The good physician treats the disease the patient has. The great physician treats the patient who has the disease. These words from Sir William Osler, father of modern medicine from the late 1800s, still ring true today. The good physician treats the disease the patient has. The great physician treats the patient who has the disease. But I'm not sure that I really understood what this meant until I was in Ocmed residency. I was rotating with a well-known physiatrist in our system, and we were seeing an individual with a work-related elbow injury. And I learned about this patient, reviewed his chart, all of the treatments he had, and it was rather extensive. And this physician and I were talking just before going in to see the patient. And this physician pulled out two pieces of paper I really hadn't seen before in relation to a clinical encounter. One was the quick dash, the quick disability of the arm, shoulder, and hand, and the other was the distress risk and assessment method, psychosocial screening. And he reviewed with me the past history of these results, and like a fortune teller peering into a crystal ball, he told me exactly how the encounter would go. He told me he would recount the treatments that had been had, he told me that this patient would become tearful, and that they would have a discussion about MMI and he would eventually close the case, that visit. Honestly, I thought that this well-respected doctor had everybody fooled. Seemed like a lot of snake oil to me, to be quite honest. But wouldn't you know it, we went in the room. He outlined the treatment that had been had, the patient cried. They had a discussion about MMI, and at the end, the patient actually thanked him, thanked him for placing him at maximum medical improvement, even though he had continued symptoms and continued pain. He said, I've never felt so heard in a doctor's office before. And this was my first exposure to these patient questionnaires, these patient reported outcome measures, and as you can imagine, that left quite an impression upon me. I thought that if a simple tool could be this helpful, even just in initiating the conversation about plateaus in recovery and maximum medical improvement with patients who are struggling, then they well could be worth their weight in gold. So today, my colleague and friend, Dr. Paul Ogden and I, want to discuss the practical application and the practical use of patient reported outcome measures in clinical practice. But before we get going, I think it's very important to note that neither Dr. Ogden nor I have any financial conflicts of interest or disclosures to make. Everything that we are going to talk to you about and show you is free to use and at your clinical discretion. We're not trying to sell you anything. But by means of introduction, my name is Ethan Moses. My primary role is that of medical director of the Colorado Division of Workers' Compensation. In addition to that, I still serve patients as the chief medical officer at Peak Form Medical Centers. I am also an assistant professor at the University of Colorado School of Medicine, where I'm part of the core faculty for the occupational and environmental medicine residency. I'm also an assistant professor at the Colorado School of Public Health, where I teach the next generation of public health graduate students. I'm a fellow and council member at ACOM, where I serve on the council for occupational environmental medicine science. And I also have started my own organization called the Jurisdictional Workers' Compensation Medical Officer Roundtable. Because that's a lot to say, we shorten it to WCMO. But this brings together the medical leadership from the medical directors in the various workers' compensation jurisdictions across North America. But last year, my friend and mentor, Dr. Catherine Miller, former ACOM president and I, presented on the use of functional patient-reported outcome measures. More from a philosophical standpoint, we discussed how pain is a poor measurement of recovery. It's a poor outcome. It does not give us a lot of information about what a worker's true recovery is or where to go when the pain is 9 out of 10 versus 2 out of 10. And so we said, if recovery is our outcome of interest, what is it that we are supposed to be measuring? Well, that's function. We're specifically charged with returning the injured worker to their pre-injury level of function, or at least as close as we can get them. But as I pointed out last year, this leaves us as physician often trying to manage something that we just aren't measuring. But evidence-based researchers have been measuring functional recovery for decades using patient-reported outcome measures. These questionnaires that they give to patients and ask them to report on their level of function. In fact, any study that you see that says there was a functional recovery as a result of a specific procedure or treatment, what they're referring to is patient-reported outcome measures specifically designed usually for that particular body part. And these measures have been tested and validated in the medical literature. And so there was a grassroots movement among physicians, such as the physiatrist that I rotated with, that said if we're using them in our evidence-based research, why in the world are we not using them to help us direct our patient-centered clinical practice? And so that grassroots movement of physicians actually gained a fair amount of traction. And about seven years ago, ACOM issued a guidance document on the use of patient-reported outcome measures, calling for their increased use in clinical encounters. Just two years after that, ACOM, APA, and NIOSH held a symposium with multiple other medical societies and called for the use of these functional patient-reported outcome measures in every clinical encounter, regardless of the specialty. ACOM led the way, and slowly but surely we have come to rely on these functional patient-reported outcome measures in more and more areas. In fact, Medicare has now integrated into their merits-based incentive payments program. It's also part of their meaningful use criteria for electronic health records. They're even requiring it for their comprehensive care for joint replacement program in the hip and the knee, requiring hospitals to take pre- and post-surgical functional patient-reported outcome measures and report them in order to show value-based care. And so Dr. Katherine Miller really led the charge on this. As the former director of the—as the former medical director of the Colorado Division of Workers' Compensation, my predecessor, she recognized that if you can't return a patient to the things that they love, then you're never going to return them to work. And so she wanted to tackle this problem in