Healthcare Review & Consulting, Inc

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What is health?What is health?• Optimal physiological, mental , social well Optimal physiological, mental , social well

being?being?

• Lack of Disease?Lack of Disease?

• Being Subluxation Free?Being Subluxation Free?

Everyone may define it differently, so how are Everyone may define it differently, so how are we to measure it or know how to monitor the we to measure it or know how to monitor the

patient or when to discharge a patient?patient or when to discharge a patient?

The SubluxationThe Subluxation (Multiple definitions) (Multiple definitions)

• MisalignmentMisalignment

• Altered joint functionAltered joint function

• Altered pathological changes in nerve, Altered pathological changes in nerve, muscle, ligamentous, and vascular muscle, ligamentous, and vascular structuresstructures

• Alterations of structural, functional and Alterations of structural, functional and pathological changes that may effect pathological changes that may effect neural integrity, and influence organ neural integrity, and influence organ function and general overall health.function and general overall health.

How do we measure it?How do we measure it?

The Problem!The Problem!

• Healthcare has outgrown the ability Healthcare has outgrown the ability of government, employers, of government, employers, individuals ability to support the individuals ability to support the costscosts

• The move in health care to cut costs, The move in health care to cut costs, allegedly by improving quality.allegedly by improving quality.

• The desire to improve quality by The desire to improve quality by asserting evidence based practice asserting evidence based practice


• Much in health care lacks strong Much in health care lacks strong evidenceevidence

((85% of current health care practices remain 85% of current health care practices remain scientifically invalid- Gunn AANA J ’98)scientifically invalid- Gunn AANA J ’98)

• Lack of understanding by the Lack of understanding by the practitioner of application, dose, practitioner of application, dose, frequency of care.frequency of care.


• Lack of knowledge of latest literatureLack of knowledge of latest literature

• Inability to keep up with the literatureInability to keep up with the literature

• Inability to understand and integrate Inability to understand and integrate literatureliterature

• Lack of interestLack of interest


• PhilosophyPhilosophy

• Complications of Healthcare systemComplications of Healthcare system

• Ignorance of appropriate clinical decisionsIgnorance of appropriate clinical decisions

• ApathyApathy

• Intentional FraudIntentional Fraud

Patient OutcomesPatient Outcomes(Changes in Evidence presented by the (Changes in Evidence presented by the

Patient)Patient)• Clinical SymptomsClinical Symptoms

• Effects on ADL, Work & Recreational Effects on ADL, Work & Recreational ActivitiesActivities

• Physiological and Anatomical Measurable Physiological and Anatomical Measurable Changes (Physical exam, imaging, Dx Changes (Physical exam, imaging, Dx test)test)

• Progressive resolution of diagnosesProgressive resolution of diagnoses

DocumentationDocumentation

• Improvement, efficacy and changes must Improvement, efficacy and changes must be noted in the clinical filebe noted in the clinical file

• Clinical Decision Making process in Clinical Decision Making process in response to the changes documented.response to the changes documented.

• Clinical Decision Making must be in Clinical Decision Making must be in concert with the evidence based concert with the evidence based literature.literature.

What is Evidence Based What is Evidence Based Medicine?Medicine?

• ““The conscientious, explicit and The conscientious, explicit and judicious use of current best evidence judicious use of current best evidence in clinical decision making”in clinical decision making”

• ““Integrating individual clinical Integrating individual clinical expertise with the best available expertise with the best available external clinical evidence from the external clinical evidence from the research”research”

-Sackett, BMJ, 1996;312-Sackett, BMJ, 1996;312


•““Good Doctors use both individual Good Doctors use both individual clinical expertise and the best clinical expertise and the best available external evidence, available external evidence, neither alone is enough”neither alone is enough”

•““Without clinical expertise, practice Without clinical expertise, practice risks become tyrannized by risks become tyrannized by evidence”evidence”


• ““Even excellent external evidence may Even excellent external evidence may be inapplicable to or inappropriate for be inapplicable to or inappropriate for an individual patient”an individual patient”

• ““Without current best evidence, Without current best evidence, practice risks becoming rapidly out of practice risks becoming rapidly out of date, to the detriment of patients”date, to the detriment of patients”


What What isn’tisn’t Evidence Based Evidence Based Medicine?Medicine?

• Cook-book approach to patient careCook-book approach to patient care

• Does not replace clinical expertise which Does not replace clinical expertise which must decide whether the external must decide whether the external evidence applies to the individual patient.evidence applies to the individual patient.

• Cost cutting healthcare, it may lower the Cost cutting healthcare, it may lower the cost, but may also raise it as it applies cost, but may also raise it as it applies the most efficacious interventionsthe most efficacious interventions


What is the Evidence?What is the Evidence?

