On a Scale from 1 to 10 – Measuring Subjective Pain

In workers’ compensation, it’s absolutely crucial to correctly detail the workers’ subjective residuals of their injury. This is because measuring objective factors like a limited range of motion are less tangible than concepts like pain, and aren’t always an accurate account of the extent that the injury affects the patient’s day-to-day life.
Continue reading On a Scale from 1 to 10 – Measuring Subjective Pain

¿Qué es un informe PR-4 o grado de discapacidad?

¿Qué es un informe PR-4 o grado de discapacidad?

La importancia de un informe PR-4 puede resultar confusa para los pacientes. Este video a continuación explica la importancia de los informes PR-4 para los trabajadores lesionados. Este video presenta el tema de los informes PR-4. Se lo he mostrado a algunos de mis pacientes antes de que se llevara a cabo el examen PR-4. Responde aproximadamente al 80% de las preguntas comunes que los pacientes tienen sobre el informe y el examen, lo que supone un ahorro de tiempo para todos.

Si es un paciente y tiene una lesión en el trabajo, este video arrojará algo de luz sobre cómo se evaluará y calificará su lesión en el trabajo.

Si es un proveedor médico o gerente de oficina en una clínica médica, no dude en usar el video para ayudar a explicar la importancia del informe de grado de discapacidad a los trabajadores lesionados que va a examinar. Envíe a sus pacientes el vínculo a esta publicación por correo electrónico, y podrán verlo en la computadora de su casa o en sus teléfonos celulares mientras están en la sala de espera.

The RateFast Parity Calculator: Tuning Dissonance into Harmony

A workers’ comp insurance adjuster receives a report saying that the patient, an injured worker, has been able to carry out all of their day-to-day functions with no sort of hindrance from their sustained work injury. The doctors measurements say that they have lost all use of their injured body part. Did that make any bells go off for you?

Continue reading The RateFast Parity Calculator: Tuning Dissonance into Harmony

RateFast Podcast: The RateFast Parity Calculator – Harmony and Dissonance in Work Comp Reports

Dr. John Alchemy describes the new feature of RateFast: the Parity Calculator, and illustrates the importance of keeping congruence between objective findings and subjective measurements when writing a workers’ comp report.

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Try RateFast Workers’ Compensation Software Suite at www.rate-fast.comAnd check out our blog at https://blog.rate-fast.com

 

RateFast Podcast: The RateFast Parity Calculator – Harmony and Dissonance in the Work Comp Reports

Cory Oleson (Host): Welcome to the California Work Comp Report. Today is Monday, July 27, 2020. This is your host, Cory Oleson, here to bring you the topic of today’s show, the RateFast Parity Calculator. Let’s hear what Dr. John Alchemy has to say about this exciting new feature to RateFast.

Cory: How are you doing today, John?

Dr. John Alchemy: Hey Cory, I’m doing great, thanks for asking. 

Cory: So today we are talking about the RateFast Parity Calculator. The RateFast Parity Calculator is another key module in the magic formula that helps make RateFast a great tool for workers compensation. John, can you tell us a little about the RateFast Parity Calculator features?

Dr. John Alchemy: Yes, the RateFast Parity Feature – we’ve been working on this for quite some time. It’s a tool that we use that basically compares the internal accuracy of a report, and answers the age long question of which information in the report is most correct, or is the data aligned between what the patient reports for pain and symptoms and function, verus what is found on the physical exam, diagnostic tests, the procedures they’ve had, and all of the information that goes into the ratings for the individual’s body part.

Cory: It seems like there is a tug of war between the objective and the subjective findings that determine the outcome of the report. How does the Parity Calculator make additional accuracy on top of all the accuracy that RateFast already does?

Dr. John Alchemy: Well, within a report there is this invisible understanding of internal consistency. And obviously if you’re getting a report, you want internal consistency between the factual information the patient is reporting to you and you want it to be credible, and the objective findings that are documented in the report like the physical exam, the range of motion, strength, etcetera. And ideally you want those two to be equal and most importantly reflective of one another and as accurate as possible between. 

