Alan Fredendall // #LeadershipThursday // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, ICE Chief Operating Officer Alan Fredendall discusses using the reMarkable writing tablet to reduce daily documentation burden to 5 minutes per day

Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog.

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EPISODE TRANSCRIPTION

ALAN FREDENDALLHow can we make our documentation more remarkable? Often a very boring topic, but a necessary topic as we are required by law to do a treatment note for every single patient that we see. So today we're going to talk about what is that law that requires us to do those notes. And then we're going to talk about new technology and a new way to think about documentation that's probably going to streamline everyone's documentation in a very significant manner. How can we potentially reduce our documentation burden to maybe five minutes per day?

DO WE HAVE TO DO DOCUMENTATION? So first things first, what is that law that says we have to do a note for every patient that we treat? That law is actually the HIPAA law. Way back in 1996, the Health Information and Portability Accountability Act, or what we know as HIPAA. And so that has a lot of things in it about not sharing protected health information, about in 1996 the emergence of the internet and what we can and can't do with submitting patient data electronically. But the main thing it establishes is that we do need to do documentation on every single patient that we see, and that that documentation be available to be transmitted electronically via fax or email upon patient request. Prior to this law, we just basically handed over copies of paper documentation, and it could be a lengthy amount of time before patients could get access to their records. In this day and age, patients need our notes sometimes for things like reimbursement. If we're a cash-based practitioner and they're trying to get out-of-network reimbursement, they may need it to submit because they got the day off work or something like that. And so there's a lot of reasons why folks may need their documentation and why they may need access to it very, very quickly. So the HIPAA law of 1996 established that documentation must be available to be transmitted electronically immediately to patients or other providers with patient approval upon request. Some of you may have interacted with a patient who needed documentation because they were involved in an automobile accident or something like that and they need that documentation to then send on forward. HIPAA also mandates that we keep documentation for up to six years and that essentially means the best way to do that is to store it electronically instead of maybe in an old filing cabinet. Now the thing about HIPAA is it says that documentation must be available to be transmitted electronically via email or via fax, but what it does not say is that our documentation must be inherently electronic. Documentation can still be written as long as it is transferred or changed into an electronic format, stored for those six years, and then available upon demand to be sent when requested. And so we're going to talk about how that opens up freedom for us today to do documentation maybe in a very different way that we have not considered before. Before we get into that, what are the penalties for not following this? What if I don't do notes? What if I just never do notes? What if I'm a cash-based practitioner? I don't interact with other healthcare providers on a regular basis. My patients pay me cash. Most of them aren't asking for auto network reimbursement, so they're not trying to see those notes or see super bills or see claim forms or anything like that. You should know the penalties here are quite severe because we are dealing with a federal law and we are dealing with the federal government. So with HIPAA, they have a four-tier system for violations, Tier 1 through Tier 4. Tier 1 is the lightest punishment. Tier 4 is the highest punishment. Tier 1 is considered that you were not aware of what you were supposed to do, and that you could have not avoided what happened. Now, this is kind of in regards to maybe accidentally revealing protected health information, but also if you don't have documentation stored electronically, and you literally can't submit it to someone, and also that you didn't know that you had to do that. That little caveat that you're not aware that you committed a violation is going to be, the burden is going to be on to you to prove that. If you can prove that though, that you literally had no idea what you were supposed to do and you have no way to fix it, the penalty for that is only $100. Very, very light. But realistically, no one lives here, right? Everyone is aware of what they're supposed to do and probably has a way to reasonably fix it. And so we kind of immediately move up to Tier 2. Tier 2 is you're aware of what you were supposed to do, but there's no way that you could have avoided that violation. This is a very common area for us to live in, right? Let's say you finish with patients for the week on Friday afternoon, and then hey, you're catching a plane, you're going on vacation with your family for a couple weeks, but oops, in that couple weeks while you're gone, a patient requests a note from you. You are aware that you needed to comply with that, but you're just not able to do that, right? Your maybe physical note is sitting on your desk next to your computer at the clinic still. There is no way for you to convert that to an electronic format and then transmit it to the patient. that comes with a little bit steeper fine, that's a $1,000 fine each time that happens. And then we kind of move things very, very quickly when we get to tier three. Tier three is the tier where we start to use the term willful neglect, that you are aware you need to do this, you did not do it, but you are willing to catch up on all of the neglect that you have committed in the past. Now when this happens, the fine jumps up to $10,000, right, a tenfold increase. And then tier four is willful neglect, but you're not willing to correct it, right? You know you're supposed to do notes, you know you're supposed to store them electronically, but essentially you show a habit, you show a pattern of just not doing that, even maybe if you've gotten in trouble in the past. And so tier four is the most punishing tier. Tier four comes with a fine of $50,000 every time that happens, so a very severe penalty. And so when we talk about that in the context of our brick by brick class, when we're teaching people to open their practice, the easy rule is just do it, right? Don't try to butt heads and win an argument with the federal government. The fines are very severe. The penalties are very severe. Just do it as annoying as it is. And my second and third part of today's podcast is showing you that we can make it we can't get rid of it completely, but that we can make it quite simple. So let's talk about that right now.

