I.C. No. 047940North Carolina Industrial Commission
FILED: 16 March 1998
OPINION AND AWARD FOR THE FULL COMMISSION BY DIANNE C. SELLERS COMMISSIONER
This matter was reviewed by the Full Commission on 9 December 1997 upon the appeal of plaintiff from an Opinion and Award of Deputy Commissioner John A. Hedrick filed on 11 June 1997.
APPEARANCES
Plaintiff: Collins, Blomeley and Woody, Attorneys, Murphy, North Carolina; James L. Blomeley, Jr. appearing.
Defendants: Young, Moore and Henderson, Attorneys, Raleigh, North Carolina; J.D. Prather appearing.
***********
The undersigned have reviewed the prior Opinion and Award based upon the record of the proceedings before Deputy Commissioner Hedrick and the briefs and oral arguments before the Full Commission. The appealing party has not shown good ground to reconsider the evidence; receive further evidence; rehear the parties or their representatives; or amend the Opinion and Award.
***********
The Full Commission incorporates herein by reference the previous Awards, including the Opinion and Award of the Full Commission filed 30 June 1992, the Interlocutory Opinion and Award by Deputy Commissioner Richard B. Ford filed 22 December 1993, and finds as fact and concludes as matters of law the following, which were entered into by the parties at the hearing as:
STIPULATIONS
1. In the spring and summer of 1994, defendants initiated a rehabilitation plan culminating in a work trial by plaintiff at Industrial Opportunities, Inc., in Marble, North Carolina. Plaintiff worked on 3 October 1994 and did not thereafter return, reporting that the effort had caused her pain.
2. A set of plaintiff’s medical and rehabilitation records, consisting of seventeen parts, marked as Stipulated Exhibit Number Two, is admitted into evidence.
3. A set of records consisting of plaintiff’s medical records from Dr. Buter, District Memorial Hospital, Dr. Gough, Dr. Marhaba and a decision of the Social Security Administration for Disability, is admitted into evidence.
4. Dr. Buter’s file for plaintiff contains the medical records of Dr. William Gough. When contacted by the parties to determine when said records were received in his office, Dr. Buter indicated that he believed he had them available at the time of his independent medical examination but could not state with certainty that he had them at that time.
EVIDENTIARY RULINGS
The objections appearing in the depositions of Dr. Gough, Ms. Fortner and Mr. Adams are OVERRULED.
***********
The Full Commission adopts the findings of fact found by the Deputy Commissioner as follows:
FINDINGS OF FACT
1. At the time of the hearing before Deputy Commissioner John Hedrick on 11 June 1997, plaintiff was fifty-three years old. She completed nine years of formal education and later obtained a GED. Her employment history included work as a cook, a sewer and as a pharmacy sales clerk/cashier. She had also worked in a manufacturing position where she was responsible for cleaning wires. Her last employment was as a pharmacy sales clerk/cashier, a position she held for approximately eleven years. Plaintiff had not worked since 11 April 1990.
2. On or about 22 February 1994, defendants retained Holder and Radford, Inc. to assist plaintiff in her rehabilitation from her 13 March 1990 knee injury. At that time, defendants continued to pay plaintiff temporary total disability compensation pursuant to the 22 December 1993 Opinion and Award of Deputy Commissioner Ford in this matter.
3. Dr. Gough began treating plaintiff for right knee pain in 1990. Following her surgery by Dr. Phillips, Dr. Gough referred plaintiff for an evaluation by Dr. Saenger for the purpose of receiving a second opinion regarding the condition of her right knee. As part of his evaluation, Dr. Saenger reviewed the videotape of the arthroscopic surgery performed by Dr. Phillips. Dr. Saenger did not recommend any additional surgical treatment for plaintiff’s right knee. Thereafter, Dr. Gough continued treating plaintiff for right knee pain, effusion and osteoarthritis. By February 1994 Dr. Gough was also treating plaintiff for diffuse pain which was caused by degenerative arthritis and fibromyalgia.
4. Plaintiff began receiving social security disability benefits on 15 November 1991 and continued to receive those benefits through the date of the hearing before the Deputy Commissioner in May 1996.
5. When defendants began their efforts to provide plaintiff with rehabilitation, plaintiff was referred back to Dr. Saenger for an evaluation of her right knee condition. Defendants sought this evaluation, in part, to determine whether plaintiff was able to participate in a vocational rehabilitation program, including participation in a sheltered workshop.
