If you don't measure it then you can't manage it. These famous words are attributed to Peter Drucker, the father of modern management thinking, and while as physicians we can poke some holes in this, there rings a kernel of truth that really can't be denied. If you don't measure it then you can't manage it, but that's just what we as occupational medicine physicians have been doing and have been asked to do. We're charged with managing the recovery of an injured worker, but how do you measure recovery? And so today Dr. Katherine Miller, my colleague and friend and mentor who I think many of you know and I, will be attempting to show you, introduce you to a way to measure recovery. It's an evidence-based validated way to do so and they're called patient reported outcome measures or PROMs for short. I'd considered titling this presentation Take Me to PROM, but I thought that might attract the wrong crowd. But before we get going, there's lots of room. This room is practically cavernous. I don't know how much I'm echoing. If you want to move up, please feel free to do so, but I want to offer a special welcome to those of our colleagues who are joining virtually and if you haven't already, please download the AOHC 2023 app, Swapcard, and if you are having any difficulties with figuring out from that app how to claim credit for CMEs and things like that, find someone with a red lanyard. They're part of the ACOM staff. They'll be able to help. But before we get going, I kind of want to fill you in on my perspective, where I'm coming from. It's important to note that I have no financial disclosures. Neither of us do. What we're showing you today is free to access, free to use clinically. We're not trying to sell you anything except maybe an idea. But my primary role is medical director for the Colorado Division of Workers' Compensation. Up until last week, I still saw patients every week at Peak Form Medical Center as their chief medical officer. In addition to that, I'm also an assistant professor at the University of Colorado School of Medicine, where I am core faculty for the Occupational and Environmental Medicine Residency and Fellowship, and I'm also assistant professor at the Colorado School of Public Health, where I teach the next generation of public health graduate students. In my spare time, I'm a fellow and council member of the ACOM Council on Occupational and Environmental Medicine Practice. And in addition to that, I'm also one of the founding members of a new organization called the Jurisdictional Workers' Compensation Medical Officer Roundtable. And you can see why I shortened that to WICMO for short. But this is essentially gathering together the leadership from the various medical directorships in workers' compensation across North America. And so with all of these activities, some people accuse me of trying to be some sort of Superman, but the reality is I see myself as kind of a mad scientist who's just trying to get his ideas to stick to the wall long enough to communicate them. This might also be how my patients and colleagues see me when I start talking about functional patient reported outcome measures, but suffice it to say that I was unfamiliar with these as well. And so let me take you back a little bit to when I was a resident in occupational and environmental medicine. I rotated with a well-known physiatrist in our system, and he pulled out two pieces of paper that I had not seen before. One was a psychosocial measure called the distress risk and assessment method, or DRAM for short. The other was the quick dash, or the quick disabilities of the arm, shoulder, and hand. This was my first exposure to these measures, but he took these two and he told me about how the encounter would go. He was like a fortune teller peering into his crystal ball, and this patient we were about to see, we'll call him John for the sake of this encounter. John had a long history of treatments for his elbow pain, and so after this, this particular doctor told me, hey I'm gonna outline all of these treatments. He's gonna tell me he's no better. He's gonna start getting tearful. I'm gonna use this quick dash thing to show him how there's nothing left for us to do, and I'm gonna place him at MMI today. I was a little surprised. To be honest, I thought this well-respected doctor was a little bit full of it, but wouldn't you know, we got into the room. The patient started off by saying, doc I'm no better, and he said, well we've done this and this and this. The patient began to get tearful. The doctor validated his stressors, pulled out the historical record of his quick dash measurements, and outlined, used that paper, that questionnaire to facilitate a discussion about maximum medical improvement, and at the end of the encounter, this really hit me, at the end of that encounter, that patient actually thanked him for placing him at MMI, and said I've never felt so hurt in a doctor's office before. This was my first foray into patient reported outcome measures being used clinically, and as you can imagine, it left a bit of an impression, because throughout my training, I had seen doctors struggling to figure out what mattered to their patients, figured out how to assess their function, figure out how to take some of these difficult cases, and progress them forward to maximum medical improvement, and so I thought, if this simple tool could even just help ease that discussion a little bit, then it was well worth its weight in gold, because for so long, the only measurement of recovery that we've had, is a zero to ten pain scale. It's the only way we've consistently measured recovery, and as a result, we focus so much of our treatment plan, and so much of our energies on pain level, with the rare clinical outcome measure, like strength, or range of motion, or something that is a surrogate measure for function, but very often, we just fall back to pain level, and I mean, why not? I mean, any patient can objectively quantify the extent of their recovery for us in a simple number, right? Well, as I saw the doctors struggling, I began to feel that maybe that wasn't exactly true, and