So for years, I can’t tell you how many times state holders, employers, attorneys, patients, everybody in the work comp system that has to deal with the Parity Report, which is everyone, they struggle with this concept of: this is not an accurate reflection, or my exam doesn’t really show what my pain is, or vice versa. And there’s this ongoing issue that no one has ever really done anything about it. 

Unfortunately because of lack of a tool like this, cases go through multiple iterations of exams, more tests, more documentation, and so forth. What the Parity Calculator serves to address is how much alignment or misalignment is here in this report that we’re looking at. And really what the most accurate rating should be, all the information is in and it’s been considered and rated. That’s basically what the Parity Calculator does. 

Cory: What are some of the basic AMA principles used in the Parity Calculator?

Dr. John Alchemy: Well that’s an excellent question. Just to start off, this is a great podcast, and I think it’s going to be groundbreaking in taking parity rating to the next level that’s going to help standardize and help create insight into the data in a way we haven’t seen it before. As I’ve said it’s required a lot of investment, it’s a really detailed tool – I won’t go into the math and the statistics but it’s very comprehensive and extremely educational once you understand what it does. 

Now, in order for us to use it, we are obviously using the AMA guides and administrative ruleset, and because of that it is founded on the premise of some of the basic AMA recommendations. I’m going to just read through a couple of them and give just a brief interpretation of what it means and why it’s important when we’re talking about something like data parity. Also in this podcast I’m going to use it and refer people to it when they have questions or are trying to understand data parity because questions are always good. It helps me understand what the marketplace is thinking about, what they’re having a hard time understanding, and what they value. So, I’ve selected just a few key elements out of the AMA guide that I’m going to read to you. Like I said I’ll make a brief comment about why or how it’s important as to how the RateFast parity calculator looks at data. 

Starting way back in chapter one of the philosophy purpose and appropriate use of the guides on page two, it simply says, “an impairment may lead to functional limitations or the inability to perform.” Pretty straightforward. 

Next, what is an impairment evaluation supposed to do? Page three. It says, “an evaluation (rating) a permanent impairment, is a medical appraisal of the nature and extent of the injury or disease as it affects an injured employees personal efficiency, again, in the activities of daily living, such as self care, communication, normal living postures, traveling, non specialized activities of bodily members, the arms and legs.” So again, it says, it’s an appraisal of function. So that is again, a second swing at the plate, and it’s saying impairment is about ADL function.

 Okay, page four. The whole person impairment percentage is listed in the guide’s estimate of the impact of impairment, and again impact is reported in percentages of zero to one hundred, of the individual’s overall ability to perform activities of daily living excluding work. That’s listed in table 1-2. That is the main reference table for the 34 activities of daily living in the AMA guides.

 So I think one of the most important things that this particular passage says, and what I want to impress upon the listener, is that the whole person impairment result of the rating is a reflection of the individual’s ability to perform activities of daily living. It is not the reverse. The findings in the whole impairment rating does not dictate what the patient’s function is. The whole person impairment rating is supposed to reflect the loss of function, and this is very important. And as you can see, up until this point as you can see with these three simple passages, we can understand there is a very tight and direct connection between a whole person impairment rating and an individual’s activity of daily living. Any questions on that so far, Cory? And then I have one more citation. 

Cory: Well I certainly see how the three go together to determine the impairment based off of the function of loss and things like that, and I can also see how the three could definitely get confused in the process amounting to a whole person’s impairment. Baking those things in together, there’s a lot of margin for error. This is a long shot, but it kind of reminds me of – I saw this chart recently that was pictures of different cookies, and the only one that looked right was the first one, and the others just looked different and weird. Then it says, “there’s too much egg in this one” or “no flour in this one.” And I’m picturing that as a lot of impairment reports, are these weird looking cookies.