• Randomized Controlled StudiesRandomized Controlled Studies

• Randomized uncontrolled studiesRandomized uncontrolled studies

• Observational Cohort StudiesObservational Cohort Studies

• Meta-analysis of the literatureMeta-analysis of the literature

What is the Evidence?What is the Evidence?• Case SeriesCase Series

• Case StudiesCase Studies

• Consensus of expert opinionsConsensus of expert opinions

• Federal, State, Professional and community Federal, State, Professional and community standardsstandards

• Published Best Practices and Practice Published Best Practices and Practice ParametersParameters

What is an Evidence Based What is an Evidence Based Review?Review?

• Knowledge of the literature baseKnowledge of the literature base

• Assessment of the documentationAssessment of the documentation

• Integration of the documented clinical Integration of the documented clinical judgment with the evidencejudgment with the evidence

• Respect for the appropriate clinical Respect for the appropriate clinical decision making process of the physician decision making process of the physician at the time care was rendered.at the time care was rendered.

What is an Evidence Based What is an Evidence Based Review?Review?

Documentation, Documentation, Documentation!Documentation, Documentation, Documentation!

• Must assess the clinical expertise and Must assess the clinical expertise and decision making through the available decision making through the available documentationdocumentation

• Documentation must conform with State Documentation must conform with State Regulations and Professional StandardsRegulations and Professional Standards

• If it wasn’t written down, then it wasn’t If it wasn’t written down, then it wasn’t done!done!

What is a Best Practice?What is a Best Practice?

Best practicesBest practices are those strategies, activities, are those strategies, activities, techniques or use of resources that have techniques or use of resources that have evidence of evidence of successsuccess in providing in providing significant improvement in significant improvement in quality, quality, performance, safety, time of reaction, cost performance, safety, time of reaction, cost and or other measurable factors and or other measurable factors which which impact on a target group (our patients)impact on a target group (our patients)

1.1. ResearchResearch2.2. Clinical Decision MakingClinical Decision Making3.3. Patient ValuesPatient Values

What is a Best Practice?What is a Best Practice?

• Best practicesBest practices are using clinical reasoning to are using clinical reasoning to guide the practice, making judgments about guide the practice, making judgments about the relevance of particular research and the relevance of particular research and clinical evidence for a specific patient and clinical evidence for a specific patient and settingsetting

• What is the best information to use to make What is the best information to use to make decisions for a particular patient and setting?decisions for a particular patient and setting?

-Higgs AACN Clinical Issues 2001;12;482--Higgs AACN Clinical Issues 2001;12;482-9090

Guidelines vs Best Practice

RCT

Guidelines

RCT

Best Practice

Cohort

Case Series

“Recommendations”Treatment options: A = 80%, B = 25%

C = 5%, D = 0%

Clinical judgement & experience

Utilization of Best PracticesUtilization of Best Practices

• Instead of defining best practice narrowly Instead of defining best practice narrowly by the strength of the current empirical by the strength of the current empirical evidence used to guide clinical decisions, evidence used to guide clinical decisions,

• ……Defined broadly by what is the best Defined broadly by what is the best information to use to make decisions for a information to use to make decisions for a given patient in a particular setting. given patient in a particular setting. Credible and accountable clinical decisions Credible and accountable clinical decisions rely on a number of forms of knowledge rely on a number of forms of knowledge and evidence.and evidence.

-Higgs:-Higgs:

Utilization of Best PracticesUtilization of Best Practices• The average healthcare clinician does not have the The average healthcare clinician does not have the

tools to evaluate researchtools to evaluate research

• The clinician must rely upon Best Practice (& The clinician must rely upon Best Practice (& experts) and integrate the information into practice experts) and integrate the information into practice appropriately.appropriately.

• Reviewing physician must do the same!Reviewing physician must do the same!

ReliabilityReliability ConsistencConsistencyy

ValidityValidity MethodoloMethodologygy

AnalysisAnalysis ConclusionConclusionss

RigourRigour CredibilityCredibility

How do we utilize Best How do we utilize Best Practices in performing Practices in performing

Reviews?Reviews?• Chiropractic Best Practices to be Chiropractic Best Practices to be

disseminated by end of 2005disseminated by end of 2005

• Knowledge of current literatureKnowledge of current literature

• Knowledge of past guidelinesKnowledge of past guidelines

• Assessment of clinical reasoning of Dr.Assessment of clinical reasoning of Dr.


Reviews?Reviews?

