Regenstrief Institute to help improve disability determination through health information technology

INDIANAPOLIS –- The Regenstrief Institute has been awarded a Recovery Act contract to help the U.S. Social Security Administration and Indiana healthcare providers shorten and improve the process of making disability case determinations through automation. Work is scheduled to begin March 31.

The process of acquiring medical information for an SSA disability claim involves numerous requests to multiple healthcare providers treating the individual seeking disability benefits. This process can take weeks or even months following an application for benefits. Physician offices, hospitals and others health care provider must gather the individual’s recent medical information and submit it via fax or U.S. mail.

The Regenstrief Institute, an international leader in heath information technology, created and operates the Indiana Network for Patient Care (INPC), a secure statewide health information exchange that providers use to help improve the quality, safety and efficiency of care that their patients receive. Improving the disability determination process complements other functions of the INPC, including surveillance for influenza outbreaks and access to a patient’s diverse medical records when providing emergency care.

“We will leverage the capability of the INPC to quickly and efficiently collect the information requested electronically by SSA, with the specific authorization of the person applying for disability benefits, and securely transfer it to the government so the disability decision process can be completed more rapidly. This will make that process more efficient – both because it will be faster and also because the medical data compiled will be more complete. It also will take the time and expense of going to many different providers, assembling the necessary records and filling out forms off the shoulders of patients and decrease the need for providers to search for and send records manually,” said Brian Dixon, MPA, project manager for Regenstrief’s SSA contract.

To effectively make decisions regarding applications for disability, the SSA needs the same kind of medical information that physicians utilize when making diagnoses, treatment, and referral decisions. Healthcare providers in Indiana rely on the INPC to securely and privately share clinical data which is utilized daily to support healthcare services throughout Indiana.

“Facilitating the processing of patients’ disability claims is another example of how healthcare providers throughout Indiana have worked together with the Regenstrief Institute and Indiana Health Information Exchange to ensure that their patients’ healthcare information is used to enhance their care,” said J. Marc Overhage, M.D., Ph.D., director of medical informatics at the Regenstrief Institute, Regenstrief Professor of Medicine at the Indiana University School of Medicine, and president and C.E.O. of the Indiana Health Information Exchange.

Disability benefits determination is a large-scale process. The SSA expects to receive more than 3.3 million disability benefits applications in fiscal year 2010, a 27 percent increase over the 2008 fiscal year. Annually, more than 15 million requests for medical records are sent to healthcare providers.

Social Security divides medical sources into two categories: “acceptable medical sources” and other health care providers who are not “acceptable medical sources”. Nurse Practitioners are in the category of other health care providers who are not “acceptable medical sources”.

In Social Security Ruling 06-03, SSA explains that it makes the distinction for three  reasons: First, SSA needs evidence from “acceptable medical sources” to establish the existence of a medically determinable impairment. Second, only “acceptable medical sources” can give SSA medical opinions.  Third, only “acceptable medical sources” can be considered treating sources whose medical opinions may be entitled to controlling weight.

This means that the medical evidence from a Nurse Practitioner can not establish your medical impairment at Step 2 of the Sequential Evaluation. You must establish your medical impairment in order to win your benefits.

This means that if all of your treatment is by a Nurse Practitioner, then you have no one who can give SSA a medical opinion about how your medical impairments restrict what you can do.

In a card game, a King beats a Jack. Social Security does not even treat a Nurse Practitioner as a Jack–more like a low card. This is not good for your case!

The bad news is that the wait is still over two years long from the Request for Hearing. It is important that you keep seeing your doctor during your long wait so that your medical condition will be documented.

Just because your doctor told you six months ago that there was nothing more the doctor could do for you – this is as good as it gets – does not mean that you can stop going to the doctor. If you do not have medical records (that third party verification) for those six months, the judge can say that there is no proof that your medical condition did not improve during that time or that it stayed the same, therefore you have not proved that your medical condition prevented you from working those six months. This could result in a complete loss of benefits. If you have seen the doctor in that time, then the medical records can document that you did not improve. Also, the doctor may document some facts that the doctor did not previously document. These facts may be what convince the judge that you can not work.

Another problem is that most doctors do not put in their medical records that they told you that this is as good as it gets. When you tell the judge that is what the doctor says, there is no way to verify this in the medical records. In preparing your case to win, you must assume that without third party verification of what you say that the judge will not believe you. Otherwise you are gambling that maybe you will be lucky and the judge will believe you. Why would you want to gamble on winning when you can continue to see the doctor and generate the third party evidence (medical records) that will show what your medical condition was?