so what happens when we focus on pain as our sole outcome measure? What happens when it's the sole goal to get our patients to a pain-free state? Go ahead and shout it out. What have you seen? We've all seen this. It doesn't work. They never reach the goal. More narcotics. Pain becomes the fifth vital sign. It's extremely subjective. It's become something we have to treat, and arguably, one could say, it's responsible for our current opioid epidemic. We've all seen how this can happen, but if recovery is our outcome of interest, how do we measure recovery? If it's not a zero out of ten pain scale, if it's not a pain-free state for our patients, how do we measure it? And so, actually, just go ahead. How do we measure it? Function. Well, that was easy. Pain was specifically excluded from the grand bargain that our jurisdictions came to about a hundred years ago in North America, and so we are, unfortunately, however, back to managing something we're not measuring, but how do you measure functional progress? Well, I've got good news, because we've been doing it for decades. In evidence-based research, they recognized early on that pain was a poor measure of recovery. Pain was a poor outcome, so what did they do? They started creating these questionnaires for patients and tracking them over time called patient-reported outcome measures, functional patient-reported outcome measures, or fPROMs, or just PROMs for short, and so they started using these, and any time you see a randomized clinical trial talking about the difference in function between two treatment arms, what they're talking about is a measurement using these functional patient-reported outcome measures. So let me introduce you to one right now. This is the one that I just mentioned. This is the quick disabilities of the arm, shoulder, and hand questionnaire. The original DASH was released, I believe, in 1996, and this quick DASH was released in 2005, almost two decades ago. Throughout the years, it has been validated. We know what the minimum clinical significant change is. We know what the minimum detectable change is, and so we have validation and evidence-based research about this particular measure. This isn't the only one, but this is a quick one because the original DASH had 30 questions. This one has 11, and you go through a little calculation that's on the bottom of the form, and if you just pull up a quick Google search for quick DASH, you'll get a PDF that looks just like this. It's free out there, it's free for you to use clinically, and you can score it by hand. And that quick DASH can give you an assessment of the patient's functional status. On a 0 to 100 scale, the higher the number, the higher the score, the higher the disability. But this isn't the only one. There are many, many validated, evidence-based, functional patient reported outcome measures out there. The Washington Department of Labor and Industry has a PDF called Options for Documenting Functional Improvement. It's included in the handouts for this lecture on the Swapcard app, but if you just Google Options for Documenting Functional Improvement on Google, it'll bring you up to that first web page. But they have a list of 20 outcome measures for various body types and also for psychosocial screening that lists the reference, how to find it, and also the minimum clinical difference, the minimally clinically significant change. And so you can go there and pull it up. It is a little bit out of date, so just use some of the links on it with caution, but it is useful for filling you in a little bit on how to use them, but hopefully by the end of this you'll be the expert. But the state of Colorado also has a similar list for our program called the Quality Performance Outcomes Payment Program, and this QPOP program takes it one step further. In addition to listing the functional and psychosocial outcome measures that are recommended, the state of Colorado actually reimburses providers when the use of those measures affects their clinical decision-making. Not only that, but about six years ago ACOM actually came out with a position paper on this and said there's clear value in patient care based on functional outcomes and the time is right to begin assimilating this well-established, results-oriented approach more widely into the US healthcare system. Just a few short years later ACOM and the American Psychological Association held a symposium with NIOSH that included key stakeholders from multiple areas including insurers, EHR developers, medical specialty societies from all walks of life, and the result of that symposium was again published in JOEM and they said the use of patient-reported assessments of function as reported in peer-reviewed literature can lead to more effective, efficient, patient-centered care that reduces impairment and work disability and results in an improved culture of health for patients and society. If that weren't enough, the Workers' Compensation Research Institute just recently published a study on physical therapy and low back pain and they quoted, they were discussing patient-reported outcome measures and how they're used in literature, but they went on to say that PROMs, patient-reported outcome measures, have been found to increase health literacy through transparency, improve patient-provider communication and trust, all of which are associated with improved patient engagement that in turn has been found to lead to better clinical outcomes. So they've been around forever. ACOM is calling for their use. The APA is calling for their use. NIOSH is calling for their use. Why aren't we using them? Let me do a quick survey. This is about the time where everybody's falling asleep after lunch. So what I want everyone to do is raise your, raise your primary, your dominant hand if you can. Raise it nice and high. Now I want you to lower it if you've never heard about patient-reported outcome measures. Wow, that's quite a lot. That's quite a lot. We may have some selection bias going on, Catherine, because they came to a title that had PROMs in the title. How many of you have heard of using it clinically to follow