Take into account:Take into account:

• The Grading of Recommendations The Grading of Recommendations

(% chance of success)(% chance of success)

• Specific patient presentationSpecific patient presentation

• Risk StratificationRisk Stratification


Reviews?Reviews?Take into Account:Take into Account:

• The Level of the evidenceThe Level of the evidence• GoodGood evidence from relevant studies: RCT, Meta- evidence from relevant studies: RCT, Meta-

analysis, analysis, • FairFair evidence from relevant studies: RCT w/different evidence from relevant studies: RCT w/different

results or single RCT with clinically significant results or single RCT with clinically significant conclusion, or Cohort studyconclusion, or Cohort study

• LimitedLimited evidence from studies or reviews, uncertainty evidence from studies or reviews, uncertainty about conclusions, relevant cohort, case control, case about conclusions, relevant cohort, case control, case series or outcomes researchseries or outcomes research

• Expert Opinion, consensus report, position statement Expert Opinion, consensus report, position statement from a national bodyfrom a national body

• Insufficient Insufficient or non-relevant evidenceor non-relevant evidence


Reviews?Reviews?• Assessment of documentation of: Assessment of documentation of:

– Subjective complaintsSubjective complaints– Objective findingsObjective findings– DiagnosisDiagnosis– Type of treatmentType of treatment– Frequency, duration of treatmentFrequency, duration of treatment– Complicating factorsComplicating factors


Reviews?Reviews?• Common Complicating/Risk Factors Common Complicating/Risk Factors (for (for

common soft tissue & joint injuries)common soft tissue & joint injuries)

– AgeAge– GenderGender– Severity of SymptomsSeverity of Symptoms– Prior SurgeryPrior Surgery– Prior recent injury (<6mo)Prior recent injury (<6mo)– Poor Body MechanicsPoor Body Mechanics– Falling as mechanism of injuryFalling as mechanism of injury– Neuro signsNeuro signs


Reviews?Reviews?• Complicating/Risk FactorsComplicating/Risk Factors

– BiomechanicalBiomechanical•Prolonged static postureProlonged static posture

•Poor Spinal motor controlPoor Spinal motor control

•Sustained trunk loadSustained trunk load

•Frequent bending, twisting, lifting, pushing, Frequent bending, twisting, lifting, pushing, pullingpulling



– PsychosocialPsychosocial• ChronicityChronicity

• Attorney RetentionAttorney Retention

• Employment SatisfactionEmployment Satisfaction

• Expectations for recoveryExpectations for recovery

• Participation in social welfare or disability programParticipation in social welfare or disability program



– PhysiologicalPhysiological•DJD, articular inflammatory dz, boney dzDJD, articular inflammatory dz, boney dz

•Spinal stenosis, or physiol. narrow canalSpinal stenosis, or physiol. narrow canal

•Osteoporosis, bone weakening disordersOsteoporosis, bone weakening disorders

•ScoliosisScoliosis

•Neurological signs or symptomsNeurological signs or symptoms

Benchmarking of CareBenchmarking of Care

• A comparison of recovery rate to population A comparison of recovery rate to population data on natural course or usual treatment hxdata on natural course or usual treatment hx

• Benchmarking ignores the complexity of Benchmarking ignores the complexity of case and complicating/risk factors of indvdlcase and complicating/risk factors of indvdl

• Benchmarking ignores differences between Benchmarking ignores differences between symptomatic episodes and underlying dzsymptomatic episodes and underlying dz

Assessment Assessment (structure=>process=>outcome)(structure=>process=>outcome)

vs Benchmarking of Care vs Benchmarking of Care

• Appropriate care administered?Appropriate care administered?

• Complexity of case documented?Complexity of case documented?

• Intervention of factors outside Intervention of factors outside provider control?provider control?

• Patient compliance?Patient compliance?

Assessment vs Benchmarking Assessment vs Benchmarking of Careof Care

• Is there documentation of the process?Is there documentation of the process?

– Dr responding to the re-evaluations with Dr responding to the re-evaluations with appropriate changes in case management?appropriate changes in case management?

– Changes in treatment plan, dx testing?Changes in treatment plan, dx testing?

– Progressing from passive to active care?Progressing from passive to active care?

Assessment vs Benchmarking Assessment vs Benchmarking of Careof Care

• Is there documentation of the process?Is there documentation of the process?

– Is the process of care reasonable?Is the process of care reasonable?

– Is the treatment efficacious?Is the treatment efficacious?

– Is progress (physiol., functional, Is progress (physiol., functional, symptomatic, diagnostic) noted in the re-symptomatic, diagnostic) noted in the re-examinations?examinations?

How do you apply the How do you apply the literature?literature?