Colorado. She was one of those forerunners, and so at the forefront of this, she recognized two major obstacles to implementing PROMs, functional patient-reported outcome measures, in clinical practice. One was physicians didn't know about it, and even if they did know about it, they didn't know how to use it. And two, there was no reimbursement for it. In fact, our overtaxed physicians adding something to their plate seemed like the wrong way to go. And so as a result, she with her colleagues at the Colorado Division of Workers' Compensation created something called the QPOP program, which stands for the Quality Performance Outcomes Payments Program. You can see why we called it QPOP instead. But it consisted of four main types. And before I get going, I want to make sure that it's clear. I'm a Colorado physician, a medical director for Colorado. What I'm about to show you is specific to Colorado. This is how Colorado decided to implement the use of functional patient-reported outcome measures within our system. And so there were four main pieces to this. The first one was an education and certification program. Then it was a psychosocial screening to accompany the functional patient-reported outcome measure. It required the use of specific tests that the division had validated, and it required a separate report. But let's dive into each one of these so you can see how we do it in Colorado. First of all, education and certification. In Colorado, we have an accreditation program for physicians. There are a couple of levels. I won't go into the details of that. But you have to be accredited with the division before you can attend a QPOP program. The QPOP program is a special lecture that is designed to show providers what functional patient-reported outcome measures are and how to use them. Once you complete that education module, you take a test. If you pass the test, then you have to submit documentation about an encounter where you would use this, and that documentation has to meet a certain sufficiency requirement. And then once all of that is done, you become QPOP certified. And you can now bill for the use of patient-reported outcome measures in your clinical practice. The second part is the psychosocial screening. Because functional patient-reported outcome measures alone are not enough. They are a reflection of the patient's perception of their functional status. As a result, it can be heavily influenced by the psychosocial status of the individual. And so the QPOP program requires that at least a baseline psychosocial screening be conducted in conjunction with the functional patient-reported outcome measures. This is the lens through which the provider can adequately interpret the functional patient-reported outcome measure. Then you have to use a division-approved test. And so there are a lot of them out there. As many as you could probably think of. If you're familiar with the research, they are coming out with new ones as well. But the division created a list of validated measures based on the evidence-based literature. And both for the functional patient-reported outcome measures and the psychosocial patient-reported outcome measures. And we published this list. And so in order to get paid for the QPOP program, you have to use the ones on our list. Now our list is not all-encompassing. Paul can attest to that. We've had discussions about TBI and things like that. We can, we sometimes will update this, but it's slow and it's rare. Our list, however, is not the only one. In SwapCard, you have a link to the presentation. And the address is on the PDF of the presentation. Additionally, in SwapCard, you actually have a copy of this document. But I also want to point you to a 2017 document from the Washington Department of Labor and Industry. They have another one called Options for Documenting Functional Improvement. And they go into a lot more detail than just listing what they are and what body parts they cover. Such as minimal clinically important difference and things like that. And so that document is also in the handouts in your SwapCard app. So if you have interest in pursuing, looking at those, I would direct you there. But in order to bill in Colorado, you have to use one from our list. Last but certainly not least, you have to write a separate report. This has to be separate from your E&M encounter. And it has to discuss what tests you administered and what your interpretation of those tests was. You also have to demonstrate how it influenced your clinical decision making. And document a meaningful discussion about function with the patient. Because the whole idea of the QPOP program was providing means for the clinic to give the provider more time to discuss these sorts of functional outcomes in a patient-centered way with every injured worker. Once all of those pieces are in place, you can then bill for performing these patient reported outcome measures. And so in Colorado, again, in Colorado only, if you are QPOP certified, you can bill a special Division Z code. This operates just like a CPT code. But you can bill it at the initial encounter, at the MMI encounter, and every two weeks in between. Two different codes. Initial closing pays around $80. The progress one that you do every two weeks is around $40. I say around because it's slightly more than this right now and it's tied to our fee schedule so it goes up annually in conjunction with the market rate for other CPT codes. Now there are some physicians who do this in every area of their clinical practice such as that physician that I mentioned who introduced me to patient reported outcome measures. And so some of them have found ways to bill non-workers comp insurers for this. And there might be a way to bill this for injured workers in some other jurisdictions that accept CPT and Medicare and adopt their interpretations of things. And so generally they are in the 9613 series such as psych testing. But again, these are just for the psychosocial portion rather than for the psychosocial and the functional patient reported outcome measure. They've had the most success with using that 9613 series of codes. And so it is possible but I would caution you to check with your jurisdiction because every jurisdiction has control over their own billing practices with their fee schedule. Just be aware that in some jurisdictions that I found that I've been able to check in with, they only permit it for psychiatrists. They only permit this code billing for psychiatrists. They don't permit a physiatrist or an occupational medicine physician to do it. You have to have psychiatric MD credentials. Additionally, Medicare, aside from their merits-based incentive payment system, they say that use of these clinically are bundled with the E&M encounter and should be included