1. Physical Therapy at
Orthopedic Sarcoma
(PTOS)
DIGANT SHAH
12/8/2016

2. Vision
 The UT Health Innovation Hospital will consistently
transform healthcare utilizing cutting-edge technology
to improve patient safety and quality each day."

3. Problem
 Sarcomas are a diverse and relatively rare group of malignant
tumors that develop in soft tissue and bone.
 According to NIH in 2014 in the US,
1. 15,000 cases of sarcomas.
2. Approximately 6,200 people had died [1].
 The 5-year relative survival rate for both bone and soft tissue
sarcoma was approximately 65 percent [1].

4. But is Survival
everything?

5.  The duration of the entire treatment process takes 1-3 months and
often involves a combination of surgery, chemotherapy and/or
radiotherapy.
 Studies have shown:
1. Relation between survival and outcomes to having an increased
diagnosis-treatment interval [2, 3].
2. Patients often become disillusioned and frequently depressed
during the process [4].
3. Other comorbidities such has hypertension, diabetes, poor
physical function, etc. have an effect on the post-surgical
outcome and patient health.

6. http://drugabuse.com/wp-content/uploads/xdrugabuse_shutterstock-243591463-sad-teen-couch-flakka-CTA.jpg.pagespeed.ic.Uv4YcEWuLF.jpg
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Preparing the patient for the surgery both mentally
and physically is the need of the hour.

7. PTOS team
 Alexander Penny - Project Leader and Head physical
therapist
 Dr. Justin Bird and Dr. Ann Ngo - Physicians
 Digant Shah – Clinical Informaticist and Change Agent
 James Wang - EHR IT representative

8. Project Governance
Division of Surgery Chair
Department of
Orthopedic Sarcoma
Chair
PTOS team
Physicians
Communication
Head Physical Therapist
Support
EHR IT representative
Software
Technology
Change Agent
Process
Deployment

9. Project Plan
 Goal of the project:
1. Improve outcomes.
2. Reduce length of stay.
3. Generate revenue for the department.
 Identify the factors that can have an impact on the patient’s
outcome by using the “Shah screening tool” and determine the
type of pre-surgical intervention required.
 The interventions are:
1. Physical therapy and counselling.
2. Prehabilitation.

10. What is the Shah screening tool?
 It is a 10 question survey
 Developed at UTHealth Innovation Hospital.
 Evidence based [5-7].
 Relying on questions that are routinely asked during h&p but may
not be usually recorded in patient notes.
 Created in RedCap and will be available in the EHR as a button.
 Total of 30 possible points.

12. Distribution of points
 10 points: No intervention.
 11-24 points: Physical therapy and counselling.
 24-30points: Prehabilitation.

13. Advantages of using a screening
tool
 Identifying vulnerable population.
 Improving quality metrics for the institute.
 More data to draw information.
 Can serve as a database to carry out cross comparative
research on having an intervention.

14. How will the process
change?
Sr.
No.
Current Process Future Process Gap analysis Individuals involved
1. No prehabilitation
protocol present at the
department.
Assessment tool developed which will
assist in judging if the patient requires
prehabilitation.
Develop 10 point questionnaire which can
be completed in less than 5 minutes based
on the information collected from the
patient.
Informaticist, senior physical
therapist and orthopedic
surgeon.
2. No questionnaire is used
for presurgical physical
therapy.
The physician assistant/resident will
complete a presurgical questionnaire
for the attending physician.
Training provided to the staff on the use
of the questionnaire.
Informaticist, physician assistant,
resident and orthopedic surgeon.
3. Patient is in the waiting
room where the physician
assistant/resident takes
the h/p.
The physician assistant/resident along
with taking the h/p completes the
questionnaire based on the patient
responses.
Altering the workflow to incorporate the
time required to fill the survey.
Informaticist, physician assistant
and resident.
4. Attending physician sees
the patient in the clinic,
takes h/p and performs
required clinical tests.
Attending physician sees the patient
in the clinic, takes h/p and performs
required clinical tests and based on
the questionnaire score recommends
intervention.
Getting the attending physician to use the
scoring tool.
Informaticist and orthopedic
surgeon.
5. Post-surgically the patient
is seen by the orthopedic
rehab team in the clinic.
The orthopedic rehab team will see
the patient pre-surgically and post-
surgically.
Modifying orthopedic rehab team
workflow to incorporate the influx of
patient for pre-surgical physical therapy
Informaticist and orthopedic
rehab team.
6. No billing for
prehabilitation in
orthopedics
Patient or patient’s insurance billed
for prehabilitation in orthopedics
Need the billing team involved to clear the
patient prior to providing prehabilitation
Informaticist, physical therapist
and institutional billing team.