6. Plaintiff was evaluated by Dr. Saenger on 15 March 1994. Plaintiff informed Dr. Saenger that she had developed fibromyalgia since her 1990 injury and that she was unable to sit without considerable discomfort. On that date, plaintiff walked with a “somewhat stiff-kneed antalgic gait.” She had no knee swelling, but she did experience pain when pressure was applied to her right knee, distal thigh and proximal leg. Plaintiff exhibited or complained of symptoms that were inconsistent with Dr. Saenger’s findings on physical examination. Dr. Saenger encouraged plaintiff to seek alternative employment. He did not understand why she could not sit without considerable discomfort.
7. On 5 April 1994 plaintiff underwent a functional capacity assessment in which plaintiff performed numerous physical activities, including various lifts, pushing, pulling, carrying, sitting, stooping, kneeling, overhead reaching and grasping. While performing these activities, plaintiff failed to exert consistent efforts which tended to invalidate the results of the assessment. Despite plaintiff’s failure to exert consistent effort, she was capable of performing work with physical demands in the “sedentary to light” sedentary categories of employment.
8. After participating in the functional capacity assessment, plaintiff presented to the District Memorial Hospital emergency room. Plaintiff sought this treatment because she was experiencing increased pain inside and behind her right knee. Plaintiff had no knee effusion and did not complain of pain in her upper extremities or in other body part.
9. Industrial Opportunities, Inc., (hereinafter IOI) was a sheltered workshop, located in the vicinity of plaintiff’s home, where employees made and packaged sportsmen’s suspenders. The workshop was designed to teach job skills to persons who were mentally or physically disabled. Persons working in the workshop were allowed to work at their own pace and could sit or stand to perform their assigned tasks. IOI provided its employees with transportation between their homes and its manufacturing facility. IOI was a reputable workshop with many connections to industry and it had a very good record of placing its employees into positions in the competitive labor market.
10. On 11 April 1994 plaintiff was scheduled to receive a brief orientation and tour of IOI’s facilities. Plaintiff went to IOI’s facility on that date, but refused to exit her vehicle to take the tour, stating that the pain in her right knee was too great. IOI offered to provided plaintiff with a wheelchair to use during the tour, but she continued to refuse to participate in the scheduled tour.
11. Plaintiff was scheduled to begin IOI’s sheltered workshop program on 13 April 1994. However, on that date, plaintiff did not go to the workshop or call to report that she would be absent.
12. On 18 April 1994 plaintiff was re-evaluated by Dr. Gough. Plaintiff informed Dr. Gough that she believed she had re-injured her right knee, and possibly her left knee during the functional capacity assessment on 5 April 1994. In his office notes from that appointment, Dr. Gough wrote, in part, that plaintiff’s disabling condition was fibromyalgia and that unless that condition improved, the likelihood of her returning to work in a position requiring repetitive motion was very low.
13. Dr. Gough referred plaintiff back to Dr. Saenger for an orthopedic evaluation on 5 May 1994. Plaintiff did not attend the scheduled appointment. However, Dr. Saenger did receive and review a copy of Dr. Gough’s 18 April 1994 office note.
14. On 22 July 1994 defendants contacted Ms. Caroline Fortner, a Medical Services Consultant of the Industrial Commission and asked Ms. Fortner to arrange for plaintiff to receive an independent medical examination. Defendants sought the independent medical examination in an effort to resolve the conflict that existed between Drs. Saenger and Gough as to whether plaintiff was an acceptable candidate for participation in the sheltered workshop.
15. Ms. Fortner arranged for plaintiff to receive an independent medical examination by Dr. Buter, which was performed on 30 August 1994. At the time that he examined plaintiff, plaintiff’s medical records from Dr. Gough were available to Dr. Buter and he was aware that she was under treatment for fibromyalgia. On that date, plaintiff complained of right knee pain. She had no swelling, no crepitus and no instability of her collateral ligaments. Plaintiff’s right knee pain was due to osteoarthritis, secondary to her 13 March 1990 injury. On that date, plaintiff was capable of sedentary employment and was able to participate in the sheltered workshop.
