Author: Tyler Shultz

With the widespread use of EMR, more and more data is being collected about the way we practice. A recent post on the Four Hour Work Week by Eric Ries, has me thinking about metrics, specifically PT metrics and how they relate to the care I provide, and the experience my patients have. Eric breaks business metrics down into two types: vanity metrics and action metrics. Vanity metrics is the data that “might make you feel good, but they don’t offer clear guidance for what to do.” On the other hand, action metrics help us make decisions and give us valuable information about our practice. Traditionally metrics in the PT world can generally be broken down into 3 categories: billing, productivity, and referral metrics. More specifically, lets explore how vanity and action metrics relate back to individual (not company wide) practice.

Vanity Metrics: Private practice owners might argue that “no data is bad data” when it comes to tracking patients and therapist performance in the clinic. However, some data points simply do not provide an accurate picture of individual therapist performance, and could be better suited when applied to company performance, or ignored altogether.

• Visits per case/referral: In my opinion, this data set is the most inconclusive of all metrics commonly tracked to individual PTs in EMR programs. The general rule-of-thumb for most private practices is that the visits per referral number should be between 10-12. This depends on several factors: skill level of therapists; number of post-operative referrals, geographic location, patient population/SES, referral source, clinic reputation, and the list goes on and on. I have found this metric has no bearing on patient outcomes, or patient/physician satisfaction. If you can obtain the same outcomes in 6-8 visits versus 10-12, your patients will be happier, and your referral sources will be impressed. In return, you see a higher volume of new evaluations – which means more and more happy patients.
• Incomplete metrics: Other metrics that are commonly applied to individual PTs are actually “incomplete,” or too variable to apply to individual performance. For example, scheduling related metrics, such as cancellation and no-show rates, are mostly out of the control of the therapist and do not reflect on the quality of care provided. Obviously, a good clinician that creates buy-in, demonstrates value, and has good outcomes will generally have a low cancel rate. But, cancellation rate does not always reflect productivity – a clinician with a cancellation rate of 4% does not mean they are more effective than a therapist with a cancellation rate of 10% – this variation could easily be due to scheduling, clinic hours, weather, traffic, or an entire host of other variables.

Action Metrics: Action metrics are the data that should be used to evaluate therapist performance and patient outcomes. These metrics help the decision making process, and can demonstrate value to your referral sources and the general public.

• Plan of Care (POC) complete to Discharge: Perhaps the most under-tracked, but most important data point is patients who complete a POC to discharge. Generally this happens when appropriate care is provided (regardless of number of treatment sessions), goals are met, and functional limitations are eliminated. The therapist and the patient are on the same page, and the patient is happy with the care they receive. And happy patients produce more business – not only by word of mouth and leaving reviews online, but also by telling their physician about the quality of care they received. A high percentage in this metric indicates that the clinician provides quality care and communicates well with their patients.
• Units/visit: Another metric that is highly variable depending on the patient population and insurance type, but useful nonetheless is units per visit. Tracking units/visit at the provider and company level is beneficial – this serves to make sure therapists are not under-billing; which is all too common in PT practice. It also allows therapists to make sure they are not over-billing, which may make you more susceptible to audits. This metric also allows for more accurate clinic budgeting and forecasting income.
• FOMs: Tracking change by using functional outcome measures is critical to evaluating therapist performance and patient outcomes. Functional outcome measures should be used with every patient, every time. However, accuracy requires that valid measures are being used, and that measures are used with the correct patient population. Understanding MCID and MDC for each measure is also important. These metrics should also be used to support Functional Limitation Reporting. In addition, physicians and referral sources often use and understand these measures, easing the communication gap while marketing to potential referral sources.
• New patients per therapist/requested therapist: Another under-tracked and under-utilized metric is new evaluations per therapist. Particularly, patients who request a therapist by name are often more satisfied with the care they receive and more likely to complete their recommended course of therapy. I find this number often correlates with patients who complete their POC to discharge, looping back into the cycle of happy patients and word of mouth referrals.

When extrapolated across a group of therapists in a company or clinic, action metrics provide a more meaningful picture of how valuable our services are. Individually, vanity metrics can be misleading and provide little value as to the value and productivity of a therapist.  Eric Reis encourages us to “measure what matters” – meaning that more data is not always better, and argues that the key to having actionable metrics is “having as few as possible.” It can be tempting with EMR to look at a seemingly endless set of metrics, but narrowing our focus on a few can provide better insight into therapist, clinic, and business performance. How do you use metrics in your clinic? Which ones are used to evaluate individual performance?

Do PTs today practice medieval therapy techniques? An ABC affiliate in San Francisco seems to think we use medieval tools, anyway. The technique reported on is the Graston Technique,® an aggressive form of soft tissue mobilization aimed at breaking up adhesions between fascia and muscle fibers using specialized tools. In theory, this treatment is essentially the same as aggressive STM; the difference lies in the use of the specialized tools.

So do the tools really make the technique more effective than traditional STM? The literature results are extremely limited. Only one study directly compared STM and the Graston Technique ®:

Burke et al. compared Graston Techniques ® to regular STM provided by the therapist’s hands for the treatment of Carpal Tunnel Syndrome. They resulted no clinical differences between the two groups, but did substantiate the clinical efficacy of conservative treatment for mild to moderate CTS.

Perhaps the effectiveness of the Graston Technique ® occurs from the ability to detect adhesions better than manual palpation alone. Users report feeling vibrations or hearing clicks as they move the tools over adhesions that were not detected by palpation. There are a few case studies that report solely on the effectiveness of the Graston technique.

Hammer reports on the ability of the Graston Technique ® user to both feel and target treatment on areas of degenerated tissues in three cases involving plantar fasciitis, Achilles tendonosis, and supraspinatus tendonosis.

Aspergren et al. effectively used thoracic (HVLAT) manipulation and the Graston Technique ® to treat a collegiate volleyball player with acute costochondritis. Although the authors did not compare to thoracic manipulation plus manual STM, pain and functional levels improved.

Other foreseeable benefits include the ability to really dig-in during STM and saving your own joints as a PT, benefits that may also be found in simple massage tools. The side effects include being too painful for many patients and causing bruising in some patients. In all, more research needs to be performed comparing the technique to regular STM by independent examiners.

Bottom line: for now, trust in your hands – they have been around since before medieval times, and are the most powerful tool a PT possesses.

1. Burke J, Buchberger DJ, Carey-Loghmani MT, et al. A pilot study comparing two manual therapy interventions for carpal tunnel syndrome. J Manipulative Physiol Ther. 2007;30(1):50-61.

2. Hammer WI. The effect of mechanical load on degenerated soft tissue. J Bodyw Mov Ther. 2008;12(3):246-256.

3. Aspegren D, Hyde T, Miller M. Conservative treatment of a female collegiate volleyball player with costochondritis. J Manipulative Physiol Ther. 2007;30(4):321-325.