the care of a patient? A few less. How many are currently using it on every patient you see? And we're left with only a couple of hands up. And so why aren't we using it? I think that there are a lot of reasons for this, not the least of which being every time I talk to a group of physicians, aside from this one, I get this distinct deer-in-the-headlights look. And why not? I mean they didn't teach us this in medical school. They didn't teach us how to use patient reported outcome measures, let alone what they were. So I think that lack of familiarity is a huge barrier to the use. But there are other barriers. Since so many of you have heard of them and have used them in clinical practice, what are some of the other barriers that you have encountered? Time. That's the biggest one. What else? EMR. So the EMR one is getting a little bit better since Medicare has updated their meaningful use criteria to say, hey, we recognize these too. They've fallen in line with what ACOM has been saying for almost a decade. But the main one that I encounter is that time issue. And it takes time not only to learn it, but also to use it in the context of a clinical encounter. And in most jurisdictions that time is unreimbursed. And so I can't solve all of these issues today, unfortunately. I wish I could have it immediately integrated into every EMR that does OccHealth. I wish that I could make every jurisdiction reimburse for the appropriate use of functional patient reported outcome measures. But today I'm hoping to increase your familiarity with it so that you're not afraid to use them. And so that you can leave here with a coherent idea of how to use this in a patient encounter. And so I'm going to take you through a couple of patient encounters and just illustrate how I use them in clinical practice. Because I am convinced that if a grassroot group of clinicians comes forward and says that this is the way to increase the quality of care for our patients, then we can together help the EMRs see that it's important to integrate. We can help our jurisdictions to figure out how to reimburse us appropriately for the time it takes to utilize something that will improve the quality of care based on every measure that we've looked at. So let's go back to the quick dash. And so these two examples I'm going to give are going to utilize the quick dash measure. And just remember as we're going through this that this is a disability score, which means that the higher the disability. The lower the score, the better the function. And so I'm going to start off with a patient of mine that we'll call her Lupe for the sake of this example. But she was a 37-year-old janitor at a high school. And she was on a ladder cleaning some stuff off of a trophy shelf when she slipped. And she caught herself with her arm and immediately developed shoulder pain. It hurt. So I administered the quick dash to her in addition to a psychosocial screen. And that psychosocial screen said she was in the normal category, normal risk category. There was no significant depressive risk. My exam didn't reveal any red flags. It looked and acted like a shoulder sprain. But she had a significant loss of function, as you can see. Her functional score placed her in the moderate disability category. And so I started formal physical therapy right away because of that evidence of loss of function in conjunction with my clinical interview. And we started PT. And as you can see, she started to get better. By week two, her quick dash score had come down. She was still in the moderate disability category. By week four, she continued to improve and was in the mild disability category. By week six, I began to suspect that we were getting as much as we could out of PT because she started plateauing. Her score at week six was similar to her score at week four. And so I addressed with her some of the barriers she was having to actively engage in physical therapy. And it hurt her. It hurt afterwards. And so I added a passive modality to help her. It was massage in this case, to help facilitate her active participation in PT. By week eight, I realized that that hadn't worked. We had reached kind of the maximum that we could with physical therapy. But she was still on work restrictions. And she was still having significant difficulties with pain. But her function had plateaued. So at that point, I'm thinking, OK, it's time to stop physical therapy because it's not helping anymore. I'm a pragmatist at heart. And if it's not working, why are we doing it? If it's not working, why are we doing it? So I stopped PT and massage and re-evaluated the diagnosis. I sent her for an MRI. And I got that MRI back. And it showed a partial but high-grade rotator cuff tear. So I said, OK, I can document now that this has not been responsive to physical therapy. It's been refractory for PT. So when I referred her to the surgeon, I did not get an argument from the insurance company because I could document that we had tried PT and that she had plateaued in the functional progress as a result. And so I sent her to the surgeon. The surgeon recommended a rotator cuff repair. And I'll just ask the audience, can you guess when she had this rotator cuff repair? Somewhere between week 14 and week 16 because we saw the expected regression of functional progress. And so after that surgery, she was immobilized for six weeks. We did start PT a little bit early just to help her with the passive range of motion exercises and things like that. And so we saw her continue to get better and better with physical therapy. But at week 28, I got the dreaded denial letter from the insurer. They said, you've used up the medical treatment guidelines recommended max for physical therapy. We don't think you should do any more. And I was able to use these patient-reported outcome measures to show that she was still continuing to improve functionally, not just with pain, not just with how she felt after PT, but with a functional response saying that functionally, I can say she is getting better and better and I can prove it to you here. And so that cleared up the denial and we were able to