16. On 29 September 1994 plaintiff attended a scheduled appointment at IOI where she toured the facility in a wheelchair. She also competed an intake interview, an interest inventory and an academic achievement test. Plaintiff was scheduled to return and begin participation in the sheltered workshop on 3 October 1994.
17. On 3 October 1994 plaintiff arrived at the sheltered workshop at 8:45 a.m., having accepted IOI’s offer to provide her with transportation from home. After completing some paperwork, she began working at 9:15 a.m. Plaintiff was assigned to fold suspenders and package them into plastic bags. IOI personnel demonstrated for plaintiff the proper method of folding and packaging suspenders and she then began performing the task herself. Plaintiff worked from 9:15 a.m. until 1:30 p.m., taking scheduled breaks at 10:30 a.m. and at 12:00 noon. She also took three unscheduled breaks which she used to walk a short distance down a hallway before returning to her work station. Plaintiff’s work station was equipped with a cushioned chair and footrest she could use to prop up her right leg. During her work, plaintiff complained of right leg and shoulder pain.
18. Plaintiff was scheduled to, but did not return to work at IOI on 4 October 1994. Rather, she telephoned IOI and stated that she would not return until she had been seen by her physician. Plaintiff presented to Dr. Gough on 6 October 1994 and informed Dr. Gough that she had participated in the sheltered workshop and that she was required to walk “quite a bit” in and out of the workshop and to and from the cafeteria on break. Plaintiff also told Dr. Gough that her participation in the sheltered workshop caused her to experience terrible pain.
19. On 12 October 1994 plaintiff was re-evaluated by Dr. Saenger and she reported that her participation in the workshop caused her to experience significant knee pain and swelling. On that date, plaintiff had no knee swelling, no ligament laxity and a full range of motion in her knee. Dr. Saenger informed plaintiff that he found nothing that would objectively explain plaintiff’s inability to walk and function in work-related activities.
20. Following her functional capacity examination and her participation in the workshop, plaintiff’s most significant complaints of pain related to her knees. Both orthopedists who evaluated plaintiff determined that she was able to participate in the workshop. Plaintiff was not required to stand or walk to perform the suspender folding and packaging task that was assigned to her. Rather, she was provided with a cushioned chair and footrest for her comfort.
21. Plaintiff was scheduled to return to IOI on 12 October 1994. Plaintiff did not return to IOI on that date, nor did she inform IOI personnel that she would be absent. Plaintiff did not thereafter return to IOI.
22. The undersigned does not accept as credible the testimony that pain associated with her fibromyalgia rendered her incapable of participating in the sheltered workshop.
23. Plaintiff was physically capable of participating in the sheltered workshop at IOI. The sheltered workshop was a reasonable method of rehabilitation designed to return plaintiff to employment in the competitive labor market. Plaintiff’s refusal to participate in the vocational rehabilitation program provided by defendants was unreasonable.
24. As a result of her injury on 13 March 1990 plaintiff sustained a twenty percent permanent impairment of her right leg.
***********
Based upon the findings of fact, the Full Commission concludes as follows:
CONCLUSIONS OF LAW
1. Plaintiff unreasonably refused to accept the vocational rehabilitation provided by defendants. N.C. Gen. Stat. § 97-27.
2. Plaintiff is entitled to no temporary disability compensation after 12 October 1994. N.C. Gen. Stat. § 97-27.
3. Plaintiff is entitled to payment of permanent partial disability compensation at the rate of $191.07 per week for forty weeks. N.C. Gen. Stat. § 97-31 (15).
4. Plaintiff is entitled to payment of all medical expenses incurred as a result of her injury of 13 March 1990 for so long as such examinations, evaluations and treatments tend to effect a cure, give relief or will tend to lessen her period of disability. N.C. Gen. Stat. § 97-2 (19); N.C. Gen. Stat. § 97-25.
5. Defendants are entitled to a credit against the permanent partial disability compensation due plaintiff equal to the amount of temporary total disability compensation paid to plaintiff after 12 October 1994.
***********
Based on the foregoing findings of fact and conclusions of law, the Full Commission affirms the holding of the Deputy Commissioner and enters the following:
AWARD
1. Defendants shall pay plaintiff permanent partial disability compensation at the rate of $191.07 per week for forty weeks. This amount shall be paid in a lump sum, subject to the credit due defendants in paragraph 3 and the attorney’s fee approved in paragraph 4.