Dr. John Alchemy: Absolutely. And the frosting needs to match the cookie. That kind of thing. What I’m trying to build here for the listener is the understanding that we have our activities of daily function or the functional loss. And that whole person’s impairment is to be a mirror as accurate as possible that serves to describe that. 

Cory: Instead of imagining that the patient’s exaggerating – not saying that the doctor would think that, but it’s as if someone else was reading the report saying that might not be true, it can’t hurt that bad. It was just their finger. Or something like that. Versus the recording of it not being accurate to the amount of agony being caused or not. Or maybe sometimes it’s even more exaggerated. Maybe the reading comes out and shows that the pain is worse than the patient is thinking or would confess to it being. 

Dr. John Alchemy: Well each stakeholder has a different take on how they’re seeing the impairment report. I’m not going to say one is better than the other, I’m just saying that people look at this through different lenses. Our job is not to say if the patient is being truthful or if the exam is being truthful. But the Parity Calculator goes in and takes a look and says, okay, what was actually said, much of the interview and history that’s supposed to be there is there, and how much functional loss is there in relation to reported whole person impairment. So, we’re basically an objective system that takes a look at it and says, does this report make sense or not? And if not, then why? And if not then what does the corrected data look like? 

So that’s really what the Parity Calculator is all about. Now I’ll say this. I’ve been citing these citations I have here, and about this point in the discussion, I usually get “well, I kind of get it, but how do we know it’s really a 1:1 relationship?” Great question. One is the AMA guide goes out of its way to define both ends of whole person impairment which are defined with numbers with following definitions, that a zero percent whole person impairment is assigned to someone that has no organ loss or functional consequences and does not limit the performance of the common activities of daily living. That’s on page five. 

Cory: Zero percent one PI is, I’m healed. I’m good. 

Dr John Alchemy: Yes, it means, I’m as good as before. And it’s interesting because if the AMA guide goes out of its way to find two numbers of impairment, the first one is zero, and the second one is one hundred, and one hundred is an individual that is dependent on others for basically all functions and even says approaching death. So this is someone in a coma, and that’s 100%. And so if we think about our function and our zero to hundred spectrum of impairment, these are what the functional expectations are bounded as. Perfect, no problem, to I can’t do anything for myself. 

Cory: And someone else is probably having to tell you that they can’t do anything for themselves. 

Dr. John Alchemy: That’s right. So the final passage that I read is the following. And this really nails it in the AMA guides. This is also the basis of the Parity Calculator. It says on page five, “for an example an individual that receives a 30 percent whole person impairment due to pericardial disease, is considered from a clinical standpoint to have 30 percent reduction in general functioning as represented by a decrease in the ability to perform activities of daily living.” It can’t be any clearer than that, there is a perfect 1 to 1 ratio of whole person impairment to percent of functional loss. End of story, it’s pretty clear. So the Parity Calculator uses all of these definitions to understand the data. Very impressive.

Cory: Yeah, absolutely, I mean it makes you wonder why the two numbers aren’t the same number in the first place. I understand they’re kind of different, like different points or stages in the report, that the information reflected by one of those numbers isn’t necessarily reflected in the other, but it does make you wonder, who thought up this system?

Dr. John Alchemy: Let me just say again, because I think part of our problem and our bias as individuals when we read a report, is that the ranges of motion, the circumference of the arm, the strength testing, the findings of the x-ray, are very concrete findings that we hold as valuable. As we should. What’s less tangible, however, is the interview of the patient, and the completeness of the data, having the patient describe how the condition is affecting their ability to function. 

I can tell you that after looking at thousands of these reports, we get very detailed reports, or sometimes the report just says “Patient with pain. Physical exam.” Or sometimes it says “Patient can’t work. Physical exam.” And sometimes the physical exam is great, or sometimes the physical exam just says “pain when bending forward.” It doesn’t say how far they bend forward, doesn’t say what level the pain is, so this is the major problem that we have throughout the industry. It’s the bias, I think, that most people believe that the WPI is derived entirely from objective findings. And it’s our inability or our blind spot to really understand how much data is missing inside of the report. 

