The Near Future of O&P

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By Morgan Stanfield

"The single-most important thing to understand when we talk about the future of O&P is that clinicians need to stop seeing ourselves as giving people new limbs or braces; what we provide in reality is maximized function."

-Dennis Clark, CPO

The concept of "the near future" has many interpretations. Ten years into the future, for example, seems near enough for a comfortable sense of familiarity that lends itself to practical predictions. However, it's far enough out that it holds the potential for disruptive technologies or social mores to take hold, unsettling us as deeply as did the advent of the Internet. As part of The O&P EDGE's ten-year anniversary celebration, we asked thought leaders across the profession for their visions of the next decade-what they expect, what they fear, and what the profession can do to nudge the long-term future toward its highest potential. What they revealed is not a wish book of new gadgetry, but rather an exploration of the themes, transformative mindsets, scientific zeitgeists, and inter-professional shifts that are in the process of shaping, or have the potential to shape, the O&P profession over the next decade.

The New Clinician

Many of the experts interviewed for this article say that the coming decade will essentially be concerned with the profession's evolving new professional role-one that functions within the coming economic and technological realities rather than struggling against them. Dennis Clark, CPO, is president of Clark & Associates and the Orthotic and Prosthetic Group of America (OPGA), both located in Waterloo, Iowa. He says, "The single-most important thing to understand when we talk about the future of O&P is that clinicians need to stop seeing ourselves as giving people new limbs or braces; what we provide in reality is maximized function."

More broadly, many of our sources agree that over the next ten years, clinicians will increasingly see themselves not as device providers but as healthcare providers-specifically as experts serving among colleagues, within cross-disciplinary teams that are driven by outcomes-based practices and science.

This evolution will be reflected in and led by advances in professional education. "Most currently practicing clinicians really matured in the computer age, and they feel comfortable with technologies like scanners and image-capture devices," explains Kevin Carroll, MS, CP, FAAOP, vice president of prosthetics for Hanger Prosthetics & Orthotics, headquartered in Austin, Texas. "However, the next wave of O&P students will graduate with a master's degree, which means they'll be thinking at a different level. They'll fully understand new research, and they'll grasp how to understand and facilitate evidence-based practice."

Kurt Schlau, CP, director of prosthetics at Wright & Filippis, Rochester Hills, Michigan, adds, "In the next ten years, the older generation of clinicians are going to have to understand that if they don't adapt and utilize technology and especially research, they'll be lucky just to survive in this business."

Peter Rosenstein, executive director of the American Academy of Orthotists and Prosthetists (the Academy) is currently engaged in developing programs that will help clinicians grow into this new paradigm. One example is an educational program being developed in conjunction with the American Physical Therapy Association (APTA). In this program, three O&P clinicians and three physical therapists will team up to present scientific insights on clinical topics whose relevance overlap both professions. This joint session will be presented at both the Academy Annual Meeting & Scientific Symposium and the APTA Annual Conference & Exposition. The session will then be posted to both organizations' online learning centers for use by members. Over the coming decade, Rosenstein says the Academy expects to develop similar cross-pollinations with orthopedic surgeons, occupational therapists, and other professional groups.

Cross Pollination

One reason why programs like the Academy's are essential for the profession's future growth is that they may shift the course of potential encroachment from other professions, a serious concern of many O&P professionals. The first issue that such interdisciplinary efforts may help mitigate comes from the APTA itself. That organization's 2007 initiative, "Vision 2020," set a goal that "by 2020, physical therapy will be provided by physical therapists who are doctors of physical therapy." Currently, 44 states allow patients to access physical therapists (PTs) directly without referral from a physician, and the next ten years holds a significant likelihood that PTs may become able to write their own prescriptions and provide various off-the-shelf orthoses directly to their patients.

Gary Bedard, CO, FAAOP, of Becker Orthopedic, Troy, Michigan, says that to ensure O&P clinicians are not cut out of this treatment scenario, they must follow the Academy's lead and establish themselves firmly as expert members of the PTs' team. Clinicians can do this by providing PTs with training, sharing their expertise freely, and co-planning patient acute care.

Bedard describes a scenario that applies to a variety of disciplines that are allied with O&P: "The basic education of the physical therapist in O&P is and will probably remain very minimal. If you invest time into training a physical therapist in what you do, that can show them your clinical capabilities. That means that instead of thinking they can guess about the patient's orthotic needs based on their own training, they've come to see that orthotists have intensive skills needed to optimize the patient's orthotic management." To strengthen the team further, the training must work both ways, though. Bedard believes that the future's most successful O&P clinicians will be able to "walk into their facility already understanding" the basics of the technology and protocols PTs use on their patients.

Learning Resources

To gain these cross-disciplinary competencies, working O&P professionals may need a variety of new resources to help them learn the methods the various professional organizations expect them to know. The American Orthotic & Prosthetic Association (AOPA) has extended its continuing education resources over the last several years, for example, with distance-learning offerings that include audio conferences and webcasts. In the next ten years, AOPA has an ambitious plan to expand these offerings. One initiative that the organization recently revealed may be especially pivotal: the Online Video Learning series, which is currently temporarily free for AOPA members. Like other new offerings, it will bring new scientific presentations directly to clinicians through the Web, helping them to develop the essential scientific literacy needed for the new paradigm.