I told the nurse that I hated the pain scale as I have had clients who had rated their pain at a number that the judge in their disability case thought was the wrong number for what they were describing. “What is a level 5, what is a level 8?” I asked. I was over-thinking this and the nurse just wanted to chart it, give me my shot, and move on. She agreed with me that the number was arbitrary, but that she needed to chart it. So I picked a number.

As I lay in my hospital bed, I could not help but think of the countless hearings I have been in where the judge has asked my clients to rate their pain. One judge said that a 10 was the worst pain you could imagine. What he did not say was that if you said a 10 he automatically disbelieved you as he believed that no one could be sitting there with a pain level of 10 (he never told them that to their faces). Other judges had no problem with a pain level 10.

I hate the pain scale because there is no way for us all to calibrate our measurements so that they are all the same. I have observed clients in great pain who state that their pain is a 6. I have had other clients who appeared to be in less pain that also said that their pain was a 6. So what is a level 6?

How did I want to compare the pain I had the two nights that I could not sleep from the pain to the pain that I had after surgery? There was a time I thought my pain might be a 10, but what about those I have seen who suffered more than I did those two nights I could not sleep? If delivering a baby is a pain level of 10, was my pain that bad? Since I am a man, I will obviously never know how my pain compares to the pain of childbirth.

So I started to answer the nurse the way I advise my clients to tell their medical providers about the pain. I started to describe the pain without putting a number on it. I started to give the nurse details about the pain. How it felt. Where it was. What aggravated it (at that point for me it was just shifting in the bed). What kind of pain it was ( by this I mean was it hot, cold, constant, throbbing, stabbing, electrifying ect.) How intense it was. She wrote down my description. Now a “real” description of my pain was recorded.

It is important to get a “real” description of your pain recorded into the medical records every time you visit your medical provider. This will allow the judge to read your descriptions and know how your pain was at the beginning of your disability and how the pain continued during all of the time that was disabled. If you only give a number, you and the judge may have different ideas as to what that means. The only way you could “both be on the same page” would be for you to calibrate with the judge your pain measurements on the same scale to discover that your 6 is his or her 8. The problem is that this can not happen until the hearing, and the judge will have already read the file and decided how bad your level 6 pain is. It may be hard for the judge to change his mind. If your full blown description of the pain is in your medical records, the judge will read that as he reads the file and decides how bad your pain is.

Your full blown description of the pain in your medical records is vital to your case.

So what are the 5 steps? What are the 5 questions?

Step 1. Are you now participating in Substantial Gainful Activity? Out on the street, we might say “are you now working”? As with everything else with Social Security, there are a lot more if, ands and buts to this, because there are certain circumstances in which you might be doing some work, but it would not be considered Substantial Gainful Activity. If you are doing some work, you will need to discuss all of the facts with someone who knows the law and rules to help you determine if it is Substantial Gainful Activity. If you are not participating in Substantial Gainful Activity, then you go on to Step 2.

Step 2. Do you have a medical impairment that is considered serious under the rules of Social Security and is it going to last at least 12 months? If you are going to die in less than 12 months from the impairment, Social Security will say that is good enough to meet the 12 month duration requirement.

Step 3. Do you meet any Listings? Social Security has a book in which it has listed some medical conditions and has listed certain requirements for those medical conditions. If you meet each of these requirements for the medical conditions, then you do not have to continue on to Step 4 and 5, you are automatically found disabled. Most of these requirements are laboratory tests or other medical tests in which you have to hit certain values dead center like a bulls-eye. Social Security has been revising the listings and adding in specific functional limitations that you must also meet.

The reality is that if you have the values that Social Security sets out in the Listings, no one would really argue that you can not work due to your medical impairment. For example, Social Security requires a creatinine level of 4 to find you disabled for renal failure. My clients who have had a creatinine level of 3 have been on dialysis, on the transplant list, and suffering from severe fatigue, and have not met the listings even though it was impossible for them to work.

The Listings at step 3 do help those that are the most seriously impacted by their medical impairments, but most people do not meet the listings and proceed on to Step 4.

Step 4. Are you able to perform any of your past relevant work? Translated: can you do any of the jobs that you have done in the last 15 years? If you can do the easiest job you have done in the last 15 years, you do not get to proceed on to Step 5.