We’ve talked about this with other tools, with data quality that we have and so forth. This tool, this parity, really brings it all together, lines it up and makes it very simple to understand how good the report is, and if we only have this information in front of us, what should the rating be? How far out of line is the subjectives with the objective findings? It’s as simple as that. 

Cory: So that which comes out of the Parity Calculator is basically the synthesis of the most important parts of the report, or the emphasis on the most important part of the report, which is the functional findings. 

Dr. John Alchemy: Right. And when the Parity Calculator finds a report that’s in parity – again, how do we know it’s in parity? We look at the AMA guides, page 20 says that it’s valid if it’s within 10 percent of one another. We look at the parity scores for the objectives, the function, and we look at the parity score of the physical exam WPI, an dwe compare those two. If it’s within ten percent, great. You get a green light, and that’s it. 

But when it doesn’t, that’s where the Parity Calculator is equally helpful. And it takes a look because there’s this tug of war of data accuracy and data completeness, going on constantly. Was the history accurate? Was the physical exam accurate? Was something missing here or there? So when things are out of parity, two numeric representations or as we refer to as scalers, the magnitude of these two things are not in alignment, we have to find the in between.

Where is the true midpoint between these two now conflicted elements? We know it’s conflicted, but that may or may not be apparent to the reader. But it is apparent to the calculator because it queries very specific information to determine the completeness, the accuracy, and also the weight of each of these objects. 

Cory: Absolutely. And I’m sure a lot of that isn’t clear to the less adept professional as well. Maybe this is something that they aren’t seeing or understanding the marriage of the two. 

Dr. John Alchemy: And I will tell you even over the 20 plus years I’ve been doing this, it is very sobering once you have a corrective tool to look into your own report and say, wow, that was missing there, this was missing here, the data was out of alignment this much, and being able to take that information and either repair it with another report or do a better job on the next one. It’s a tool of understanding and guidance, consistency and making the rating overall more accurate in a way that’s never been seen before. 

Cory: Honing in on that perfect impairment rating that RateFast has been doing the whole time. So that brings us to the next question, John. If you’re reading a report, and it’s talking about parity, what am I supposed to be learning from the report?

Dr. John Alchemy: The main thing that the reader should understand from the report.. So the report’s going to have the standard rating report in it, so let’s say the rating of the low back is 7 percent, whole person impairment, and then it’s going to have the parity analysis. And the parity analysis is very short and brief. It tells you this simple information: is the data in alignment for this rating? And if it’s yes, like I said that’s a good thing, if it’s a no, the question is how far out of alignment is the data? Is it 20 percent, 40 percent? 

This is reflected in something we call the Delta Score or difference. Delta is a term used frequently in math for determining the difference between two numbers or two objects. And so it’s this Delta Score that tells the reader, yep this has good parity or no it does not. Now if it does not have good parity, what it does is it finds the correct number set that best reflects evenly and accurately the two differences. It takes the objective and subjective findings, it weighs them based on their credibility and accuracy and completeness, and it reconfigures and enhances the data and basically re rates it. 

So if I’m coming into a 7 percent whole person impairment on my back, the Delta score said this information is 40 percent out of line. It’s going to give us what the rating should be. Sometimes it’s higher and sometimes it’s lower. But it’s what the data in the report best reflects. It could go to twelve, it could be down to three. It all depends on the sensitivity of the data. 

I always have to chuckle when organizations publish these tables saying the rating for a strain should be 5 percent. Or for a post surgical it’s supposed to be a 9 percent. These are in my opinion, completely ridiculous because as we know, until you understand the deficiencies and the accuracies of the data, the specificity of the measurements all taken into account, it just doesn’t mean anything. And tables like that are really what put the bias blinders on stakeholders because everyone thinks “I read this table from this organization and they said no knee should be minus three points from seven percent whole person impairment.” 