continue formal physical therapy, even though the insurer was calling for discontinuation. However, by week 32, I realized that there was not a significant change from week 30 to week 32. So that prompted me to talk to her physical therapist and determine whether or not it was appropriate to transition to a home exercise program. And we determined that it was, so we discontinued physical therapy. You'll see that week 32 through week 40, that's eight weeks, that's two months, which, well, if we're not doing physical therapy, what's the other treatment? The other treatment was returning her to full duty, slowly, over time, in a gradual way, and using the functional patient-reported outcome measures to make sure that it was not causing a regression in function. So that by week 38, we determined that she was at MMI because she had returned to full duty. There are no further treatment options that we reasonably believed would help lead to further functional progress. And by week 40, we did the impairment rating because, as you can see, she didn't return to her baseline level of function. And she still had some limitations as a result of the surgery. Now, let's take a look at a different person. We'll call this gentleman Jack. He was a 50-year-old gentleman who was working. He had a slip and fall. He caught himself on his right arm. And he developed immediate shoulder pain. Just like Lupe, I administered the quick dash and the Zoom self-rating depression scale, a psychosocial screen. They started in a similar place. But his psychosocial screen actually told me that he was in the severely depressed category. Treatment started similarly with physical therapy. However, we quickly saw that it was not helping him to recover. And so we discontinued physical therapy and offered psychosocial treatment as well. That was declined. But we ordered an MRI. It showed nothing but essentially degenerative changes, nothing acute in the shoulder. I counseled him on this. And he continued to get worse functionally. We tried a second trial of physical therapy because, as we all know, sometimes an MRI is therapeutic. When you get the MRI, oh, you're fine. Then they're, oh, yeah, you're right, I am fine. So we tried physical therapy one more time. Unfortunately, it actually made him a little bit worse at week 12, from week 12 to week 14. And he was again offered psychotherapeutic services. It was again declined. But he was referred to a specialist who did an injection and said, well, that didn't help. And he was wondering if he could have surgery. And the orthopedic surgeon specialist said, I'm sorry, you're just not a surgical candidate. And after having gone through all of that, I was actually able to place him at maximum medical improvement at around the four-month mark because we had gone through all of the medically reasonable and appropriate treatments for his shoulder injury. And although he still had a high level of functional loss based on his reports, unfortunately, we've reached the end of what we could do. And this brings up an important point because functional patient-reported outcome measures can't be used in isolation. They can't supplant your clinical decision-making. But perhaps most importantly, they have to be used in conjunction with an evidence-based medical treatment guideline. Because otherwise, you would put yourself at risk of perhaps putting someone to MMI without giving them all of the reasonable and appropriate treatment that they actually need. And so it's important to utilize an evidence-based medical treatment guideline so that you can soundly say that we have offered or attempted all reasonable guideline consistent treatments. It also brings up another important point that these measures can only assess the patient's perception of their functional status. As a result, it is prone to symptom magnification, exaggeration, and things like that. But it's also directly affected by the patient's psychosocial status. If we are not addressing the patient in a true biopsychosocial way, then we are going to be misled by the functional patient-reported outcome measures. And this is why, for every patient, I do a psychosocial screen. There are many of them out there. The one that I used in these examples was the Zoom Self-Rating Depression Scale. But there are many, many others. The Zoom is the one that I use, but there's the PHQ-9, the GAD-7. There are many of them, and they're available to look at on the handouts that are part of your Swapcard app today. But if we're not treating patients as a complex biopsychosocial organism, then we're going to miss something. Because we all know that pain is a complex biopsychosocial phenomenon. But the same holds true for recovery. And if we're not treating patients in a holistic manner, treating them biologically, physiologically, psychologically, and socially, then we're going to miss something. But going back to our time issue that we had before, this takes time. This is hard. And these psychosocial patient-reported outcome measures are an integral part of administering functional patient-reported outcome measures, because it can provide a platform for that discussion. Now, again, it cannot supplant your clinical decision-making or your clinical assessment, but it can provide an avenue to discuss it with the patient in a more concrete way, rather than just bringing it up. Oh, man, you look depressed. I'm sending you to psych. That generally doesn't work out too well. But in the end, if we're not helping our patients get back to the things that they love, then we're never going to get them back to work. But clinical treatment is just one aspect of the usefulness of patient-reported outcome measures. They can also be very, very useful for impairment rating purposes. In fact, the AMA guides uses functional patient-reported outcome measures for the functional grade modifier for impairment ratings. But I'm getting ahead of myself, because what I'd like to do is introduce Dr. Katherine Miller. And she's going to discuss the work that she and the American Psychological Association have been doing on functional patient-reported outcome measures