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We recently interviewed a fabulous group of athletic trainers and the sports medicine director from Mercy Regional Medical Center, part of the Centura Health family, and discussed proving value when it comes to the work they do. So, we dug deep into measuring the ROI of using an injury tracking system and how they got started, got AT buy-in, and how they’re measuring data.
Tell us about your program at Mercy Regional Medical Center:
Kolin Tomlinson - LAT, ATC, CSCS, Supervisor of Athletic Training: We are an outreach athletic training program in Southwest Colorado. We have 15 athletic trainers in secondary and collegiate settings. And we've been a program through the hospital going on 13 years. And mostly the last couple of years we've grown to include full-time or part-time athletic trainers at middle school settings, high school settings, and now college, as well, and this is our third year with Health Roster. We adapted that as our EMR and part of our group is about Work Groups and trying to find ways we can improve the profession, our work settings, and continue to grow professionally. And so one of those groups was built around the idea of productivity.
We met in a coffee shop in town and started arguing about things we didn't agree on: What was a productive athletic trainer? What was a good athletic trainer? How would we capture that? But what it broke down to was having a tool like Health Roster that allowed us to customize a lot of different things. Having a tool like that was fundamental because we knew we could make that work for us.
So what was the data that you wanted to collect and the overall purpose once you had that data?
Kolin: We all have our different things that we think are important… so, the initial conversation five years ago was that we were capturing daily log-ins and that was through a different program that allowed us to have athletes come in, sign-in and say “I'm coming in for one of four things: an eval, a treatment, wound care, or taping.” Those were the four categories. So, we started there. We knew we could capture patient log-ins but then we wanted to dive into more specifics:
- What are they coming in for?
- Why is that valuable in our setting?
- What value does that have to people outside our settings?
Concussions were the big one. We looked at concussion codes in Healthy Roster, and rather than it just being an evaluation code, we built it out and added a graded symptoms code, a balance code, let's do a BOMBS score, let's do an impact. Let's do exertional testing. So, we split out concussions and all those areas that we knew were really important to good quality concussion management that no other professional really does. Your primary care doesn't do it. Your physical therapist doesn't do it. Your neurologist doesn't do it. They all do pieces of it, but they don't do that consistently from start to finish. Since we know we do that well, let's capture that. Then, when we want a seat at the table to talk about how we manage concussions, we can articulate how much we're doing in the value that comes with that.
What are High versus Low Level Codes?
Daniel Mummert - MS, LAT, ATC, CSCS, Clinic-based Athletic Trainer: Give an overall summary we've got High, Medium, Low value codes and that's based on the amount of time that we expect that code to take in a clinic or in your athletic training office, as well as the value of that code— the cash value of that code. So we broke those out into higher-level or Higher value-per-time codes, Medium-per-time codes and Low value-per-time codes. And we want to use the best skills that we have as athletic trainers—the highest competencies. We don't want to be just physical therapy techs, where we're throwing ice bags and modalities at everybody we see, and then that's all we do… we're qualified healthcare professionals. And so we want to use the scope of that certification.
What are good Numbers? How do the numbers compare for the middle school level differ from the college level? How do you utilize your numbers to know this is a good athletic trainer? What is a good number? How does that look?
Daniel: That's something we are still exploring, still trying to figure out. Right now, we're in the stage of let's get accurate data and see what it tells us. Not so much a “Here's where you should be” as a middle school athletic trainer, “Here's where you should be as a high school athletic trainer.” Or “Here's where you should be as an outpatient, cash-based clinical athletic trainer.” “Here's where you should be as a college athletic trainer.” We haven't gotten that far yet. Right now, it's more “Let's accurately document what we're doing. Let's see what the numbers tell us.”
Robert Marks - LAT, ATC, Middle School AT: We do have a handful of metrics. And based on our documentation practices, there are many things we are looking at. We're looking at a productivity value of “at least over one” higher than that, the better based upon time in-clinic. Then, we're looking at what we spent a long time defining what we’ve decided were the primary codes and establishing, based upon time and value that they had. We took out every code that we made Health Roster and, for a long time, debated effectively every single definition and the value of every single code. And we divided those into two major categories, Primary and Accessory codes. And we've also established what we believe to be a better ratio of Primary to Accessory codes. So you take in the volume that the athletic trainer is seeing, the total value, the ratio of coding (High, Medium, and Low value of coding), and combine those all together and you get some form of a productivity measure.
Robert, as a middle school AT, what are your eyes drawn to in reports when comparing your numbers vs other settings?
Robert: Since I'm going to have a typically lower volume compared to other sites, that Primary to Accessory code ratio and a Number of Codes per Hour is going to be pretty important. I'm not going to see the same volume or number of middle school athletes as a high school athletic trainer, but while most people may either write-off a middle school athlete, that's an opportunity to really dive-in and make the most of your time with your middle school athletes—taking the time to establishing care, good communication, and home exercise routines, since I typically split my time between multiple sites. So I'm not going to be seeing that athlete every single day so I’m making the most of that small amount of time that I get with that middle school athlete. It's going to be primarily the number of codes-per-hour and that Primary-to-Accessory code ratio.