in your overall E&M encounter and it's not separately payable. I think that's an undue burden, especially for an organization that has recognized the value in many other areas, but just to caution you, but those of us who are true believers in this, regardless of whether we get reimbursed or not, we would use it anyway. We find it to be too valuable of a tool to leave on the table. And so with that in mind, I'm going to hand it over to my friend and colleague, Dr. Paul Ogden, to discuss implementing these and where the rubber meets the road and how to implement these in a vibrant occupational medicine practice. OK, thanks, Ethan. First question, how many of you have used patient reported outcome measures in your practice? Smattering, so mostly not. So I'm assuming that's why you're here. And then the second question is, how many of you stay involved in a case from day one until the case is closed, regardless of whether they had surgery or they had some other thing? How many of you are through the whole case? So I think there's a place for this in all the scenarios, even if you don't stay involved all the way through. So how many of you have been to an AI-oriented talk during this session? So this is not it. This is kind of a low-tech, how do you implement this? I'll talk just a little bit about the why, but mostly about the how and why you would choose. So just like Ethan, I have no conflicts of interest. My primary job, I'm the residency program director at University of Colorado, and I do some other odds and ends around the edge to support my hobby of teaching residents. So we're going to define again what a patient reported outcome measure is, how to use it. I'll talk about the mistakes I've made in implementing these. So if you're doing it, you can maybe dodge some of those mistakes. And then we'll talk about how you choose questionnaires and how you judge the quality of the questionnaires. One of the things that I've seen in Colorado, and I do independent medical evaluations, and in Colorado, these can add a lot of revenue to a practice. In my practice, we were splitting the revenue, whatever got paid with our providers, and providers were taking home an extra $3,000 a month doing these, even at those $80 and $40 things. So it added up. But I've certainly seen practices where people would do the screening and then not act on it. They would find psychological problems and they wouldn't address it. They were taking the money, but they were not addressing those issues. So if you're going to do this, you should be able to follow up and do the right thing with that. So my practice is limited to Colorado, just like Ethan's. So there's some bias there. I'll try to incorporate some generic information. So a couple of things. CMS will require for total hip and knee arthroplasties that these be done by the orthopedic surgeons. So they're paying a lot of attention to these. And certainly in Colorado, I see these used by the physical therapy practices. One of things I see is they'll do it at the beginning. So they've got a baseline, but then they never repeat it. And so you don't know how the patient's really progressing. They might have in there did 40 reps of something, but that doesn't tell you, are they getting better? And when I look at the medical notes many times, they don't tell you this patient better. So here's another thing just out of the Federal Register requirements for using these in medical device for true outcomes, is these are being studied and approved for use. OK. What was the number that you learned as a medical student that was statistically significant? Everybody knows that number. P equals 0.05, right. Is that really meaningful? So there's been this move now. So poems came out several years ago, patient-oriented evidence that matters, patient-reported outcomes. There's lots of definitions in this. Couple of other ones, Ethan mentioned meaningful clinically important differences. So if you choose a questionnaire, it's nice for you to know, is two or three points really meaningful, or is it 15 or 20 points? So those are useful things to think about. Health-related quality of life is another one. So what we're talking about with this, and by the way, I've got too many slides. So I won't get through them all. But as Ethan said, our slide deck is there. And particularly, if you want to look at some of the references and choose your questionnaires or have a shortcut on which ones to choose, you can refer back to that. So what we're talking about is moving from the simple question, which is, how are you doing today, and then trying to get through all the bits and pieces of a clinical encounter, or a simple pain scale. Pain scales are OK, but it doesn't tell us that functional component. And the functional component, there's some details there, which is nice to use. And these patient-reported outcome measures can get that detail for you so that you can really assess how people are doing. So this is an example of a common questionnaire, Quebec Back Pain Disability Scale. How many of you have seen this before, maybe used it? I really like this one for a couple reasons. I still think 20 questions is too many for somebody to sit in my waiting room and go through. But if you look at some of the questions, I've got to blow it up just a little bit. So this is not, how is your pain level 0 to 10? It's, how are you doing getting out of bed? Is that really an issue for you? Can you ride in a car? Can you turn over in bed? And they just do this on this 0 to 5 scale. So they just mark it. And then you're able to take that information, track it over time. And you can see, are they really having functional outcomes? It's really nice to be able to show somebody, you know, the first time I saw you, you were at 90 points. And now look at you, you're at 20 points. Because people forget where they were. They focus on what's not going well, et cetera. Having these kind of details is extremely helpful with patient care. And in Colorado, we get paid extra to do this. So we're talking about moving from this pain concept to a functional concept. How many of you have sent a patient for their rotator cuff repair? They get their cuff repair done. You've got your note back from the surgeon. Surgeon says, I think they're doing fine. I don't need to see him again. And the patient gets to you, and they tell you all the problems. How many of you have had that experience? Right, the surgeon looked at him, decided this is a pretty good outcome. They can move their arm around. I can't operate on them anymore. They must be doing pretty well. We're done. And then we get to try to work through all this stuff in the end. So this is what we're talking about, a more objective measure, subjectively captured patient, in their own words, their own