Chiropractic + Naturopathic Doctor • June 2020 • The new normal

The Covid-19 crisis forced pretty much everyone in the rehab community to pivot quickly to avoid catastrophic pain to their businesses. Unable to see anything but the most urgent patients, many practitioners have taken a hard look at how to address their ‘inner healer’ while also keeping their businesses afloat. Pivoting to online tele-health consults and exercise classes have been at the front of this adjustment. In this article we’re going to address some of the greatest ways digital technology has affected a traditionally hands on practice and look at some of the pros and cons of tele-health, rehab programs, and electronic health records (EHRs).

We have had the privilege of growing up and working in a time in history that allows us to understand how technology truly affects our lives. Kids now play games so realistic you’d think you were on the battlefield, versus the original Nintendo: Who remembers blowing into a game cartridge to make it work?

With every challenge, there is an opportunity. Those who embrace these opportunities will potentially thrive, those who eschew them will have a tougher road moving forward.

This was truly an opportunity to shine. Knowledge is power. We can empower our patients, just by providing high-quality knowledge of their problem. Canadian chiropractic education is of the highest quality in the world, and we can imprint that knowledge onto our patients, empowering them, and giving them tools to solve their own problems. Tele-health was the answer for this patient empowerment process, and we review some of the most common available programs used over the past few months.

Given the increase in video conferencing over the course of this pandemic, I imagine some of you reading would immediately think of using Zoom to achieve this service. Unfortunately, although it has superior imagery and functionality, Zoom has had some well-publicized security lapses that make it inappropriate for patient engagement at this point in time. Truth be told, Zoom would have been a great stock buy in February! Regulatory bodies wanted to ensure patient information was secure, and legislative requirements were being followed. Most electronic health records systems pivoted themselves to provide secure transmissions that could be recorded in house. Programs used by chiropractors and other HCPs quickly provided this service.

Many practice management software programs offer fantastic functionality: An easy to share platform, low bandwidth requirements, a chat feature to share images, and videos sent directly to the patient’s email. In some programs, practitioners can also write directly in their patient’s chart while speaking to them. Seamless use of desktop or mobile options adds to the quality of these programs.

However, with no hands-on assessment, there will always be limitations to how much “physical” assessment you can do. From day one, we were told that the history should give us the diagnosis 70%+ of the time, with the physical exam used to confirm it. This may be less of an issue to practitioners that rely more on movement observation versus those who rely more on palpation. Seasoned practitioners will be able to make judgements based on a minimal amount of data, while newer practitioners may struggle to make sense without having the entire picture.

Most practice management software companies will provide the clinician and patient with an excellent experience and meet most regulatory bodies requirements (at least as far as EHR is concerned). While Zoom is one of the most known programs – and frankly has the most superior functionality – it does not meet the regulatory requirements of our colleges for the purpose of patient engagement.

No matter what your practice style is, we all know that exercise is therapeutic. The science has shown that exercise benefits essentially all aspects of our health, from the physical to the mental. So, in a remote engagement practice standpoint, exercise is our key home management tool, with ergonomic advice likely following behind. Motion is lotion!

Being able to utilize rehabilitation exercise program apps can be a great help to our patient management. Even though our hands on care should be second-to-none, what really sets our profession apart is how we understand the body and are able to problem solve. There are numerous exercise apps that help fit the bill. Some examples of this technology include the “Straighten Up Canada” app and the CCGI series (www.chiropractic.ca), as well as the “Injurymap” app, a new innovative program based out of Denmark. Many Canadian docs are familiar with the GLA:D program for arthritic conditions. The Dane’s take their musculoskeletal care seriously and InjuryMap is no exception. There are more, however, we’ll focus on these options.