2. Defendants shall pay all medical expenses incurred by plaintiff as a result of her injury of 13 March 1990 for so long as such examinations, evaluations and treatments tend to effect a cure, give relief or will tend to lessen her period of disability.
3. Defendants shall receive a credit against the permanent partial disability compensation due plaintiff in paragraph 1 equal to the amount of temporary total disability compensation paid to plaintiff after 12 October 1994.
4. A reasonable attorney’s fee of twenty-five percent of the compensation due plaintiff is approved for plaintiff’s attorney and shall be paid as follows: twenty-five percent of the lump sum due plaintiff, after the credit due defendants, shall be deducted from that amount and paid directly to plaintiff’s attorney.
5. Defendants shall pay the costs, including $100.00 to Mr. Adams as an expert witness fee if this has not been previously paid.
This is ___ January 1998.
S/ ______________ DIANNE C. SELLERS COMMISSIONER
CONCURRING:
S/ ______________ CHRISTOPHER SCOTT COMMISSIONER
DISSENTING:
S/ _____________ THOMAS J. BOLCH COMMISSIONER
DCS:bjp
THOMAS J. BOLCH, Commissioner, DISSENTING:
In the spring of 1994, the Plaintiff was under the care of Dr. William Gough, a physician specializing in arthritis and rheumatology in Asheville, North Carolina. She had been seeing Dr. Gough on a consistent basis since 1990, and he was treating her for both the arthritic condition in her right knee and for fibromyalgia. In the spring of 1994, Ms. Graves was asked to participate in a rehabilitation effort by the Defendants. To coordinate that effort, the Defendants had hired an Asheville vocational rehabilitation firm named Holder Radford, and had directed them to send Ms. Graves to Dr. Paul Saenger, an orthopedic doctor in Asheville. Ms. Graves had seen Dr. Saenger for a second opinion on one occasion on July 30, 1990.
The Plaintiff was concerned about the details of the rehabilitation plan, and asked Dr. Gough to comment on the appropriateness of the plan. On February 17, 1994, Dr. Gough concluded that “the only way to possibly help the patient re-enter the work field is to provide her extensive re-education to allow her to perform higher cognitive activities such as those of a paralegal. Even with such training my estimate would be that her ability to work full time even at limited activities would be questionable.”
Nonetheless, Ms. Graves saw Dr. Saenger on March 15, 1994. He examined the Plaintiff, and endorsed the rehabilitation plan being proposed. The Plaintiff testified, however, that Dr. Saenger did not discuss with her the effect of her fibromyalgia. Ms. Graves subsequently was directed to undergo an examination by a physical therapist in Franklin, North Carolina, and on April 5, 1994, she complied. That evening, after undergoing the examination, Plaintiff presented at the emergency room of District Memorial Hospital in Andrews, North Carolina, complaining of tenderness and pain in the right knee. Thereafter, the Defendants’ rehabilitation firm directed Ms. Graves to report to Industrial Opportunities, Inc (IOI), a sheltered workshop in Marble, North Carolina, on April 11, 1994. Ms. Graves went to Marble, but refused to tour the premises.
Concerned about her knee and the course and tenor of the rehabilitation plan, the Plaintiff went back to Dr. Gough on April 18, 1994. He reported that in his view, he did “not think that she will tolerate any type of repetitive type motion manufacturing type activities.” Ms. Graves advised Holder Radford that she would follow the advice of Dr. Gough, and would be happy to participate in cognitive re-training, but not the plan then being contemplated. She further advised the Defendants that she did not consider Dr. Saenger to be her physician, and that she believed Dr. Gough to be her treating physician.
In order to resolve the dispute, Caroline Fortner, then a rehabilitation nurse with the Industrial Commission, was asked to intervene. She arranged an independent medical examination with Dr. Thomas Buter, an orthopaedic surgeon in Charlotte, which took place on August 30, 1994. Dr. Buter endorsed the rehabilitation plan from an orthopedic perspective, but conceded that he had “no specific comments regarding the fibromyalgia, since this is not in my area of expertise.”
At about that same time, Ms. Fortner made a determination that, in her opinion, Dr. Saenger should be the treating physician in the case.
