Today’s Dreams, Tomorrow’s Reality in O&P Technology

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By Paul Prusakowski, CPO, FAAOP

Over the last 15 years, we've all heard a lot of hype about computer and Internet technologies and the changes they would bring in our lives. By the late 90s, kids who were barely old enough to order a beer at a local bar were becoming Silicon Valley millionaires by promising to revolutionize every sector of business--including healthcare--within a few short years. The mix of lofty PowerPoint presentations and venture capital funding led to a lot of lost money and huge headaches.

Sobriety hit quickly, and we were all reminded once again that real change doesn't happen overnight. A vision of the future is necessary in order to create it, but it is not sufficient. It also takes years of hard work to overcome the hidden development and implementation obstacles that rear their ugly heads, and it takes a critical mass of people who recognize what can be and are willing to make changes in the way they work.

When we honestly examine what happened to the promises of the information technology boom, we find some very interesting things. First, that what was touted as a pending revolution, was actually an overstated awareness of the real possibilities for evolution. And second, we find that in most ways technology actually has lived up to its promises--the capabilities that were talked about in dreamy language only a few short years ago already are a reality, and are being used in many sectors of society in very practical ways. Where both O&P and healthcare in general have lagged behind, is in the awareness of technology, and the practical implementations of it that meet our needs. In short, we already have the way--what we lack is the will.

Pressures in the healthcare marketplace have forced us to change the way we run our businesses. Utilization of technology is not an option anymore. Where the availability of technology may not have been enough motivation for change, the impossibility of survival without that technology will fill the gap. This isn't future-speak--it is already happening right now. O&P suppliers have recognized that they can no longer afford the overhead of manual processes, especially customer service and ordering that rely almost exclusively on phones and fax machines. Third-party payers are not only encouraging electronic submissions, but demanding them--the cost and time savings to everyone is clearly evident.

At this time in the history of O&P, we should not fear change--but we should embrace it. The evolution of technology is true progress , and the day will arrive when we will all wonder how we got along without the advancements that we will have grown accustomed to using in our daily practice.

Tomorrow's O&P Practitioner

What follows is a tale about a day in the life of tomorrow's practitioner. It's meant to take us to the edge and look a little further, but make no mistake about it--nothing that is presented here is outside the capabilities of technology that already exists. And the aspects that are most crucial in facing our current crisis--the integrated information systems that manage all patient and product data and transfer it seamlessly and securely between various healthcare providers, vendors, and patients--could be right around the corner.

The Dream Unfolds...

The first patient of the day just arrived, swiping her universal medical card through the card reader at the front desk. Her complete demographic and insurance profile loaded immediately into our clinical practice management software, eliminating any entry by our office staff.

Our practice management software received an electronic prescription directly from the physician's office two days ago. When the patient was recognized by the software, it matched the queued prescription with the patient's electronic chart. Before even notifying me that the patient had arrived, Sheila, our office manager, clicked directly to the patient's insurance company from within the software and received an immediate authorization for the services that we were about to provide.

I happened to be finishing a few things up at my second office at the time when a notification chirped from the communication device in my pocket. Flipping open the integrated mobile video phone / Pocket PC, Sheila's face appeared to let me know that my first patient had arrived. Of course, the software could have notified me without involving Sheila, but she knows that I prefer the immediate opportunity to discuss things with her if necessary. In this case, the patient, who was new to our office, had told Sheila about her previous prosthetic care in Iowa. So I asked Sheila to request her past prosthetic medical records from the Iowa clinic, and notify me when this had been received.

Within minutes, I was notified that the prosthetic history portion of the electronic record arrived from the Iowa clinic, and after entering a special password, I was able to access the entire record through my Pocket PC via an encrypted wireless connection. I quickly reviewed her complete history to familiarize myself with the components she had been fitted with previously, as well as a history of fitting challenges that she had experienced throughout her years as an amputee. On the drive over to the clinic, I reflected on how fortunate it was that I would not have to reinvent the wheel', benefiting from a detailed account of how her difficult fitting issues had been overcome in the past.