15. How will it work in the EHR?
Source: http://twimgs.com/informationweek/galleries/automated/755/01_EpicResolutescreen_full.jpg
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http://img.medscape.com/thumbnail_library/is_160224_doctor_computer_800x600.jpg

16. Types of Users
 Nurses
 Resident Assistants/Physician Assistants
 Physicians

17. Stakeholders
Stakeholder group Role in
Charge
Opinion leader Level of
commitment
needed to
succeed
Barriers to change Initial contact
Attending Physician
Team
Directly
Affected
Dr. Justin Bird Internalization Always apprehensive about
using a new tool. Skeptic
about spending additional
time.
Resident Assistant
Team
Directly
Affected
Internalization Busy with patients.
Additional work to answer
the screening tool.
February – 2nd week
Physician Assistant
Team
Directly
Affected
Internalization Busy with patients.
Additional work to answer
the screening tool.
February – 2nd week
Nursing Team Directly
affected
Internalization Busy with patients.
Additional work to answer
the screening tool.
February – 2nd week
Physical Therapist Team Directly
Affected
Alexander Penny Internalization Needs assistance with
patient scheduling.
February – 2nd week
EHR Informatics Team Indirectly
Affected
James Wong Busy due a different system
Go-Live. Have drained
existing resources.
February – 1st week
Insurance verification
Team
Indirectly
Affected
March – 1st week
Patients Directly
affected

18. Stakeholder individual Position Barriers to change Initial contact
Dr. Valerie Lewis Ortho Dept. Chair – Champion Extremely busy with patient, other
on-going projects and meetings
January – 2nd week
Naruto Uzumaki Graduate Research Assistant January – 2nd week
Dr. Tyler Who Surgery Division head –
Champion, Opinion leader
Extremely busy with patient, other
on-going projects and meetings
January – 4th week
Steve Martin Rehab department chair Receives incentives based on the
number of patients being treated
in the department
February – 2nd week
Megan Taylor Patient Scheduler for PT Additional workload. March – 1st week

19. Communication Plan
Who? What? When? Where? How?
Target Audience Communicator Stage Message Timing Location Type Specific tools or
approaches
Dr. Ino Yamanaka Dr. Justin Bird Knowledge and
persuasion
Need for the change and
“Go Ahead”.
January – 2nd
week
Personal office Interpersonal
Naruto Uzumaki Graduate Research
Assistant
Knowledge January – 2nd week January – 2nd
week
Personal cubicle Interpersonal Provision of Shah
scoring tool and access
to RedCap
Dr. Tyler Who Dr. Valerie Lewis Knowledge Need for the change and
“Go Ahead”.
January – 4th
week
Personal office Interpersonal
EHR Informatics
Team
James Wong and
Digant Shah
Knowledge and
persuasion
Proposed plan and
expectations
February – 1st
week
Conference room Interpersonal
Attending
physician team
Dr. Justin Bird Knowledge Sense of urgency and
proposed plan
February – 2nd
week
Email Mass media Email – which includes
the proposed plan and
links to hospitals
having prehab care.
Physical therapist
team
Alexander Penny Knowledge Sense of urgency and
proposed plan
February – 2nd
week
Email Mass media Email with the
proposed plan and
links to hospitals
having prehab care.
Physician
Assistant team,
Resident assistant
team, nursing
team
Digant Shah Knowledge Sense of urgency and
proposed plan
February – 2nd
week
Email Mass media Email with the
proposed plan and
links to hospitals
having prehab care.
Steve Martin Dr. Valerie Lewis Knowledge and
persuasion
Sense of urgency,
proposed plan,
expectations.
February 2nd
week
Office Interpersonal
Ortho department
meeting
Alexander Penny, Dr.
Justin Bird and Digant
Shah
Persuasion Proposed plan, and
communicating vision
and strategy.
February – 4th
week.
Conference room Interpersonal Visual aids and copy of
the questionnaire.

20. Target Audience Communicator Stage Message Timing Location Type Specific tools or
approaches
Megan taylor Alexander Penny Knowledge and
persuasion
Proposed plan and
expectations
March – 1st
week
Email Interpersonal Needs for the
modified
patient
scheduling
template.
Insurance
verification
Team
Alexander Penny Knowledge and
persuasion
Proposed plan and
expectations
March – 1st
week
Email Interpersonal as
only 2 members
are involved
Ortho
department
Alexander Penny Persuasion Results of the pilot April –
beginning of
3rd week
Email Mass media
Ortho
department
Persuasion Modifications
required or not
Monthly
meeting –
April 3rd week
Conference
room
Interpersonal
Ortho
department
PTOS team Decision “Go” or “No Go” May - 1st
week
Conference
room
Interpersonal Poll
Ortho
department
and Dr. Tyler
Who
PTOS team Implementation Notification of
implementation
May – end of
1st week
Email Mass media
Ortho
department
and Dr. Tyler
Who
Dr. Valerie Lewis Implementation One month update June – 2nd
week
Email Mass media
Ortho
department
and Dr. Tyler
Who
Dr. Valerie Lewis Confirmation 6 month update
successful
completion of
project
November Email Mass media

21. Readiness Assessment
 Before the Go-Live, users and department leaders will
be asked to complete a survey to assess their
readiness for the implementation.
 The criteria for this is 100% user training being
completed.