Step 5. Given you age, education, any transferable skills you might have from your past work, and the medical impairments that Social Security finds that you have (which may be different from what you know you have), can you do any other work that exists in significant numbers in the regional or nationally economy? Social Security usually has a vocational expert at the hearing that will help the Administrative Law Judge decide if you can do other work as the Social Security Administration has the burden of proof on the issue you being able to do other work that exists in the regional or national economy.

As with everything at Social Security, there are a lot of rules, regulations, and laws that apply to each step. You will need someone knowledgeable about the rules, regulations and laws of each step to help you determine what evidence you will need to prove to win your case.

When you are proving that it is your medical impairment that is keeping you from working, SSA will want to know how your medical impairment prevents you from being able to work. SSA will look to see if the medical impairment you have could produce the problems you describe. If the medical community generally does not believe that you could have the problems you describe as a result of the medical impairment you identify, then SSA will find that your medical impairment does not prevent you from working. For example, if you identify that you have a hang nail, that would not explain why you have back pain that prevents you from working. Social Security would ignore that you have back pain because you have not proved that your impairment, a hang nail, causes the back pain that prevents you from working.

There is a big difference between what you know and what you can prove. You will not be able to win your disability claim based only on your testimony about how your medical impairment affects you. Even though your immediate family knows you the best and they are most likely to know what you could do before you were disabled and what you can now do, SSA is suspicious of this testimony because SSA thinks your family is likely to say anything to help you get the disability money. SSA will be looking to your medical records to decide how severe your medical impairment really is. From your medical records SSA will be deciding how long you can sit, stand, and walk in an eight hour competitive work day. SSA will also decide from your medical records how much you can lift and carry and how often you could do this, your ability to reach, handle, and finger and many other physical tasks. Any limitations in your abilities must be due to your medical impairments. And the best source of evidence is usually your medical records.

Behind every question that Social Security asks is the real question: how does your medical impairment keep you from working and how does what we are now talking about show how your medical impairment keeps you from working?<–>

When I first started representing claimants in 1994, I also would not take a client until they had been turned down at least once. I reasoned that if someone could be approved on their initial application without an attorney, why not let them go ahead on their own and find out if their claim could be approved. They could save an attorney fee and it would not hurt their case if they did lose, so why not wait to see who really needed an attorney to help them?

But then I started to notice something. When people applied by themselves, they were making it harder to win their case by not having an attorney at the beginning to explain to them the rules of Social Security. They were unknowingly lowering the odds for success at that stage and at the appeal stages. They were not realizing that they were making strategic decisions that might ruin their claim before some administrative law judges. They did not have someone to help them figure out what was the relevant evidence that they needed to be sure they presented to Social Security. I figured out that I was wrong-people were hurting their case by not having an attorney at the beginning of their case.

Several years ago I decided that I had to start taking claimants as clients as soon as possible. Claimants needed to be represented before they filed their claim. If I made a claimant wait until they were turned down before I would represent them, their not knowing the rules put them at a disadvantage: bad evidence was created, good evidence was not brought forward, other strategic choices were being made that could not be undone, and good claims were being unnecessarily tainted with misinformation.

Do not wait to hire an attorney. Get competent help before you file so that the job will be done correctly from the beginning. Do not hope that the attorney can tear out the bad and re-do it. Do it right the first time. It can shorten the whole disability process. Get an attorney that will represent you from the beginning of your claim. Have someone on your side that knows the rules of Social Security and can explain them to you.

The best proof of you having a medical impairment is the medical records that document a doctor diagnosing the impairment. When someone has something wrong and the doctors just can not figure out what it is, this can be a problem. This is why I believe that the best thing you can do for your claim is to get as much medical treatment as possible. There is still an art to practicing medicine, and it can take many visits to the doctor before the doctor gets that one piece of the puzzle that causes all of the other pieces to fall into place so that the doctor can give a diagnosis.

Sometimes the doctor has a pretty good idea what the problem is, but can not give an official diagnosis because one of the items that is required for that diagnosis is missing. For example, if the doctor must find six things to give the diagnosis, but can only find five, then most doctors will not give the official diagnosis of “X”. They may go ahead and treat the situation as if it is “X”, and they may tell the patient that the doctor thinks that the person has “X”, but no where in the chart will the doctor say that the person has “X”. With many visits, the doctor may learn information so that the doctor can confirm that the person has “X”. Without a diagnosis, many at Social Security do not want to find that you have proven you have a medical impairment even though you know that medically something just is not right. It is important that you understand the difference between what you know and what you can prove. Seeing your doctor as often as you can will help prove what you know.