USING THE REMARKABLE  Let's talk about making your documentation remarkable with the remarkable. So if you're listening on the podcast right now and you're only hearing my voice, go over to our YouTube channel, the Institute of Clinical Excellence YouTube channel, and find the video of this so you can see what I'm doing. So this is a Remarkable. I'll close it up for you. It's got just a little folio and then it opens up and it's essentially just a tablet, right? This does allow finger input, but more importantly, it comes with a very nice stylus that lets you write the same as if you were writing on paper. So what we have been trialing here at our clinic in Michigan is using the Remarkable to replace our electronic documentation. So you can see what I have on here is I have a bunch of body chart templates. And so we have a folder for every day of the week stored on this tablet. And then we have body charts for every patient that has come into the clinic for treatment that day. So let me open up a brand new template for you all to look at. And now you can see here is our body chart template, just like we used to do on physical paper. Now it is on this tablet. We can write all over this thing. We can write eggs and eases. We can shade body charts so we can do our subjective and objective when patients come back into the clinic. And then the nice thing is with remarkable, we can add blank pages so we can itemize our manual therapy. And we can write all over this thing. And whatever we want to itemize, should we choose so can also be included in this template. And so what's nice is as soon as I finish this, it's automatically saved as a PDF, both on this tablet. But more importantly, it is saved back to a laptop or desktop computer. And I'm going to tell you in a second how we can put the tablet together with your EMR and basically have your documentation burden fall off a cliff in a really nice way.

INTERLUDE So before we do that, I just want to take a break, introduce myself. My name is Alan. I am the Chief Operating Officer here at ICE. This is Leadership Thursday. We talk all things small business management, practice management ownership, tips and tricks. I am the lead faculty in our fitness athlete division, so you'll see me on Fridays for Fitness Athlete Fridays, and also the lead faculty in our practice management division, where we talk about all things related to practice management in our brick by brick course. It is leadership Thursday, that means it's gut check Thursday. This one, very simple, 30-20-10, toes to bar, paired with single arm devil's press. Rx weight for gentlemen, a 35 pound dumbbell. Ladies, a 20 pound dumbbell. And then just to make it hurt a little bit worse, you're gonna do a 400 meter run after each round. I tested that workout last weekend. I think I came in somewhere around 11 minutes. So not as fast and intense as last week. And then our Brick by Brick course starts up again on October 2nd. That class always sells out. Our current cohort is finishing up week six, talking about Medicare, talking about documentation, doing a deep dive into the stuff that we're gonna talk about.

SYNCING NOTES TO YOUR EMR So how do we put our knowledge that we need to do documentation, it needs to be electronically available, with something like the Remarkable tablet. And the nice thing about Remarkable, like we talked about, is that when you finish a document on the tablet, and you close it out, it automatically syncs via the cloud to an app on your laptop or desktop computer, and that document is available immediately. So our previous documentation system, we would still do paper body charts, we would come back to our EMR, and we would hand type our notes. And that was okay. That maybe took three to five minutes for daily note, maybe 10 minutes for initial evaluation. That is all gone now, right? Because we have our body chart on the, on the remarkable and now we're doing electronically and it is updating to our computer in real time. What does that mean? That means we no longer need to come back to the computer and hand type our notes. It also means for maybe some of you that we're doing that and maybe taking a picture of your body chart or scanning it into your printer, that is okay. But again, that is a lot of burden, right? That's a couple more minutes per patient. What's great about Remarkable is that document, that body chart is available immediately as a PDF on your desktop that you can simply upload into the patient's chart on your EMR. And so now our documentation, all of the boxes of our soap note just says see PDF from this date, right? We are no longer typing. That carries over from daily visit to daily visit, see PDF this date, see PDF this date. And in that patient's chart of that date is August 1st, 2024, August 7th, 2024. And it is a PDF copy of the body chart and it is HIPAA compliant, right? It's electronically available and it has all the stuff that documentation needs to be sound and legally compliant, right? It has a subjective, it has objective, it has assessment, it has plan, it has some itemized treatment to justify if we're gonna bill insurance, for example, why we're billing insurance and for how much. And so for us, switching to this system has reduced our total documentation load to about five minutes per day, which is really, really, really incredible when you think about it. We already had given two hours in the workday for admin time, following up with patients, documentation, that sort of thing, and now that administrative burden has reduced down to about five minutes a day. And so that's just extra time that our therapists have that's not spent typing stuff that they have already written down on a paper body chart anyways. What's nice about this, this remarkable system is that you can take it into the treatment room and it looks no different than if you have a body chart on a clipboard or something like that. It's not as intrusive as a laptop. Obviously it's not as annoying as typing, right? just chipping away and typing as somebody's trying to talk to you. It's very, very low maintenance and it's really awesome. Now, what are the cons of this? There are some cons. They are expensive. They're about $500. I have asked for a coupon. I have asked if they do volume discounts. They do not do any of that. They know what they're doing. So there is a con of the price. And then the other con is that this thing is really kind of worthless outside of this specific niche, right? Unless you happen to want to journal on it, unless you happen to hand write a lot of other stuff in your life that you also wish could be available immediately electronically, the remarkable doesn't have a lot of value for you. That being said, We love how nice it writes. It writes the same as paper. We love that because it really can't do anything else, it has a super long battery life as well. So we have transitioned our documentation system to that and we're very, very happy with it. So with documentation, HIPAA law requires that we do documentation for every single patient, that there is a penalty if we don't do that, and that we should probably follow that unless we wanna get in trouble. But there are different ways to think about doing documentation other than just typing forever into those boxes on your EMR. That this might seem like a step backwards, because we're writing now, but because of the technology that powers the Remarkable, because it is available instantly as an electronic PDF, and can significantly speed up your documentation time. So give it a shot. The company's name is literally remarkable. Look it up. There are a lot of other competitors emerging as well. And I'm sure in the next couple of years, we'll see more of these become prevalent. Writing on these has on electronic devices has been around for a while. Many of you may remember the Palm Pilot. However, you know, it had a two inch screen and you couldn't read what you wrote. So this is a significant step forward. The writing is beautiful. We're very happy with it. And if you try it out, let me know how it goes. So make your documentation remarkable. Hope you have an awesome Thursday, a great weekend. Have fun with Gut Check Thursday. See you later, everybody.

OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.