This article is a transcription of an episode of the RateFast podcast, which you can listen to by searching “RateFast” in iTunes or the iOS podcast store.
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When it comes to injury mapping, there are four sets of data points that go into building a customized roadmap to recovery for each patient. These include the patient data set, the Activities of Daily Living, the biometric data set and work tolerance.
These groups of data allow doctors and stakeholders to see the whole picture regarding patients’ injuries, rates of recovery and other factors that may be involved in a workers’ compensation case. The more transparent each case is, the faster they will reach resolution and the patient can heal and get back to work.
Injury map (noun) – a new kind of medical technology that is personalized for each patient that can point to how quickly they will recover and what their unique recovery trends are.
Patient data set (noun) – things that are experienced by the patient, including levels of pain and pain frequency, symptoms, and side-effects of medications.
Biometric data set (noun) – measurable and objective data that is reported by the provider, including things such as degrees of motion, grading strength, determining the density of a sensory disturbance, reflexes, and diagnostic tests.
Activities of daily living (noun) – (ADL) routine activities that people perform every day without assistance.
Work tolerance (noun) – how the patient is able to return to work. They can heal completely and return to full-duty, or if they can only do some of the job their job duty is modified, or they can have a total disability where they are not able to work at that job any more.
Claire Williams: Hello, and welcome to the California Workers’ Comp Report. Today, I follow up with Dr. John Alchemy in the second part of our three-part special on injury mapping in workers’ compensation. Good morning, John.
Dr. John Alchemy: Oh hi, Claire.
Claire Williams: Hello. So last week, we introduced the concept of injury mapping. Maybe let’s review that concept for our listeners who are just tuning in.
Dr. John Alchemy: Yeah, sure. So what we’re talking about is collecting a data set and using it to make objective determinations on a claim, in this case, with an injured worker. And the format and the platform we’re going to be talking about is the RateFast platform, which is unique from anything else out there, because it’s actually a smart platform that’s looking at data and making determinations on the information being put in it. One of the problems we wanted to solve, currently, is when someone is hurt, it’s left up to the subjectivity of the doctor to interpret the case for all the stakeholders in the system. And as you can imagine, each doctor’s gonna have a different opinion, and then we have the problem of everyone getting a different distribution of results and subsequent benefits, and everyone wants a second opinion – and rightfully so, slowing the system down, expense, delay, all those things. So, with injury mapping, what we’re doing is we’re removing a lot of the subjectivity from the process, and we’re allowing stakeholders, for the first time, to really have some transparency and understand how things are obtained, what critical questions should be and need to be in reports, and then finally, the results of those reports as the law wants them to be communicated and distributed. So we talk about things like administrative rule sets, and California, for instance, uses the AMA Guides, 5th Edition as its administrative rule set, but the process here can actually be applied to any type of system that needs objective interpretation and consistent application of the rules across all the patients that are in the system.
Claire Williams: Great. So instead of sort of that interpretation of a work injury, we’re asking the providers to use sort of a road map. What sort of things do we look for in injury mapping to introduce to that road map?
Dr. John Alchemy: Right, and just a clarification, we’re not just asking providers to have knowledge here, we’re asking everyone participating in the system to have access to it. So the providers are one of the stakeholders. So what we can do is, you know, there are some basic data sets that need to be collected here when we’re building the map and understanding what road or path we’re gonna take, we’re going to use the map as an analogy. Now, we know where people start, and then we need to know where they finish. And the administrative rule set is going to tell us kind of how quickly we can move forward on that rule, depending on what happens. So for instance, I request an MRI for the patient, and that gets denied. Then we go on maybe to ask for a specialty consult, and so forth. So the injury travels down the road, it just kind of takes a different route, depending on what the conditions are for the claim. That being said, I just want to remind everyone that specifically using California work comp as an example, sometimes I get some feedback saying “Well, the pain is really subjective and we can’t use that at all.”
Claire Williams: Mhm.
