News From ACFAS

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Power has been fully restored at ACFAS’ Chicago headquarters, following last week’s three-day outage that delayed delivery of This Week @ ACFAS and interrupted the College’s telephone, e-mail and e-commerce. All services are now available for your convenience. Thank you again for your patience! If you are concerned and confused as you prepare to make difficult and costly decisions for an electronic health record (EHR) system, join us for a free webinar on July 26. ACFAS and Welch Allyn will review a proven program to help you manage the complex EHR preparation and selection process.

Title: "Taking Your EHR Selection Process from Confusion to Confidence"
Date: Tuesday, July 26, 2011
Time: 9:00–10:00 a.m. EDT

This webinar will include an insightful review of five key elements of a successful EHR selection project: planning and preparation; organizational readiness; technology and workflow assessment; capital assessment; system evaluation and selection.

Visit the ACFAS website for more information and to register now for this valuable free presentation! Are you a beginning researcher seeking help in learning to secure funding and other survival skills for pursuing an academic career? The United States Bone and Joint Decade/Initiative (USBJD/I) is now accepting applications for its grant mentoring program, the Young Investigator Initiative.

This program is open to junior faculty, senior fellows or postdoctoral researchers nominated by their department or division chairs, and to senior fellows or residents who are conducting research and have or will have a faculty appointment. Investigators selected for the program attend two workshops, 12 to 18 months apart, and work with experienced researchers in between to develop their grant applications.

More information is available at the USBJD/I website. Application deadline for the Fall 2011 Workshop is July 15, 2011.

Foot and Ankle Surgery

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A young female patient underwent a tibiocalcaneal arthodesis for infected talus necrosis following total talus extrusion. The procedure involved total talectomy and implantation of antibiotic spacer, followed by tibiocalcaneal fusion using a blade plate. Bone loss was compensated with autodigested, antigen extracted allogeneic bone, and the follow-up time was 18 months and the fusion was achieved after eight months.


Researchers performed a study to assess the results of patients older than 80 years who underwent operative fixation for unstable ankle fractures, focusing on 92 consecutive patients, 80 women and 12 men, with an average age of 85.2 years. Danis-Weber B type fractures were determined to be the most common fracture pattern, and the superficial wound infection rate was 7 percent (six cases) while the deep infection rate was 4.6 percent (four cases). The 30-day postoperative mortality was 5.4 percent (five cases), and 86 percent (75 out of 87 cases) were able to resume their pre-injury mobility at the last follow-up. Diabetes, dementia, peripheral vascular disease, and smoking were determined to be statistically significant risk factors affiliated with wound complications.


Researchers reported the results from 26 athletic patients subjected to percutaneous internal fixation with a Charlotte Carolina screw system of a proximal fifth metatarsal Jones fracture (zones II and III) and bone marrow aspirate concentrate. The average Foot and Ankle Outcome Score rose substantially from 51.15 points preoperatively to 90.91 at final follow-up. Significant improvement also was seen in the average physical component of the SF-12 score from 25.69 points preoperatively to 54.62 at final follow-up. The average mental component of the SF-12 score climbed from 28.20 points preoperatively to 58.41 at final follow-up, while the mean time to fracture healing on standard radiographs was five weeks after surgery. Two patients did not resume their previous levels of athletic activity. One patient underwent a delayed union, and one healed but later suffered a refracture.

Practice Management

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According to the American Medical Association's annual report card on the health insurance industry, nearly 20 percent of medical claims are inaccurately processed by health insurance firms, which slows down payments to doctors and other healthcare providers. Commercial health insurance companies' error rates jumped 2 percent to 19.3 percent, according to the report card. The group suggests that improving claims processes could save patients money and improve medical care by reducing bureaucratic procedures. AMA Board Member Barbara McAneny, MD, says, "A 20 percent error rate among health insurers represents an intolerable level of inefficiency that wastes $17 billion annually. Health insurers must put more effort into paying claims correctly the first time to save precious healthcare dollars and reduce unnecessary administrative tasks that take time and resources away from patient care." The report also measured the timeliness of claim processing at the seven largest health insurers in the United States. However, the insurance sector's health plans continue to reduce costs and improve efficiency, particularly in reducing denial rates and speeding up claim response time.