experience. So here's an example of three different patients. And on our vertical scale, let's just say this. It doesn't matter what body part this is. But 100 is terrible, and zero is great. And then the captured result over time. And if you look at the blue person, that's kind of, this is our ideal patient. They started off with a poor score. It's a high score. And over time, they get better, they get better, they get better. I'm a good doctor. Look at what I've achieved. Maybe mother nature and time was what cured this person. But that's what we want to see. How about the orange one? What's going on there? They're getting worse, they're getting worse. Then they reach a point where something happens, who knows, an injection. Maybe they quit their job they didn't like. But life got better, and then they got there. The gray one, to me, is the most worrisome patient here. So the gray one, their score was flatline. They did not get better. And I need to figure out what's going on with this person. And this is a very visual way to track that based on their own report. So many of us trained in primary care. I really like the feeders and growers concept in the nursery. That applies to our injured workers. So newborns, they're not feeding. If they're not growing, then we've got a problem. Same way with our work comp patients. If we can't remove their restrictions, if we're not seeing that kind of progress, something's wrong. This helps identify what's wrong and can sort that out for you. So Ethan mentioned the psych tool. So in Colorado, we have to do on the initial one. I don't think that's enough. I think we should do it, if not every visit, then every couple of weeks. And I'll give you an example here. So Maria is a 40-year-old Spanish speaker who works in a hotel laundry. Injured her lower back at work. How many have seen this case? Everybody's seen this case, right? And she's got mostly central lumbar symptoms, a question of some radiation to the right posterior thigh. You're not convinced it's radiculopathy. It seems unlikely, but there she sits. And with this psych stuff, so sometimes providers are afraid to address psych. They don't want to deal with it, but it can catch you off. So here's what happens with Maria. So this is her back scale score. And the high scores are worse. So she starts off, and she's doing OK. She's getting better, getting better. We're getting down. We're roughly, say, four weeks into this thing. And her score's getting better. But what happens then? All of a sudden, her scores get worse. So as an Achmed doc now, you've got a back pain patient. Questionable radiculopathy. What are you going to do? Are you going to, what all would you do? Would you order an MRI? Anybody going to order an MRI? No MRIs here. Are you? With worsening leg symptoms. OK, so the leg symptoms are still, you're like, eh, straight leg raise, maybe. There's no convincing. But you're not sure. And her back is worse. So this is all things like, she's having trouble now getting out of bed. And she's having trouble sitting in a car. And so her score has gotten worse. So how about a referral to a specialist? Anybody think about that? Physiatry, maybe a spine surgery. Your patient's worse. It's time to do something different, right? OK, so let me show you this. So is everybody familiar with PHQ-9 and GAD-7? So they're common psych screening. GAD-7 is an anxiety scale. PHQ-9, depression, really very commonly used. So if you look at what's happening here, even before her back started going up. So the GAD-7 is the blue. It's an anxiety scale. That started going up. And the depression scale started going up before her back pain got worse. And they hit high numbers. They're not all to scale there. So what's really happened? If you focused on the back pain, then you missed the point that one of her loved ones was in a terrible car accident, has been in the ICU. She's not sleeping. She's probably going to get fired because she's been hanging around the hospital instead of going to work. We got all those challenges there, which she may or may not have shared with us. But as we're doing the psych screening, you're going to pick that up. And then you're not going to order the MRI, which is going to show degenerative changes and then this bulging disc. And now she's got that in her head that she has to deal with that. Do you need to necessarily send her for counseling or behavioral therapy? Or maybe you just know that that's going on. And you can incorporate that into your plan. Hold your breath. And guess what? All of a sudden, she does get better. Her family member gets better. So this is a really practical reason to use these in your day-to-day practice. OK, so now I'm going to jump to some implementation things. If you choose to do this in your practice, there's a bunch of questions you're going to ask yourself. How am I going to do this? Where do I start? When do I do the first thing? So one of the questions you'll ask is, when do I have the patient fill this out? And there's two schools of thought. Some of the practices will do it on day one. I disagree with that, partly because somebody got hurt an hour ago. And then I'm going to hand them an upper extremity questionnaire that asks them about opening a jar. They just fell down at work, banged their elbow up, and then they come in here. And I'm like, hey, are you having any trouble opening a jar? I can't hold my pen, but I don't know anything else. So doing them on the first day, I don't think makes sense. There's some practices that like to get that information on day one. The other reason is because we use these with goal setting. Because we use these with goal setting. And it's the same thing if I say, tell me your goals to get better. They're like, my elbow's bleeding. Can you sew me up and get this done? But some practices will do it on day one. I don't like to do that. So the next question is, how often are you going to do these? Colorado, we can get paid every two weeks. You certainly could do it with every visit. But most of these, they don't progress quite that fast, unless it's such a minor injury that you really don't need it. And then, when do you actually stop the process? So patients at MMI, that's obvious. If the patient's sort of flat lining and you're just running out of things that you can offer them, maybe you're not quite ready to close the case. But it doesn't make sense to keep doing it. So that's kind of the process. So the next question is, how are you going to get the scores from whichever format you're using, from out of your patient and in? And there's a gazillion ways to do this. And now, after this week, I'm going to add AI. I'm sure there's an AI way that can do this better than any of us can. It's going to be very much dependent on your EMR. So you're