OPGA plans to provide equivalent offerings in the business realm. "Our vision for continuing education over the next ten years encompasses technicians, office staff, and case managers as well as clinicians, because they all affect the way O&P is delivered," Clark says. "To help answer their needs, we've created a live video studio in our building for simulcasts of up to 1,000 computers at a time. We also plan to help whole practices advance by tracking for customers the kinds of education their staff is receiving."

Soft Skills, not Software

Many of the professionals interviewed for this article note that the importance of technological developments, particularly in information technology (IT), over the coming ten years will be less about the technology than about how innovations will shape their clinical relationships. Some see IT as an Ouroborus-like loop, causing patients to arrive at appointments increasingly self-educated, which will require clinicians to become correspondingly more educated to be able to respond to them. This, in turn, will help patients to become even more educated-all of these things are byproducts of the office's use of IT.

Stefania Fatone, PhD, BPO(Hons), research associate professor in physical medicine and rehabilitation in Northwestern University's Feinberg School of Medicine, Chicago, Illinois, believes that over the coming decade, the answer to elevated patient expectations will lie in the collection of outcomes data, and that such knowledge will be increasingly easy to tailor to each patient.

"More discerning consumers and clinicians [will be] demanding real evidence of effectiveness, not just marketing hype," she predicts. "Technology is going to continue getting smarter. Components are going to not only provide functionality, but also allow us to assess what is going on during everyday use." She adds, "Prosthetists and orthotists need to learn to routinely evaluate the effectiveness of their interventions. How do we interpret the data from these smart components? How do we integrate that into our patient care?"

Fatone says that the answer to such questions will only be gained through "integration of evidence-based practice [and] routine adoption of outcome measures as part of patient assessment."

Clark believes that collecting outcome measures already is, and will further become, a far less daunting task than most clinicians currently believe. "People are so afraid that data collection is going to eat up all their time and profits...," he says. "That's simply not true. Most of the baseline information that we're gathering today, other than a little ADL [activites of daily living] information that we're gathering during the interview process anyway, is found in the initial patient evaluation. We simply need to create reliable, repeatable processes for gathering information and sharing it globally."

Schlau believes that if clinicians do so, they'll be indirectly fueling the next decade's growth in patient education. "When you're taking extensive data from a patient for their electronic medical records, they're going to be learning from you what's important for their condition. Specifics, like what kinds of pills they take that can affect their limb size, and the names of the bones in their residual limb. I think that will be a huge benefit to the patient, and it's an approach that lets patients really develop more confidence in you as a clinician."

Clark notes that the coming decade will see many new manufacturers "stepping up to provide the devices that will make all this easier." He envisions nearly every component that the patient wears becoming a "smart component" that provides outcomes data automatically, with minimal effort from the clinician to collect and use.

What We Don't Discuss

A ubiquity of higher-tech componentry would not come without cost, though-literally. Several persons interviewed for this article expressed deep concerns about patient access in the coming decade. They wished to remain anonymous out of concern that they might be perceived as discouraging innovation.

"I worry that the cost of these technologies is outpacing the ability of the health system to cover them," one says. "It's just a matter of time before a lack of ability to pay places significant downward pressure on the propensity of researchers and the industry to continue to advance our market."

Others express apprehension that much-anticipated technologies achieved through programs such as the Defense Advanced Research Projects Agency (DARPA) Revolutionizing Prosthetics program will never become available to average patients. One professional asserts, "The economies of scale just aren't in place to sufficiently reduce the costs. And if ordinary people can't have this technology, we might spend the next ten years wishing we'd spent that money on something that people would actually be using."

The specter of competitive bidding also troubled the corners of many discussions. "We've been spared so far," was another anonymous comment. "I think most people have no idea how lucky they are compared to DME [durable medical equipment] providers and doctors. Who knows how that's going to play out for us over the next ten years?"

The Great Uncertainty

Peter Thomas, JD, general counsel of the National Association for the Advancement of Orthotics & Prosthetics (NAAOP), says that a great deal of the foundation on which these issues will come to rest will be legislative. Whether O&P parity is established or preserved will be of central importance, especially in regard to the Affordable Care Act.

"There are two main challenges to the Affordable Care Act as we speak," Thomas says, "and it's pretty clear that if the President is not reelected the Affordable Care Act is going to be delayed significantly, reformed significantly, or perhaps repealed altogether.... The next ten years hold a great deal of uncertainty for O&P because of this.

"NAAOP plans to continue to make the case that O&P needs to be covered in that essential benefits package...," Thomas continues. "Will there be some limitations? Probably. O&P care is not cheap, especially prosthetic care. This is supposed to be an essential benefits package that everyone can afford, and those are very different countervailing considerations."

In any case, he affirms, "I think the Affordable Care Act represents an incredible opportunity that the coming decade may see come to fruition. If it doesn't, we'll deal with that. Our goals will be to ensure that no matter what the Congress or President does, NAAOP will try to watch out for the O&P patient as best we can. As long as that survives, we're pretty confident that we'll be doing the right thing."

Schlau agrees. "No matter what, we're going to be extremely fortunate in this decade because we're going to spend it affecting lives in a positive way. That's the passion and objective that will never change. If we continue to provide the patient with the best possible care for them and their activity level, to give people back their abilities and in some cases even more, then we have enough to be grateful for."

Morgan Stanfield is the director of communications and marketing at Tensegrity Prosthetics, Louisville, Colorado, and a freelance writer for  The O&P EDGE. She can be reached at