Colby Smith - LAT, ATC, High School AT: In each setting, there's going to be a change of volume, to be a change of Patient Seen and, in college, you're going to have your regular routine because you're working with your one, two or three sports. In high school, you're working with all the high school athletes. In middle school, you may have a smaller population, but with that information that we've taken from that is we're looking at the figures. So, the accurate documentation. With values, we have the values of each of our coding separated into three different values. And, we feel, to be proficient, you're going to be using your higher level of skills on any athlete, in any setting. So we're not looking at the basic trainer skills, we're looking more at the high level skills of, are you able to actually do this competency? Are you able to do this evaluation with the skill that you've been trained with? So that's the information we're using in this program.
The V-VOOT Model - How do you use this model to have diversity in the settings and to establish different metrics and expectations?
Daniel: We got into an acronym that we figured out together and that was V-VOOT. Volume - how many encounters you are seeing, Value - what is the actual dollar amount of the value of services you are providing. Outcomes - so we started thinking, with evidence-based practice, that’s patient-rated outcomes, that functional testing and those kinds of things. And, Over Time - how quickly you do it, and that’s our metric for proficiency. How much are you seeing? How much value are you providing? Do they like the value that you’re giving them? Are they functionally able to return to sport? And how quickly can you do it?
How is V-VOOT applied in all settings?
Robert: And this V-VOOT metric is something that was one of the initial things that we worked hard to agree on because I was brought in into this work group because my primary clinical setting is middle school. I work at two middle schools and middle schools have different limitations compared to high school sports because of the size of schools and the amount of funding. Typically you will have one sport going at a time where, compared to a high school, you'll have three to six sports going on at the same time. So, if we're going to look at some data and we're going to pull together encounters to determine “Is this person a good athletic trainer? Are they using their time? How can you determine if someone's proficient with their skills?” Well, how do you make a metric that's consistent to me where I may only have 45 to 50 kids on a roster, and then compare me to a high school athletic trainer who may see 150 kids a day? So that's where we came up with this metric.
John Jewel - MS, LAT, ATC, College AT: It really provides a look into the different clinical settings that we have available here at Mercy Sports Medicine. Like Robert said, he's at the middle school setting and we have staff in a collegiate setting, where we have a staff of six and maybe 350 student athletes. And the high school has probably 400 student athletes and 2 athletic trainers. Well, when we're looking at our productivity measures, now we can see what an athletic trainer is capable of doing right. A high volume, low-staff high school is going to have different metrics than a staff of six in a college setting. So, that helps us look at the differences between settings and the differences of what our athletic trainers are capable of doing. And it's like in a short amount of time. The high school can easily see 200 kids a day between the two of them. Whereas I might only see 30 kids a day. What is the difference there? What is my setting? What am I capable of doing in my setting, in my time, and what is the high school capable of doing in their setting in their time?
How are you taking it to the next level?
Colby: So thanks to all this metric feedback that we developed together as a group, we needed some basic information to start with, some of our accurate documentation and time sheets that were needed. And like Kolin brought up, I worked with Kolin for seven years now, and we used an older system that had some basic information that we were looking for to kind of kickstart this whole proficiency program. Now that we’ve been more involved with Health Roster, there's been a lot more data that we're able to pull from the system, using our athletic trainers with their daily log-ins, with our documentation requirements that we have here with Mercy Sports Medicine. And with the time sheets, we were able to actually collect all this data and develop this metric that we've put together to actually put what we have said into numbers. Because what we need to do is show, and be at the table at the same time, what we're trying to do for the community and what we're trying to do in our work settings. So with this information, we are able to now articulate what we're trying to do to find the proficiency of our athletic training services.
How does Healthy Roster compare?
Kolin: For us, when we looked at Health Roster initially, it was how user-friendly it really was. We've used other systems— and you can use them—but once you start trying to get any more level of detail or in-depth tracking codes or creating SOAP notes, or things like communicating with parents… they just didn't do that. Which was fair for what we were doing at the time. So initially when we looked at Healthy Roster, it came across as very user-friendly.
But I think the biggest thing is people like to use it, once you give them a little bit of a navigation on what we're doing specifically within it. I mean it’s not not like, we’re telling them well now you have to learn how to use an Excel spreadsheet. It's not that only tech-savvy people can get in it and be successful. You can use it with just a little bit of knowledge.
