Background


Workers compensation schemes have witnessed a long-term trend of rising medical expenditure. Proposed solutions to decrease costs and duration of claims have been of limited success. Ultimately, control of medial expenditure is one of the responsibilities of claims adjustors and case managers employed by insurers and self insurers.

These professionals are required to make decisions regarding the appropriateness of continued treatment. Such decision making requires guidelines to ensure that treatment has an appropriate evidence base. This process should lead to more effective treatment utilisation, improvement in return to work and a reduction in both claim duration and medical costs. Central to treatment guidelines are the principles of evidence based medicine. The definitive definition of evidence based medicine by Sackett is

the conscientious, explicit and judicious use of current best evidence when treating patients.

The underlying hypothesis of evidence-based medicine (EBM) is that access to evidence based clinical treatment will result in better outcomes than clinical practice that is based on intuition, unsystematic clinical experience and reliance on pathophysiologic grounds for decision-making (Sackett et al, 1996).

Evidence-based practice, as defined by Sackett, necessitates the combination of clinical experience/judgement and the relevant medical literature. Sackett goes to considerable lengths to make the point that the medical literature does not replace clinical experience and individual patient factors remain at the forefront clinical decision-making. Therefore, any system based on the principles of evidence-based medicine must incorporate this flexibility. Despite the simplicity of the definition, implementing the principles of evidence-based medicine is complex and requires a systematic and diligent approach.

Treatment guidelines are a popular method by which evidence are disseminated to the appropriate target audience. Research regarding the efficacy of the implementation of guidelines, across all health fields, has been met with varying success and provides one of the major barriers to guidelines achieving their full potential (National Health and Medical Research Council, 1998).


Evidence based medicine and workers compensation

To date there has been no attempt to systematically incorporate the fundamental principles of evidence-based medicine into the decision-making processes of the professionals (claims adjustors and case managers) who control the expenditure on workers’ compensation claims. Given the unique role of evidence based medicine within the workers compensation environment (as means of determining appropriate treatment and decreasing medical expenditure) specific resources are required.

Claims adjustors and case managers are often concerned with cost containment and have turned to guidelines to provide a justifiable method of decreasing inappropriate medical expenditure. The treating provider is, quite rightly, concerned with decision making regarding the most efficacious treatment for an individual injured worker. Clearly the provision of the most efficacious treatment to injured workers is consistent with claims adjustors and case managers objective to facilitate recovery. Therefore, it becomes critical that the differing skill sets, in addition to the differing roles, be considered when using treatment guidelines.

Workers compensation schemes around the globe are increasingly turning to treatment guidelines as a means of delivering the benefits of evidence based practice to the management of workers compensation claims. There has been an explosion in the number of treatment guidelines (The National Guideline Clearinghouse lists over 2000 guidelines) for a vast array of medical conditions. However Indico is the first treatment guideline designed specifically for workers compensation that provides an explicit link between insurer/TPA decision making and the medical evidence.

Until now there have been significant logistical barriers to the disciplined and effective implementation of evidence-based medicine within the insurance industry. Computer decision support systems provide an opportunity to overcome these barriers.


Computer decision support systems and medical treatment

Decision support systems are designed to improve decision-making by the providing straightforward access to information. Characteristics of individuals are matched to a computerized knowledge base. Commonly they use an algorithmic approach to generate patient-specific recommendations. Systematic reviews (Kawamoto) of decision support systems in the health industry have demonstrated their capacity to change the decision-making behaviour of the user. The features of decision support systems that have been shown to have the most impact on improving user (clinician) decision-making are listed below.


Features of decision support systems associated with improved clinical practice


  1. Automatic provision of decision support as part of clinician workflow
  2. Provision of decision support at time and location of decision-making
  3. Provision of recommendation rather than just an assessment
  4. Computer-based generation of decision support

Summary

Through the use of evidence-based decision support systems, the principles of evidence based practice can be combined into a cohesive process in which the sometimes competing interests of delivering a high quality of treatment and containment of medical costs can be managed in a judicious manner. Indico is an evidence-based decision support system developed specifically for the workers’ compensation environment. Indico provides a means by which the complexities of evidence-based practice can be managed by insurers, TPA’s and self-insurers in a systematic fashion.