Despite her misgivings, Ms. Graves reported to IOI on September 29, 1994, for a tour of the facilities, and thence again on October 3, 1994, to begin work. Ms. Graves reported significant pain from the effort, and did not again report to the facility. On October 6, 1994, she returned to Dr. Gough, who found her fibromyalgia to have flared and her knee to be “somewhat worse” than in her visit in April. He concluded that it “sounds as if the job which she was placed in also required repetitive motion activities which would cause her fibromyalgia symptoms to flare.” On October 12, 1994, she also returned to Dr. Saenger, who concluded that he could find nothing which would explain the problems the Plaintiff was having.
The Defendants then filed a Form 24, seeking to terminate her compensation, on December 21, 1994. That motion was allowed after a telephonic hearing, the order being entered on February 20, 1995.
In my view, plaintiff’s refusal to follow through on therehabilitation plan was not unreasonable.
The rehabilitation plan designed by the Defendants, and implemented by Holder Radford, was, from the very beginning, short-sighted and afflicted with tunnel vision. Seemingly consciously, it ignored the whole person in order to focus only on a specific condition.
Without a doubt, the law allows insurers to formulate and carry out rehabilitation plans in an effort to help injured workers regain their ability to work N.C. Gen. Stat. § 97-25 and § 97-27. Quite properly, claimants are required to participate in good faith in properly designed programs. Such programs, however, must be designed taking into account the specific limitations under which the claimant labors. Bridges v Linn-Corriher Corp., 90 N.C. App. 397, 368 S.E.2d 388 (1988). A program designed to address only one condition, and not taking into account other conditions suffered by the Plaintiff, is not a legitimate rehabilitation effort.
At the hearing in the case, Linda Ownbey, the case manager for Holder Radford, the rehabilitation firm employed by the Defendants, testified that she was directed at the outset by the insurer to schedule Ms. Graves to see Dr. Saenger. Ms. Ownbey testified that Farm Bureau told Holder Radford that Dr. Saenger was the treating physician, and did not reveal that Ms. Graves had not seen Dr. Saenger in four years. At that time, of course, by virtue of being in possession of his records, the insurer was aware of the fibromyalgia and Dr. Gough’s belief that Ms. Graves was totally disabled.
Despite this, the initial referral from Farm Bureau did not mention the presence of fibromyalgia. Ms. Ownbey conceded that it was important to factor in the fibromyalgia in the rehabilitation plan, and that her own knowledge of the condition was not particularly detailed. Ms. Ownbey testified that she became aware of Dr. Gough’s views regarding the rehabilitation plan in the spring of 1994, but that the plan she formulated had nothing to do with the type of cognitive re-training called for by Dr. Gough. Indeed, Ms. Ownbey conceded that the coordinator at IOI, Lynn Woodruff, was not explicitly informed by Holder
Radford that Ms. Graves suffered from fibromyalgia. She suggested that Ms. Woodruff would have derived that from the medical records, but then conceded that she could not say whether or not Dr. Gough’s records were ever provided to Ms. Woodruff. Dr. Saenger, who is an orthopedic surgeon with no expertise in fibromyalgia, simply evaluated from an orthopedic standpoint. There is substantial doubt as to whether or not Dr. Saenger had been informed of the fibromyalgia or Dr. Gough’s views at the time of that exam, since his record notes that “[S]he (Ms. Graves) also states that she has developed fibromyalgia since this all developed, i e, since her knee injury.” Ms. Ownbey testified that she had told Dr. Saenger that Ms. Graves suffered from arthritis, but not fibromyalgia. She also testified that while it would have been important for the physical therapist, Matt Hornsby of Healthworks, who examined Ms. Graves on April 5, 1994, to know of the fibromyalgia, she had no recollection of informing him of the condition. Despite these oversights and omissions, however, the plan proceeded apace.
The record reflects that on April 15, 1994, a packet of materials was provided to Dr. Gough by Holder Radford describing the program at IOI, presumably in an effort to have Dr. Gough endorse the program. On April 18, Dr. Gough dictated a report that concluded that the plan then underway was completely inappropriate for Ms. Graves. Incredibly, Ms. Ownbey’s response to that report was to conclude that “it is apparent that Dr. Gough did not review this information (the IOI information) before discussing with the client his recommendations of continued vocational assistance.” Is it any wonder that a conflict developed between the parties regarding the plan?