I picked up my trusty Tablet PC on the way into the patient room, using the larger screen to quickly review the patient's prosthetic history with her, flipping through digital pages with a few taps of the input pen. The patient commented on how pleased she was to be at one of the newer "digital clinics." She noted that the whole atmosphere of these clinics was much different, and that she really felt her practitioners were more thorough in their care, and better able to help her understand her own prosthetics management, using these new computer systems.

After reviewing her past history, it was time now for our evaluation and measurement process. I pulled up the appropriate forms and simply clicked through the dozens of questions necessary to obtain a thorough and appropriate initial evaluation, using the "compare with past history" button to see how this evaluation had differed from evaluations she had in the past. It was apparent that there were physiological changes taking place, resulting in the need for advanced prosthetic technology in order to allow this patient to maintain the highly active and independent lifestyle she had been used to living for over 50 years as an amputee.

The measurement process was extremely clean and simple. The menu in my clinical practice management software had a selection of advanced CAD systems to choose from, and also integrated with a variety if advanced data input devices. In this case, due to orthopedic complications secondary to a unique surgical procedure, I decided that the most accurate input mechanism would be a combination of MRI data, tissue density data, and input from a laser scanner. The latest CAD software combined that data seamlessly to provide a perfect visual of her limb, including representation of internal and external anatomy. This provided me with a great starting point for beginning my shape manipulation in my new holographic projection monitor which provided the most lifelike representation of the residual limb ever seen before (see "Imagining A Holographic Projection..." below).

Imagining A Holographic Projection Monitor For O&P...

I think that the coolest application of the latest computer technology in orthotics and prosthetics are the new holographic visual field monitors. When the monitors are off they appear to be no more than a clear 20"x20"x20" block of lexan, propped on a metallic monolithic base- like a big ice cube, or a work of modern art. But when you turn this thing on it is completely amazing. An actual sized three dimensional holographic model of the limb appears to be floating within the block with a visual representation of both the bone and muscle tissue that was determined from the MRI data. With a pair of instrumented gloves as an input device, I am able to use true virtual tools within the holographic field to manipulate the residual limb shape. Through switching the density switch between "plaster tone" and "muscle tone" the properties of the hologram completely change, allowing me to reduce and reshape the model in the plaster mode, and then switch to "muscle tone" mode and see a visualization of how the shape changes would impact the muscle tissue within a socket with pinpoint accuracy by applying the tissue density data to the model. One of the most helpful features is the ability to view realtime pressure distribution maps on the holographic residual limb as it passes through a complete range of motion during a simulated gait cycle within the monitor. The wildest part about this is that you have the ability to move and manipulate this image as if it was a real leg just floating in space.

Once I was done with my shape manipulation, I already had a live connection with the CAM facility that I prefer to use for outsourcing my fabrication. Their fabrication management system allows me to collaborate with them on my fabrication processes directly from within our software. This is one of the ways in which the electronic medical record is more than just notes and measurements, but a complete window into the entire spectrum of clinical care that was provided to my patients. Through direct connections with all of my partnering suppliers, I have instantaneous communication and documentation available to me regarding every action that was taken related to each of my patients. No more using telephone and fax machines to send status reports and information back and forth, with no coherent record of what happened. Now I just open the patient's digital file and have direct access to reports on componentry and fabrication statuses and processes, as well as immediate notification if any of the components that are being used by any of my patients have been recalled by a manufacturer.

Before the patient leaves my office, I click a few buttons on my Tablet PC and a video appears to educate the patient on functionality of all the components that will be used on her new prosthesis, and it also reviews certain steps that she can take when working with her physical therapists to prepare herself to take advantage of the advanced knee and foot system. The entire educational process is documented in her electronic medical record, and a copy goes home with her on the Smart Card that we provide. Before she left, I checked and saw that her previous prosthetist in Iowa was currently logged on to the O&P global network of digital clinics. I clicked the "pager" button on the Tablet PC, and luckily he was not too busy to say a quick hello via the live video connection that came up between our Tablet PCs. This feature is typically used to provide clinical assistance at remote locations for challenging cases, but in this case it worked well for social interaction.