HIPAA violations no longer result in a simple warning letter from the U.S. Department of Health and Human Services, with medical practices encouraged to prepare for HIPAA audits. Physicians face fines starting at $100 for first-tier violations and anywhere from $1,000 to $25,000 for second-tier violations, and the total can add up when multiple violations are involved. While random audits are possible, HIPAA audits generally are triggered by three types of events: a breach or complaint of a breach, a complaint of a privacy or security violation, and applications for EHR reimbursements. In the event of an audit, practices must provide documentation of HIPAA compliance efforts, so they should have a privacy/security officer to maintain and update these records. They also should have a HIPAA consultant to ensure that their EHRs are HIPAA compliant. During the audit, the practice owner, IT person, and HIPAA compliance officer should be present. They should be prepared to answer questions about such things as the practice's disaster recovery plan and employee violations/sanctions policy and provide lists of terminated employees, users with remote access capabilities, and software, among other things. Additionally, an assortment of documents should be on hand, such as policies for encryption, employee background checks and confidentiality agreements, and authentication methods, as well as their entity-wide security plan, data backup plan, disaster recovery plan, and risk management plan.


The ICD-10-CM will replace the ICD-9-CM, with Oct. 1, 2013, as the start date, and providers will need to be actively involved in the conversion process as many of the issues are provider-driven. For example, medical record (MR) documentation covers the current ICD-9-CM life cycle, is foundational for the entire process of diagnosis coding, and there has been no indication of change with ICD-10. Provider documentation initiates the assignment of codes, drives the assessment of medical necessity for payment of services, and serves to validate those services upon review by oversight entities. Physician practices can get off to a good start in preparing for ICD-10 by performing a baseline MR documentation assessment because it will help expose areas where improvement is needed, and also reveal where opportunities for diagnosis (ICD-9-CM) and service (CPT) coding were missed. Practices should keep in mind that the final reported ICD-9-CM codes for each case selected may need to be compared with information contained on the practice superbills. In order to conduct a full MR documentation assessment, practices will need original MR documentation (e.g., office visit note); ancillary documents such as provider orders, operative reports, pathology reports, radiology reports, etc., if germane to the office visit; practice superbills or encounter forms (i.e., the 'charge tickets'); and CMS-1500 claim form copies, among other source documents. An ICD-10 tool will be needed to compare and contrast ICD-10-CM and ICD-9-CM codes, such as a pre-2013 ICD-10-CM book, an encoder with ICD-10 mapping, or the public CMS files that include listings of the ICD-10-CM/PCS codes as well as 'GEM files, tying ICD-9 and ICD-10 together. Practices would select a patient date-of-service and prepare the array of MR documentation, the superbill and a copy of the CMS-1500 claim form; then scan the progress (office visit) note for the recorded diagnostic data; and also scan the History section of the office visit note.

Health Policy and Reimbursement

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A task force is being formed by the California Podiatric Medical Association (CPMA), the California Medical Association, and the California Orthopaedic Association (COA) to review curricula at the state's two podiatric schools and identify any lapses in comparison with medical education. The plan is to have the podiatric schools fulfill accreditation standards established by the Liaison Committee on Medical Education, which COA executive director Diane Przepiorski says are the same standards that medical schools must satisfy. The initiative's success would mean that California podiatrists could one day be licensed as physicians and surgeons. American Podiatric Medical Association CEO Glenn Gastwirth says the collaboration could serve as a template for other states. CPMA executive director Jon Hultman says that as accredited physicians and surgeons, podiatrists would have unrestricted medical licenses and would be allowed to practice nationwide within their education and training. "The [American Orthopaedic Foot & Ankle Society] supports any initiative that can improve patient safety and the quality of care for patients," says AOFAS president Keith L. Wapner.