going to start by looking at your EMR and figuring out the most efficient ways. So some, you can use a kiosk, almost an iPad, and have the patient fill it out themselves. That's the best. It goes directly into the EMR. You can use paper forms. There's websites that offer this that will score it for you and track it. You can email the patients in advance. As many ways as you can think of. You can even have staff call somebody and do these. So here's an example of a very low-tech way that I did this in my most recent practice. This is the pain scale, and are they better or not? But same thing. You can just have your paper form, laminate it, have them use a marker. They can sign it. You can scan it in so you've got it saved in the EMR. And then your staff can put the scores into the system. So. We see a lot of people who come in with multiple injuries at the same time. How do you deal with that? I mean, like a person with a shoulder injury, a knee injury, and their back is jammed. That's a great question. And we'll talk about that just a little bit when I talk about the different body parts that you maybe want to use. I have not found the perfect one for that. And so we've cheated, and we use the Dallas Pain Questionnaire. And that way you're not doing a shoulder, and a knee, and a foot, and it plays out. But it's important. And you also don't want to overwhelm them with eight questionnaires. So. OK. And then, so scoring. If you all were going to score this one by hand, and the patient had put X in each one of the cells that were relevant, wouldn't be too hard, right? You could do that. Your MA could do that. How about this one here? How many of you could do this one quickly in your head? When I gave this to my MAs, they freaked out. And actually, the docs all freaked out, too. So yeah, so for something like this, you need some help. So any time you can, have the EMR do your math for you. You can create PDFs that'll do the math and add things through. You can use a live spreadsheet. I would say the live spreadsheet. So I thought, OK, I'll be smart. And I'll just take an Excel. I'll put the formula in. I'll give it to the MAs across all these different clinics. And they'll be able to use it. Well, somebody erased it in the spreadsheet. They couldn't find it the day they needed it. So that was not so brilliant. But something like just creating a cheat sheet for them and putting it up on the wall so they can convert the points to a score. Not all these add up nicely to the 100 points. So the other thing is having the graph that looks like that. That's the easiest thing for everybody to look at, whether it's us or patients or an insurance company who's trying to decide, is your patient getting better or not? But the graphing is dependent, of course, on your EMR. The last one I worked at was really good with vital signs. And then they wanted to charge us, I can't remember, $8,000 or something to create a module just to be able to create data points on this. But you can do this however you want to do it. On a smartphone, it took me about three minutes to create a graph. The standard spreadsheets, you can do that. Problem is keep track of those in your clinic if they're not in your EMR because you want to be able to update them. You could even use this thing. Does anybody know what this is? Any young people that know what that actually is? Good old-fashioned graph paper. But, you know, we've moved into new ages. So the EMR I've most recently worked with was not friendly with graphs, but it's pretty good on being able to create these types of tables. And then you can just add, you can copy this table from one visit to the next and then add in your new dates. And it works pretty well. And for this person, you can see the Quebec score dropped and their GAD-7 and their PHQ-9 dropped. So that's an example. Here's another one that's sort of flatlined over time. But I think the important piece is regardless of how you choose to do this, whether it's with a graph paper or a high-tech thing, you've got to have the patient look at it. You've got to get them on the same side of the computer as you. It's like they like looking at their x-rays. How many of you have a mirror in some of your exam rooms? How many times do you find the patient kind of looking at themselves in the mirror and adjusting, and that people like to look about themselves, think about themselves, showing them their data? It helps them get engaged. So it's useful. And there's one other piece here. So patients like to know where they're at. They like to see their progress. Or if they're flatlined, you can talk with them. You can say, look, you've had 20 visits of physical therapy. You've seen the psychologist. The surgeon's not going to operate on you. And here's where we're at. We've made no progress. We've done everything we can do. We're at the point we need to call it a day. And they can look at that, and it helps them process. But a word of caution. So like the PHQ-9 has a question about suicide. So if you've looked at their score and you didn't look at that particular question, you're going to miss something maybe really important that you don't want to miss. OK. So Colorado, as part of this, we set goals. So we pair this patient-reported outcome with very specific goals. And you can do this whether you're getting paid for it or not. It really helps to track people along. Even in times where I've got somebody with a minor injury and I'm not using one of these, I'll set a goal. And my goal is, well, next time I see you, you've got to be off those crutches. You've got to be doing something more. And I was surprised at how hard this was for OcMed providers, experienced providers, to set goals for patients. And I found that sometimes the provider would just sit down across from the patient and say, well, what's your goal? And the patients would go, I'm going back to work. That's my goal. And that doesn't give you some stepwise progress to track along and function with. So pairing these along together are really helpful. So as an example, here's a goal of somebody who wants to run a 5K by August 1st. And this would be a great we try to set a short-term goal and a long-term goal. But to get this, you've got to talk to the patient, find out why are they having trouble. So this is somebody with an ankle injury. You're looking to get them better. All right, let's set our goal that you're going to be able to run that 5K. It just helps with that target. And then you can set a short-term goal. So, all right, you want to run a 5K in August. We've got to get you off your crutches when I see you in two weeks. And we know there's no reason you shouldn't be able to be off your crutches. So I want you walking every day. I want you moving towards that. And then what we'll do is we'll