Earlier this morning I was running some reports on the current clinical and technical operations within our practice and could see that we should anticipate a stressful week ahead unless we reorganize our schedule. A report predicted that in order for all of our fabrication to be completed on time, it would require the technicians to work significant amounts of overtime. We decided that in order to minimize our turnaround time without stressing our staff, we would use one of the electronically integrated central fabrication companies. A selection of work orders were reassigned to the c-fab, digitized images of the casts were transmitted instantly, and then the operational reports were performed again. The results showed that if all the scheduled patients showed up for their appointments, the combination of reduction in turnaround time and the higher volume of deliveries within a shorter period of time would actually result in a higher profit margin for the company. How did I ever get by without all this powerful information at my fingertips?

Before I leave the office to see my next patient in the hospital, my lead technician (and purchasing agent) stops me to show off the latest upgrades to the purchasing module of the practice management software. We have already been spoiled by having seamless ordering with direct connections to all of our suppliers' computer systems, but Hector now demonstrates how every component that was ordered for the patients that we had just decided to send to c-fab were immediately being rerouted to the c-fab facility, via integration of the software directly with UPS. This really has come a long way since the days of using paper to keep track of all of our purchasing and inventory. Speaking of inventory, adoption of the latest advances in miniature RFID (radio frequency identification) technology by O&P suppliers has made inventory management at our facility completely automatic! As soon as an item is placed in or removed from our stock room, the RFID reader in the doorway automatically updates our electronic inventory status and financial records, placing items that need replenishment into our facility's electronic shopping cart. It just doesn't get much easier than that!

Although the trip to the hospital is going to take at least 45 minutes with traffic, I am already planning on getting a lot accomplished on the way. With the latest wireless technologies, my Pocket PC is directly connected to my office network wherever I am in the world, so those few patient notes that I need to dictate into the practice management system can easily be done while traveling. From my car, I will be able to listen to a portion of today's New York Times, and also register for the upcoming virtual O&P symposium that is expected to involve over 10,000 practitioners from around the world.

Before I leave the office for a weeklong sailing vacation, we'll have our monthly management meeting, where we perform a medical records audit to review our compliance in documentation and charting with 100-percent accuracy. With all the burdens of regulation that now exist, we must be in complete compliance for every one of the patients we treat. Luckily our clinical practice management software evaluates compliance in every aspect of our practice within seconds, and we have a complete picture of where we need to increase our efforts over the next few weeks to keep everything in perfect shape.

From the boat, I will wirelessly connect to the office for a half hour a day to assist in managing my practice by monitoring every aspect of the clinical and business pulse of the office.

How Do We Get There?

The technologies required to make this happen are already available today, and, with the possible exception of commercially available holographic monitors, this dream can be a practical reality. Are you ready to take the next step into really using technology in your practice?

Network your office and provide broadband Internet access to all of your staff in the places where they will benefit from connectivity (i.e. staff room, patient care rooms, ordering area, technical room). Be sure that you have current operating systems and updated hardware, because hanging on to outdated technology isn't worth the limitations it will put on your staff. Become familiar with what's available online and use the Internet and e-mail for business communication both internally and with your referral sources and vendors. Progressive vendors are starting to provide topnotch services online for communicating, ordering, and interacting more efficiently. This will be the norm in the near future.

Make a commitment to integrating technology into your clinical and business processes. Evaluate how you are doing things currently, and imagine what the possibilities are if every process in your office was linked seamlessly together. There's a lot of room in our current processes to become much more efficient, and technology is the answer to many of our problems. With commitment to evolving your practice with technology, you will find that the initial hurdle is not that difficult to clear, and once you start to see the outcomes, you will wonder how you ever lived without it.

It is the vision of a better world for O&P that has driven me to commit a significant part of my professional career to developing and bringing Internet and computer technology to the field. The changes are happening rapidly, and I hope that O&P continues to make the commitment to shaping our own future with intelligent use of computer technology.

Paul E. Prusakowski, CPO, FAAOP, owns a private clinical practice in Gainesville, Florida. He has been active in state and national professional leadership roles, founded the OANDP-L listserv, and is president of O&P Digital Technologies (