• Organized, Published Best PracticesOrganized, Published Best Practices

• Synthesizing of the literature to the Synthesizing of the literature to the particular patient circumstanceparticular patient circumstance

• Documenting the patient uniquenessDocumenting the patient uniqueness

• Use it to manage the care process vs Use it to manage the care process vs allowing the management of costs by allowing the management of costs by other parties.other parties.

How do you apply the How do you apply the literature?literature?

• Documenting complicating factorsDocumenting complicating factors• Awareness of different patient Awareness of different patient

populationspopulations• Use it as a guide to treatment Use it as a guide to treatment

planning for the greatest likelihood of planning for the greatest likelihood of benefit for majoritybenefit for majority

• Closely observe progress for pt’s with Closely observe progress for pt’s with significant number of risk factors, significant number of risk factors, and and respond!respond!

Does the literature apply to all Does the literature apply to all cases?cases?

• Most literature applies to select pop grpsMost literature applies to select pop grps

• + Physiological Changes + pt + Physiological Changes + pt outcomesoutcomes

• POEM’sPOEM’s=Patient Oriented Evidence that =Patient Oriented Evidence that MattersMatters

Does the literature apply to all Does the literature apply to all cases?cases?• Was Study Design methodologically sound?Was Study Design methodologically sound?

• Was analysis of data performed correctlyWas analysis of data performed correctly

• Was the study results interpreted correctly?Was the study results interpreted correctly?

• How was the quality, validity, sensitivity, specificity of How was the quality, validity, sensitivity, specificity of the study?the study?

• Is there systematic bias or inferential error?Is there systematic bias or inferential error?

Does the literature apply to all Does the literature apply to all cases?cases?

(How can a clinician evaluate this?)(How can a clinician evaluate this?)• Reliability on Best PracticeReliability on Best Practice

• Demonstration of Clinical ReasoningDemonstration of Clinical Reasoning

• Documentation of ProcessDocumentation of Process

• Regular re-evaluations of patient, monitoringRegular re-evaluations of patient, monitoring

• Look @ all outcome measures and compare to EBM, Look @ all outcome measures and compare to EBM, taking into account the particular patient situation, taking into account the particular patient situation, risk factors and benchmarks for majority pop.risk factors and benchmarks for majority pop.

Record Review: What to Record Review: What to look at!look at!HistoryHistory

• Is there doc. of mode of onset?Is there doc. of mode of onset?

• If MVA, is there a description of If MVA, is there a description of accident?accident?

• Is causal relationship plausible?Is causal relationship plausible?

• If work related, is there description of If work related, is there description of mode of onset?mode of onset?

• Was there any immediate or Was there any immediate or emergency care?emergency care?


• Is there concurance of injuries @ ER Is there concurance of injuries @ ER with complaints at doctor’s office?with complaints at doctor’s office?

• Was there a gap in time prior to Was there a gap in time prior to seeking care? If so, why?seeking care? If so, why?


• Does subjective complaints correlate Does subjective complaints correlate to the mode of injury?to the mode of injury?

• Is there a review of systems?Is there a review of systems?

• Is there sufficient HPI to substantiate Is there sufficient HPI to substantiate code level?code level?

Record Review: What to Record Review: What to look at!look at!

ExaminationExamination• Are there sufficient body areas/organ Are there sufficient body areas/organ

systems to substantiate coding level?systems to substantiate coding level?

• Are there descriptors with +Ortho tests to Are there descriptors with +Ortho tests to indicate true positives vs false positives?indicate true positives vs false positives?

• Is there a loss of ROM?Is there a loss of ROM?

• Do the findings substantiate/concur with Do the findings substantiate/concur with subj?subj?


DiagnosisDiagnosis• Dx concur with Hx, subj. complaints Dx concur with Hx, subj. complaints

& Exam findings?& Exam findings?

• Simple or complicated DX?Simple or complicated DX?

• Multiple tissues types or body areas Multiple tissues types or body areas or anatomical/physiological or anatomical/physiological structures injured?structures injured?


PrognosisPrognosis• Prognosis documented?Prognosis documented?

• Pt @ MMI?Pt @ MMI?

• Has pt been discharged?Has pt been discharged?


Treatment PlanTreatment Plan• Is there a written treatment plan?Is there a written treatment plan?

• Is there duplication of types of care?Is there duplication of types of care?

• Are all tx modalities applied appropriately?Are all tx modalities applied appropriately?

• Is the dose/duration of treatment Is the dose/duration of treatment substantiated as per EBM & clinical substantiated as per EBM & clinical reasoning?reasoning?