move our goals along. So once they hit the off the crutches, my next goal is when I see them, they're going to walk eight blocks within 30 minutes, something like that. So this process of setting goals, how many of you set goals for the next visit with your patients? Very specific. When I see you next time, I want you doing this. So if you walk away with nothing out of this because you can't get paid for doing these in your state, take this goal-setting thing with you because this can be really, really helpful in moving people along and realizing when they're flatlined. So patients sometimes, the first time they're doing this, particularly if I'm working with an interpreter, it can be hard if the interpreter doesn't know where we're going with it. And for the doctors who were learning to do this and the PAs and the NPs, they struggled with this concept. So some great ones are tell me about who's at home with you or who's the most important. Well, a child or a grandchild is incredibly important. Everybody knows how much their kids weigh. When they're little, they have to pick them up, move them. If they want to get down on the floor and play with them, that's a great motivator, and you can use that to set your goals. But if you can't find a good goal or you're struggling, you've got a written list in front of you in your questionnaire. So the back pain we looked at, so there's bend over to clean the bathtub is a goal. Carrying two bags of groceries is a great goal. How are you doing with carrying the groceries? Can you do that now? Why can't you do that? The quick dash, which is the arm, shoulder, hand, can you open a new jar? Can you use a knife to cut food? I'm surprised. That's a question I never used to ask people. How's it going cutting food? But since it's in the questionnaire now, it's in my head. And it's amazing how many people struggle with that and how frustrating it is for them. The lower limb questionnaire, are you still needing the crutches to get around? How are you doing going upstairs? Do you need to hang on to the rail? Let's have you practice that. In therapy, let's have you practice that. So tagging those goals are really important. How are we on time? Okay, we have 17 minutes. Okay. Okay, work goals. So many times people say, I just want to go back to work. And particularly if you're trying to set a goal an hour after they got hurt, they're going to say, I just want to go back to work. Because now they're doing that catastrophic thinking. I'm going to lose my job. I'm going to lose my house. I'm going to lose my kids. I'm going to lose my car. All those things that go on. But that's really not a goal, because you need to understand what they do for work and how to notch them back towards it. So if you were using a goal, a work-oriented goal, somebody that uses a press. So you might start with, okay, well, let's get you to just raise your arm overhead. And that'll be our first step. And then eventually we'll get you to pull that press down. I find the goals, people are better motivated for the non-work-related goals. The things that are most important to them. Jobs are really important to people, but not like some of those other things. Okay, here's another goal-setting bonus. So one of my jobs is I do reviews for requests for additional physical therapy in Cairo for an insurance company in Colorado. And if I can see in there that they have set goals and progress, I'll keep approving therapy till the cows come home. But if there's no way to track that they're improving, I can't say, yeah, let's do some more therapy. But having that nice progress in there, and even if you just put it in your note, it doesn't have to be a formal thing like this, but putting in your note, they couldn't walk across the street. Now they're walking six blocks. Now they're walking without crutches. They can go upstairs now without... Having those details in the note can be very helpful. Okay, one of my favorite places, nice mogul run in Colorado. Change of pace. So when we started this, I argued with our CEO about how we were going to pay our providers, because this is extra work. And I said, we're going to split the money. And he said, no. And I said, then nobody's going to do it. So we said, okay. So we agreed we would split the money. So basically what happened was when the dollars hit the books, we would put that on the provider's schedule, and they got 50% of the revenue that came in. And in Colorado, we can do that every two weeks. Having it very clearly lined up so the providers can see what they've done and what those dollars look like, my recommendation would be you also do that for the staff who's doing the extra bits of work, because they're the ones that capture the data and go back if somebody missed a line on something and make sure it's done and make sure it's in your chart. And also if the staff know the docs are getting paid extra and they're not, they're going to forget to do them. We'll get it next time. So here's the school of hard knocks. So we had set revenue goals. So on our vertical line we had this percentage of revenue. We were rolling this out, kind of one practice to another over time, and it was going great. And then we had the pandemic, and we all freaked out, and we said, all right, no more bonuses, no more special things. We moved everything to telemedicine to try to keep the doors open. Our providers just quit. So if you have this set up in your system and you want to find out if your incentive program's working, stop paying it. So we cratered. But then we said, okay, after a few months we realized, all right, we're not going to go under. You know, the extra funds became available and everything. So we put it back in, and it went right back up, even when we were mostly telemedicine. It worked great on telemedicine. It was very functional. So we went up, and it became a significant source of revenue for our company, enough that it's equivalent to having, you know, and this is a six-clinic practice. It's like having a couple of extra providers working full time just by adding this bit of piece into it. So I'm a big believer in carrots, and I think the bonus structures that I've seen not work on things like this is if you bundle it with, well, okay, we've got, here's your quarterly bonus, but it's going to be based on 3% of your net revenue and the company's net revenue, and then the people up front need to answer the phone right, and then somebody else needs to make sure the parking lot's clean. If you guys do all that, then about every quarter we'll give you a little bit of money. Well, okay, you tell me which one worked. So make it visible, pay it regularly, make sure everybody can see what they're doing, and yeah, it's the right thing to do, but it's nice to throw a little something in