for impairment ratings. And I just want to make a few comments, because it was very interesting and illuminating to start that Colorado program that Dr. Moses just told us about. And several of the family practitioners who did occupational medicine in the Western Slopes, so they were mainly family practitioners, loved it so much that they used it on all their patients. They said, this is the best thing you ever gave us. We get these right away. We use them when we go in and talk to the patient. The patient's respected. They say, oh, thank you. Like, you're listening to me. I see you are listening to the things I wrote down here. And so it doesn't have to be that huge of a time sink. It can actually help you do more patient-oriented care. And so there are a lot of physicians who viewed it that way, just as Dr. Moses did when he was working with a physiatrist. So I'd keep that in mind. And the other thing to keep in mind, oh, and I wanted to know, how many of you actually have something in your EHRs? Because if you're working with large centers, most of the EHRs have PROMIS or some other type of tool embedded in your system. Does anyone know if you have it? Yes, some people say yes. You might not even know it's there. You might need to ask your centers to find out if it's there. But if it's embedded in there, it will automatically do all the, come up with the percentages and everything by itself. And then one other thing that if you're doing IMEs, so when I used to do a fair amount of IMEs, we used to give them a whole set of questionnaires. And if you've read Dr. Brigham's book and other people's books, they tell you you should definitely use a certain set of questionnaires. But I found it helped me, because I immediately knew, OK, how did they answer these? And I could see, because I knew the questionnaires, well, uh-oh, I see I have an issue here. I see I have this kind of issue. So when I go in, I can start out, and I know what direction I'm going in. So there's really some advantages to just using it. I'm going to go fairly quickly through just some stuff we've done at ACOM, so you know where we're at. And then I'm going to get to what is likely to happen in the impairment rating area regarding this. So Dr. Moses really covered a lot of these. I don't have any relevant disclosures regarding this. And when we started out, as Dr. Moses mentioned, we did those two papers. And the efforts back when we started were that we wanted to increase the FPROM use for the reasons you've already heard about, right? So I don't need to go over why. But they weren't very available in EHRs. And apparently, a lot of you still don't know that you have it in your EHR. So that is improving over time. Many large systems are using them because Medicare pays you to do it. So if you're in a larger system, it's probably available. I can tell you almost all the orthopedic and spinal surgeons, there's a Sine Quanon. That's their clinical registry. They're all using it. OK. So as we pointed out, we started working with the American Psychological Association. And what we're going to talk about a little bit now is how did we get to the PROMIS tools? So how many of you have heard of PROMIS? Do you know anything about it? Yay. OK. I'm not going to go through the complexity of all the PROMIS tools. If you have questions, I will be happy to talk about that later. I'm going to concentrate on what we found out when we went through this and developed it. OK. So we had this multi-specialty meeting, as we talked about. We had the main sponsors were the APA and NIOSH. And we were trying to increase use of the PROMIS in regular treatment. And as mentioned before, all of these people were there. So we had insurance companies. We had Albertsons. We had everybody represented. And asked them, what did they want? What did they want to come out with? And so what they said was, look, we know we're losing money because of disability. We know SSDI is unsustainable. The costs are too high. And the medical costs are too high. We know that we want value-based medicine. And so we should be using these. And we already discussed evidence-based studies. I already used them. And so therefore, we should be increasing their use. So this was what came out of that meeting. So it kind of says, OK, well, great. And now what are we going to do? Like, is there something we can attack here? Well, guess what? There was. So the sixth edition, as you know, is being redone, the AMA Guides for Impairment. And we knew that the tools being used in the sixth edition had some problems. And I'll show you what they are. So the APA, which these are the people who are psychometrically trained, right? So we can go to them. And they actually can look at these tools. So that's what we started to do. And the basis of the sixth edition, because I was one of the co-editors for the sixth edition, is the ICF model, the WHO model. And of course, it has a biopsychosocial portion to it. And so we're saying, well, what are we measuring? So classically, in the AMA Guides, we only measured that biological side, right? We said, oh, that's the only thing we want to know. I just want to know, can you move your finger? If you can move your finger, then I'm going to rate that. And I'm good. That's all I need to know about you. So we said, well, maybe that's not really quite right. And maybe we should be looking at the activity circle, which is what WHO says is the most important thing. What can your patient do at the end, right? What can they actually do? So for instance, if your patient, like in Colorado, is a rock climber, they need their fingers, yeah? So if they lose a large portion of four of their fingers, I can give them an impairment rating. They probably can do many, many things. But they can't rock climb anymore. Now, maybe they're a person, and they say that's OK. Or maybe their entire social life, and all of their friends, and all of their social community was with that. So you might say, OK, their life has changed a little. Not big, little. And the way function works in the sixth edition, by the way, is little. It only changes it very few percentage