22. Questionnaire [8]
Disagree  Agree
1. People who work here are committed to implementing this change. 1 2 3 4 5
2. People who work here will do whatever it takes to implement this
change.
1 2 3 4 5
3. People who work here want to implement this change. 1 2 3 4 5
4. People who work here are determined to implement this change. 1 2 3 4 5
6. People who work here feel confident that they can handle the
challenges that might arise in implementing this change.
1 2 3 4 5
7. People who work here feel confident that they can keep track of
progress in implementing this change.
1 2 3 4 5
8. People who work here feel confident that they can coordinate tasks so
that implementation goes smoothly.
1 2 3 4 5
9. People who work here feel confident that the organization can support
people as they adjust to this change.
1 2 3 4 5
10. People who work here feel confident that they can manage the politics
of implementing this change.
1 2 3 4 5

23. Time frame
Jan 2017 Feb 2017 Mar 2017 Apr 2017 May 2017 Nov 2017
Shah scoring tool
created in RedCap
Communication
Integration of
Redcap tool in EHR
Pilot
Modification of tool
or system is
required
Departmental
implementation
Monitoring

24. Project Charter
 Timeframe – January, 2017 – November, 2017.
 Focus:
1. Pilot testing from March 2017 - April 2017 in Dr.
Bird’s clinic.
2. Communication.
 Proposed budget - $50,000.
 Fund allocation:
1. Graduate Research Assistant (GRA).
2. Training.
3. Overtime.

25. Expected outcome
 Reduced length of stay.
 Decreased recovery time.
 Improved patient satisfaction.
 Happy patients.

26. Challenges
 Non compliance by the user.
 Delay in getting the button the EHR.
 Training everyone before the Go-Live.

27. Factors needed for success
 Support from leadership.
 Support from the user community.
 Timely delivery of the EHR button from the IT
department.
 Feedback from the patient population on the
effectiveness of this intervention.

28. References
1. https://www.cancer.gov/research/progress/snapshots/sarcoma.
2. McLaughlin, J. M., Anderson, R. T., Ferketich, A. K., Seiber, E. E., Balkrishnan, R., & Paskett, E. D.
(2012). Effect on survival of longer intervals between confirmed diagnosis and treatment initiation
among low-income women with breast cancer. Journal of Clinical Oncology, 30(36), 4493-4500.
3. Sandar, M., Hsiang, L. G., Yew, C. K., & Guat, L. B. (2014). Use of Population-Based Cancer Registry
Data to Determine the Effect of Timely Treatment on the Survival of Colorectal Cancer
Patients. Journal of registry management, 41(4), 130-138.
4. http://www.cancer.org/treatment/treatmentsandsideeffects/emotionalsideeffects/anxiety-fear-
depression-and-cancer
5. Arshi, A., Sharim, J., Park, D. Y., Park, H. Y., Yazdanshenas, H., Bernthal, N. M., & Shamie, A. N.
(2016). Prognostic Determinants and Treatment Outcomes Analysis of Osteosarcoma and Ewing
Sarcoma of the Spine. The Spine Journal.
6. May, P., Garrido, M. M., Cassel, J. B., Kelley, A. S., Meier, D. E., Normand, C., ... & Morrison, R. S.
(2016). Palliative care teams’ cost-saving effect is larger for cancer patients with higher numbers
of comorbidities. Health Affairs, 35(1), 44-53.
7. Houdek, M. T., Beahrs, T. R., Wyles, C. C., Rose, P. S., Sim, F. H., & Turner, N. S. (2016). What Factors
Are Predictive of Outcome in the Treatment of Soft Tissue Sarcomas of the Foot and Ankle?. Foot
& Ankle Specialist, 1938640016666925.
8. Shea CM, Jacobs SR, Esserman DA, Bruce K, Weiner BJ. Organizational readiness for implementing
change: a psychometric assessment of a new measure. Implement Sci. 2014 Jan 10;9(1):7. PMCID:
PMC3904699.

29. Source: http://il9.picdn.net/shutterstock/videos/4388282/thumb/1.jpg

30.  Source: http://il5.picdn.net/shutterstock/videos/15802915/thumb/6.jpg