For text messages to be truly secure, messages should not be saved, copied, or forwarded to other recipients, in order to prevent sensitive content from being viewed by anyone except the intended recipient.
  • Audit. The fact that messages are not stored on your phone might seem to complicate audit functions, but if your provider makes usage data and monitoring information easily available to administrators, you will preserve compliance with HIPAA’s audit rules.

Secure Email

Email remains an extremely helpful tool for quickly sharing files, but it is not secure. However, encrypting your email will enable HIPAA-compliance and ensure that only authorized users will be able to open and read your messages.

  • Identity validation. Find a provider that validates the recipient’s identity. Common approaches including requiring recipients to answer a secret question or otherwise verify their email methods.
  • Audit. Seek out tools that provide the option of tracking and logging emails, which is necessary for auditing purposes.
  • Mobile. Because lost or stolen mobile devices pose such a big HIPAA breach threat, it is essential to use an encrypted email provider that also works on mobile devices—key for therapists working on the go.
  • Sender support. One of your biggest email threats lies in emails sent by patients. If your encrypted email setup is too onerous, patients are far less likely to use it. Many email encryption programs do not make it easy for non-users to collaborate. That’s where cloud-based file encryption can come in handy, because it can allow patients to launch encrypted files securely to you without requiring downloads or setup.
  • Message storage. Many email encryption products do not securely store and back up all files in a centralized way. This can pose problems down the line with record retention, so ask questions of your provider about how you can obtain an audit trail.

End-to-end Encryption

Cloud-based file sync and share programs make it extremely simple to store files, exchange them with other health care professionals and patients, and sync them across computers and mobile devices. When a provider makes changes to a file from a tablet, for instance, a cloud-based file-sharing program will store and show the changes when the file is opened again from the provider’s laptop or desktop.

  • Encryption. Most cloud providers encrypt data at rest and in transit, but the real key is finding solutions that encrypt on devices; otherwise, file synchronization poses a tangible risk of an HIPAA breach. Protecting your files in the cloud with file-level end-to-end encryption, however, adds that additional layer of protection that ensures that the file is always encrypted, regardless of its location, turning the cloud into a HIPAA-compliant safe haven.
  • Easy sharing. One of the nice features of cloud sync and share programs is that shared folders make it easy to exchange information with frequent collaborators. The ability to sync across different devices and share files externally makes cloud-based file-sharing ideal for managing patient files at a clinic that contracts with multiple physical therapists, or at a practice that frequently interacts with external organizations. But it is essential to find a security provider that preserves encryption while sharing data.
  • Seamless security. Bear in mind that encryption solutions, like everything else, should preserve the user experience that makes the cloud so convenient. Otherwise, therapists and others will not use them, exposing you to potential violations.
  • Separate data from keys. Ideally, you should seek out a security provider that is independent from your storage provider. This way, the encryption keys will be totally separate from the content, which means that neither your encryption program nor your cloud storage provider can access your files. This assures that only you and the users you authorize are able to retrieve and work with encrypted data.

As we have outlined, employing these safeguards can help health care providers take the necessary precautions to keep patient records safe and meet HIPAA security requirements—and even boost productivity.

Asaf Cidon is the chief executive officer and cofounder of Sookasa. He can be reached at

Technically Successful


Physical therapists need to define success, then measure and report it.

By Eric Cardin, PT

Advances in technology are all around us. The evolution of telecommunications, computers, and medicine continues at an exponential pace. Medical technological advances in the past 20 years have brought radical change to surgery and postoperative care and have saved and prolonged lives. However, what about physical therapy? How does a profession rooted in the basic human connection of communication and personal contact benefit from the frenetic pace of technological change? Should it? Can it?

Measuring success is a complicated task. First it must be defined, then measured and repeated. Understanding the “outcome” of physical therapy is as varied as the patients we serve. Two patients with the same diagnosis could and will have varied paths to “success.” On one table is a patient with a total knee replacement with excellent motion—but continued complaints of pain and poor function. The next client has what would be considered poor motion but feels they are “doing great!” How will these patients fare in a “pay for performance” environment? How do we measure, report, and define their success or failure? Can success be defined? Can technology hold the key to an effective (i.e., cost effective/efficient) method of saying, “This patient had a good/great/bad outcome?” The response pain from surgery or injury as well the emotional, spiritual, and physical changes related to disease and recovery are too variable to neatly fit into a standardized set of questions. It requires a distinct combination of measures and judgment. Taking clinical judgment, which evolves quickly in the mind, and combining it in real time with the patient in front of you and documenting and educating in the frenzied pace of physical therapy is a daunting task. Measuring outcomes is essential and the time is coming fast, if it is not already here, when we will prove what we have done has worked above the obligatory batch of thank-yous and fresh-baked chocolate chip cookies. (If you are not getting cookies you might be doing it wrong.)

Private practice physical therapists need to lead the way. We must define how we measure success and use and/or develop the methods and technologies necessary to measure success. The American Physical Therapy Association’s (APTA’s) Evaluation Database to Guide Effectiveness (EDGE) initiative has been in place for close to a decade; Dr. Rebecca Craik called for the need to classify our patients, standardize our interventions, and effectively measure outcomes in 2005.1 Are we doing it? Are we identifying our patients, treating them with generally accepted interventions (backed by evidence) and documenting the outcome? Physical therapists have been aggressive and competent adopters of Physician Quality Reporting System (PQRS) and therefore capable of collecting and reporting information. However, what about that information? Does collecting information on body mass index (BMI) or medications accurately measure the quality of care? If we have shown that we can collect and report information, the next logical step is to define what is pertinent to our practice. We must define success and continue to demonstrate that physical therapy is a highly valuable and essential part of recovery from injury, illness, and surgery. Successful (and happy) clients are an important tool. We must harness their satisfaction and use it to our advantage. Each day thousands if not hundreds of thousands of “physical therapy evangelists” are discharged into the world. We can use them to help us define success.

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The answer may lie in technology. Activity trackers, worn on the wrist or belt, can provide useful information. Smartphones can track movement and patients can log activity in a digital diary. Video can be an effective tool for objectively defining a patient’s start and end point. Tablets can streamline the data collection process and electronic medical records (EMRs) can integrate standardized tests. Innovations continue in gadgets that accurately measure motion and movement and help us to quantify our observations. We must stand atop this heap of information and decide what is relevant and define what success is and how it is measured. We cannot wait for “the doctor said I’m doing great!” or the “insurance says I am functional.”

Last month 450 different humans walked into my practice. They were tall, short, fit, overweight, young, old, English speaking, non-English-speaking—the list goes on as they were as diverse as the country we live in. Effectively collecting, documenting, and interpreting information about their current, past, and potential function is essential. Doing it while continuing to provide quality care while generating adequate revenue to provide that care and run the business is a monumental task. The patients we serve, and the injuries that limit them, are diverse as are the resources the patients bring to the recovery process. Perhaps the app or the software or the hardware we need has not been invented or it is evolving right now. Evolving payment structures and increasing patient-cost sharing is moving us toward an environment where results matter more than ever. Technology investments already strain our budgets in an era where so many things chip away at revenue. We need to define success, measure it, and report it. Therapists are making dramatic steps toward success every day but unless we collaborate (via technology) and innovate—it will be defined for us. 


1. Craik RL. Thirty-Sixth Mary McMillan Lecture: Never satisfied. Phys Ther. 85:1224-37, 2005.

Eric Cardin, PT, is the executive director of South County Physical Therapy, Inc. He can be reached at

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