By Dr. John Robinton, Medical Director, One Call Medical
Electromyography (EMG) and Nerve Conduction Studies (NCS) are invaluable diagnostic tools. When an injured worker sustains a possible neurologic injury, causing symptoms of pain, numbness, tingling, burning, or weakness, EMG and NCS provide the roadmap to locate and evaluate the type and severity of an injury, as well as to rule out other potential medical conditions.
During the performance of an EMG, the examining physician inserts a small needle into the muscle to detect and assess any damage. Muscle activity is evaluated both while at rest and during voluntary contraction. During NCS, mild electrical stimulation is applied directly over the nerve(s) in increasing strength to measure motor and sensory nerve responses.
Quality EMG and NCS help to determine the right course of treatment, such as whether surgery or physical therapy may be required. Poor quality EMG and NCS can lead to unnecessary surgery, extended disability, delayed return to work, and overall costly claim outcomes.
The Question of Quality Providers
Today, there is no barrier to entry in the field of electrodiagnostic medicine. Essentially, any licensed provider is allowed to perform an EMG or NCS. As a result, outcomes vary widely from physician to physician due to training, experience, and the accuracy with which they perform tests.
In workers compensation, a significant percentage of providers who perform EMG and NCS have not undergone any type of evaluation, qualification, or credentialing process. As a result, tests performed by these “non-prequalified” providers may not be medically useful in determining the next course of treatment for an injury.
Study Results Confirm Unreliability Among Non-Prequalified Providers
In 2009, a study presented at the annual American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM) meeting confirmed this hypothesis. The study reviewed 140 reports to assess the medical usefulness of EMG and NCS reports performed by providers who had not undergone a pre-qualification process.
Each report was graded by an American Board of Electrodiagnostic Medicine board certified neurologist who was also certified in clinical neurophysiology. Failure to satisfy “medical usefulness” was determined by factors that included, but were not limited to: a lack of adherence to AANEM guidelines, incomplete examination information, and data inconsistency and unreliability.
Out of the 140 NCS/EMG reports reviewed, 68 percent were considered not medically useful. As a result of this quality review, surgeries were cancelled in a number of cases, and repeat studies were requested by other physicians.
A Comparison of Two EMGs
Perhaps the most apparent and compelling way to examine today’s key testing challenges is to look at an actual patient example. In this case, we’ll review two EMG tests—one that was inaccurately performed, and a second test that provided accurate, medically useful information.
EMG #1: At work, a patient had “supposedly” sustained a back injury during an un-witnessed fall. The provider who performed the initial test was not pre-qualified to perform EMGs, so his credentials and quality of his reports were not reviewed or confirmed. A historical analysis of this provider’s test reports revealed he performed the same standard test on each and every patient.
As a result, the provider did not customize the test accordingly to the patient’s clinically affected muscles. His test results claimed that back surgery was required. This surgery was performed, but ultimately it did not alleviate the patient’s medical condition or pain. Instead, the surgery actually worsened the patient’s condition.
EMG #2: Since the patient was still experiencing significant pain, a second post surgery EMG was performed by a credentialed provider from a specialty diagnostic network. This provider has previously undergone a rigorous pre-qualification process to assure the quality of his medical reports. The second test revealed that the patient actually had been suffering from a diabetes-related condition, which was the root cause for the pain and therefore would have not been compensable under workers’ compensation.
Due to the initial inaccurate test results and the inappropriate surgery, the worker is now permanently and completely disabled with a claim projected to cost more than $2.5 million dollars. Since the workers’ compensation insurer had authorized the back surgery, it was liable for the full costs of the claim.
In short, this comparison of two EMGs exemplifies some of today’s key testing challenges:
- Use of an unqualified provider who lacked proper training and credentials.
- Test performed to study the wrong muscles.
- Inaccurate test results that can lead to a misguided treatment plan, unnecessary surgery, and a costly permanent disability claim.
- Poor quality of care for the injured worker.
Specialty Diagnostic Networks: Focus on Quality
Although the quality of providers may vary widely, the good news is that there are specialty diagnostic networks that now help payers ensure the quality of providers, and thereby, ensure the medical usefulness of their EMG and NCS results.
Specialty diagnostic networks use a rigorous provider credentialing process to ensure that its providers meet and continually adhere to pre-defined quality guidelines. This credentialing process also includes a clinical review of sample tests to ensure adherence to report standards. With this pre-qualification process, the network identifies and selects quality, qualified neurologists and physiatrists.
The network also employs “clinical service” resources to review all provider reports on an ongoing basis to ensure continual adherence to quality guidelines and report standards. Through this monitoring process, a network can detect any deficiencies and take corrective action to improve outcomes.
In short, a specialty diagnostic network offers a quality delivery model for EMG and NCS in workers compensation. In addition to improved diagnosis, quality outcomes and better care for injured workers, the cost savings delivered from a quality-driven program can be significant in light of today’s skyrocketing medical costs.
About Dr. John Robinton
Dr. Robinton is a neurologist based in Montclair, New Jersey, and Medical Director at One Call Medical. Dr. Robinton’s laboratory received recognition by the American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM) as the first accredited electronic laboratory in the state of New Jersey—and the additional distinction of “Accreditation with Exemplary Status.”
Dr. Robinton helped to author an article sponsored by the AANEM, which outlines the key issues regarding EMG and NCS reporting. He has more than 25 years of experience in electrodiagnostic medicine, and the importance of these tests in workers’ compensation injury cases.
Dr. Robinton graduated from Princeton University and went on to receive his medical degree from Cornell. Following medical school, Dr. Robinton completed a Neuromuscular Fellowship at Tufts, New England Medical Center in Boston. He is now one of only five percent of physicians across the country boarded in both Electrodiagnostic Medicine (ABEM) and Clinical Neurophysiology (ABPN-CN), and he is one of three practicing physicians in New Jersey who is also a Fellow of the American Academy of Neurology.
He can be reached at John_Robinton@onecallmedical.com.
About One Call Medical, Inc.
Based in Parsippany, NJ, One Call Medical, Inc. (OCM) is the nation’s leading partner in providing specialized services that lead to faster, more efficient and more cost-effective resolution of claims. From high-end diagnostic procedures, to transportation and language services, to superior dental programs and other medical specialties, OCM provides reliable, consistent connections to care and improved outcomes. With rapid scheduling of services, clinical oversight, coordination, and delivery of medical reports, no other partner gives you the depth of support and service excellence that OCM provides. Our team of experts is always ready to connect you to a broad spectrum of qualified providers and specialized services. For more information, visit www.onecallmedical.com.