Dr. John Alchemy: Or “It’s too difficult to categorize pain, so you know, this type of thing can never really be done or scaled.” And I want to just turn people’s attention, in the AMA Guides, on the second page, there’s a pretty interesting sentence, and it’s about three quarters of the way down. And it simply says this: “An impairment can be manifested objectively, for example, by a fracture, and/or subjectively through fatigue and pain.” And so, right there, in the very first part of the book, that basically lays out the philosophy, purpose and appropriate use of the AMA Guides, and clearly calls out that pain needs to be or can be factored into impairment. And arguably, that’s one of the biggest complaints that people come in for an injury, they hurt. Or they hurt and subsequently can’t do something. So starting out there, we have what’s called the patient data set. And these are things that are experienced by the patient. And one of the interesting things about mapping is that it is unique, and it allows the unique application of the administrative rule set to each and every patient as they’re experiencing their injury or illness. So for instance, we’re gonna need to know what their pain level is. We commonly use something called the analog pain scale. Zero is no pain and ten is severe, but we can also ask the frequency of the pain. Maybe they’re not in pain all of the time. Maybe they’re not having pain, maybe they’re having some other symptom, like tingling, or numbness. Something else that belongs in the patient data set is the medications that they take, and what kind of benefit or impact has that had on their symptoms? And also we ask things like side-effects, as the listener may know, medication’s side-effects are a rateable finding when the case becomes maximally medically improved. So for our talk here, we’re just gonna classify that as the patient data set.
Claire Williams: Okay. And then, what about this whole section of the AMA Guides that focuses on Activities of Daily Life?
Dr. John Alchemy: Yes. So the Activities of Daily Living, or as they’re called, the ADL’s, those are 34 activities that the book calls out, and they’re consistently used as threads throughout most, if not all, of the chapters in the book. And these are activities that the administrative rule set has called out as things that are important for an individual to do, and these are things at home, not in the workplace, okay? And so this ADL section is very important, in sections of the AMA Guides where the provider is given a range to make a determination. Right? So the ADL’s are basically a checklist, and we actually have a whole section of that, called the ADL data set. And so we go through there, we ask all 34 questions, and RateFast also makes a determination between ADL’s that can’t be performed, and ADL’s that can be done, but with pain. Because those are two different situations. And furthermore, for making that distinction, we want to know that if an ADL is done, but with pain, has the endurance and the rate of the activity been altered by the symptoms of the injury? So it gets, and should get, very granular, because again, the whole overarching goal of impairment in California work comp, or any system that’s trying to objectively apply these administrative rule sets, is consistency and accuracy. And so that’s really what we strive for on the platform in coming up with this process. Again, we want to be sure that the patient’s voice is heard, but it’s consistently processed in a way from one patient to the next to the next, and that’s the scaling process of the proposition here.
Claire Williams: So the injury mapping is taking two data sets that can be pretty subjective regarding pain, tingling, and how the ADL’s are affected — and then what other data sets are we working with?
Dr. John Alchemy: Okay, so moving on, we’ve talked about the patient data set, we’ve talked about the ADL’s. The third one is the biometric data set. So this is the measurable objective data that is reported by the provider, and these are things such as degrees of motion, grading strength, there’s determining the density of a sensory disturbance, such as a monofilament, or a two-point discrimination, there are reflexes, and then there’s diagnostic tests. We have common tests such as X-rays, and this can be anywhere from how well or how poorly a fracture heals, to dynamic X-rays that demonstrate changes in position, such as flexion and extension views of the spine, they have things such as clenched fist X-rays that will show translation or misalignment of bones in the wrist, there’s MRI’s, there’s of course nerve conduction studies, et cetera, et cetera. And it’s interesting, because throughout the administrative rule set of the AMA Guides, these things are very clearly called out as measurements of impairment. And so when we have an injury such as a wrist fracture, or anything like that, we can now define all of the pieces of information that need to be in that data set to make it 100 percent complete. And that is something that just has not been available to stakeholders in the past. Basically, they’ll look at a doctor’s report, they’ll look at the result, they’ll have no idea if the provider has put in all of the questions and done all of the biometric data, and then they’re just left with the result. And they’re really not sure how complete the data set is on that result that’s just been delivered.
Claire Williams: Sure, yeah, there’s no point of comparison as to how complete it is at all.
Dr. John Alchemy: Absolutely. And arguably, this book is very complex. And to be asking providers to understand it and consistently apply it and do it in a way that is fast and accurate, it’s just really not a reasonable request of a provider if they do not have a tool such as RateFast.
Claire Williams: Sure. So we’ve got the data on the patient report, what they’re experiencing, the ADL’s, biometrics, any last data sets that go into this injury map?
Dr. John Alchemy: Well, in workers’ compensation, you know, there is another one, and that’s actually work tolerance. So work tolerance is really how is the patient able to return to work, or the workplace? And you really only have three choices, Claire: The first one is “I’m working full duty, I can do everything in my job, and I may have pain or symptoms, but I’m able to do that.” The second one is “I can do some of my work, but I can’t do all of it. And if the job formally says I have to lift 50 pounds, and I can really only lift 25, and my provider writes that down, now I’m at modified work.” And so we have full-duty, modified, and then the third choice is “I can’t work at all. I’m totally disabled from my job, I can’t meet the requirements, or my employer cannot accommodate the limitations that I have.” So in that case, it’s just like you can’t work at all, because there’s just nothing for you to do at work. So that’s our fourth data set on the map.