points in most categories. So it isn't the predominant way you rate. The predominant way you rate is the biological system that exists. But when we started the sixth edition, we put in this functional part, right? So we said, well, we're not sure the tools we're using here make any sense. So this is the way we set it up. The Inter-Divisional Health Care Committee, so I just want to give all the credit, and particularly to Dr. Burns, if many of you may have worked with him. He works on our evidence-based guidelines, the ACON guidelines for mental health and chronic pain. So he had gotten me interactive with the Interdivisional Healthcare Committee for the APA and the APA sponsorship. So Dr. Gurkhaf and Dr. Gillespie were major players here. And what we said was, all right, well, if we're going to do this, we're going to do it right. We're going to do it evidence-based. So we're going to use the University of Colorado librarians, go in, look for all of the available tools that we would want to see, look and see what is the scientific basis of them, and they are psychometrically rated. Okay, so that was the idea. So we have 18 task force from the APA psychometrically trained psychologists who do the rating. And this is the problem we were looking at with the current sixth edition. So look at this. These were the three things that are in the current edition that you technically can use to do a functional change. Do you think they're checking the same thing? I think maybe not, right? So the patient disability questionnaire is pain. That's it, pain. How does pain affect you? The quick dash is the best, as you can see, because it's balanced between the basic ADLs, the instrumental ADLs, and the advanced ADLs. So think about what I was telling you before. The categories we're talking about now are in the intermediate or advanced ADLs, right? We're saying those are the things that weren't being addressed that we would like to see slightly addressed in the functional changes. And think about who you're rating. You are mostly not rating people who have impairments of 50%, right? Those people are already either fully disabled or getting maximum payouts. The arguments are within the other range, and they're about people who have instrumental or advanced instrumental ADL problems. They're not about people who can't dress themselves because those people have a different disability system. So we said, okay, well, we want to make sure we're rating those other things, and none of these questionnaires actually work very well. Not saying you can't use the quick dash and not saying you can't use these for some other reasons, if you like, to follow certain things. But for the purposes of a generalized impairment, they're not a particularly good tool. So what we decided was we want to make sure that this was a very, very broadly based instrument used in the broad adult population. It has to be short. It has to be easy to use. Otherwise, who's going to use it, right? And then the psychometric validity issues are listed there, as you can see. And that was what they were responsible for grading. There are thousands of articles out there, and there are actually thousands of pages that describe PROMIS, which is what you'll see we finally ended up with. So they developed a system for rating. They went through the best tools that were left that qualified, given what I've already told you. And they got innovator reliability of 82%, so that was pretty good. And then this is another summary of everything we're talking about. They looked at validity, reliability, norms, fairness, harmonization, because what we wanted to do was find a tool we could use for almost all the chapters. We didn't want to have separate tools, just one tool that tells us how is this person vis-a-vis the normal population. So the answer you get with these is, how is your patient vis-a-vis the rest of the normal population? Obviously, it is done on the Western U.S. population, so you have to take that into account. That is who most of these studies were done on. They did try to have race and gender in there, but it's probably not the biggest influence. Okay, and then the other issues regarding the AMA guides, what does it address that we talked about? Okay, so here was our first proposal, and that was the PROMIS-29. But the PROMIS-29 is, guess what, 29 questions, right? So maybe not the easiest one to use. But the way the PROMIS-29 is set up is there's smaller subscales that have been tested on large, large populations across huge numbers of diagnoses and thousands and thousands of patients. So it has the largest, most robust testing behind it. And there are little parts that are put in to make the PROMIS-29. So we said, well, okay, is there something else we can look at? So there is technically a physical health summary score. If you are doing research, the PROMIS people recommend that you would use the physical health summary score. It relies mainly on physical functioning and ability to perform social roles. Those other two have very little input. So about 80% of it is between the physical functioning and ability to perform social roles. And remember, we're looking for something short. So in the end, our recommendation to them was to use those two. Let me go back again for a minute. So our recommendation was to use the physical functioning ability to perform social roles. So I want to show you just quickly what those look like so you understand how easy they are to use. And hopefully, if they're available on your system already, you might want to start using ones that you think work for you. So the AME is going to. The only thing they've sort of agreed to is that after two years that they are probably going to use PROMIS. But we don't yet know exactly which ones and we don't exactly know how. So I can't tell you that because that's not been publicly decided yet. I can only tell you we're moving in this direction. So here's an example of the ability to participate in social roles and activities. So you can see these are the questions. They're rated and all the PROMIS tools are usually rated pretty much the same way with five