Using innovative tools to diagnose workers’ comp injuries
Getting injured workers back to work quickly is contingent on getting them the right treatment as soon as possible. Unfortunately, that’s not possible when the initial diagnosis is incorrect — something that happens frequently, according to physicians at the Mayo Clinic. A study that compared the diagnoses from primary care providers with those of specialists found the vast majority were at least partially if not totally wrong.
The results of misdiagnoses are “treatment delays, complications leading to more costly treatments, and even patient harm or death,” the authors said. “Effective and efficient treatment depends on the right diagnosis.”
Better, faster and more accurate diagnoses are vital to helping injured workers heal and recover. Several innovators in the workers’ compensation space have developed new tools to ensure correct diagnoses of physical, emotional and psychosocial conditions.
The vast majority of occupational injuries are soft tissue — such as muscles or ligaments — but diagnosing these can be challenging. Even the most experienced, competent physician must rely on technology that lacks pinpoint accuracy.
X-rays and MRIs go a long way to identifying the cause of pain, but they don’t tell the whole story. Physicians must depend on the patient’s description along with their own instincts. All too often there are misdiagnoses — resulting in unnecessary surgeries, procedures and medications.
However, a new technology recently cleared by the FDA enables physicians to see the specific source of pathology. It also provides something that has been sorely missing in the workers’ compensation system: objective information for the elusive soft tissue injury.
Called the “Electrodiagnostic Functional Assessment,” or EFA, it works much the same way an EKG assesses the heart muscle. An EKG measures the electrical activity of the heart to determine whether there is any damage and what it might be. EFA essentially does the same for soft tissues. By comparing test results of the affected area at baseline with those after an injury, medical experts can clearly see what new damage there is, if any.
EFA was developed by MaryRose Reaston, Ph.D., and Phil Reaston to help her address injuries she sustained in an auto accident. Dr. Reaston, the chief science officer and co-founder of Emerge Diagnostics, has incorporated telemedicine technology to expand the application of EFA anywhere.
Here’s how it works: A medical professional connects with a board-certified physician, who conducts a telemedicine evaluation of the patient. To analyze the soft tissue injury, the medical professional applies the electrodes to the patient and conducts the EFA. The physician can immediately see the results and compare them with those of the baseline test, giving the physician more information than a traditional telemedicine visit. The technology is catching on with medical directors in the workers’ compensation system.
“The EFA gives immediate, objective evidence,” says Frank Tomecek, MD, a Tulsa, Oklahoma-based neurosurgeon, appointed member of the Physicians Advisory Committee for Worker’s Compensation of Oklahoma, and the medical director of Emerge Diagnostics. “For soft tissue it’s better than a personal visit because it provides much more objective evidence,”
In a published study on EFA, Adam L. Seidner, MD, chief medical officer at The Hartford, compared the results of 22 injured workers with soft tissue injuries who had been evaluated with the EFA to a control group of 151 who did not undergo EFA testing.
“The EFA group average return to work was 213 days versus 275 for the Control group or an average of 62 days sooner,” Seidner wrote in a published report. “Direct costs, including medical and lost wage payments to injured workers and their healthcare providers, were 25% lower in the EFA group for an average saving of $10,000 per claim versus Control.”
MSDs and treating physicians
One of the biggest reasons musculoskeletal disorders (MSDs) are often misdiagnosed is because assessment is often left to the best judgment of the worker’s treating physician. Especially in states in which employer-directed care is not allowed, workers typically visit physicians they know and trust — even though the physicians generally are not experts in the nuances of soft tissue injuries.
Far from using a solution such as the EFA, treating physicians provide what they believe is the best method for diagnosing injuries: X-rays, MRIs and the patient’s description.
“To the Insurer or TPA, nothing is a greater driver of cost than an incorrect medical diagnosis,” says Michael M. Best, MD, of Louisville, Ky. “Sometimes this erroneous diagnosis is corrected, but sometimes it follows the claim all the way to settlement. This process wastes serious claim dollars and creates considerable internal inefficiencies in the adjustment process and may result in undue suffering to the worker. Current claims systems are blind to this cost driver.”
An orthopedic surgeon by background, Best sustained an eye injury that rendered him unable to continue his surgical practice. He became keenly aware of the failure to accurately diagnose soft-tissue injuries while working with various multinational employers in his native Kentucky. Companies asked him to help control their workers’ compensation costs.
“It became very obvious, that a lot of the problem with workers’ compensation was the poor job we as physicians tend to do in diagnosis and following up with evidence-based treatment protocols,” he explains. “What we know is that the incidence of misdiagnosis is extremely high and the problem is, if you start with the wrong diagnosis, it’s impossible to provide appropriate treatment or to maintain the cost of care. Getting the right diagnosis is the key component of quality health care: It provides an explanation of the patient’s health problem and commands the subsequent health care decisions.”
