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Today’s Dreams, Tomorrow’s Reality in O&P Technology
By Paul Prusakowski, CPO, FAAOP  Over the last 15 years, we've all heard a lot of
hype about computer and Internet technologies and the changes they
would bring in our lives. By the late 90s, kids who were barely old
enough to order a beer at a local bar were becoming Silicon Valley
millionaires by promising to revolutionize every sector of
business--including healthcare--within a few short years. The mix
of lofty PowerPoint presentations and venture capital funding led
to a lot of lost money and huge headaches.
Sobriety hit quickly, and we were all reminded once again that
real change doesn't happen overnight. A vision of the future is
necessary in order to create it, but it is not sufficient. It also
takes years of hard work to overcome the hidden development and
implementation obstacles that rear their ugly heads, and it takes a
critical mass of people who recognize what can be and are willing
to make changes in the way they work.
When we honestly examine what happened to the promises of the
information technology boom, we find some very interesting things.
First, that what was touted as a pending revolution, was
actually an overstated awareness of the real possibilities for
evolution. And second, we find that in most ways
technology actually has lived up to its promises--the capabilities
that were talked about in dreamy language only a few short years
ago already are a reality, and are being used in many sectors of
society in very practical ways. Where both O&P and healthcare
in general have lagged behind, is in the awareness of technology,
and the practical implementations of it that meet our needs. In
short, we already have the way--what we lack is the
will.
Pressures in the healthcare marketplace have forced us to change
the way we run our businesses. Utilization of technology is not an
option anymore. Where the availability of technology may not have
been enough motivation for change, the impossibility of survival
without that technology will fill the gap. This isn't
future-speak--it is already happening right now. O&P suppliers
have recognized that they can no longer afford the overhead of
manual processes, especially customer service and ordering that
rely almost exclusively on phones and fax machines. Third-party
payers are not only encouraging electronic submissions, but
demanding them--the cost and time savings to everyone is clearly
evident.
At this time in the history of O&P, we should not fear
change--but we should embrace it. The evolution of technology is
true progress , and the day will arrive when we will all
wonder how we got along without the advancements that we will have
grown accustomed to using in our daily practice.
Tomorrow's O&P Practitioner
What follows is a tale about a day in the life of tomorrow's
practitioner. It's meant to take us to the edge and look a little
further, but make no mistake about it--nothing that is presented
here is outside the capabilities of technology that already exists.
And the aspects that are most crucial in facing our current
crisis--the integrated information systems that manage all patient
and product data and transfer it seamlessly and securely between
various healthcare providers, vendors, and patients--could be right
around the corner.
The Dream Unfolds...
 The first patient of the day just arrived, swiping
her universal medical card through the card reader at the front
desk. Her complete demographic and insurance profile loaded
immediately into our clinical practice management software,
eliminating any entry by our office staff.
Our practice management software received an electronic
prescription directly from the physician's office two days ago.
When the patient was recognized by the software, it matched the
queued prescription with the patient's electronic chart. Before
even notifying me that the patient had arrived, Sheila, our office
manager, clicked directly to the patient's insurance company from
within the software and received an immediate authorization for the
services that we were about to provide.
I happened to be finishing a few things up at my second office
at the time when a notification chirped from the communication
device in my pocket. Flipping open the integrated mobile video
phone / Pocket PC, Sheila's face appeared to let me know that my
first patient had arrived. Of course, the software could have
notified me without involving Sheila, but she knows that I prefer
the immediate opportunity to discuss things with her if necessary.
In this case, the patient, who was new to our office, had told
Sheila about her previous prosthetic care in Iowa. So I asked
Sheila to request her past prosthetic medical records from the Iowa
clinic, and notify me when this had been received.
Within minutes, I was notified that the prosthetic history
portion of the electronic record arrived from the Iowa clinic, and
after entering a special password, I was able to access the entire
record through my Pocket PC via an encrypted wireless connection. I
quickly reviewed her complete history to familiarize myself with
the components she had been fitted with previously, as well as a
history of fitting challenges that she had experienced throughout
her years as an amputee. On the drive over to the clinic, I
reflected on how fortunate it was that I would not have to reinvent
the wheel', benefiting from a detailed account of how her difficult
fitting issues had been overcome in the past.