there. So some practical things. So I don't know how you do this in a multi-state practice. I didn't have to do that. Some of the other things getting paid, Ethan mentioned those out of state, but I think everybody should get bonused on something like this when there's extra revenue coming through. So nice picture from Killarney, Ireland, a repurposed phone booth. So let's talk a little bit about choosing your measures, and how are you going to choose? So the most important thing is that it's practical and doable for the patient. Many times an interpreter sitting with them, kind of talking them through it, although many of the more common ones are translated into a lot of different languages, and been perfectly well validated, and so that can save you time. Ethan and I are big believers in public access. You do not want to have to pay somebody else to work through this program, or somebody else gets a nice little cut every time you do it. So I would stay away from those. And then figuring out which body parts. Had a question earlier about what do you do for somebody with multiple body parts. You need to figure out what you want to do and how detailed you want to go. There's a nice one that covers arm, shoulder, and hand, but there's also some really good hand ones. So choose what's most relevant for your practice. Figure out what's going to work. Some of this stuff where there's copyrights and you're paying, if you want to use a vendor and it's slick, sure. Number of questions. So how many of you have done the, like a National Vital Statistics home interview or something like that? Oh my God. And yeah, so there's hundreds of questions. They're really well thought out. They're valid. All those things. We can't do that. We need things that are very practical. How much time is it going to take to complete? Tell your patients to be there 15 minutes early? Well, all of us, we can't even get to our meetings on time here. We know patients have trouble getting just in time. And all those things play into it. So you could end up an hour and a half behind if people were in your waiting room all afternoon trying to get these done. And then how does it work with your EMR courses, practical? So I mentioned my mistakes with staff already with scoring. Automate, automate, automate as much as you can with that. Let me run through a couple of other things and then we'll open it up for questions. So there is a whole science to these that looks at the psychometrics. Whatever you choose, you don't want it to be Joe's patient reported outcome measure. You want something that's been truly validated, that it's reliable, that it's relevant, sensitive, specific, all the things that we know are supposed to be helpful. And it's important to have a standard scale for meaningful difference. So here's a recent study. Somebody looked at patient reported outcome measures. They found 315. There is no way, well, and maybe AI could do this for us now, but for any of us to try to put the time in to go through these and figure out what they are. So we're going to just sort of concede all this point about validity. We don't want to have time to go through that. A couple of interesting things. So how many of you are doing 6th edition ratings, impairment ratings? A few. There's places in the printed version. I don't know if the new version is going to play out this way, but you can swing your impairment a little bit based on one of these patient reported outcome measures. So it might tip them up, it might tip them down. And so there's three of them that are listed here. In there, the disability, pain disability questionnaire, lower limb questionnaire, and the quick dash that are actually in that. So Ethan mentioned the Colorado Division. American Academy of Orthopedic Surgeons has a nice list. And some of the things that they're going through with THAs where they need to report that. I'm not sure. Every one of those that they list is perfect. So if you're going to choose one of those, take a look for the validity and how it's been truly validated. Let me just talk about this. So I think you're going to want some basic things for the common injuries that you see. So spine, neck, lumbar spine. We see so much spine stuff. And there's some good easy ones. I've got examples later in the presentation. It's in your app. Something for the upper extremity, something for the lower extremity. I think the depression anxiety psych one is critically important. PHQ-9 and GAD-7 have been really functional for our practices. And then something for the multiple trauma. And we've kind of, we've used that Dallas pain questionnaire. It's more of a spine questionnaire, but it works pretty well for multiple trauma. And so we've used it that way if there's more than one body part. And it seems to get through. No science behind that though, so disclaimer. Head injuries. So one of our head injury lecturers is here. And he, just as I have, have not found a good one for concussions. So things like the SCAT-5, they're symptom lists. They're not functional lists. And there's others like, there's a Glasgow scale that's designed to be done months and months out. They don't help us with that functional stuff. So you may want to kind of cheat on that. And then I think making it as easy for your staff so that they're not going to forget to do it this time is important. So I would stay away from the proprietary things. And everything else from here on is really in the handouts. I've got a couple of slides where I've laid out how many questions are in a few of these and how easy they are to score. That's all in the deck. So let's stop there and kind of open it up. I'm interested in people's experiences about this and feedback, particularly from states outside of Colorado. And then Ethan and I will do our best to answer questions that you may have. Thank you very much. I have a quick question. John Burris, Boston. So you mentioned this for clinical, but what if you were doing a disability evaluation? Which ones would you use for that? I'll use WHO-DAS, for example. WHO-DAS is a good one. I will say that in Colorado, it's rapidly become very common in impairment rating exams and independent medical exams to use these to help quantify condition. As you know, the AMA Guide 6th edition uses patient reported outcome measures as part of their functional modifier. But the 3rd edition revised, which, yes, we are still stuck on in Colorado, does not have anything like that. But we're finding that providers are still using them. And so a lot of it depends on the preferences of the provider. And the ones, many of our independent medical examiners are still in clinical practice. So it depends on which ones they prefer to use in clinical practice. But it really depends on the body part. But in general, if