The Health IT Policy Committee has voted to delay Stage 2 meaningful use from 2013 to 2014, with some in the healthcare field pushing for an even longer delay. Trade groups representing healthcare providers say Stage 1 results should be examined before proceeding with Stage 2. The meaningful use requirements have generated controversy over timing since the incentive program's inception, as it remains to be seen whether providers have the ability to meet implementation deadlines. Vendors of electronic health records (EHR) systems say the federal government gave signals about what should be included in EHR products during the Stage 1 planning process, which resulted in costly corrections when some of the signals were excluded from the final regulations. Paul Tang, MD, chair of the committee's Meaningful Use Workgroup, stresses that Stage 2 timing and criteria ultimately will be set by the federal government and that he wants the group to commence work on Stage 3 guidelines soon.

Medicine, Drugs and Devices

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The National Quality Forum (NQF) has made four additions to its list of serious reportable events. The list, which was created in 2002, includes such events as wrong-site surgery. The list now contains 25 updated events and four new ones. New ones include patient death or serious injury resulting from failure to communicate test results. The updated list of events will be available for a 30-day appeals process closing July 12.


Of all the malpractice claims made in 2009, 52 percent were for services delivered in outpatient settings, costing nearly $1.5 billion in malpractice payments. Though outpatients’ visits outnumber hospital care 30 fold, the number of outpatient-related claims is higher than expected and rising, suggesting the need for more attention to patient safety. Nearly 46 percent of outpatient malpractice claims were over misdiagnosis, with research showing diagnostic errors caused by not one but a series of mistakes. “For every missed or late diagnosis, an average of three things went wrong,” says chief quality and safety officer at Partners Healthcare, Tejal Gandhi. “It’s easier — though not easy — to develop systems to improve test-result management rather than to tackle mistakes that spring from bad judgment or memory slips.” Well-implemented e-prescriptions and electronic medical record systems were recommended to avoid medications errors, which were also common. Building better partnerships between hospitals and follow-up with primary-care providers, specialists, and rehabilitation and skilled nursing facilities will also help improve care and eliminate errors during transitions from hospital to community-based care. The National Quality Forum recently released its list of serious reportable events, and for the first time applicability to office-based practices, ambulatory surgery centers, and nursing facilities were included.


Intuitive Surgical's da Vinci robot has drawn attention to the contentious issue of robot-assisted surgery, with advocates such as Khurshid Guru at Roswell Park Cancer Institute arguing that the marketing of such procedures has warped the discussions doctors and patients should have over what treatment is most suitable. A recent Johns Hopkins School of Medicine study suggests that many hospitals employ industry-supplied content and overstate claims of robotic success; the researchers' analysis of 400 hospital Web sites found that most of those that promote robotic surgery cite its superiority in spite of a dearth of evidence that this is indeed the case. Da Vinci robot supporters say the device lets them see where they are working in high definition, and allows them to work with more precision in challenging and harder-to-reach spaces in the body. Brigham and Women's Hospital urologist James Hu, who led a 2009 study in the Journal of the American Medical Association focusing on the greater incidence of urinary and sexual problems following minimally invasive prostatectomies, contends that not all hospitals should have a da Vinci, in view of its expense, the lack of data about when it is most appropriate to use, and the steep learning curve. For neophyte robotic surgeons, one the key challenges of robotic surgery is the lack of tactile feedback.


The response of breast cancer survivors to 2009 U.S. Preventive Services Task Force recommendations that women in their 40s did not need routine mammograms, using e-mail, social networking sites, and electronic bulletin boards to express their anger, reflects the impact that social networking is having on medicine. Not long after the issuance of the guidelines, women organized on message boards and submitted petitions to lawmakers, and neither federal health insurance programs nor private insurance companies lowered their mammogram coverage for women in their 40s, which is proof that the outcry affected policy, according to Oregon State University sociologist Kristin K. Barker. "People have their own health experience and they have often been suspicious of medicine, but you get a lot of people together with their own experiences that contradict medical advice, and it becomes a very potent social force," she observes. Along with young people, women in their 30s, 40s, and 50s are among the most likely to employ social networking sites, says Susannah Fox with the Pew Research Center's Internet & American Life Project. She reports that many who post on message boards for breast cancer or other conditions are doing more than simply venting; they are investigating, sometimes reading source material to educate themselves.