I picked up my trusty Tablet PC on the way into the patient
room, using the larger screen to quickly review the patient's
prosthetic history with her, flipping through digital pages with a
few taps of the input pen. The patient commented on how pleased she
was to be at one of the newer "digital clinics." She noted that the
whole atmosphere of these clinics was much different, and that she
really felt her practitioners were more thorough in their care, and
better able to help her understand her own prosthetics management,
using these new computer systems.
After reviewing her past history, it was time now for our
evaluation and measurement process. I pulled up the appropriate
forms and simply clicked through the dozens of questions necessary
to obtain a thorough and appropriate initial evaluation, using the
"compare with past history" button to see how this evaluation had
differed from evaluations she had in the past. It was apparent that
there were physiological changes taking place, resulting in the
need for advanced prosthetic technology in order to allow this
patient to maintain the highly active and independent lifestyle she
had been used to living for over 50 years as an amputee.
The measurement process was extremely clean and simple. The menu
in my clinical practice management software had a selection of
advanced CAD systems to choose from, and also integrated with a
variety if advanced data input devices. In this case, due to
orthopedic complications secondary to a unique surgical procedure,
I decided that the most accurate input mechanism would be a
combination of MRI data, tissue density data, and input from a
laser scanner. The latest CAD software combined that data
seamlessly to provide a perfect visual of her limb, including
representation of internal and external anatomy. This provided me
with a great starting point for beginning my shape manipulation in
my new holographic projection monitor which provided the most
lifelike representation of the residual limb ever seen before (see
"Imagining A Holographic Projection..." below).
Imagining A Holographic Projection Monitor For O&P...
I think that the coolest application of the latest computer
technology in orthotics and prosthetics are the new holographic
visual field monitors. When the monitors are off they appear to be
no more than a clear 20"x20"x20" block of lexan, propped on a
metallic monolithic base- like a big ice cube, or a work of modern
art. But when you turn this thing on it is completely amazing. An
actual sized three dimensional holographic model of the limb
appears to be floating within the block with a visual
representation of both the bone and muscle tissue that was
determined from the MRI data. With a pair of instrumented gloves as
an input device, I am able to use true virtual tools within the
holographic field to manipulate the residual limb shape. Through
switching the density switch between "plaster tone" and "muscle
tone" the properties of the hologram completely change, allowing me
to reduce and reshape the model in the plaster mode, and then
switch to "muscle tone" mode and see a visualization of how the
shape changes would impact the muscle tissue within a socket with
pinpoint accuracy by applying the tissue density data to the model.
One of the most helpful features is the ability to view realtime
pressure distribution maps on the holographic residual limb as it
passes through a complete range of motion during a simulated gait
cycle within the monitor. The wildest part about this is that you
have the ability to move and manipulate this image as if it was a
real leg just floating in space.
Once I was done with my shape manipulation, I already had a live
connection with the CAM facility that I prefer to use for
outsourcing my fabrication. Their fabrication management system
allows me to collaborate with them on my fabrication processes
directly from within our software. This is one of the ways in which
the electronic medical record is more than just notes and
measurements, but a complete window into the entire spectrum of
clinical care that was provided to my patients. Through direct
connections with all of my partnering suppliers, I have
instantaneous communication and documentation available to me
regarding every action that was taken related to each of my
patients. No more using telephone and fax machines to send status
reports and information back and forth, with no coherent record of
what happened. Now I just open the patient's digital file and have
direct access to reports on componentry and fabrication statuses
and processes, as well as immediate notification if any of the
components that are being used by any of my patients have been
recalled by a manufacturer.
Before the patient leaves my office, I click a few buttons on my
Tablet PC and a video appears to educate the patient on
functionality of all the components that will be used on her new
prosthesis, and it also reviews certain steps that she can take
when working with her physical therapists to prepare herself to
take advantage of the advanced knee and foot system. The entire
educational process is documented in her electronic medical record,
and a copy goes home with her on the Smart Card that we provide.
Before she left, I checked and saw that her previous prosthetist in
Iowa was currently logged on to the O&P global network of
digital clinics. I clicked the "pager" button on the Tablet PC, and
luckily he was not too busy to say a quick hello via the live video
connection that came up between our Tablet PCs. This feature is
typically used to provide clinical assistance at remote locations
for challenging cases, but in this case it worked well for social
interaction.