The Mayo Clinic study revealed a misdiagnosis rate of 22%, meaning 22% of the patients included in the study had been erroneously diagnosed by their treating physicians. The study also showed that another 66% of patients had diagnoses that needed to be better defined or refined. That, Best notes, accounts for huge cost overruns in workers’ compensation and all of healthcare. So he began working with computer technicians.
“I decided ‘let’s write an orthopedic treatment software, intuitive to physicians, and see how we can do that and see if we can reduce some problems,’” he says. “We put together common orthopedic problems and treatments with evidence-based solutions and, low and behold, reduced workers’ compensation costs by about 30%. We developed our software company, Clinical Decision Solutions.”
Fast forward several years and much tweaking, and the result is a software designed for physicians who are not IT experts and do not have access to technology such as the EFA. The interactive touch-screen program functions as a soup-to-nuts diagnostic tool.
“We put together the appropriate questions that an orthopedic surgeon would ask about an injury or illness,” Best added. “Each ‘answer’ has an evidence-based numerical ‘weight’ — appended to offer the end user the 5 most likely diagnoses. An interactive touch screen pinpoints ‘where does it hurt’… the weighted response further delineates the diagnosis. Therefore, the system continues to ‘get smarter’ as the examination progresses. Finally, standard physical examination procedures are mandated, relative to the patient complaint. These answers are also weighted and combined with the responses from the clinical history and ‘where does it hurt’ protocol. The most likely diagnosis is then chosen by the physician or other medical professionals.”
Best is working with a large workers’ compensation payer to further refine the technology and get it into mainstream use. “The ultimate benefit is improved outcomes through better care,” he says.
Although the vast majority of workplace injuries resolve quickly, there are some that qw2unexpectedly deteriorate. Rather than the severe catastrophic injuries, these are relatively minor injuries that turn into long-term, expensive claims. Often called “creeping catastrophic,” these claims are the result of psychosocial factors present in the injured worker.
Much research over the last few years has provided needed insight into these issues — what they are, what may cause them, and how they manifest in injured workers. The industry has become focused on identifying these injured workers as soon after an injury as possible. Caught early and with the proper intervention, these workers can heal and return to productivity much sooner.
One of the pioneers of diagnosing and treating injured workers with psychosocial risk factors is Michael Coupland, the CEO and Network Medical Director of Integrated Medical Case Solutions, which provides screening and interventions to injured workers throughout the country. Coupland has been instrumental in developing a way to accurately identify injured workers with risk factors for delayed recovery through a simple pain screening questionnaire (PSQ). Though widely used in Canada and several other countries it is just starting to catch on with the U.S. workers compensation system. But results of studies on it are significant.
The PSQ was initially developed by Steve Litton and included 21 questions. Coupland collaborated with Litton and last year was able to reduce the number of questions to just 10.
Injured workers are given the 10 questions and statements and asked to rate on a scale of 1 to 10 how much they agree or disagree with each. The questions or statements relate to the injured worker’s pain attitudes, beliefs and perceptions. The answers provide insight into whether and to what extent psychosocial factors are present. It can detect such things as:
- Catastrophic thinking — or OMG! thoughts — one of the main issues affecting injured workers with delayed recovery. Despite the injury or illness, the person believes he is beyond the ability to recover.
- Fear avoidance. The patient is so concerned he will further injure his body that he avoids doing anything that might exacerbate the pain, such as any movement.
- Anger and perceived injustice. Regardless of how long the person has worked at his company, he feels a disservice has been done to him.
- External locus of control. The worker relies on his medical providers and others to fix him, rather than taking any responsibility for his own recovery.
“My favorite question is, ‘I should not do my normal work with this amount of pain,’” Coupland says. “The answer to this identifies the person’s work attitudes, catastrophic thinking and fear-avoidance behavior.”
The test has been shown to be highly accurate in predicting whether an injured worker is likely to have a delayed recovery. The most recent study involved workers at Albertson Safeway, where the PSQ was first introduced in 2013. Injured workers deemed to be at “high” or “very high” risk of delayed recoveries are offered the opportunity to participate in a short-term, cognitive-based therapy intervention program.
Recent analyses from 2013–2015 show the average amount paid per claim rose exponentially with the risk level identified on the PSQ.
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These results are similar to those of other studies that show the PSQ is very predictive of disability duration and medical spend,” Coupland says.
As technology continues to develop, more innovative tools to help injured workers heal more quickly are sure to follow.