Claire Williams: Okay, so then let’s overview one more time: How can knowing, first of all, that all four of these data sets need to be present, and then also, what goes into each of them, benefit not just the providers but all of the stakeholders in the system?
Dr. John Alchemy: Great question. So what we’re now talking about is allowing transparency to all of the stakeholders. So if the stakeholders know what needs to go into the recipe for determining an injury and mapping its recovery and knowing how quickly they’re coming along and what the data sets should require, it then just becomes a matter of communication and clarifying between the different stakeholders. So, let me give you an example: Right now, for instance, say the case is open three months, and I get a letter from the adjuster, saying “Hey, look, when is this case gonna be maximally medically improved?” Very common, very common. And currently, I might flip through the chart, and I’ll say “They were doing okay here, they were doing a good spell, they had sort of a bad spell, you know, and gosh, they’re improving, they’re kinda going slowly, I think, and I’m just gonna throw a number out — another six to eight weeks, I’m gonna write that down.” So with data mapping and injury mapping now available, the stakeholders now actually have the ability to A. Look at the data sets and say “You know what, doc, I really appreciated the last note that you wrote, but we left out the section on ADL’s. What’s going on there?” Or “Some of the biometric measurements, like the, you didn’t report on three or four planes of the shoulder, how is that coming along?” So, the goal and one of the great benefits in injury mapping, is that we don’t have these large gaps of knowledge between the two stakeholders. What we really have now is a communication just talking about completeness. So a letter, instead of saying “Doctor, I don’t agree with your report,” now becomes “Doctor, hey, we’re missing this section of the report. Can you please include that for us and reformulate your opinion on that case?” And that’s a much more collaborative way to be moving things forward, than maybe the traditional way where people are just frustrated that they can’t get the information and understand what’s happening. So at the end of the day, that’s the 10,000-foot benefit of injury mapping and why this is such a big category and a new and fresh idea for workers’ compensation.
Claire Williams: Definitely. It sounds like, you know, you’re interested in building a mutually educated community that can work together in getting injured workers the best treatment in the most timely way possible.
Dr. John Alchemy: Absolutely. You know, what we want to do is we want to lower costs, we want to be more objective about the findings, we want to understand that when a treatment or a surgery is done, exactly how the needle has been moved on the claim, and we want to be able to see return on investment. And that is just not an insurance company’s reluctance to pay for a treatment, it’s that everybody’s able to see the benefit of the treatment. Because if you’re an injured worker, you don’t want to invest nine hours of your time going to six visits of physical therapy if it’s really not helping. And we really have no way of knowing that right now, other than “Well, I feel a little bit better, but my pain is still the same.” So we really don’t have a way without a tool similar to RateFast to say “Look, each time new data gets put in, we reconfigure the case and we now have a new opinion on how things are going and where we are in the map.” You know, maybe we just took a sharp right turn and we’re going way off track. So that’s really the big benefit of this tool, injury mapping, and what it has to offer.
Claire Williams: Great, well I think this is such an exciting topic for workers’ compensation in California, and we’ll look forward to part three. Do you have any last closing comments for today, John?
Dr. John Alchemy: Well, I would say regardless of who you are listening to this podcast, I’d really like you to think about how standardized and objective you are in the role that you play for workers’ compensation. Are you someone who knows what that data set needs to be, and more importantly, do you know what to do with the data set? A chart review can be played two ways. You can be defensive about it and just go through the chart review and kind of hope you’re gonna run into stuff that you wanna see, but really, the way to do it is be objectively offensive about it, and say “I have the stack of papers in front of me. I know the three things that I’m looking to get out of this chart review, and I’m gonna go find ‘em or I’m not.” And that’s really the way that this tool and people who are working in a system like workers’ compensation need to approach their task.
Claire Williams: Definitely. A great question to reflect on. So thanks so much, and we’ll look forward to chatting next time.
Dr. John Alchemy: Great, well see you next time, Claire.
Claire Williams: Thanks.
Narrator: Thank you for joining us for this episode of the California Workers’ Comp Report. You can follow RateFast on Twitter at @ratefast, or visit www.rate-fast.com to learn more.