As a workers’ compensation professional, one of the ongoing challenges is assessing whether the recommended interventions are clinically appropriate, medically necessary, and will genuinely help the injured person return to work with maximum medical improvement. Certain decisions are entirely suitable for the requested treatment. A slip and fall in a 63-year-old individual resulting in a comminuted fracture of the femoral head clearly requires surgical intervention to include total hip replacement arthroplasty.
However, some requests or interventions are questionable. While understanding there is a clinical indication for a total hip arthroplasty in the case noted above, there is no indication for whole-person massage therapy every other day for the next six weeks.
In the past, there was a traditional reliance on intuition or anecdotal experience. With the implementation of the standards of evidence-based medicine (EBM), this is no longer a sufficient basis to endorse any intervention. Instead of applying the standard of “this is how we’ve always done it” it now becomes secondary to the identified citations; this is best practice for this clinical situation.
The clear solution is to apply EBM standards to the determinations that are being made. The utilization of evidence-based medicine is not about denying care or cutting corners; it is about applying the most recent and best scientific evidence to support the request. When a provider uses research-backed guidelines and recommends treatment supported by these clinical studies or established protocols, you can confidently approve the request. However, when the request falls outside these accepted standards, there is a clear objective basis to question the noted intervention.
Additionally, the application of evidence-based medicine starts with the determination of the extent of injury as a function of the reported mechanism of injury. The evidence-based medicine process is straightforward: note the symptoms, identify the findings on objective diagnostic imaging studies or other clinical data, and boil this down to the lowest common denominator. This is where the diagnosis relative to the compensable injury lies.
Subsequent applications relative to clinical questions advance the determination from a subjective judgment call to a transparent, medically defensible process that serves the interests of all parties concerned.
It is no secret that healthcare costs continue to rise. However, with the utilization of evidence-based medicine in the decision-making process, it is clear that over-treatment or unnecessary interventions will be mitigated. Not only will this minimize the length of the claim, but it will also accelerate recovery and alleviate any complications or other friction points noted.
Lastly, for all decision makers noted in the adjudication process, the application and utilization of this particular standard will be a career differentiator. Understanding and applying appropriate evidence-based medicine guidelines establishes you as that trusted advocate for the injured employee and your organization. Do it right the first time.