Earlier this morning I was running some reports on the current
clinical and technical operations within our practice and could see
that we should anticipate a stressful week ahead unless we
reorganize our schedule. A report predicted that in order for all
of our fabrication to be completed on time, it would require the
technicians to work significant amounts of overtime. We decided
that in order to minimize our turnaround time without stressing our
staff, we would use one of the electronically integrated central
fabrication companies. A selection of work orders were reassigned
to the c-fab, digitized images of the casts were transmitted
instantly, and then the operational reports were performed again.
The results showed that if all the scheduled patients showed up for
their appointments, the combination of reduction in turnaround time
and the higher volume of deliveries within a shorter period of time
would actually result in a higher profit margin for the company.
How did I ever get by without all this powerful information at my
fingertips?
 Before I leave the office to see my next patient
in the hospital, my lead technician (and purchasing agent) stops me
to show off the latest upgrades to the purchasing module of the
practice management software. We have already been spoiled by
having seamless ordering with direct connections to all of our
suppliers' computer systems, but Hector now demonstrates how every
component that was ordered for the patients that we had just
decided to send to c-fab were immediately being rerouted to the
c-fab facility, via integration of the software directly with UPS.
This really has come a long way since the days of using paper to
keep track of all of our purchasing and inventory. Speaking of
inventory, adoption of the latest advances in miniature RFID (radio
frequency identification) technology by O&P suppliers has made
inventory management at our facility completely automatic! As soon
as an item is placed in or removed from our stock room, the RFID
reader in the doorway automatically updates our electronic
inventory status and financial records, placing items that need
replenishment into our facility's electronic shopping cart. It just
doesn't get much easier than that!
Although the trip to the hospital is going to take at least 45
minutes with traffic, I am already planning on getting a lot
accomplished on the way. With the latest wireless technologies, my
Pocket PC is directly connected to my office network wherever I am
in the world, so those few patient notes that I need to dictate
into the practice management system can easily be done while
traveling. From my car, I will be able to listen to a portion of
today's New York Times, and also register for the upcoming virtual
O&P symposium that is expected to involve over 10,000
practitioners from around the world.
Before I leave the office for a weeklong sailing vacation, we'll
have our monthly management meeting, where we perform a medical
records audit to review our compliance in documentation and
charting with 100-percent accuracy. With all the burdens of
regulation that now exist, we must be in complete compliance for
every one of the patients we treat. Luckily our clinical practice
management software evaluates compliance in every aspect of our
practice within seconds, and we have a complete picture of where we
need to increase our efforts over the next few weeks to keep
everything in perfect shape.
From the boat, I will wirelessly connect to the office for a
half hour a day to assist in managing my practice by monitoring
every aspect of the clinical and business pulse of the office.
How Do We Get There?
The technologies required to make this happen are already
available today, and, with the possible exception of commercially
available holographic monitors, this dream can be a practical
reality. Are you ready to take the next step into really using
technology in your practice?
Network your office and provide broadband Internet access to all
of your staff in the places where they will benefit from
connectivity (i.e. staff room, patient care rooms, ordering area,
technical room). Be sure that you have current operating systems
and updated hardware, because hanging on to outdated technology
isn't worth the limitations it will put on your staff. Become
familiar with what's available online and use the Internet and
e-mail for business communication both internally and with your
referral sources and vendors. Progressive vendors are starting to
provide topnotch services online for communicating, ordering, and
interacting more efficiently. This will be the norm in the near
future.
Make a commitment to integrating technology into your clinical
and business processes. Evaluate how you are doing things
currently, and imagine what the possibilities are if every process
in your office was linked seamlessly together. There's a lot of
room in our current processes to become much more efficient, and
technology is the answer to many of our problems. With commitment
to evolving your practice with technology, you will find that the
initial hurdle is not that difficult to clear, and once you start
to see the outcomes, you will wonder how you ever lived without
it.
It is the vision of a better world for O&P that has driven
me to commit a significant part of my professional career to
developing and bringing Internet and computer technology to the
field. The changes are happening rapidly, and I hope that O&P
continues to make the commitment to shaping our own future with
intelligent use of computer technology. Paul E. Prusakowski, CPO, FAAOP, owns a private clinical practice in Gainesville, Florida. He has been active in state and national professional leadership roles, founded the OANDP-L listserv, and is president of O&P Digital Technologies (oandp.com). 
Table Of Contents - October 2004
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