Tuesday, May 26, 2015

Perfect Access to Perfect Information

What if we could have instant access to perfect information? 

Access is not a problem limited to information. If a manufacturer had perfect information about the demand for its product, that would allow planning and would minimize costs for warehousing and inventory. If a service provider knew precisely when it would need how much of a supply, warehousing and storage are likewise minimized. 

The manufacturing and retail marketplace have been struggling with the challenges of what has been labelled "just in time inventory" or perfect access to perfect inventory. Through careful management, the right inventory shows up at the retailer or manufacturer at the right time; as product is sold or used, it is timely replaced on the shelf for the next customer but there is no excess supply to be stored "in the back" awaiting that sale. When you are ready to purchase, the last thing most people want to hear is that it is "out of stock, but can be ordered."

Information might be similar. What if we had perfect access (right now, easily) to perfect information? in March, WorkCompCentral ("WCC," subscription) reported on Maximus Federal Services, a company that provides an "independent medical review," or "IMR" process in California.  In California, this IMR process is used to resolve medical disputes. 

IMR is designed to be an "efficient process" that places medical disputes in the hands of physicians. It is not completely dissimilar to the Florida "expert medical advisor," or "EMA" process. However, it is designed to function in a much broader context within the California dispute resolution process. California has contracted with Maximus to provide this service. Its success has been the subject of some discussion there. 

As WCC reported in March, almost 7,000 cases in the IMR process are "missing medical records." The records are critical to the IMR process, just as they would be to any dispute resolution process. Step one in resolving medical disputes is gaining a full understanding of the diagnosis, the foundational testing results and medical findings that support that diagnosis, and whatever logic supports a recommended course of care. 

The medical information challenges are not unique to California IMR. When cases in Florida are in dispute, it is common for attorneys to begin sending subpoenas and releases to medical care providers and facilities to obtain complete sets of medical records. These efforts all to often produce a volume of irrelevant or marginally relevant records in addition to the pertinent records. 

For example, an injured worker presents at a hospital emergency room after the work accident. The release or subpoena to that hospital, in an attempt to be thorough, asks for "all records" regarding that patient. The response therefore includes the ER record following the work accident and also all of the records from the injured worker's hospital admission 14 years ago for appendicitis. 

These records are complete with nurses' notes carefully documenting the patient's temperature and medication course over a four day appendicitis hospital stay 14 years ago. The response will include all of the testing for that condition, consultations, surgery reports, etc. Sometimes too much information can be as troubling as too little. 

Seemingly, the carrier or third party administrators should receive timely copies of the records from the work injury. The statute requires medical providers to produce records when they bill for services. Pursuant to the authority in Fla. Stat. 440.13(4)(a), the Division of Workers' Compensation requires health care providers to periodically report on medical care rendered. The providers use the DWC-25 to report diagnosis, treatment rendered, testing needed, and work capacity. It is a self-contained wealth of information when it is properly completed. That is the rub, however, the form is not always complete. The process of obtaining records is not perfect. 

When the records are produced in response, they are not always relevant or complete. Often, the references in the produced records lead to a host of additional providers or facilities whose records must then be sought. The workers' compensation law, Fla. Stat. 440.13(4)(b), calls on the medical provider to provide those records to the injured worker and the employer/carrier. 

Then the law says that Carriers are supposed to review bills from medical providers, called "utilization review" under Fla. Stat. 440.13(6). The review is to "identify over-utilization," and to assure compliance with "practice parameters and protocols." There is an industry of medical bill review that specializes in this process so that insurance company claims adjusters do not have to do so personally. 

So, there is a need for information. It is required for compliance with the law, and more important it is required for imortant decisions. Adjusters or medical bill review specialists need to see the medical records and DWC-25 forms. Employers would benefit from information in the forms, such as work restrictions, duration of anticipated care and more. The injured worker would likewise benefit from easy access to the medical records from the workers' compensation treatment. Even when we are handed a piece of paper, putting our hands on that particular page a few days later can be a real challenge. 

The WCC story in March says that California's struggle in those 7,000 cases appears to be a combination of failures. It says that some submitted records have not been matched to the appropriate case for review. In others, the records have not been submitted by claims administrators because "the treating physician never supplied them." 

It is not that data does not exist. Presumably the medical providers create records to document what they see, feel, conclude, and treat. It is possible that those records are submitted with the medical billing, but are detached in the process of bill review. It is possible that the records are submitted after the bill and that there are then issues with getting the right record attached to the right bill. The information is out there, but there are organization and access issues that are hampering the use of the information. 

After the fact, there is a significant volume of time and effort invested in attempting to effectively use the information; to plan treatment, to assess capacity, to consider return to work, and more. Access to information is imperfect because it is in multiple formats and locations. The data itself may be imperfect because boxes are not checked, explanations are not clear, or internal inconsistencies confound valid conclusions. 

What if we had perfect access to perfect information? Is it possible? Perhaps it is not possible, perfect is a tough goal. There may always be failures in the quality and accessibility of data despite our best efforts. But, arguably things can always be better than they are. While we may never have perfect access, it is practical to think that we could have better access. 

In 2013, the International Association of  Industrial Accident Boards and Commissions (IAIABC) issued its Electronic Billing and Payment National Companion Guide. The IAIABC advocates an electronic billing system for workers' compensation and proposes a national standard for the process. With a national standard, billing from medical providers in any jurisdiction would produce data that is reasonably consistent in format and content. This would simplify the operations of medical bill review companies and insurance companies. With consistent inbound data, the processes for review and approval could likewise be significantly consistent. 

With electronic medical billing, the associated support information such as the doctor's office note or the DWC-25 would be electronically connected to, or associated with, the billing. The protocol could be similar to the manner in which doctor's notes or other medical records are associated with the petition for benefits filed seeking adjudication of workers' compensation issues today. 

The greatest benefit, however, would be in the area of access to information. If all incoming medical billing for an injured worker was connected to an electronic version of the treatment documentation (office note or DWC-25) then that information could be easily and inexpensively put at the fingertips of the injured worker, the employer, and their respective counsel. 

There could be a repository of medical information at the fingertips of the concerned parties. While that access might not be perfect, it would be more contemporaneous and complete than the current release and subpoena process. Time would be saved, as could be expense. Less paper moving through the U.S. Postal Service, and more being reviewed online in an accessible and convenient database. The digital nature of the documents would promote searching and organizing efficiently as well. 

In the WCC article, an official was quoted "there is always room for improvement." That is likely true. We can always be on the lookout for ways to decrease the friction in workers' compensation disputes and decisions. The more ready access to critical information, the quicker and more reliable the decisions that are required. Whether that is medical authorization, workplace accommodation, or otherwise, more rapid, thoughtful, and accurate decisions benefit everyone in the system.

 So, the questions we may want to ask are:

(1) why are the states not implementing electronic medical billing? (2) what can be done in the interim to increase access to better information without subpoenas or releases. 

Christopher Smith, a Tampa attorney representing injured workers has repeatedly proposed a "data warehouse" that would facilitate access to information. Social Security already has one. If suuch a system were replicated here, that warehouse could be stocked with the data that may one day come from electronic billing in WC cases. Does it make sense to wait for the electronic billing process to facilitate this tool, or would it make sense to build it now and stock it with the imperfect data that we already have? This is a question like whether to wait until we have books to build shelves, or whether we should build shelves in hopes the books will come. 

If we cannot have perfect access to perfect data today, should we instead strive for better access to better information in the near term? What kinds of logistical, programming, and privacy concerns will we have to confront to do so? Why are we not working on this?

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