numbers. So never, rarely, always, whatever. And you can see this one is how are they able to interact with families, activities, and so forth. Very simple, right? You just have numbers there for each of those and you add them up. Great, right? I got a gross score. All right, what am I going to do with that? You're going to go to the table that gives you a T score. So you have the raw score on the left-hand side. Then you have the T score. It's basically just set up like a normal population. So the median 50 is right in the middle, right? If you go 10 in either direction, you've covered one standard deviation. So therefore, if I go to 40 or less, I am less than the average, and that's only 14% of people. So here, just look at the, you want to just look at this, right? So that's the middle. That's that middle. That's where you're going to find the 50, right, on the T score is right in the middle. Then when you go one standard deviation, which is going to be 40 on one side or 60 on the other, you then get to the outlying part of the population, right? And so if you're 40 or below, that means you're in the bottom 15% of the population. Also useful, I think, because you can look at those things and talk to your patient about where they actually score vis-a-vis the norm. So you are talking about a huge norm, and you can say, here's where you are. You could use them in treatment to say, you know, I think you can do better. I think you can move over here. Do you want to? Should we try that or not? And you can also tell if there are two standard deviations down. There might be a problem with the way they're reporting, I think, maybe. So remember to go back and look at your questions when you do it. And if you get something crazy like that, and you've got two standard deviations down, and that doesn't make any sense for who you're looking at. One, you can already throw it out in the guides because you don't use things that are that far off. But even if you're working with a patient for treatment and so forth, please go back and look at the specific questions that are being scored when you're seeing something like that so you can actually have a meaningful discussion with the person and see. One example was somebody scored very low, and they had a workload injury, but they weren't trying to score COVID, and the person was recovering for COVID. So they came up with this really low rating. But the thing was the person was still so fatigued from COVID that it had nothing to do with the injury. It had to do with the COVID that they were recovering from. So just make sure that whenever you're using any of these tools, you're looking more specifically for the individual. And just to let you know, ACOM is looking to work with PROMIS and actually put up our own site. The orthopedists and other people have our own site on PROMIS. And so if we succeed at that, we'll have an ACOM site on PROMIS where you can just go in, punch on the tools that the council on practice thinks is good, and you will have the information right there. So you don't have to sort through PROMIS, because if you go to PROMIS, it's hard to sort through. So that's our goal. And that's where we are now. These are my colleagues, Dr. Burns and others who helped us. So I think we're open for any questions, any way we can help you. One quick point of clarification. I know that on the slide, you said that don't use that exact table from the slide because it's copyrighted. I just want to mention that PROMIS is also free to access, free to use. Yes, it is free. And if you go to their site, the reason I have to tell you not to copy off of anything is because you have to go to their site because they periodically change things. And so if you, for instance, used a questionnaire that was two months old and they changed one word on it, then maybe the scoring table wouldn't be the same. So you have to use the one that's on their site. But yes, at this point, we'd like to open it up for any questions. We have about 10 minutes to discuss. Or if you don't have any questions, feel free to tell us your experience with using PROMS or things like that. Yeah. Thank you, Dr. Moses. Dr. Miller, that was a great presentation. So I'm monitoring questions from the streaming audience. One of them asked about the sample patient you did, the gentleman who came in who had depression. What do you do to manage that depression? So workers' comp is not going to want to pay you for that prescription, that time spent on that. Do you send it back to the personal physician or what do you do with that? So this highly depends because a lot of it will depend on the jurisdiction and what is allowable because not all jurisdictions will permit treatment of a preexisting condition, even when it does affect the work-related outcome. Colorado, fortunately, even if it is a preexisting condition, anything that combines with, aggravates or accelerates a preexisting condition is still considered compensable. And anything that inhibits the progress of a patient to recovery can still be covered. It can spark some debates and things along those lines. Fortunately, the largest insurer in Colorado, Pinnacle Assurance, is highly bought into the biopsychosocial model of care. And so they support the use of and intervention, behavioral health interventions for patients such as John. Okay. Thank you. The second question, let me see if I can summarize this. How can we leverage PROMS and similar tools to combat the criticism that we rely too heavily on subjective factors like the patient's self-report? So I think this is really important. That's why I was trying to talk about looking at the actual questions themselves. I mean, you should be using this as a tool just like you use any laboratory or a physical therapy functional test, right? You don't necessarily believe what it says. You have to look and say, does that make sense? And discuss it with the patient. So you are not just taking the patient said this. You are applying it to, oh, you told me you can't do any of these things? Oh, but wait a minute. I think you can do that over there. We already saw you do that. Should we