Unfortunately, the error was compounded by Ms. Fortner. It may well have been appropriate for Ms. Fortner to order an orthopedic evaluation. In and of itself, however, that exam was not sufficient to review the whole person, including the fibromyalgia. Indeed, Dr. Buter was remarkably candid when he confessed that the effects of fibromyalgia were beyond his expertise, and that his evaluation was purely an orthopedic. Unfortunately, no effort was thereafter made to address the specific limitations from which Ms. Graves suffered.
Randy Adams, an expert in vocational evaluation and rehabilitation, and a former director of the Center for Work Rehabilitation and Pain Management at Thoms Rehabilitation Hospital in Asheville, testified in deposition that it was not within the standards of the profession to formulate a rehabilitation plan taking into account only Ms. Graves’ osteoarthritis, and not the fibromyalgia. He evaluated Ms. Graves himself, administering to her a battery of mental and physical tests. He concluded that the IOI program was inappropriate for Ms. Graves in light of her array of physical problems. Mr. Adams noted that he was familiar with IOI, and had referred clients to the program himself. He pointed out, however, that all of the positions at IOI involve repetitive motion, which aggravates fibromyalgia. He concurred in the recommendations of Dr. Gough and Ms. Graves’ later physician in 1995, Dr. Ali Marhaba, that the only appropriate rehabilitation program was one involving cognitive education and retraining, but even at that he concluded that she was not employable.
Mr. Adams also addressed a contention of the Defendants that Ms. Graves had not put forth full effort in the physical capacity evaluation performed by Matt Hornsby on April 5, 1994. Mr. Hornsby noted that Ms. Graves’ performance in the maximum voluntary effort tests suggested that “she did not give full effort throughout the entire testing process” and concluded that “it’s been my experience that patients who routinely rank below the fifth percentile are not giving full effort during the testing process.” Mr. Adams, however, noted that most maximum voluntary effort tests utilize the upper extremities, which are the very areas affected by the fibromyalgia. The lack of success in these tests suggested to Mr. Adams that Mr. Hornsby was not aware of the fibromyalgia. Mr. Adams administered one of the same tests, the Perdue Peg Board test, and found that Ms. Graves tried hard, but performed very poorly. He found this to be consistent with Dr. Gough’s observations and findings.
In sum, it is readily apparent that the rehabilitation plan in this case was not at all appropriate for someone with Ms. Graves’ specific limitations. Ms. Graves made an honest effort to comply, but the shortcomings of the plan itself doomed any effort to failure. It is not in compliance with the law to now hold Ms. Graves responsible for that failure.
PLAINTIFF IS ENTITLED TO ADDITIONAL COMPENSATION UNDER THE ACT.
In and to the extent that Plaintiff was unjustifiably cut off, it follows that she is entitled to additional benefits. If the Defendants desire, she has shown herself more than willing to participate in a rehabilitation plan that has been intelligently tailored to address her limitations and abilities. Failing that, Drs. Gough and Marhaba and Mr. Adams are in agreement that Ms. Graves is completely and totally disabled, and she is entitled to benefits on that basis.
In my view, the Deputy Commissioner and the majority of the Full Commission panel reviewing this case erred in finding that the Plaintiff unreasonably refused to cooperate in the rehabilitation plan in this case. All reliable evidence in the record indicates that the plan was, at best, ill-conceived and completely inappropriate, and that under the circumstances Ms. Graves made her best effort to comply. Having found that, it follows that Ms. Graves is entitled to additional benefits, either during a period of appropriate rehabilitation, or as completely and totally disabled.
In this case the Industrial Commission is in violation of its own rules regarding rehabilitation. Section I (E) (3) of those rules provide, in pertinent part: “Placement shall only be directed toward prospective employers offering the opportunity for suitable employment.” That rule is violated when a worker is directed toward a prospective employment that would be impossible in view of the worker’s medical condition. The Commission is also in violation of its rehabilitation rule I (G), which provides: “`Suitable employment’ means employment in the local labor market or self-employment which is reasonably attainable and which offers an opportunity to restore the worker as soon as possible and as nearly as practicable to pre-injury wage, while giving dueconsideration to the worker’s qualifications (age, education, work experience, physical and mental capacities), impairment,
vocational interests, and aptitudes.” Emphasis supplied.
This 3rd day of February, 1998.
S/ ____________ THOMAS J. BOLCH COMMISSIONER