there's multi-trauma or something like that, we're seeing the SF-12 or the Dallas Pain Questionnaire or one of the PROMIS measures being used. Can you talk a bit about malingering and the use of these questionnaires? Yes. So malingering, I don't like the term malingering because I think so many times people have a psychological component to their complaints and they don't recognize it. It's not volitional, which malingering usually implies something volitional. But there are some times where you look at these and you think, really? Did you even read it? Where they've taken their pencil and gone straight line all the way down through the worst side or the middle, and then it's that way every time. That's laziness, not malingering. Yes. Well, there are times. So I think they also, you see crazy inconsistency from one like, okay, last time you were going well. Now you're all the way up at the top. What's really going on? And many times there'll be some psychological component, something else going on. Or occasionally it's a true malingerer who's volitionally augmenting their symptoms. So they do help. There are some tests that are designed more for that. These are not specifically designed to identify that. And I will just add to that that for some of these measures, if they're an ambulatory patient that comes walking in and their score is above a certain point, part of the interpretation of that is that they may be exaggerating their symptoms or something along those lines. But I will say that when it does come to someone who is truly malingering and is volitionally trying to put everything, all of their eggs in this basket, their scores do look different and they don't change. They start high and they stay high. Now, again, there's no science to this, but just in my clinical practice from seeing it, the individuals who were trying to game the system, who were trying to get something out of it and who later got caught on security footage or something, they tended to start high and just stay up there. But individuals where it was their psychosocial status, they had more variability from test to test. But again, not science-based, just anecdotal. Thank you both for the great talk. I'm Balaji Sridhar from the University of Washington. My question is with patient-reported outcomes, there's always a subjective component to it. Are there other things like hand-grip strength or other objective findings that can help or were very limited? So clinical outcome measures are also very important and we're not trying to diminish the usefulness or the need for those. I will say that many of our physical exam findings are, oh, does this hurt and we're passively moving the patient's arm or something. That is subjective. The objectivity comes from the interpretation, the physician interpretation of it. And so I will say that absolutely, this needs to be combined with clinical outcome measures as well as sound clinical decision-making and an evidence-based medical treatment guideline. I would add to that. I've heard a couple of times here at the conference the importance of talking to your patient, getting a good history. This is essentially a structured history where we're asking the same questions on the same scale and forcing our hand at that. And it's unusual when patients are thriving here that we're finding anything on the physical exam that's not consistent. So it's when they're not thriving that we've got to bring in those other tools and think about why are they not getting better? What do I need to do different? Why are they not growing, feeding and growing? I've got to do something different. One comment. Functional assessment, job simulation, what are they comfortable lifting? What's their tolerance? The second question is what about a pain diagram? I get a lot of utility from that. Not only where they show pain, but how they fill it out. It's a great way to measure or to think about. It absolutely is. Again, we're not trying to supplant anything that anyone is currently using or the tools that we've created. This is just something that can be supplemental and can supplement your clinical decision making. It's not in any way designed to supplant it. And again, it moves us from just the pain component to the functional component. So we still include that. We are at time, so please, last question. Thank you. So actually two very, very brief questions that are related to the same thing. How do you, in your decision to approve additional physical therapy because patient is showing improved function, do you take into consideration the physical therapist notes? Because a lot of times the physical therapist notes during their physical therapy sessions tend to be more detailed. And the physical therapists actually spend more time than we do as the physicians. And do you ever get pushback on the other side in court if you're deposed upon why you made the decisions that you made? So the physical therapy notes are super detailed and usually useless in terms of really getting there. Because they will have done one of these many times on the initial one, or they'll have copied their initial evaluation. You know, they've got walks in on crutches today and they've got them doing 40 toe stands on something. So I wish the physical therapy notes were better and not designed to justify their billing. So I should be sending my patients with instructions for their physical therapist to be thorough and detailed in their notes? Yes. I will say the QPOP program actually did have a piece for the physical therapist as well called the rehab communication form. Because we know that good physical therapists are going to document functional progress and achievement of goals. And the physical therapists that I worked with and the ones that I referred to, I absolutely trusted them to document exactly that stuff. Because we worked together and they knew what I needed in order to justify it to the insurance company and things like that. And so we modeled that sort of communication, the things that we needed, into what we call the rehab communication form and incentivized physical therapy providers to send that information to the primary care doctor for the injured worker so that they could then take all of that information and make the justification for it. And so I absolutely agree with the importance of adequate information from the physical therapist because very often they do spend more time than we do with the patient. But I want to end there. We're a little over time. So thank you so much for your attendance and your interesting questions.

patient-reported outcome measures

PROMs

clinical practice

disability evaluations

structured history

functional assessment

hand grip strength

pain diagrams

physical therapy documentation

collaborative approach