discuss this a little more? I'm not sure that I'm understanding what's happening. So you never rely on it as an end-all. It has to be evaluated by you as the evaluator in conjunction with the patient as a whole. And I'll add that the answer to the question is kind of posed in the question itself. Using them can combat some of the accusations that we're relying purely on subjective measures because this is what becomes interpreted by a physician appropriately through the appropriate biopsychosocial lens. It is an objective measure because it's just like range of motion is measured by us, but it's the patient that does it. These tools, the patient does them, but we interpret them. So one more question is actually from my own pea brain. I've heard this addressed using the quick dash and stuff. It was kind of said you don't need it at the first visit because you don't know what the longer-term outcome is. I've had patients like that have horrible shoulder pain. They come back. I see them back about three or four days later. They're like 80% improved. Do a little bit of monitoring for a week or two and they go. I've had others with horrible shoulder pain that ended up in surgery. At what point do you start using the PROMISE tool? Is it first visit or is it at a certain point in time? I'm happy to take this one because I use it at the first visit every time because even though it can't supplant your own clinical gestalt, it still provides some value. For example, there may be a patient that comes in and they say, oh, yeah, I'm completely functional because the quick dash actually talks about the last week. How has it been over the last week? Or I don't know. I haven't tried this yet. So their disability score is zero, which means they should be at full function, but they can't move their arm at all. So obviously it can't supplant that clinical decision making. However, it can be very useful in certain situations to if someone says, yeah, I'm fully functional and they fill it out and their disability is very mild, you may not have such a problem returning them back to full duty without exhaustively investigating what their true level of function is because you can trust that they are reporting that accurately. Or it helps us to understand kind of where we're at. And like I said, it doesn't supplant anything that we do as physicians. It doesn't take away our clinical reasoning, but it can be very helpful to help supplement that and then also to start the conversation with the patient about those functional outcomes. And let me make one other comment. There is a well-done study that shows that there is, I forgot what the term of bias is, as it's called, but people forget how bad they were initially. They totally forget. And so they say, I'm as bad as I was. You haven't made me any better. And in fact, if you look at their self-reports, their self-reports, they are better. And so it can also sometimes be helpful to say, yes, here's where you are. Here's where you were. That's a great point because there have been patients where I've taken those functional outcome measures and they're like, I'm no better, I'm no better. And I show them the downward slope of their disability scores, and it helps reassure them. John Burrus, Boston. I have a comment. I use the WHO-DAS for my disability evaluations, but clinically I do my own function slash tolerance, and I put that as a paragraph in each and every note. In my office I have a 15-pound stool, a 25-pound object, and a 50-pound crate of bricks. And I put these things in the patient's hand, and I can each time comment on those and show them the next time, oh, look how much easier you can hold that. I call it function slash tolerance. Now, how does that compare to what you're doing? So I think they answer different questions. Yeah. Psychometrics. What's that? It's psychometrics. It's what Stover Snook used to create the safe lifting guides. It's true. And so in the controlled environment, so like I said before, this doesn't supplant your functional assessment in your office, whether that's done by having objects that they can do or checking physical therapy notes to see what they're actually lifting or things along those lines, whether it's blinded or not. This gives a different sort of perspective on their quality of life as a whole because it gives you an idea of where they are suffering outside of the office. Right, yes. But I think to rely on physical therapy to assess function is foolhardy. Oh, absolutely, 100%. Yeah, that's a different question. Totally different point. I mean, one of the reasons the AMA was doing this and looking again at these issues is because one of the criticisms of the guides is it's only you doctors, and it's only you doctors making these decisions, and you're not paying any attention to what the patient is actually, you know, the patient's point of view. And so now you have that information so you can incorporate it. Because it really is a patient-centered focus to help improve quality of care. Do you have any suggestions for initial screens for people with head injuries and concussions? Yes. There are two that are mentioned in the Colorado mild traumatic brain injury guideline. One is the Rivermead. The other one is the post-concussion symptoms inventory. I don't remember. I'll be happy to take a look. But the first one that comes to mind is the Rivermead. The other one is post-concussion symptom inventory or something along those lines. I can find those references for you relatively easy. But those are functional patient-reported outcome measures for TBI. And they are online. You just have to know where to look for them, but we can tell you. Well, it looks like we don't have any other questions, any other discussion. And I guess we're at time, so no further discussion needed. But thank you very much. Thank you. Good job. Good job. I want you to do it first all the time. You're the actor. You're too kind. I just wanted to say hello.

patient-reported outcome measures

PROMs

recovery management

functional assessment

QuickDASH questionnaire

clinical assessment

barriers to using PROMs

AMA Guides

PROMIS-29