Treatment PlanTreatment Plan• Has the treatment plan been Has the treatment plan been

updated as per re-examinations and updated as per re-examinations and progress or lack thereof?progress or lack thereof?

• If patient progressing, is there If patient progressing, is there decrease dosage of care?decrease dosage of care?

• If patient progressing, is there If patient progressing, is there transition to active care?transition to active care?


DocumentationDocumentation• Daily notes? Legible?Daily notes? Legible?

• Notes organized in standard format?Notes organized in standard format?

• Computer generated or computer Computer generated or computer organized?organized?


DocumentationDocumentation• Documentation of progress &/or efficacy?Documentation of progress &/or efficacy?

• Regular Re-exams?Regular Re-exams?

• Substantiation of Care Rendered?Substantiation of Care Rendered?

• Passive modalities discontinued after Passive modalities discontinued after acute phase?acute phase?

Independent Chiropractic Independent Chiropractic ExaminationExamination

Introduction:Introduction:• Obtain the date, place and mode of onset of Obtain the date, place and mode of onset of

the incident and any previous care. the incident and any previous care.

• Review any past accidents or injuries and the Review any past accidents or injuries and the importance to the incident under examination. importance to the incident under examination.

• Any previous similar complaints? Any previous similar complaints?

• Has the injuries affected the patients ADL, or Has the injuries affected the patients ADL, or work activities? Any loss of time from work? If work activities? Any loss of time from work? If so how long?so how long?

Independent Chiropractic Independent Chiropractic ExamExam

Presenting Complaints:Presenting Complaints:• List primary and secondary complaints. List primary and secondary complaints.

• Review onset, course, duration, Review onset, course, duration, frequency, frequency, – intensity, character, location, intensity, character, location, – aggravating & alleviating factors, aggravating & alleviating factors, – any associated manifestations, any associated manifestations, – radiation or referral of pain, loss of functionradiation or referral of pain, loss of function– current and past care or medication and current and past care or medication and

responses to past care.responses to past care.


Past Medical, Family & Social Past Medical, Family & Social HxHx• Any relation to current presenting Any relation to current presenting

complaints?complaints?

• Any complicating factors?Any complicating factors?


Systems ReviewSystems Review• Review all relevant systemsReview all relevant systems

• Any relation to current presenting Any relation to current presenting problem?problem?


Physical ExaminationPhysical Examination• Perform a full examination of all Perform a full examination of all

systems with attention to the systems with attention to the presenting complaints. presenting complaints.

• Assess current findings whether they Assess current findings whether they are consistent with presenting are consistent with presenting history and clinical records of history and clinical records of treating physician treating physician


Special StudiesSpecial Studies• Review any imaging or relevant Review any imaging or relevant

laboratory tests. laboratory tests.

• Do not order any tests unless given Do not order any tests unless given prior permission by referring party.prior permission by referring party.


DiagnosisDiagnosis• Does the diagnoses concur with the Does the diagnoses concur with the

treating physician ? treating physician ?

• Are there additional DX’s?Are there additional DX’s?

• Is patient at MMI?Is patient at MMI?


Statement of CausalityStatement of Causality• Taking into account the description Taking into account the description

of the accident, the presenting of the accident, the presenting complaints of the patient, the complaints of the patient, the findings on examination and the findings on examination and the diagnosis rendered is there a diagnosis rendered is there a reasonable degree of medical reasonable degree of medical certainty that the accident/incident certainty that the accident/incident had a direct causal relationship to had a direct causal relationship to the injuries?the injuries?


Summary & ConclusionsSummary & Conclusions• Comment on the appropriateness of care to date.Comment on the appropriateness of care to date.• Is the patient at a medical end point? Is the patient Is the patient at a medical end point? Is the patient

at preinjury status?at preinjury status?• Was any previous outcome measured utilized? Did Was any previous outcome measured utilized? Did

they show progress? Are there any Wadell signs? they show progress? Are there any Wadell signs? – Any indications of magnification, hypochondriasis, or Any indications of magnification, hypochondriasis, or

malingering? malingering? • Was patient cooperative throughout the Was patient cooperative throughout the

examination? Is further care necessary? If so, how examination? Is further care necessary? If so, how much? Is there a recommended change in the much? Is there a recommended change in the treatment plan? treatment plan?

• Make general comments answering similar Make general comments answering similar questions raised in record review template, questions raised in record review template, especially if you have the previous records to especially if you have the previous records to review. All comments need to be substantiated.review. All comments need to be substantiated.

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Billing ProceduresBilling ProceduresReviewers-send all bills to HRC onlyReviewers-send all bills to HRC only

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Online reviews will have a second tier Online reviews will have a second tier oversight.oversight.

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