John: Compared to other systems, and I think I've used at least all of the major systems, at least the commonly used ones that athletic trainer use in terms of their EMR— from SportsWare to ATS and now Healthy Roster—it's mostly comparable to the simplicity of it and how effective that simplicity really is. It’s surprising to have this kind of effect that we were having with the system itself actually. It doesn't take a ton of time, once you get the flow of getting into Healthy Roster. Whereas in ATS, it can be, you're spending more time just loading the information, just trying to extract the information, let alone the additional time it takes to enter it and save it. So the usability and the way you guys are able to help individual people—your clients—customize it is just kind of hats-off to you as well.
Colby: I've used a couple of different medical record systems as well. ATS is one and the user-friendliness of Healthy Roster for the patient as well as the parents is fantastic. You do not see that with other programs. ATS does not allow parents to be involved in the program like Healthy Roster. The thing I absolutely love and that my parents utilize with the sports I work with is the communication of being able to contact their athletic trainer through a direct texting through the system, as well as they can input some information in there. So, sometimes I can update and say, “Hey, this is what your athlete has done with me in the past 24 hours.” And then parents will contact me through Health Roster saying, “Let's talk some more about this. I would love my athlete to get back into their sport in the next couple of weeks. What do we need to do at home?” And there's great programs that are in Healthy Roster to kind of have that user-friendly side for the family and the patients.
Daniel: I love the communication on the coaching side. Similar to a parent saying, “Hey, let's do some stuff!”, when you're working with collegiate cycling, for example, and a practice is a 50 mile bike ride that I don't have the skills or the ability to keep up with. I can have a coach send me a message through Healthy Roster, send me a notification saying, “I think this athlete sustained an injury. You need to check in on them.” And I can quickly stay updated with the team and check in on the athlete as soon as the ride is done.
John: I use Healthy Roster and, just yesterday, I can make 3 or 4 notifications updates to injuries and my coaches have it set up as a notification on their phone. So, it's literally a simple swipe and they’re logged into the phone and they automatically get a student notification from me. They instantly know that they have this athlete available for practice. They can adjust practice accordingly. I go up to practice, and I'm always available for questions and I always make sure to ask them if they have questions. It's getting to the point where they don't... it's almost like they don't need me up there at this point because they know exactly what their athletes can and cannot do. It's the user-friendliness for parents. And for athletes, as well, because we love having our athletes be able to get into the system, especially with pre-participation physicals and stuff like that. And the communication on the coaching side is amazing. It's great. I love how I'm able to use it that way.
Colby: Also, the simplicity of coding for us is really nice. It's in other programs but it can be a little bit of a hassle going into all these different windows, just to put down that I put ice on this individual, or I did an evaluation. Healthy Roster is a pretty simple program of putting in the information that you need. And it's also customizable, cause I know Kolin has talked with Healthy Roster often about this as well. We talk to you and how we want to set up our own evaluations. This is how we want to set up MMTs (Manual Muscle Testing) and stuff like that. And it's been really nice to have an actual customized program set up from us, communicating to you, of what we want.
Daniel: Being able to upload documents like the SCAT5 and being able to just go into somebody's documents, scroll down, and add that real quick. It's super effective, especially going through a concussion eval or going through a follow-up eval. And being able to add that, or being able to say to you, “Hey guys, we need this document and we want it formatted this way!” and Healthy Roster will come back a day or two later and it's ready to go. I mean, it's fantastic.
Robert: I particularly liked the ability to add documents into a treatment session because that just makes finding that particular document, like a graded symptom checklist or a physician's note, even that much easier. In my setting currently, I'm working with another athletic trainer and splitting my time between a high school and the middle school. And some days I may see an athlete two times or every other day. And so just the ease of being able to pull up a treatment log quickly, glance at what the other person has done, and to appropriately either increase or to do a different type of rehabilitation or treatments based upon what's previously been done. It just makes everything go by really easily when there's a central place for that communication.
Kolin: On the backside, just the ability to pull reports out, I think that is super unique. As a supervisor, that was something that I hadn't seen before. The problem with EMRs is a lot of the time you're putting information in and no one ever looks at it again, I think documentation as a CYA against getting sued is why athletic trainers do it. And we wanted to move beyond that. We wanted to turn this into data that would improve us individually, as well as a group. So, the ability to go find a simple treatment log and pull that report and then pull a daily value and pull treatment cost breakdowns. Those reports are super helpful and I know Healthy Roster continues to improve those.
But the ability to customize that as Colby said, and then the ability to pull information out, put it in an Excel sheet and start building the tools that we built out of it is just, I mean... it's really simple to say, but it all started with, “Let's make treatment codes that reflect what we want to do.” We'll Healthy Roster let us do that. And that's cool! Well, let's see how much that actually counts and we can pull that out. So we've added some things, but to be honest, the ability to customize and then pull information out on the back end is fundamentally the reason why we've gotten where we've gotten with our dashboard.
If you'd like to watch their entire interview, we have it all on video. You'll find even more valuable information on how they use dashboards to track their metrics, how they train staff on the V-VOOT model, how they show progression, and how you can implement what they're doing in your setting.