Anyway, it’s hard because people want things done simply and they want to be able to understand them, and that’s where the parity calculator comes in. We do all the work for you, we’ve done all the analysis, all the calculations, all the specifics, we just want to be able to tell you whether or not it’s a good report and here’s what the rating is based on best practices, for this individual.

Cory: What you’re describing reminds me of – and this is going to be a very paraphrased version – but you can’t begin to work on the problem until you’re aware of what it is. And I’m sure a lot of people aren’t even aware of the harmony and dissonance between the two items that come together that the parity calculator does. And by the way this is the PARITY calculator, not the PARODY calculator. 

Dr. John Alchemy: Yes, meaning consistency. And I’m going to piggyback on that analogy, and talk about the ways some of the stakeholders view these reports. I’m not saying it’s bad, it’s just what I’ve observed. 

There is this funny story that goes: a man lost a quarter in his basement, and he was found outside in the yard looking for it. And someone came up to him and asked what he was looking for, and he says he’s looking for a quarter that he lost in the basement. And the question is then, why are you out here in the yard and not in the basement looking for it, and his answer is “the lighting is better out here.” And we see that all the time, people go and try to make sense of the report somewhere else and it really has no realistic connection to what’s in the report. So the Parity Calculator is a flashlight you can bring into the basement to find that quarter. 

Cory: Absolutely. So we’re talking about the Parity Calculator, the thing that’s making everyone’s life easier, just to put it that way. So when do we see it in effect?

Dr. John Alchemy: Right now on the commercial platform for RateFast, it’s already there and working. So if you’ve submitted any cases to our platform after the beginning of July of this year, you will find a parity description in your work report. I’m very much looking forward to the questions and feedback that I’m going to get from stakeholders, and like I said, this is not something we made up, this is simply a deeper dive into the AMA guides to make understanding of impairment more accessible for stakeholders, that’s all it is. 

Cory: So I think at one point I called the Parity Calculator a new module that has been added to RateFast, which it very much is, a new algorithm that’s been plugged into the greater formula and everything. What it reminds me of, being a musician, I’m very much into synthesizers. There’s a type of synthesizer called a Eurorack, and what it does you take the little pieces of the synthesizer, the pieces that make different sounds. And the reason that I draw the parallels between RateFast adding new feature after new feature is because the way that a synthesizer works is on one end you get a degree of voltage, and that single thing of voltage travels through all of these modules and comes out the other end as a rich tapestry of sounds, even though it started out as one piece of data. And the way that RateFast relates to Eurorack in a way is that you always want to add more. More is always better. Especially because we are figuring out for you the things that you didn’t know that you needed. 

Dr. John Alchemy: Yes that’s right, because we are obsessed with accuracy and consistency. It’s as simple as that. 

Cory: Well that was the RateFast Parity Calculator. If you are a RateFast user look for that section in the report and if you have any more questions, I’ll be giving you contact information at the end of this episode. So thank you again, John, for joining us at the California work comp report.

Dr. John Alchemy: Cory, always a pleasure. 

Cory: For more information about the RateFast Parity Calculator, and how it plugs into the RateFast Workers compensation software suite, visit our blog at blog.rate-fast.com and to try the RateFast workers compensation software suite, or the RateFast express three day impairment rating writing service, visit our website at rate-fast.com.

 

Video Series: PR-4 Reports Explained!

Welcome to the RateFast Video Series, PR-4 Reports Explained!

This video series is intended to show those who are new (and even some who are experienced) to workers’ compensation to give valuable information on writing the PR-4 Permanent Stationary report. If you have any questions, or if you would like to give RateFast or RateFast Express a try, visit our website at www.rate-fast.com or email us at info@rate-fast.com.
Continue reading Video Series: PR-4 Reports Explained!