An aesthetic user interface, algorithm acuity, and simple to understand design will assist with compliance. These are key features for any exercise app. Generally, these apps are user friendly and provide exercise programming that takes minutes to do (no excuse for the busiest of people). These plans are, for the most part, simple and easy to follow along as well as they don’t require any gym equipment either. Accessibility is one click away and, once they have it, they have the potential of self-managing the plan until they’re able to get in to see their trusted chiropractor for their expertise and care. Both applications provide ways for patients to track progress, set daily reminders, as well as provide them with a library of general health tips. What sets them apart is that the Straighten Up Canada app deals directly with spinal health with providing a generic exercise program to achieve this goal. With Injurymap, they’ve provided programming for different areas of the body based on the feedback given by the patient.

Despite these positives, patients may risk relying too heavily on these apps as their source of knowledge and management for pain. Now this is not necessarily a bad thing, as it can make them feel and move better, it is important to remind your patients that these apps don’t know the specifics of their bodies like a thorough physical assessment can in order to provide specific rehab. On the other end of the spectrum, patient’s compliance becomes problematic. Not being able to track how patients are doing within the respective programs leads clinicians to feel somewhat helpless, solely reliant on subjective feedback.

In general, InjuryMap takes the win, as it is the more intuitive of the programs, and can be followed very easily by the patient. If a patient finds an exercise painful, or too easy, the apps algorithm will reallocate the next set of exercises based on that feedback. So it definitely makes a clinician’s job easier as long as they trust the parameters within which the patient is working.

Fortunately, this EHR technology (which began in a less than user friendly manner), has advanced well enough to be more functional, run smoothly, and provide more features and services than its predecessors. Using an electronic health record is helpful in keeping patient records neatly organized, and keeping physical records to a minimum. This creates a tidy patient filing system that takes up less space. With less paper in the file, you could make the argument that these programs are also environmentally friendly.

Graduates of CMCC would be very familiar with “OSCAR,” which has been the EHR used during the final clinical year for prospective graduates. Like any server-based program, it is only accessible from the clinic computers, adding to its security. Cloudbased programs are accessible online to the practitioner at any given moment which makes remote patient management possible. Some programs maintain a clean, user-friendly experience by navigating through its system page by page; Other programs can become tedious by creating “overlapping” windows that become layered while navigating a file.

One of the best features of an electronic patient file system is having all the information at a push of a button. There is no need to flip through pages of files to create a list of contact information if you wanted said list for a marketing campaign, or for sending out important clinic information to all your patients. The patient files are under more security than simple lock and key by being password protected which no crowbar or brute force can unlock. Using the electronic system, it is a matter of three clicks and a list of our patients’ contact information is created in a neat and tidy list to use as needed. Cybersecurity is a major issue in today’s world and it will not be going away anytime soon. Expect any serious program to keep this top of mind.

It’s obvious to note that EHRs face the risk of being inaccessible if there is a power failure or issues with Internet connection. If all of your treatment notes and the majority of the patient information is stored on a computer that has no power to it, than this would put a large wrench into your day of practice. What would make this even more stressful is the fact that this interruption is likely to occur with no warning and with scheduled patients on the horizon. In personal experience, this is where we appreciate the interconnectivity of the current technology landscape. Imagine if this situation occurred over 10-15 years ago, then you’d be essentially winging our patient load for the day. However, in today’s world, pulling up patient information and managing your day is still possible thanks to our smartphones. Using data and a fully charged phone, you’ll be able to weather the storm until operations are back to normal. We’ve had to access our EHR through our mobile phones from time to time, but this has been a rare circumstance.

We’ve touched on a number of important areas regarding technology in today’s practice and how it relates to our ‘new COVID normal.’ It is a means as a cursory 30,000 foot view of what options are available, to get those started who want to know more on how to approach this element of their business.

DR. ERIK KLEIN is the CEO of Town Health Solutions, an Atlantic Canadian Network of corporate owned and franchised clinics, establishing a new model to rapidly scale chiropractic practice and businesses for new grads and established docs alike. Visit townhealthsolutions.com/franchising or email [email protected].

DR. JOHN NEAL is the owner of the Town Health Solutions clinic in Woodstock, New Brunswick, as well as an active member of the River Valley Health Solutions clinic in Fredericton. A CMCC graduate in 2016, Dr. John thrives on solving musculoskeletal problems, incorporating many different techniques. Dr. John can be reached at [email protected].