Can a clinical documentation system be developed and capture the details of what therapists do with patients during inpatient rehabilitation therapy sessions?

The Study:
In order to study what therapy approach produces better outcomes, researchers must be able to collect details of what therapists do with patients during therapy sessions. Comparing Treatment Approaches to Promote Inpatient Rehabilitation Effectiveness for TBI (CARE4TBI) has goals to compare different treatment approaches used during inpatient rehabilitation to find out which produce the better outcomes at discharge and at one year following TBI. This type of comparative effectiveness research (i.e., finding out what is better) requires as much data as possible about who is getting therapy, who is delivering therapy, and what therapy is being delivered (when, why, how, and what). All of these pieces of information are included in therapy session notes that therapists must complete at least once a day as part of their clinical patient care. CARE4TBI researchers therefore collaborated with occupational, physical, and speech-language therapists from across 14 TBI Model Systems to design a note template that could capture the details from every OT, PT and ST session during a patient’s stay in inpatient rehabilitation. Once documented, the data in each note could be extracted from the electronic medical records (EMR), summarized across days, across patients, and across research sites and provide researchers with the level of therapy detail needed to categorize and then compare the various treatment approaches.

A team of therapists from across the 14 sites worked to identify all of the necessary and relevant data to meet the documentation needs of clinical care, regulatory agencies, and research. Two distinct categories of data were identified—session data (what is common to most therapy sessions) and therapy activity data (what is unique to each therapy session). Within the session data, a total of 14 different pieces of information about the session were captured (e.g. purpose of the session, who was present in the session, factors that influenced the session) . Within therapy activity data, 54 distinct activities were identified (e.g. walking, dressing, swallowing). The therapists also identified important information that should be used to describe the activities (e.g. whether an assistive device was used). This identification process took an entire year and demonstrated that EMRs can be designed to capture large volumes of data across many sites.

Who may be affected by these findings? Clinical providers, specifically inpatient rehabilitation therapists, and researchers at the 14 TBIMS sites can utilize the data collected through the EMR to collaborate and study rehabilitation therapies and improve outcomes.

Caveats: Despite the large-scale therapy data that will be collected, it is possible that relevant data elements about therapy may have been missed.

Bottom Line: This large-scale collaboration provides a national model for rehabilitation therapists to continuously study, assess, and update their knowledge about best rehabilitation practices. This is what a learning health system is all about—continuously updating knowledge and practice.